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Hahn D, Samuel SM, Willis NS, Craig JC, Hodson EM. Corticosteroid therapy for nephrotic syndrome in children. Cochrane Database Syst Rev 2024; 8:CD001533. [PMID: 39171624 PMCID: PMC11339925 DOI: 10.1002/14651858.cd001533.pub7] [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] [Indexed: 08/23/2024]
Abstract
BACKGROUND In nephrotic syndrome, protein leaks from the blood into the urine through the glomeruli, resulting in hypoproteinaemia and generalised oedema. While most children with nephrotic syndrome respond to corticosteroids, 80% experience a relapsing course. Corticosteroids have reduced the death rate to around 3%; however, corticosteroids have well-recognised potentially serious adverse events such as obesity, poor growth, hypertension, diabetes mellitus, osteoporosis, cataracts, glaucoma and behavioural disturbances. This is an update of a review first published in 2000 and updated in 2002, 2005, 2007, 2015 and 2020. OBJECTIVES The aim of this review was to assess the benefits and harms of different corticosteroid regimens in children with steroid-sensitive nephrotic syndrome (SSNS). The benefits and harms of therapy were studied in two groups of children: 1) children in their initial episode of SSNS and 2) children who experience a relapsing course of SSNS. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 July 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) performed in children (one to 18 years) during their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent. DATA COLLECTION AND ANALYSIS Summary estimates of effects were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS In this 2024 update, we included five new studies, resulting in 54 studies randomising 4670 children. Risk of bias methodology was often poorly performed, with only 31 studies and 28 studies respectively assessed to be at low risk for random sequence generation and allocation concealment. Ten studies were at low risk of performance bias (blinding of participants and personnel), and 12 studies were at low risk of detection bias (blinding of outcome assessment); nine of these studies were placebo-controlled RCTs. Twenty-seven studies (fewer than 50%) were at low risk for attrition bias, and 26 studies were at low risk for reporting bias (selective outcome reporting). In studies at low risk of selection bias evaluating children in their initial episode of SSNS, there is little or no difference in the number of children with frequent relapses when comparing two months of prednisone with three months or more (RR 0.96, 95% CI 0.83 to 1.10; 755 children, 5 studies; I2 = 0%; high certainty evidence) or when comparing three months with five to seven months of therapy (RR 0.99, 95% CI 0.74 to 1.33; 376 children, 3 studies; I2 = 35%; high certainty evidence). In analyses of studies at low risk of selection bias, there is little or no difference in the number of children with any relapse by 12 to 24 months when comparing two months of prednisone with three months or more (RR 0.93, 95% CI 0.81 to 1.06; 808 children; 6 studies; I2 = 47%) or when comparing three months with five to seven months of therapy (RR 0.88, 95% CI 0.70 to 1.11; 377 children, 3 studies; I2 = 53%). Little or no difference was noted in adverse events between the different treatment durations. Amongst children with relapsing SSNS, four small studies (177 children) utilising lower doses of prednisone compared with standard regimens found little or no differences between groups in the numbers with relapse (RR 1.01, 95% CI 0.85 to 1.20; I2 = 0%). A fifth study (117 children) reported little or no difference between two weeks and four weeks of alternate-day prednisone after remission with daily prednisone. A recent large, well-designed study with 271 children found that administering daily prednisone compared with alternate-day prednisone or no prednisone during viral infection did not reduce the risk of relapse. In contrast, four previous small studies in children with frequently relapsing disease had reported that daily prednisone during viral infections compared with alternate-day prednisone or no treatment reduced the risk of relapse. AUTHORS' CONCLUSIONS There are four well-designed studies randomising 823 children, which have demonstrated that there is no benefit of prolonging prednisone therapy beyond two to three months in the first episode of SSNS. Small studies in children with relapsing disease have identified no differences in efficacy using lower induction doses or shorter durations of prednisone therapy. Large, well-designed studies are required to confirm these findings. While previous small studies had suggested that changing from alternate-day to daily prednisone therapy at the onset of infection reduced the likelihood of relapse, a much larger and well-designed study found no reduction in the number relapsing when administering daily prednisone at the onset of infection.
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Affiliation(s)
- Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Susan M Samuel
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Narelle S Willis
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Locatelli F, Paoletti E, Ravera M, Pucci Bella G, Del Vecchio L. Can we effectively manage chronic kidney disease with a precision-based pharmacotherapy plan? Where are we? Expert Opin Pharmacother 2024; 25:1145-1161. [PMID: 38940769 DOI: 10.1080/14656566.2024.2374039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/25/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION In recent years, thanks to significant advances in basic science and biotechnologies, nephrology has witnessed a deeper understanding of the mechanisms leading to various conditions associated with or causing kidney disease, opening new perspectives for developing specific treatments. These new possibilities have brought increased challenges to physicians, who face with a new complexity in disease characterization and selection the right treatment for individual patients. AREAS COVERED We chose four therapeutic situations: anaemia in chronic kidney disease (CKD), heart failure in CKD, IgA nephropathy (IgAN) and membranous nephropathy (MN). The literature search was made through PubMed. EXPERT OPINION Anaemia management remains challenging in CKD; a personalized therapeutic approach is often needed. Identifying patients who could benefit from a specific therapy is also an important goal for patients with CKD and heart failure with reduced ejection fraction. Several new treatments are under clinical development for IgAN; interestingly, they target specifically the pathogenetic mechanisms of the disease. The understanding of MN pathogenesis as an autoimmune disease and the discovery of several autoantibodies allows a better characterization of patients. High-sensible techniques for lymphocyte counting open the possibility of more personalized use of anti CD20 therapies.
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Affiliation(s)
- Francesco Locatelli
- Past Director, Department of Nephrology and Dialysis, A Manzoni Hospital, Lecco, Italy
| | - Ernesto Paoletti
- Department of Nephrology and Dialysis, ASL 1 Imperiese - Stabilimento Ospedaliero di Imperia, Imperia, Liguria, Italy
| | - Maura Ravera
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Giulio Pucci Bella
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
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Carrillo J, Del Bello A, Sallusto F, Delas A, Colombat M, Mansuy JM, Izopet J, Kamar N, Belliere J. Effect of steroid pulses in severe BK virus allograft nephropathy with extensive interstitial inflammation. Transpl Infect Dis 2024; 26:e14260. [PMID: 38547002 DOI: 10.1111/tid.14260] [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: 08/21/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION As there is no specific antiviral treatment currently available for BK polyomavirus associated nephropathy (BKVAN), its management relies on immunosuppression reduction in kidney transplant patients. Data on efficacy of steroid pulses in this indication are lacking. METHODS We performed a retrospective monocenter study on 64 patients diagnosed with biopsy-proven BKVAN. Patients within the "pulse group" (n = 37) received IV methylprednisolone 10 mg/kg 3 days consecutively. In the "low dose" steroid group (n = 27), patients were continued oral prednisone 5 mg daily. RESULTS Mean follow up was 78 months in the steroid pulse group and 56 months in the low dose group (p = 0.15). Mean eGFR values at diagnosis were comparable, as well as other demographic characteristics. Mean BK plasma viral load was higher in "pulse" than in "low dose" steroid group. Pulse group had higher inflammation and tubulitis (p < 0.05). Graft loss reached 57% in the "pulse" group versus 41% in the "low dose" group, p = 0.20. Rejection events were similar. No major adverse event was statistically associated with steroid pulse, including infections, cancer, and de novo diabetes. CONCLUSION No significant differences were found in the evolution of both groups of patients, despite patients receiving "pulse" steroids were identified as the most severe sharing higher BK viral load and more frequent active lesions on histology.
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Affiliation(s)
- Julien Carrillo
- Department of Nephrology and Organ Transplantation, Referral Centre for Rare Kidney Diseases, French Intensive Care Renal Network, University Hospital of Toulouse, Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Referral Centre for Rare Kidney Diseases, French Intensive Care Renal Network, University Hospital of Toulouse, Toulouse, France
| | - Federico Sallusto
- Department of Urology and Kidney Transplantation, CHU Rangueil, Toulouse, France
| | - Audrey Delas
- Department of Pathology, University Hospital of Toulouse, University Cancer Institute of Toulouse, Toulouse, France
| | - Magali Colombat
- Department of Pathology, University Hospital of Toulouse, University Cancer Institute of Toulouse, Toulouse, France
- Université Toulouse III, Toulouse, France
| | - Jean Michel Mansuy
- Laboratory of Virology, Institut fédératif de Biologie, University Hospital of Toulouse, Toulouse, France
| | - Jacques Izopet
- Laboratory of Virology, Institut fédératif de Biologie, University Hospital of Toulouse, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Referral Centre for Rare Kidney Diseases, French Intensive Care Renal Network, University Hospital of Toulouse, Toulouse, France
- Université Toulouse III, Toulouse, France
- INSERM UMR1291-CNRS UMR5051, Toulouse, France
| | - Julie Belliere
- Department of Nephrology and Organ Transplantation, Referral Centre for Rare Kidney Diseases, French Intensive Care Renal Network, University Hospital of Toulouse, Toulouse, France
- Université Toulouse III, Toulouse, France
- INSERM U1297, Institute of Metabolic and Cardiovascular Diseases, Toulouse, France
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de Zoysa N, Haruhara K, Nikolic-Paterson DJ, Kerr PG, Ling J, Gazzard SE, Puelles VG, Bertram JF, Cullen-McEwen LA. Podocyte number and glomerulosclerosis indices are associated with the response to therapy for primary focal segmental glomerulosclerosis. Front Med (Lausanne) 2024; 11:1343161. [PMID: 38510448 PMCID: PMC10951056 DOI: 10.3389/fmed.2024.1343161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
Corticosteroid therapy, often in combination with inhibition of the renin-angiotensin system, is first-line therapy for primary focal and segmental glomerulosclerosis (FSGS) with nephrotic-range proteinuria. However, the response to treatment is variable, and therefore new approaches to indicate the response to therapy are required. Podocyte depletion is a hallmark of early FSGS, and here we investigated whether podocyte number, density and/or size in diagnostic biopsies and/or the degree of glomerulosclerosis could indicate the clinical response to first-line therapy. In this retrospective single center cohort study, 19 participants (13 responders, 6 non-responders) were included. Biopsies obtained at diagnosis were prepared for analysis of podocyte number, density and size using design-based stereology. Renal function and proteinuria were assessed 6 months after therapy commenced. Responders and non-responders had similar levels of proteinuria at the time of biopsy and similar kidney function. Patients who did not respond to treatment at 6 months had a significantly higher percentage of glomeruli with global sclerosis than responders (p < 0.05) and glomerulosclerotic index (p < 0.05). Podocyte number per glomerulus in responders was 279 (203-507; median, IQR), 50% greater than that of non-responders (186, 118-310; p < 0.05). These findings suggest that primary FSGS patients with higher podocyte number per glomerulus and less advanced glomerulosclerosis are more likely to respond to first-line therapy at 6 months. A podocyte number less than approximately 216 per glomerulus, a GSI greater than 1 and percentage global sclerosis greater than approximately 20% are associated with a lack of response to therapy. Larger, prospective studies are warranted to confirm whether these parameters may help inform therapeutic decision making at the time of diagnosis of primary FSGS.
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Affiliation(s)
- Natasha de Zoysa
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
| | - Kotaro Haruhara
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
- Division of Nephrology and Hypertension, Jikei University School of Medicine, Tokyo, Japan
| | - David J. Nikolic-Paterson
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
| | - Jonathan Ling
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
| | - Sarah E. Gazzard
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
| | - Victor G. Puelles
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - John F. Bertram
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
- ARC Training Centre for Cell and Tissue Engineering Technologies, Melbourne, VIC, Australia
- ARC Training Centre for Cell and Tissue Engineering Technologies, Brisbane, QLD, Australia
| | - Luise A. Cullen-McEwen
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
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Keskinis C, Moysidou E, Christodoulou M, Pateinakis P, Stangou M. Diagnosing and Treating IgAN: Steroids, Budesonide, or Maybe Both? Diagnostics (Basel) 2024; 14:512. [PMID: 38472984 DOI: 10.3390/diagnostics14050512] [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: 12/27/2023] [Revised: 01/24/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
IgA nephropathy (IgAN), the most common primary glomerulonephritis worldwide, is characterized by a mesangial IgA deposit and a variety of histological lesions, as described by the Oxford classification system. Despite the well-described "four-hit hypothesis", there are still plenty of less or undescribed mechanisms that participate in the disease pathogenesis, such as B-cell priming, which seems to be initiated by different antigens in the intestinal microbiota. Diagnosis of the disease is currently based on kidney biopsy findings, as the sensitivity and specificity of the many serum and urinary biomarkers described so far do not seem to have diagnostic accuracy. Therapeutic strategies consist of the initial step of non-immune medication, aiming to reduce both the intraglomerular pressure and proteinuria to below 0.5 g/day, followed by systemic corticosteroid administration in patients who remain at high risk for progressive chronic kidney disease despite the maximum non-immune treatment. The 6-month systemic corticosteroid treatment reduces proteinuria levels; however, the increased possibility of adverse events and increased relapse rate after treatment raises the need for a new therapeutic approach. Targeted-release budesonide is a therapeutic modality that aims to inhibit disease pathogenetic pathways at early stages; it has minor systemic absorption and proven beneficial effects on renal function and proteinuria. In the present systemic review, the benefits and adverse events of steroids and budesonide are described, and the possibility of combined treatment is questioned in selected cases with active histologic lesions.
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Affiliation(s)
| | - Eleni Moysidou
- 1st Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Michalis Christodoulou
- 1st Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | | | - Maria Stangou
- 1st Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
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Liu X, Cao Y, Wang S, Liu J, Hao H. Extracellular vesicles: powerful candidates in nano-drug delivery systems. Drug Deliv Transl Res 2024; 14:295-311. [PMID: 37581742 DOI: 10.1007/s13346-023-01411-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Abstract
Extracellular vesicles (EVs), which are nanoparticles that are actively released by cells, contain a variety of biologically active substances, serve as significant mediators of intercellular communication, and participate in many processes, in health and pathologically. Compared with traditional nanodrug delivery systems (NDDSs), EVs have unique advantages due to their natural physiological properties, such as their biocompatibility, stability, ability to cross barriers, and inherent homing properties. A growing number of studies have reported that EVs deliver therapeutic proteins, small-molecule drugs, siRNAs, miRNAs, therapeutic proteins, and nanomaterials for targeted therapy in various diseases. However, due to the lack of standardized techniques for isolating, quantifying, and characterizing EVs; lower-than-anticipated drug loading efficiency; insufficient clinical production; and potential safety concerns, the practical application of EVs still faces many challenges. Here, we systematically review the current commonly used methods for isolating EVs, summarize the types and methods of loading therapeutic drugs into EVs, and discuss the latest progress in applying EVs as NDDs. Finally, we present the challenges that hinder the clinical application of EVs.
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Affiliation(s)
- Xiaofei Liu
- State Key Laboratory of Reproductive Regulation & Breeding of Grassland Livestock, School of Life Science, Inner Mongolia University, Hohhot, Inner Mongolia, People's Republic of China
| | - Yinfang Cao
- Department of Laboratory Medicine, Inner Mongolia People's Hospital, No. 17 Zhaowuda Road, Saihan District, Hohhot, Inner Mongolia, People's Republic of China
| | - Shuming Wang
- State Key Laboratory of Reproductive Regulation & Breeding of Grassland Livestock, School of Life Science, Inner Mongolia University, Hohhot, Inner Mongolia, People's Republic of China
| | - Jiahui Liu
- State Key Laboratory of Reproductive Regulation & Breeding of Grassland Livestock, School of Life Science, Inner Mongolia University, Hohhot, Inner Mongolia, People's Republic of China
| | - Huifang Hao
- State Key Laboratory of Reproductive Regulation & Breeding of Grassland Livestock, School of Life Science, Inner Mongolia University, Hohhot, Inner Mongolia, People's Republic of China.
- Department of Chemistry and Chemical Engineering, Inner Mongolia University Research Center for Glycochemistry of Characteristic Medicinal Resources, Inner Mongolia University, Hohhot, Inner Mongolia, People's Republic of China.
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Jiang H, Shen Z, Zhuang J, Lu C, Qu Y, Xu C, Yang S, Tian X. Understanding the podocyte immune responses in proteinuric kidney diseases: from pathogenesis to therapy. Front Immunol 2024; 14:1335936. [PMID: 38288116 PMCID: PMC10822972 DOI: 10.3389/fimmu.2023.1335936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
The glomerular filtration barrier, comprising the inner layer of capillary fenestrated endothelial cells, outermost podocytes, and the glomerular basement membrane between them, plays a pivotal role in kidney function. Podocytes, terminally differentiated epithelial cells, are challenging to regenerate once injured. They are essential for maintaining the integrity of the glomerular filtration barrier. Damage to podocytes, resulting from intrinsic or extrinsic factors, leads to proteinuria in the early stages and eventually progresses to chronic kidney disease (CKD). Immune-mediated podocyte injury is a primary pathogenic mechanism in proteinuric glomerular diseases, including minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and lupus nephritis with podocyte involvement. An extensive body of evidence indicates that podocytes not only contribute significantly to the maintenance of the glomerular filtration barrier and serve as targets of immune responses but also exhibit immune cell-like characteristics, participating in both innate and adaptive immunity. They play a pivotal role in mediating glomerular injury and represent potential therapeutic targets for CKD. This review aims to systematically elucidate the mechanisms of podocyte immune injury in various podocyte lesions and provide an overview of recent advances in podocyte immunotherapy. It offers valuable insights for a deeper understanding of the role of podocytes in proteinuric glomerular diseases, and the identification of new therapeutic targets, and has significant implications for the future clinical diagnosis and treatment of podocyte-related disorders.
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Affiliation(s)
- Hong Jiang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Zhirang Shen
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Jing Zhuang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chen Lu
- Division of Nephrology, Department of Internal Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yue Qu
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chengren Xu
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Shufen Yang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xuefei Tian
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
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Li YQ, Wu M, Wang YJ, Zhang YX, Lu J, Zhao YN, Ji BF, Chen ZQ, Tang RN, Liu BC. The analysis of low-dose glucocorticoid maintenance therapy in patients with primary nephrotic syndrome suffering from COVID-19. Front Mol Biosci 2024; 10:1326111. [PMID: 38274101 PMCID: PMC10808412 DOI: 10.3389/fmolb.2023.1326111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
Objectives: This study aimed to describe the effects of low-dose (prednisolone acetate 2.5-7.5 mg/day) glucocorticoids (GCs) maintenance therapy in patients with primary nephrotic syndrome (NS) suffering from coronavirus disease 2019 (COVID-19). Methods: A single-center retrospective study of NS patients with COVID-19 infection in Zhongda Hospital Affiliated to Southeast University from 1 February 2022 to 31 March 2023 was conducted. All enrolled patients underwent renal biopsy for the pathological diagnosis and reached complete remission (CR) or near-CR before COVID-19 infection. According to the maintained therapy regimen, patients were divided into low-dose GCs group and non-GCs group. Results: A total of 125 patients were enrolled in the study. Their median age was 46.0 ± 15.6 years, and the median value of 24-h urine protein was 0.77 g. The majority of these patients received treatment for more than 6 months, with a significant portion achieving CR (29.6%) or near-CR (43.2%). The leading cause of NS was membranous nephropathy (52%). There were no significant differences in the baseline characteristics between low-dose GCs and non-GCs group. As compared to those in the non-GCs group, patients receiving low-dose GCs treatment showed less fatigue or muscle weakness, smell disorder, palpitations, decreased appetite, taste disorder, dizziness, sore throat or difficult to swallow and fever (p < 0.05). Moreover, patients in the low-dose GCs group were with higher median quality of life scores (85.0) than in the non-GCs group (p = 0.001). Further serum inflammatory factor analysis indicated that interleukin-6 (IL-6) levels in the non-GCs group were significantly higher than that in the low-dose GCs group (p < 0.05). Conclusion: Patients with NS in low-dose GCs maintenance therapy stage showed milder symptom, higher quality of life and decreased serum IL-6 levels compared to those, who were not on GCs maintenance therapy. These results suggest the beneficial effect of low-dose GCs therapy in NS patients with CR/near-CR suffering from COVID-19 infection.
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Affiliation(s)
- Yong-Qi Li
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Institute of Nephrology, Zhongda Hospital, Nanjing Lishui People’ Hospital, Nanjing, China
| | - Min Wu
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yu-Jia Wang
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yu-Xia Zhang
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jing Lu
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi-Nan Zhao
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Bo-Fan Ji
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhi-Qing Chen
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Ri-Ning Tang
- Institute of Nephrology, Zhongda Hospital, Nanjing Lishui People’ Hospital, Nanjing, China
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Ma S, Qiu Y, Zhang C. Cytoskeleton Rearrangement in Podocytopathies: An Update. Int J Mol Sci 2024; 25:647. [PMID: 38203817 PMCID: PMC10779434 DOI: 10.3390/ijms25010647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/14/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024] Open
Abstract
Podocyte injury can disrupt the glomerular filtration barrier (GFB), leading to podocytopathies that emphasize podocytes as the glomerulus's key organizer. The coordinated cytoskeleton is essential for supporting the elegant structure and complete functions of podocytes. Therefore, cytoskeleton rearrangement is closely related to the pathogenesis of podocytopathies. In podocytopathies, the rearrangement of the cytoskeleton refers to significant alterations in a string of slit diaphragm (SD) and focal adhesion proteins such as the signaling node nephrin, calcium influx via transient receptor potential channel 6 (TRPC6), and regulation of the Rho family, eventually leading to the disorganization of the original cytoskeletal architecture. Thus, it is imperative to focus on these proteins and signaling pathways to probe the cytoskeleton rearrangement in podocytopathies. In this review, we describe podocytopathies and the podocyte cytoskeleton, then discuss the molecular mechanisms involved in cytoskeleton rearrangement in podocytopathies and summarize the effects of currently existing drugs on regulating the podocyte cytoskeleton.
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Affiliation(s)
| | | | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.M.); (Y.Q.)
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Li Y, Gao Z, Zhu J, Su J, Chen P, Li J, Feng M. Comparison of Dosage of Glucocorticoid in Idiopathic Membranous Nephropathy: A Systematic Review and Network Meta-Analysis. Cureus 2024; 16:e51936. [PMID: 38333440 PMCID: PMC10851919 DOI: 10.7759/cureus.51936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE Idiopathic membranous nephropathy (IMN) with moderate risk or above was recommended to receive immunosuppressive therapy. We attempted to evaluate the optimal dose of glucocorticoid when combined with evidence-proven effective immunosuppressants by network meta-analysis. METHODS A systematic review of the literature was conducted in PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception until January 2022. Randomized controlled trials (RCTs) in IMN limited to supportive care, glucocorticoids, cyclophosphamide, chlorambucil, calcineurin inhibitors (CNIs), and rituximab were screened. RESULTS Twenty-eight RCTs of 1,830 patients were included. Therapeutic regimens were divided as follows: moderate- to high-dose glucocorticoids plus CNIs (HMSCn), moderate- to high-dose glucocorticoids plus cyclophosphamide (HMSCt), moderate- to high-dose glucocorticoids plus chlorambucil (HMSCh), zero- to low-dose glucocorticoids plus CNIs (LNSCn), zero- to low-dose glucocorticoids plus cyclophosphamide (LNSCt), rituximab alone (R), glucocorticoids alone (SE), and supportive care alone (SP). Compared with SP, HMSCh (risk ratio [RR]: 1.77, 95% confidence interval [CI]: 1, 3.18), HMSCn (RR: 2.5, 95%CI: 1.25, 5.11), HMSCt (RR: 2.15, 95%CI: 1.29, 3.64), LNSCn (RR: 2.16, 95%CI: 1.25, 3.95), and R (RR: 2.07, 95%CI: 1, 4.39) had a higher probability of total remission rate, while HMSCn represented the highest probability depending on the surface under the cumulative ranking area (SUCRA) ranking values. Regarding infection, no significant difference was found between different doses of glucocorticoids plus the same immunosuppressant. HMSCn and HMSCt showed superiority in reducing 24-hour urine total protein compared with HMSCh, LNSCn, SE, and SP, while HMSCn seemed to be the most effective regimen through the ranking of SUCRA value. CONCLUSION Moderate- to high-dose glucocorticoids showed superiority in proteinuria remission when combined with CNIs in IMN, with no increasing risk of infection.
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Affiliation(s)
- Yanhua Li
- Department of Rheumatology, Nanhai District People's Hospital, Foshan, CHN
| | - Ziqing Gao
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Guangzhou, CHN
| | - Jianhong Zhu
- Department of Pharmacy, Sun Yat-sen Memorial Hospital, Guangzhou, CHN
| | - Jianan Su
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Guangzhou, CHN
| | - Pengwei Chen
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Guangzhou, CHN
| | - Jiande Li
- Department of Pain Management, The First People's Hospital of Foshan, Foshan, CHN
| | - Min Feng
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Guangzhou, CHN
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11
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Anders HJ, Fernandez-Juarez GM, Vaglio A, Romagnani P, Floege J. CKD therapy to improve outcomes of immune-mediated glomerular diseases. Nephrol Dial Transplant 2023; 38:ii50-ii57. [PMID: 37218706 DOI: 10.1093/ndt/gfad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Indexed: 05/24/2023] Open
Abstract
The management of immunoglobulin A nephropathy, membranous nephropathy, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis, C3 glomerulonephritis, autoimmune podocytopathies and other immune-mediated glomerular disorders is focused on two major treatment goals, preventing overall mortality and the loss of kidney function. Since minimizing irreversible kidney damage best serves both goals, the management of immune-mediated kidney disorders must focus on the two central pathomechanisms of kidney function decline, i.e., controlling the underlying immune disease process (e.g. with immunotherapies) and controlling the non-immune mechanisms of chronic kidney disease (CKD) progression. Here we review the pathophysiology of these non-immune mechanisms of CKD progression and discuss non-drug and drug interventions to attenuate CKD progression in immune-mediated kidney disorders. Non-pharmacological interventions include reducing salt intake, normalizing body weight, avoiding superimposed kidney injuries, smoking cessation and regular physical activity. Approved drug interventions include inhibitors of the renin-angiotensin-aldosterone system and sodium-glucose cotransporter-2. Numerous additional drugs to improve CKD care are currently being tested in clinical trials. Here we discuss how and when to use these drugs in the different clinical scenarios of immune-mediated kidney diseases.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Department of Internal Medicine IV, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | | | - Augusto Vaglio
- Nephrology Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - Paola Romagnani
- Nephrology Unit, Anna Meyer Children's Hospital, Florence, Italy
- Department of Clinical and Experimental Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
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12
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Casuscelli C, Longhitano E, Maressa V, Di Carlo S, Peritore L, Di Lorenzo S, Calabrese V, Cernaro V, Santoro D. Autoimmunity and Infection in Glomerular Disease. Microorganisms 2023; 11:2227. [PMID: 37764071 PMCID: PMC10538233 DOI: 10.3390/microorganisms11092227] [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: 07/26/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
The ongoing glomerular damage of infections is not limited to the most widely known form of post-streptococcal glomerulonephritis, which is today less common in the Western world; other forms of glomerulonephritis are associated with several bacterial, viral and parasitic pathogens. The mechanisms responsible range from the direct damage of glomerular cells to the formation and deposition of immunocomplexes to molecular mimicry to the secretion of superantigens. Similarly, in the course of glomerular disease, infections are more frequent than in the general population due to the loss of immunoglobulins in urine and the immunosuppressive agents used to treat the autoimmune disease that decrease the activity of the immune system. Recognizing this two-way link, understanding its pathogenetic mechanism, and identifying the most appropriate therapeutic choice are essential for the personalized management of patients. In this continuously developing field, this short review summarizes the current state of the art as support for physicians, who are increasingly involved in managing patients with glomerular disease and infections.
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Affiliation(s)
- Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino”, University of Messina, 98122 Messina, Italy; (E.L.); (V.M.); (S.D.C.); (L.P.); (S.D.L.); (V.C.); (V.C.)
| | | | | | | | | | | | | | | | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino”, University of Messina, 98122 Messina, Italy; (E.L.); (V.M.); (S.D.C.); (L.P.); (S.D.L.); (V.C.); (V.C.)
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13
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Angelousi A, Liapis G, Gazouli M, Kofotolios I, Sakellariou S, Boletis I, Marinaki S. Analysis of glucocorticoid receptor and microRNAs expression in pathological renal tissues. Mol Med Rep 2023; 28:169. [PMID: 37477126 PMCID: PMC10433714 DOI: 10.3892/mmr.2023.13056] [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: 12/10/2022] [Accepted: 05/15/2023] [Indexed: 07/22/2023] Open
Abstract
Glucocorticoid receptor (GR) is expressed in normal renal podocytes; however, its expression differs among renal diseases. The expression of GR as well as its epigenetic regulators microRNA (miR)30a, miR24 and miR370 was studied in the renal tissues of patients with systemic lupus nephritis (LN), minimal changes disease (MCD) and pauci-immune glumeronephritis (PIN). A total of 51 patients undergoing renal biopsy and 22 nephrectomised controls with no history of parenchymal renal disease were recruited from the Clinic of Nephrology and Renal Transplantation of General Laikon hospital between November 2016 and March 2019. All patients were newly-diagnosed and they were naïve of any treatment. The mRNA and protein expression were analyzed through reverse transcription-quantitative PCR and immunohistochemistry respectively. Written consent was obtained from all participants. GR mRNA expression was significantly reduced in all pathological samples compared with the 'normal' renal tissues used as controls (P=0.023 for LN, P=0.05 for MCD and P=0.004 for PIN). Similarly, GR protein expression was lower in all pathological samples (>6 GR positive podocytes/glomerulus in 50% of patients with LN and MCD and 18% with PIN) compared with controls (>6 positive podocytes/glomerulus in all the controls). PIN samples presented significantly lower GR mRNA and protein expression compared with LN and MCD samples. No significant differences were observed in the miR30a expression when comparing pathological with 'normal' renal samples. miR24 and miR370 expression demonstrated statistically significant difference in all pathological compared with 'normal' tissues. Moreover, GR expression was not significantly associated with either LN disease activity score or the response to the treatment. GR and miR24 expression was significantly reduced whereas miR370 significantly increased in all pathological compared with 'normal' renal tissues implying their protentional role in nephritis pathogenesis and treatment. Analysis of larger samples are required for more robust statistical analysis.
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Affiliation(s)
- Anna Angelousi
- 1st Department of Internal Medicine, Unit of Endocrinology, Laikon Hospital, 11527 Athens, Greece
| | - Georgios Liapis
- 1st Department of Pathology, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
| | - Maria Gazouli
- Laboratory of Biology, Department of Basic Medical Sciences, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Ioannis Kofotolios
- Department of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
| | - Stratigoula Sakellariou
- 1st Department of Pathology, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
| | - Ioannis Boletis
- Department of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
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Evangelista JE, Xie Z, Marino GB, Nguyen N, Clarke DB, Ma’ayan A. Enrichr-KG: bridging enrichment analysis across multiple libraries. Nucleic Acids Res 2023; 51:W168-W179. [PMID: 37166973 PMCID: PMC10320098 DOI: 10.1093/nar/gkad393] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/23/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023] Open
Abstract
Gene and protein set enrichment analysis is a critical step in the analysis of data collected from omics experiments. Enrichr is a popular gene set enrichment analysis web-server search engine that contains hundreds of thousands of annotated gene sets. While Enrichr has been useful in providing enrichment analysis with many gene set libraries from different categories, integrating enrichment results across libraries and domains of knowledge can further hypothesis generation. To this end, Enrichr-KG is a knowledge graph database and a web-server application that combines selected gene set libraries from Enrichr for integrative enrichment analysis and visualization. The enrichment results are presented as subgraphs made of nodes and links that connect genes to their enriched terms. In addition, users of Enrichr-KG can add gene-gene links, as well as predicted genes to the subgraphs. This graphical representation of cross-library results with enriched and predicted genes can illuminate hidden associations between genes and annotated enriched terms from across datasets and resources. Enrichr-KG currently serves 26 gene set libraries from different categories that include transcription, pathways, ontologies, diseases/drugs, and cell types. To demonstrate the utility of Enrichr-KG we provide several case studies. Enrichr-KG is freely available at: https://maayanlab.cloud/enrichr-kg.
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Affiliation(s)
- John Erol Evangelista
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Zhuorui Xie
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Giacomo B Marino
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Nhi Nguyen
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Daniel J B Clarke
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Avi Ma’ayan
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
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15
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Patel NJ, Jayne DRW, Merkel PA, Bekker P, Zhang Y, McDowell PJ, Johal J, Heaney LG, Murrell D, Stone MN, Yue H, Stone JH. The Glucocorticoid Toxicity Index-Metabolic Domains, an abridged version of the Glucocorticoid Toxicity Index: post-hoc analysis of data from the ADVOCATE trial. THE LANCET. RHEUMATOLOGY 2023; 5:e413-e421. [PMID: 38251552 DOI: 10.1016/s2665-9913(23)00131-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Quantifying glucocorticoid toxicity is crucial to efforts to reduce it. The Glucocorticoid Toxicity Index (GTI) measures toxicity effectively in clinical trials by calculating two scores: the cumulative worsening score (CWS) and the aggregate improvement score (AIS). However, in clinical practice, high patient volumes limit the time available for standardised assessments. We aimed to compare the GTI with an abbreviated version of the GTI, the GTI-Metabolic Domains (GTI-MD), which could help to address this issue by using data that are collected easily at routine visits and do not require additional effort from clinicians. METHODS We did a post-hoc analysis of data from ADVOCATE, a randomised, double-blind, double-dummy, phase 3 trial in which avacopan replaced a standard prednisone taper in patients with antineutrophil cytoplasmic antibody-associated vasculitis. We calculated the cumulative worsening score (CWS) and aggregate improvement score (AIS) for each domain of the GTI-MD-comprising the BMI, glucose tolerance, blood pressure, and lipid metabolism domains of the GTI-to test its ability to differentiate the avacopan and prednisone groups by glucocorticoid toxicity. Data from two additional disease cohorts, one comprising patients with asthma and the other comprising patients with autoimmune blistering disease, constituted the validation set. FINDINGS Complete data were available for 321 (97%) of the 330 participants comprising the intention-to-treat population in the ADVOCATE trial at week 13, and 307 (93%) at week 26; data from these individuals were included in our post-hoc analysis. In ADVOCATE, 98 (59%) of 166 participants in the avacopan group were men and 68 (41%) were women, 88 (54%) of 164 in the prednisone group were men and 76 (46%) were women; the mean age of participants was 61·2 years [SD 14·6] in the avacopan group and 60·5 years [14·5] in the prednisone group. The validation cohort included 159 patients (89 with glucocorticoid-dependent asthma, of whom 40 [45%] were men and 49 [55%] were women, and 70 with autoimmune blistering disease of the skin, of whom 30 [43%] were men and 40 [57%] were women). The Spearman's rank correlation coefficient in ADVOCATE for the GTI-MD CWS with the GTI CWS for the treatment groups combined was 0·78 (95% CI 0·75-0·81; p<0·0001). The corresponding correlation for the AIS was 0·73 (0·69-0·77, p<0·0001). The GTI-MD distinguished the groups by glucocorticoid toxicity at both 13 weeks and 26 weeks. The mean GTI-MD CWS was lower in the avacopan group than in the prednisone group, consistent with less toxicity (15·9 vs 23·0 at 13 weeks [p=0·0010]; 26·7 vs 31·7 at 26 weeks [p=0·0092]). The GTI-MD AIS values were also consistent with less toxicity in the avacopan group (2·5 vs 13·0 at 13 weeks [p=0·0003], 4·4 vs 10·1 at 26 weeks [p=0·027]). A GTI-MD score of 0 corresponded to a low likelihood of toxicity in the other GTI domains. In the validation set, the Spearman's rank correlation coefficient for the GTI-MD CWS with the GTI CWS was 0·61 (95% CI 0·50-0·70; p<0·0001) and the corresponding correlation for the AIS was 0·58 (0·47-0·68; p<0·0001). INTERPRETATION The GTI-MD correlates well with the full GTI and could be incorporated readily into routine clinic workflows without additional input from the clinician. Using the GTI-MD on the background of electronic medical records systems could help clinicians to monitor glucocorticoid toxicity longitudinally, with the goals of preventing the burden of chronic, treatment-related harms and reducing long-term costs to health systems. FUNDING ChemoCentryx.
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Affiliation(s)
- Naomi J Patel
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Yuqing Zhang
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - P Jane McDowell
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Joslin Johal
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Liam G Heaney
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Dedee Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | | | | | - John H Stone
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA.
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16
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Ai Z, Wang M, Zhou Y, Yuan D, Jian Q, Wu S, Liu B, Yang Y. Deciphering the pharmacological mechanisms of Rostellularia procumbens (L) Nees. Extract alleviates adriamycin-induced nephropathy in vivo and in vitro. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 113:154736. [PMID: 36907143 DOI: 10.1016/j.phymed.2023.154736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 02/09/2023] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Rostellularia procumbens (L) Nees. is an effective traditional Chinese herbal medicine for the treatment of patients with chronic glomerulonephritis (CGN) in the clinic. However, the underlying molecular mechanisms need further elucidation. PURPOSE This study aims to investigate the renoprotective mechanisms of n-butanol extract from Rostellularia procumbens (L) Nees. (J-NE) in vivo and in vitro. METHODS The components of J-NE were analyzed by UPLC-MS/MS. In vivo, the nephropathy model was induced in mice by tail vein injection with adriamycin (10 mg·kg-1), and mice were treated with vehicle or J-NE or benazepril by daily gavage. In vitro, MPC5 cells exposed to adriamycin (0.3 μg/ml) were treated with J-NE. The effects of J-NE inhibit podocyte apoptosis and protect against adriamycin-induced nephropathy were determined by Network pharmacology, RNA-seq, qPCR, ELISA, immunoblotting, flow cytometry, and TUNEL assay, according to the experimental protocols. RESULT The results showed that treatment significantly improved ADR-induced renal pathological changes, and the therapeutic mechanism of J-NE was related to the inhibition of podocyte apoptosis. Further molecular mechanism studies found that J-NE inhibited inflammation, increase the proteins expression levels of Nephrin and Podocin, reduce TRPC6 and Desmin expression levels and calcium ion levels in podocytes, and decrease the proteins expression levels of PI3K, p-PI3K, Akt and p-Akt to attenuated apoptosis. Furthermore, 38 compounds of J-NE were identified. CONCLUSION J-NE exerted the renoprotective effects by inhibiting podocyte apoptosis, which provides effective evidence for the treatment of J-NE targeting renal injury in CGN.
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Affiliation(s)
- Zhongzhu Ai
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China; Key Laboratory of Traditional Chinese Medicine Resources and Chemistry of Hubei Province, Wuhan 430065, China; Modern Engineering Research Center of Traditional Chinese Medicine and Ethnic Medicine of Hubei Province, Wuhan 430065, China
| | - Mengfan Wang
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China; Key Laboratory of Traditional Chinese Medicine Resources and Chemistry of Hubei Province, Wuhan 430065, China; Modern Engineering Research Center of Traditional Chinese Medicine and Ethnic Medicine of Hubei Province, Wuhan 430065, China
| | - Yi Zhou
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China
| | - Dongfeng Yuan
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China
| | - Qiuyuan Jian
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China
| | - Songtao Wu
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China
| | - Bo Liu
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China; Key Laboratory of Traditional Chinese Medicine Resources and Chemistry of Hubei Province, Wuhan 430065, China; Modern Engineering Research Center of Traditional Chinese Medicine and Ethnic Medicine of Hubei Province, Wuhan 430065, China
| | - Yanfang Yang
- Faculty of Pharmacy, Hubei University of Chinese Medicine, Wuhan 430065, China; Key Laboratory of Traditional Chinese Medicine Resources and Chemistry of Hubei Province, Wuhan 430065, China; Modern Engineering Research Center of Traditional Chinese Medicine and Ethnic Medicine of Hubei Province, Wuhan 430065, China.
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17
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Patel NJ, Jayne DRW, Merkel PA, Bekker P, Zhang Y, Yue H, Stone JH. Glucocorticoid Toxicity Index scores by domain in patients with antineutrophil cytoplasmic antibody-associated vasculitis treated with avacopan versus standard prednisone taper: post-hoc analysis of data from the ADVOCATE trial. THE LANCET. RHEUMATOLOGY 2023; 5:e130-e138. [PMID: 38251609 DOI: 10.1016/s2665-9913(23)00030-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND The ADVOCATE trial, in which the complement C5a receptor inhibitor avacopan was compared with a standard prednisone taper in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, used the Glucocorticoid Toxicity Index (GTI) to measure glucocorticoid toxicity change. We set out to do a post-hoc analysis of the ADVOCATE data to evaluate changes in individual GTI domains and their ability to differentiate treatment groups. METHODS The ADVOCATE trial was a phase 3, double-blind, double-dummy, randomised trial comparing oral avacopan (30 mg) twice daily for 52 weeks plus a prednisone-matching placebo for 20 weeks with oral prednisone tapered over 20 weeks plus an avacopan-matching placebo for 52 weeks in patients with ANCA-associated vasculitis. GTI data were collected within each of the included domains (BMI, blood pressure, glucose tolerance, lipid metabolism, glucocorticoid myopathy, skin toxicity, neuropsychiatric effects, and infections) at baseline, 13 weeks, and 26 weeks. In this post-hoc analysis, we calculated the cumulative worsening score (CWS) and aggregate improvement score (AIS) for each GTI domain, assessed to what extend each domain contributed to the GTI score, and which domains differentiated between the avacopan and prednisone groups. Differences in domain scores between the two groups were compared using Mantel-Haenszel χ2 tests. FINDINGS Among the 330 patients included in the intention-to-treat population of the ADVOCATE trial, 321 (97%) had complete data at week 13 (160 in the avacopan group, and 161 in the prednisone group), and 307 (93%) had complete data at week 26 (154 in the avacopan group, and 153 in the prednisone group) and were assessed in this post-hoc study. In ADVOCATE, mean age in both groups was 61 years (61·2 years [SD 14·6] in the avacopan group; 60·5 years [14·5] in the prednisone group); 98 (59%) of 166 patients in the avacopan group were men and 68 (41%) were women; 88 (54%) of 164 patients in the prednisone group were men and 76 (46%) were women. 278 (84%) of 330 patients were White. The mean glucocorticoid use over 26 weeks was lower in the avacopan group than the prednisone group (1073 mg [SD 1669] vs 3192 mg [1174]). Significantly less glucocorticoid toxicity was observed in the avacopan group than the prednisone group by week 13 in four domains of the GTI (BMI, glucose tolerance, lipid metabolism, and skin toxicity), based on both the CWS and AIS. CWS values in the BMI, lipid metabolism, and skin toxicity domains were significantly lower in the avacopan group than the prednisone group at 26 weeks. No domain favoured the prednisone group for glucocorticoid toxicity reduction. 280 (91%) of 307 patients had glucocorticoid toxicity at 26 weeks. Blood pressure (35% in the avacopan group vs 25% in the prednisone group), infection (22% vs 24%), and lipid metabolism (20% vs 15%) contributed the most weight toward CWS values at 26 weeks. 128 (42%) of 307 patients had combinations of improvement and worsening in different domains at 26 weeks. INTERPRETATION Replacing a standard prednisone taper with avacopan in patients with ANCA-associated vasculitis reduced glucocorticoid toxicity in multiple GTI domains. For individual patients, glucocorticoid toxicity was often nuanced, improving in some domains while worsening in others. These findings emphasise the value of a composite measure of glucocorticoid toxicity that quantifies cumulative worsening and aggregate change directly. FUNDING ChemoCentryx.
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Affiliation(s)
- Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | | | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA.
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18
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Ekrikpo U, Obiagwu P, Chika-Onu U, Yadla M, Karam S, Tannor EK, Bello AK, Okpechi IG. Epidemiology and Outcomes of Glomerular Diseases in Low- and Middle-Income Countries. Semin Nephrol 2023; 42:151316. [PMID: 36773418 DOI: 10.1016/j.semnephrol.2023.151316] [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: 02/11/2023]
Abstract
Glomerular diseases account for a significant proportion of chronic kidney disease in low-income and middle-income countries (LMICs). The epidemiology of glomerulonephritis is characterized inadequately in LMICs, largely owing to unavailable nephropathology services or uncertainty of the safety of the kidney biopsy procedure. In contrast to high-income countries where IgA nephropathy is the dominant primary glomerular disease, focal segmental glomerulosclerosis is common in large populations across Latin America, Africa, Middle East, and South East Asia, while IgA nephropathy is common in Chinese populations. Despite having a high prevalence of known genetic and viral risk factors that trigger focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis also is common in adults and children in some African countries. Treatment of glomerular diseases in adults and children in LMICs largely is dependent on corticosteroids in combination with other immunosuppressive therapy, which often is cyclophosphamide because of its ready availability and low cost of treatment, despite significant adverse effects. Partial and/or complete remission status reported from studies of glomerular disease subtypes vary across LMIC regions, with high rates of kidney failure, mortality, and disease, and treatment complications often reported. Improving the availability of nephropathology services and ensuring availability of specific therapies are key measures to improving glomerular disease outcomes in LMICs.
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Affiliation(s)
- Udeme Ekrikpo
- Department of Medicine, University of Uyo, Uyo, Nigeria
| | - Patience Obiagwu
- Department of Paediatrics, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ugochi Chika-Onu
- Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Manjusha Yadla
- Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India
| | - Sabine Karam
- Division of Nephrology, University of Minnesota, Minnesota, MN; Division of Nephrology, Faculty of Medicine and Medical Sciences, University of Balamand, Balamand, Lebanon
| | - Elliot K Tannor
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Canada; Division of Nephrology, University of Cape Town, Cape Town, South Africa.
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19
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Tang J, Wang Z. Genome wide analysis of dexamethasone stimulated mineralization in human dental pulp cells by RNA sequencing. J Gene Med 2023; 25:e3466. [PMID: 36464925 DOI: 10.1002/jgm.3466] [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: 10/26/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022] Open
Abstract
Human dental pulp cells (hDPCs) contain mesenchymal stem cells and are therefore indispensible for reparative dentin formation. Here, we present a pilot study of transcriptomic profiles of mineralized hDPCs isolated from sound human maxillary third molars. We observed altered gene expression of hDPCs between control (dexamethasone free) and experimental (dexamethasone 1 nm) groups. Differential expression analysis revealed up-regulation of several inflammation and mineralization-related genes in the experimental group. After a Gene Ontology analysis for predicting genes involved in biological process, cellular component and molecular function, we found enrichment of genes related to protein binding. Based on the results of Kyoto Encylopedia of Genes and Genomes pathway analysis, it is suggested up-regulated genes in mineralized hDPCs were mostly enriched in the mitogen-activated protein kinase (MAPK) signaling pathway, fluid shear stress and the atherosclerosis signaling pathway, etc. Importantly, Gene Set Enrichment Analysis revealed dexamethasone was positively related to the Janus kinase/signal transducer and activator of transcription, MAPK and Notch signaling pathway. Moreover, it was suggested that dexamethasone regulates signaling pathway in pluripotency of stem cells. Collectively, our work highlights transcriptome level gene regulation and intercellular interactions in mineralized hDPCs. The database produced in the present study paves the way for further investigations looking to explore genes that are involved in dental pulp cells mineralization.
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Affiliation(s)
- Jia Tang
- Shanghai Engineering Research Center of Tooth Restoration and Regeneration, School of Stomatology, Tongji University, Shanghai, China
| | - Zuolin Wang
- Shanghai Engineering Research Center of Tooth Restoration and Regeneration, School of Stomatology, Tongji University, Shanghai, China
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20
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Shah M, DeLaat A, Cavanaugh C. Treatment of membranous nephropathy: Perspectives on current and future therapies. FRONTIERS IN NEPHROLOGY 2023; 3:1110355. [PMID: 37675368 PMCID: PMC10479573 DOI: 10.3389/fneph.2023.1110355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/09/2023] [Indexed: 09/08/2023]
Abstract
Primary membranous nephropathy remains one of the most frequent causes of nephrotic syndrome in adults. It is an autoimmune disorder in which auto-antibodies target antigens at the podocytes cell membrane-basement membrane interface. Our understanding of membranous nephropathy has expanded dramatically as of late. After the initial discovery of the phospholipase A2 receptor auto-antibody in 2009, eight more antigens have been discovered. These discoveries have led to refinement in our understanding of the pathogenesis, diagnosis, and natural history of primary membranous nephropathy. Now, many experts advocate for redefining primary membranous nephropathy based on antigen, potentially shedding the primary and secondary nomenclature. Recently, therapies for primary membranous have also expanded. Immunosuppressive therapies like cyclophosphamide and rituximab, which primarily target B-cells, remain the cornerstone of therapy. However, there is still significant room for improvement, as many as 30-40% do not respond to this therapy according to recent trials. Additionally, drugs targeting complement, and other novel therapies are also under investigation. In this review we will discuss the available therapies for primary membranous nephropathy in light of recent clinic trials like GEMRITUX, MENTOR, RI-CYCLO, and STARMEN, as well as management strategies. While the last 10 years have seen a boom in our mechanistic understanding of this ever-diversifying disease, we are likely to see a similar boom in the therapeutic options in the years to come.
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Affiliation(s)
- Monarch Shah
- Division of Nephrology, University of Virginia, Charlottesville, VA, United States
| | - Andrew DeLaat
- Liberty University College of Osteopathic Medicine, Lynchburg, VA, United States
| | - Corey Cavanaugh
- Division of Nephrology, University of Virginia, Charlottesville, VA, United States
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21
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Riedel JH, Robben L, Paust HJ, Zhao Y, Asada N, Song N, Peters A, Kaffke A, Borchers A, Tiegs G, Seifert L, Tomas NM, Hoxha E, Wenzel UO, Huber TB, Wiech T, Turner JE, Krebs CF, Panzer U. Glucocorticoids target the CXCL9/CXCL10-CXCR3 axis and confer protection against immune-mediated kidney injury. JCI Insight 2023; 8:160251. [PMID: 36355429 PMCID: PMC9870076 DOI: 10.1172/jci.insight.160251] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 11/09/2022] [Indexed: 11/12/2022] Open
Abstract
Glucocorticoids remain a cornerstone of therapeutic regimes for autoimmune and chronic inflammatory diseases - for example, in different forms of crescentic glomerulonephritis - because of their rapid antiinflammatory effects, low cost, and wide availability. Despite their routine use for decades, the underlying cellular mechanisms by which steroids exert their therapeutic effects need to be fully elucidated. Here, we demonstrate that high-dose steroid treatment rapidly reduced the number of proinflammatory CXCR3+CD4+ T cells in the kidney by combining high-dimensional single-cell and morphological analyses of kidney biopsies from patients with antineutrophil cytoplasmic antibody-associated (ANCA-associated) crescentic glomerulonephritis. Using an experimental model of crescentic glomerulonephritis, we show that the steroid-induced decrease in renal CD4+ T cells is a consequence of reduced T cell recruitment, which is associated with an ameliorated disease course. Mechanistic in vivo and in vitro studies revealed that steroids act directly on renal tissue cells, such as tubular epithelial cells, but not on T cells, which resulted in an abolished renal expression of CXCL9 and CXCL10 as well as in the prevention of CXCR3+CD4+ T cell recruitment to the inflamed kidneys. Thus, we identified the CXCL9/CXCL10-CXCR3 axis as a previously unrecognized cellular and molecular target of glucocorticoids providing protection from immune-mediated pathology.
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Affiliation(s)
- Jan-Hendrik Riedel
- Division of Translational Immunology, III. Department of Medicine and,III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Robben
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Yu Zhao
- Division of Translational Immunology, III. Department of Medicine and,Institute of Medical Systems Biology, Center for Molecular Neurobiology Hamburg (ZMNH), Hamburg, Germany
| | - Nariaki Asada
- Division of Translational Immunology, III. Department of Medicine and
| | - Ning Song
- Division of Translational Immunology, III. Department of Medicine and
| | - Anett Peters
- Division of Translational Immunology, III. Department of Medicine and
| | - Anna Kaffke
- Division of Translational Immunology, III. Department of Medicine and
| | - Alina Borchers
- Division of Translational Immunology, III. Department of Medicine and
| | - Gisa Tiegs
- Institute of Experimental Immunology and Hepatology,,Institute of Pathology, Section of Nephropathology, and
| | - Larissa Seifert
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicola M. Tomas
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute of Pathology, Section of Nephropathology, and
| | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich O. Wenzel
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias B. Huber
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jan-Eric Turner
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian F. Krebs
- Division of Translational Immunology, III. Department of Medicine and,III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Panzer
- Division of Translational Immunology, III. Department of Medicine and,III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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22
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Flores VAG, Chicano S, Resontoc LP, Aragon EE. Diffuse proliferative glomerulonephritis in a patient with COVID-19 infection. BMJ Case Rep 2023; 16:16/1/e251962. [PMID: 36604108 PMCID: PMC9827186 DOI: 10.1136/bcr-2022-251962] [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: 01/07/2023] Open
Abstract
COVID-19 primarily presents with respiratory involvement. Extrapulmonary manifestations as the sole manifestation also occur although rare. The kidney, being one of the organs with the greatest number of ACE receptors, is usually reported as part of multiorgan involvement. We report an early adolescent boy who presented with nephrotic-nephritic syndrome with severe kidney dysfunction from COVID-19 infection. He had low C3 and undetected antineutrophil cytoplasmic antibodies, antinuclear antibody and antistreptolysin O. Kidney biopsy revealed findings consistent with diffuse proliferative glomerulonephritis with a focal glomerular crescent formation and thin basement nephropathy. Due to the rapidly progressive deterioration of kidney function, he was given pulse methylprednisolone therapy followed by oral prednisone. Complete recovery was documented 12 weeks after the onset of post-infectious glomerulonephritis. The possible pathogenesis of glomerulonephritis in a patient with COVID-19, its differential diagnosis and treatment are discussed.
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Affiliation(s)
- Vincent Albert Galvez Flores
- Department of Pediatrics, Division of Pediatric Nephrology, University of the Philippines Manila, Manila, Philippines
| | - Sonia Chicano
- Department of Laboratory Medicine, National Kidney and Transplant Institute, Quezon City, Philippines
| | - Lourdes Paula Resontoc
- Department of Pediatrics, Division of Pediatric Nephrology, University of the Philippines Manila, Manila, Philippines
| | - Eric Emmanuel Aragon
- Department of Pediatrics, Division of Pediatric Nephrology, University of the Philippines Manila, Manila, Philippines
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23
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Dall’Era M, Kalunian K, Eaddy M, Ogbonnaya A, Farrelly E, Turowski E, Birardi V, Solomons N, Randhawa S, Mina-Osorio P. Real-world treatment utilization and economic implications of lupus nephritis disease activity in the United States. J Manag Care Spec Pharm 2023; 29:36-45. [PMID: 36190835 PMCID: PMC10657222 DOI: 10.18553/jmcp.2022.21496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND: Lupus nephritis (LN) is a common and severe complication of systemic lupus erythematosus (SLE), with approximately 40% of patients with SLE developing LN. Even with treatment, 10%-30% of patients will progress to end-stage renal disease (ESRD). Although many studies have assessed the clinical value of low disease activity in LN, the economic implications are less defined. OBJECTIVE: To evaluate treatment utilization and health care costs associated with active disease, low disease activity, and ESRD in patients with LN. METHODS: A retrospective analysis of Optum pharmacy and medical claims data from 2015 to 2019 was performed and included patients with a diagnosis of SLE (International Classification of Diseases, Ninth Revision or Tenth Revision codes 710.0 or M32, respectively) and additional prespecified criteria for LN. Total health care payer costs for medical and pharmacy services and treatment utilization for commonly prescribed medications were determined for periods of low disease activity, active disease, or ESRD. RESULTS: A total of 21,251 patients (mean age 60.3 years; 87% female; 55% White patients and 18% Black patients) with a mean follow-up period of 30.6 months were included; the majority of patients had active disease (67.3%), followed by low disease activity (51.3%), and ESRD (10.5%). Glucocorticoids were used 2 times more often and mycophenolate mofetil was used 4 times more often in patients with active disease vs low disease activity. Glucocorticoids, mycophenolate mofetil, and tacrolimus were more commonly used in patients with ESRD vs those with low disease activity. Mean medical costs were $4,777 per month in active disease and $18,084 per month in ESRD vs $2,523 per month in low disease activity. CONCLUSIONS: Treatment burden and costs are high for patients with active disease and ESRD in LN. Treatments that allow patients to achieve and maintain low disease activity may help improve patient outcomes and reduce medication use and overall health care costs. DISCLOSURES: Maria Dall'Era and Kenneth Kalunian are consultants of Aurinia Pharmaceuticals. Eric Turowski, Vanessa Birardi, Neil Solomons, Simrat Randhawa, and Paola Mina-Osorio are employees and stockholders of Aurinia Pharmaceuticals. Michael Eaddy is a former employee of Xcenda, LLC. Augustina Ogbonnaya and Eileen Farrelly are employees of Xcenda, LLC, which was contracted by Aurinia Pharmaceuticals to assist in the conduct of this study and the writing of this manuscript. Aurinia Pharmaceuticals provided funding for this study and the preparation of the manuscript. Aurinia Pharmaceuticals had a role in writing the report and decision to submit for publication.
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Affiliation(s)
- Maria Dall’Era
- Division of Rheumatology, Department of Medicine, School of Medicine, University of California, San Francisco
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy, and Immunology, School of Medicine, University of California, San Diego, La Jolla
| | - Michael Eaddy
- Xcenda, LLC, Carrollton, TX
- Abbvie, North Chicago, IL
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24
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Fu B, Shang Z, Song S, Xu Y, Wei L, Li G, Yang H. Adverse reactions of Niaoduqing granules: A systematic review and meta-analysis. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 109:154535. [PMID: 36610168 DOI: 10.1016/j.phymed.2022.154535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/14/2022] [Accepted: 11/01/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The therapeutic benefits of Niaoduqing granules (NDQG) in kidney diseases has been comprehensively studied, but its adverse drug reactions remain unexplored. OBJECTIVE To evaluate the safety of NDQG in kidney disease treatment. METHODS The literature was searched in Embase, Medline via PubMed, Cochrane Library database, Wanfang database, Chinese National Knowledge Infrastructure, SinoMed, and Chinese VIP Database from inception to January 15, 2022, for randomized controlled trials (RCTs) and observational studies. The ClinicalTrials.gov website was searched for ongoing trials. The frequency and characteristics of adverse drug reactions (ADRs) were the primary and secondary outcomes, respectively. Subgroup analysis were conducted to explore the effects of clinical trial types, different kidney diseases, drug combinations and dosage on the safety of NDQG. RESULTS This review included 132 trials comprising 115 RCTs and 17 cohort studies. Additionally, 118 studies reported ADR rates with complete data, including 10381 participants. Regarding ADR frequency, no significant difference was observed between NDQG (7.26%) and control (8.39%) groups (RR = 0.890, 95% confidence interval (CI): 0.788-1.007); with no heterogeneity among the studies (I2 = 0.0%, P = 0.958). ADR frequency in patients with chronic kidney disease (65 trials, n = 5823) was significantly lower in the NDQG treatment group than in the control group (RR = 0.810, 95% CI: 0.67-0.969, I2 = 0.0%, P = 0.993); however, for patients with diabetic nephropathy there was no difference between both groups (26 trials, n = 2166, RR = 1.077, 95% CI: 0.802-1.446, I2 = 0.0%, P = 0.611). Similarly, the incidence of ADR in patients on dialysis and patients with pyelonephritis and nephrotic syndrome was the same for both groups, with 95% CI overlapping the line. For different interventions, including NDQG monotherapy or its combination with other commonly used drugs (including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statin drugs, and compound α-keto acid) or dialysis, the incidence of ADR showed no significant difference between the experimental and control arms. The ADR in the NDQG group primarily affected the gastrointestinal system (64.74%), central and peripheral nervous system (9.07%), whole body (5.79%), and skin and appendages (4.53%). The most common clinical manifestations were diarrhea, nausea, and vomiting. CONCLUSIONS Our meta-analysis showed that compared with supportive therapy, the incidence of ADR was similar when NDQG was added. However, current evidence is not definitive and more well-designed and conducted RCTs are warranted to definitively establish the reliable evidence. PROTOCOL REGISTRATION NUMBER PROSPERO CRD 42018104227.
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Affiliation(s)
- Baohui Fu
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zongjie Shang
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Simian Song
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yupei Xu
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Lijuan Wei
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ge Li
- Public Health Science and Engineering College, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Hongtao Yang
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.
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25
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Zhao Q, Dai H, Hu Y, Jiang H, Feng Z, Liu W, Dong Z, Tang X, Hou F, Rui H, Liu B. Cytokines network in primary membranous nephropathy. Int Immunopharmacol 2022; 113:109412. [DOI: 10.1016/j.intimp.2022.109412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022]
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26
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Zhang X, Wang G, Shen D, Feng Y, Zhang Y, Zhang C, Li Y, Liao H. Protective effects of budesonide on LPS‑induced podocyte injury by modulating macrophage M1/M2 polarization: Evidence from in vitro and in silico studies. Exp Ther Med 2022; 24:589. [PMID: 35949344 PMCID: PMC9353530 DOI: 10.3892/etm.2022.11526] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/21/2022] [Indexed: 11/05/2022] Open
Abstract
Budesonide (Bud), one of the most widely used lung medicines, is currently used as a repurposing medicine for immunoglobulin A nephropathy (IgAN) treatment. The progression of IgAN is related to inflammation involving macrophages and podocytes. The present study aimed to explore the effects of Bud on classically activated (M1)/alternatively activated (M2) macrophage polarization and podocyte injury under lipopolysaccharide (LPS)-induced inflammatory stress in vitro. Anti-inflammatory bioinformation of Bud was identified based on the Gene Expression Omnibus database. RAW264.7 cells were treated with normal medium, LPS, curcumin (Cur, positive control), or Bud 5, 10, or 20 µM. The expression levels of inducible nitric oxide synthase (iNOS), TNF-α, mannose receptor (CD206) and arginase (Arg)-1 were quantified by western blotting. The collected supernatants from macrophages were termed (Nor)MS, (LPS)MS, (Cur)MS and (Bud)MS. The TNF-α, IL-1β and nitric oxide (NO) levels in the supernatants were evaluated by ELISA and Griess assay. The podocytes were cultured in different supernatants and their survival rates were assessed by bromodeoxyuridine assay. TNF signaling is an important pathway by which Bud exerts anti-inflammatory activities. Compared with the LPS group, 5, 10 and 20 µM Bud significantly increased Arg-1 and decreased iNOS expression (Six: P<0.05) and 20 µM Bud significantly increased Arg-1 and CD206 and decreased iNOS and TNF-α expression (Four: P<0.05). Cur significantly decreased iNOS and TNF-α expression (Two: P<0.05). Compared with LPS, 5, 10 and 20 µM Bud and Cur significantly decreased TNF-α, IL-1β and NO levels (All: P<0.05). The podocyte survival rates of (Bud)MS and (Cur)MS were significantly higher than those of (LPS)MS (Four: P<0.05). The protective effect of Bud on podocyte injury is related to its modulation of M1/M2 polarization.
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Affiliation(s)
- Xilan Zhang
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Guangying Wang
- Department of Pharmacy, Fifth Hospital of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, Shanxi 030012, P.R. China
| | - Dayue Shen
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Yating Feng
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Yan Zhang
- Department of Nephrology, Fifth Hospital of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, Shanxi 030012, P.R. China
| | - Chao Zhang
- Department of Nephrology, Fifth Hospital of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, Shanxi 030012, P.R. China
| | - Yuanping Li
- Department of Pharmacy , Fifth Hospital of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, Shanxi 030012, P.R. China
| | - Hui Liao
- Departments of Pharmacy, Fifth Hospital of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, Shanxi 030012, P.R. China
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27
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How immunosuppressive drugs may directly target podocytes in glomerular diseases. Pediatr Nephrol 2022; 37:1431-1441. [PMID: 34244853 DOI: 10.1007/s00467-021-05196-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
Podocytes are the direct target of immunologic injury in many immune-mediated glomerular diseases, leading to proteinuria and subsequent kidney failure. Immunosuppressive agents such as steroids, calcineurin inhibitors, and rituximab are the commonly used treatment strategies in this context for their immunotherapeutic or anti-inflammatory properties. However, in recent years, studies have demonstrated that immunosuppressive agents can have a direct effect on podocytes, introducing the concept of the non-immunologic mechanism of kidney protection by immunomodulators. In this review, we focus on the mechanisms by which these agents may directly target the podocyte independent of their systemic effects and examine their clinical significance.
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28
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Tang TT, Wang B, Lv LL, Dong Z, Liu BC. Extracellular vesicles for renal therapeutics: State of the art and future perspective. J Control Release 2022; 349:32-50. [PMID: 35779658 DOI: 10.1016/j.jconrel.2022.06.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/21/2022]
Abstract
With the ever-increasing burden of kidney disease, the need for developing new therapeutics to manage this disease has never been greater. Extracellular vesicles (EVs) are natural membranous nanoparticles present in virtually all organisms. Given their excellent delivery capacity in the body, EVs have emerged as a frontier technology for drug delivery and have the potential to usher in a new era of nanomedicine for kidney disease. This review is focused on why EVs are such compelling drug carriers and how to release their fullest potentiality in renal therapeutics. We discuss the unique features of EVs compared to artificial nanoparticles and outline the engineering technologies and steps in developing EV-based therapeutics, with an emphasis on the emerging approaches to target renal cells and prolong kidney retention. We also explore the applications of EVs as natural therapeutics or as drug carriers in the treatment of renal disorders and present our views on the critical challenges in manufacturing EVs as next-generation renal therapeutics.
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Affiliation(s)
- Tao-Tao Tang
- Institute of Nephrology, Zhong Da Hospital, Nanjing, China; Department of Pathology and Pathophysiology, Southeast University School of Medicine, Nanjing, China
| | - Bin Wang
- Institute of Nephrology, Zhong Da Hospital, Nanjing, China
| | - Lin-Li Lv
- Institute of Nephrology, Zhong Da Hospital, Nanjing, China.
| | - Zheng Dong
- Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhong Da Hospital, Nanjing, China.
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29
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Riella LV, Cravedi P. Kidney immunology: embracing the complexity to advance the field. Clin Kidney J 2022; 15:366-367. [PMID: 35145653 PMCID: PMC8824824 DOI: 10.1093/ckj/sfab222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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30
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Luan ZL, Zhang C, Ming WH, Huang YZ, Guan YF, Zhang XY. Nuclear receptors in renal health and disease. EBioMedicine 2022; 76:103855. [PMID: 35123268 PMCID: PMC8819107 DOI: 10.1016/j.ebiom.2022.103855] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/31/2021] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
As a major social and economic burden for the healthcare system, kidney diseases contribute to the constant increase of worldwide deaths. A deeper understanding of the underlying mechanisms governing the etiology, development and progression of kidney diseases may help to identify potential therapeutic targets. As a superfamily of ligand-dependent transcription factors, nuclear receptors (NRs) are critical for the maintenance of normal renal function and their dysfunction is associated with a variety of kidney diseases. Increasing evidence suggests that ligands for NRs protect patients from renal ischemia/reperfusion (I/R) injury, drug-induced acute kidney injury (AKI), diabetic nephropathy (DN), renal fibrosis and kidney cancers. In the past decade, some breakthroughs have been made for the translation of NR ligands into clinical use. This review summarizes the current understanding of several important NRs in renal physiology and pathophysiology and discusses recent findings and applications of NR ligands in the management of kidney diseases.
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Affiliation(s)
- Zhi-Lin Luan
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Dalian Medical University, Dalian 116044, China; Dalian Key Laboratory for Nuclear Receptors in Major Metabolic Diseases, Dalian, Liaoning 116044, China
| | - Cong Zhang
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China
| | - Wen-Hua Ming
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China
| | - Ying-Zhi Huang
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China
| | - You-Fei Guan
- Advanced Institute for Medical Sciences, Dalian Medical University, Dalian 116044, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Dalian Medical University, Dalian 116044, China; Dalian Key Laboratory for Nuclear Receptors in Major Metabolic Diseases, Dalian, Liaoning 116044, China.
| | - Xiao-Yan Zhang
- Health Science Center, East China Normal University, Shanghai 200241, China.
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31
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Tan XY, Jing HY, Ma YR. Interleukin-33/ Suppression of Tumorigenicity 2 in Renal Fibrosis: Emerging Roles in Prognosis and Treatment. Front Physiol 2022; 12:792897. [PMID: 35046838 PMCID: PMC8761767 DOI: 10.3389/fphys.2021.792897] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/02/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) is a major public health problem that affects more than 10% of the population worldwide and has a high mortality rate. Therefore, it is necessary to identify novel treatment strategies for CKD. Incidentally, renal fibrosis plays a central role in the progression of CKD to end-stage renal disease (ESRD). The activation of inflammatory pathways leads to the development of renal fibrosis. In fact, interleukin-33 (IL-33), a newly discovered member of the interleukin 1 (IL-1) cytokine family, is a crucial regulator of the inflammatory process. It exerts pro-inflammatory and pro-fibrotic effects via the suppression of tumorigenicity 2 (ST2) receptor, which, in turn, activates other inflammatory pathways. Although the role of this pathway in cardiac, pulmonary, and hepatic fibrotic diseases has been extensively studied, its precise role in renal fibrosis has not yet been completely elucidated. Recent studies have shown that a sustained activation of IL-33/ST2 pathway promotes the development of renal fibrosis. However, with prolonged research in this field, it is expected that the IL-33/ST2 pathway will be used as a diagnostic and prognostic tool for renal diseases. In addition, the IL-33/ST2 pathway seems to be a new target for the future treatment of CKD. Here, we review the mechanisms and potential applications of the IL-33/ST2 pathway in renal fibrosis; such that it can help clinicians and researchers to explore effective treatment options and develop novel medicines for CKD patients.
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Affiliation(s)
- Xiao-Yang Tan
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hao-Yue Jing
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yue-Rong Ma
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Jiang Y, Gen N, Wang P, Feng N, Lu X. Prednisolone induces sleep disorders via inhibition of melatonin secretion by the circadian rhythm in zebrafish. Pharmacotherapy 2022; 147:112590. [PMID: 35007999 DOI: 10.1016/j.biopha.2021.112590] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/02/2022]
Abstract
Prednisolone (PN) is a glucocorticoid (GC) analog that is clinically used to treat allergic inflammation and autoimmune diseases. However, the long-term use of GC-like drugs results in many side effects, among which sleep disorders caused by PN have attracted much attention. Many studies have showed that GCs indirectly cause sleep disorders by disrupting the circadian rhythm of the peripheral biological clock. However, the detailed mechanism of this effect in zebrafish remains unclear. In the present study, we aimed to study the pharmacology and toxicology of PN by analyzing the sleep phenotype and internal circadian oscillation of zebrafish. Exposure of zebrafish to PN resulted in decreased melatonin secretion and shortened sleep time. Additionally, analysis of the internal circadian rhythm of the zebrafish revealed that the expression of per and cry was significantly upregulated, resulting in a significant delay in the phase of the zebrafish behavioral rhythm. A dual-luciferase reporter assay further revealed that PN repressed per2 and cry1aa expression via the GC receptor (GR), which inhibited aanat2 expression. This caused a decrease in melatonin secretion and led to sleep disorders. The findings of this study highlight the mechanisms underlying the effects of GCs on sleep.
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Affiliation(s)
- Yu Jiang
- Department of Orthopedics, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214000, China
| | - Nan Gen
- Department of TeZhen, Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China; Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical University, Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Peisong Wang
- Department of Cardiac Surgery, DongE Hospital, 275 Shuguang Road, DongE County, Liaocheng City, Shandong Province 252200, China
| | - Ninghang Feng
- The Affiliated Wuxi Clinical College of Nantong University, Jiangsu 214000, China.
| | - Xiaojie Lu
- Department of Orthopedics, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214000, China.
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Role of Endothelial Glucocorticoid Receptor in the Pathogenesis of Kidney Diseases. Int J Mol Sci 2021; 22:ijms222413295. [PMID: 34948091 PMCID: PMC8706765 DOI: 10.3390/ijms222413295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 01/12/2023] Open
Abstract
Glucocorticoids, as multifunctional hormones, are widely used in the treatment of various diseases including nephrological disorders. They are known to affect immunological cells, effectively treating many autoimmune and inflammatory processes. Furthermore, there is a growing body of evidence demonstrating the potent role of glucocorticoids in non-immune cells such as podocytes. Moreover, novel data show additional pathways and processes affected by glucocorticoids, such as the Wnt pathway or autophagy. The endothelium is currently considered as a key organ in the regulation of numerous kidney functions such as glomerular filtration, vascular tone and the regulation of inflammation and coagulation. In this review, we analyse the literature concerning the effects of endothelial glucocorticoid receptor signalling on kidney function in health and disease, with special focus on hypertension, diabetic kidney disease, glomerulopathies and chronic kidney disease. Recent studies demonstrate the potential role of endothelial GR in the prevention of fibrosis of kidney tissue and cell metabolism through Wnt pathways, which could have a protective effect against disease progression. Another important aspect covered in this review is blood pressure regulation though GR and eNOS. We also briefly cover potential therapies that might affect the endothelial glucocorticoid receptor and its possible clinical implications, with special interest in selective or local GR stimulation and potential mitigation of GC treatment side effects.
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Zhang Z, Ran Y, Xu L, Pan Z, Xie Y. High-dose dexamethasone injection disordered metabolism and multiple protein kinases expression in the mouse kidney. Biosci Rep 2021; 41:BSR20211847. [PMID: 34735568 PMCID: PMC8607334 DOI: 10.1042/bsr20211847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/08/2021] [Accepted: 10/27/2021] [Indexed: 12/05/2022] Open
Abstract
Glucocorticoids (GCs) have been widely used in clinical treatment as anti-inflammatory, anti-shock and immunosuppressive medicines. However, the effect of excessive GCs on immune response and metabolism of kidney remains unclear. Here, we profiled the gene expression of kidney from mice with high-dose dexamethasone (DEX) treatment. A total of 1193 differentially expressed genes (DEGs) were screened in DEX treatment group compared with the saline group, including 715 down- regulated and 478 up-regulated. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses of these DEGs showed extracellular matrix (ECM)-receptor interaction, cell adhesion molecules signaling pathway were significantly enriched, and that the vast majority of DEGs were involved in monocarboxylic acid metabolism, leukocyte cell-cell adhesion and fatty acid metabolism. Gene set enrichment analysis (GSEA) revealed that DEGs were strongly associated with immune-response and cell adhesion gene sets, such as Fc γ R-mediated phagocytosis, leukocyte transendothelial migration, T-cell receptor signaling pathway, cell adhesion, ECM-receptor interaction and focal adhesion-associated pathways. KEGG pathway analysis of differentially expressed kinases (DEKs) showed T-cell receptor and forkhead box class O signaling pathway were enriched. Furthermore, we found multiple protein kinases expression were dysregulated greatly after dexamethasone treatment, including classical effector of GCs stimulation-serum and GC-regulated kinase. These protein kinases are involved in multiple signaling pathways in mice kidney, such as mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K)/Akt signaling pathway. We profiled the gene expression of the kidney from high-dose dexamethasone-treated mice and provided important information for further study the mechanism of side effects of GCs in clinical therapy.
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Affiliation(s)
- Zaikuan Zhang
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, P.R. China
| | - Yingchun Ran
- Department of Emergency Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, P.R. China
| | - Lei Xu
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, P.R. China
| | - Zheng Pan
- The College of Traditional Chinese Medicine, Chongqing Medical University, Chongqing 400016, P.R. China
| | - Yajun Xie
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, P.R. China
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Al Mushafi A, Ooi JD, Odobasic D. Crescentic Glomerulonephritis: Pathogenesis and Therapeutic Potential of Human Amniotic Stem Cells. Front Physiol 2021; 12:724186. [PMID: 34721059 PMCID: PMC8554237 DOI: 10.3389/fphys.2021.724186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/24/2021] [Indexed: 12/15/2022] Open
Abstract
Chronic kidney disease (CKD) leads to significant morbidity and mortality worldwide. Glomerulonephritis (GN) is the second leading cause of CKD resulting in end stage renal failure. The most severe and rapidly progressive type of GN is characterized by glomerular crescent formation. The current therapies for crescentic GN, which consist of broad immunosuppressive drugs, are partially effective, non-specific, toxic and cause many serious side effects including infections, cancer, and cardiovascular problems. Therefore, new and safer therapies are needed. Human amniotic epithelial cells (hAECs) are a type of stem cell which are isolated from the placenta after birth. They represent an attractive and novel therapeutic option for the treatment of various inflammatory conditions owing to their unique and selective immunosuppressive ability, as well as their excellent safety profile and clinical applicability. In this review, we will discuss the immunopathogenesis of crescentic GN, issues with currently available treatments and how hAECs offer potential to become a new and harmless treatment option for this condition.
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Affiliation(s)
- Ahmed Al Mushafi
- Department of Medicine, Monash Medical Centre, Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Joshua D Ooi
- Department of Medicine, Monash Medical Centre, Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Dragana Odobasic
- Department of Medicine, Monash Medical Centre, Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
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Yeaman MR. Immunosuppression in Glomerular Diseases: Implications for SARS-CoV-2 Vaccines and COVID-19. GLOMERULAR DISEASES 2021; 1:277-293. [PMID: 34935004 PMCID: PMC8678218 DOI: 10.1159/000519182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Glomerular diseases (GD) are chronic conditions that often involve immune dysfunction and require immunosuppressive therapy (IST) to control underlying pathogenesis. Unfortunately, such diseases appear to heighten risks of severe outcomes in COVID-19 and predispose to other infections that may be life-threatening. Thus, averting preventable infections is imperative in GD patients. SUMMARY The advent of vaccines demonstrated to be safe and efficacious against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has favorably impacted the COVID-19 pandemic epidemiology. However, patients on ISTs were excluded from initial vaccine clinical trials. Thus, only limited and incomplete data are available currently regarding the potential impact of immunosuppression on immune response to or efficacy of the SARS-CoV-2 vaccines. However, new insights are emerging from SARS-CoV-2 vaccine studies, and impacts of ISTs on conventional vaccines are useful to consider. Mechanisms of immunosuppressive agents commonly used in the treatment of GD are reviewed with respect to implications for immune responses induced by SARS-CoV-2 vaccines. ISTs discussed include corticosteroids; alkylating agents; antimetabolites; calcineurin or mammalian target of rapamycin inhibitors; CD38+, CD20+, or CD19+ cell depletion; and complement protein C5 inhibition. KEY MESSAGES Many immunosuppressive therapies may potentially attenuate or impair protective immunity of the SARS-CoV-2 vaccines. However, as vaccines currently in use employ mRNA or nonreplicative viral vectors, they appear to be safe in patients on immunosuppression, further favoring vaccination. Moreover, predominant SARS-CoV-2 vaccines are likely to afford at least partial protective immunity through one or more immune mechanisms even in patients on IST. Guidelines and emerging strategies are also considered to optimize vaccine protection from COVID-19.
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Affiliation(s)
- Michael R. Yeaman
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Divisions of Molecular Medicine & Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
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Ponticelli C, Patrizia P, Del Vecchio L, Locatelli F. The evolution of the therapeutic approach to membranous nephropathy. Nephrol Dial Transplant 2021; 36:768-773. [PMID: 32206786 DOI: 10.1093/ndt/gfaa014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/12/2023] Open
Abstract
Primary membranous nephropathy (MN) is a frequent cause of nephrotic syndrome (NS) in adults. In untreated patients, the outcome is variable, with one-third of the patients entering remission while the remaining ones show persisting proteinuria or progression to end-stage renal disease. Randomized clinical trials reported the efficacy of a 6-month regimen alternating intravenous and oral glucocorticoids with an alkylating agent every other month. The potential side effects of this regimen were limited by the fact that the use of glucocorticoids and alkylating agent did not exceed 3 months each. Two randomized trials with follow-ups (FU) up to 10 years provided assurance about the long-term efficacy and safety of this cyclical therapy. Calcineurin inhibitors have also been used successfully. However, in most responders, NS relapsed after the drug was withdrawn. Conflicting results have been reported with mycophenolate salts and adrenocorticotropic hormone. Observational studies reported good results with rituximab (RTX). Two controlled trials demonstrated the superiority of RTX over antiproteinuric therapy alone and cyclosporine. However, the FUs were relatively short and no randomized trial has been published against cyclical therapy. The available results, together with the discovery that most patients with MN have circulating antibodies against the phospholipase A2 receptor 1, support the use of cytotoxic drugs or RTX in MN. It is difficult to choose between these two different treatments. RTX is easier to use, but the FUs of the available studies are short, thus doubts remain about the long-term risk of relapses and the safety of repeated administrations of RTX.
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Affiliation(s)
| | - Passerini Patrizia
- Nephrology, Dialysis and Renal Transplant Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Francesco Locatelli
- Past Director, Department of Nephrology and Dialysis, ASST Lecco, Lecco, Italy
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Imeri F, Stepanovska Tanturovska B, Schwalm S, Saha S, Zeng-Brouwers J, Pavenstädt H, Pfeilschifter J, Schaefer L, Huwiler A. Loss of sphingosine kinase 2 enhances Wilm's tumor suppressor gene 1 and nephrin expression in podocytes and protects from streptozotocin-induced podocytopathy and albuminuria in mice. Matrix Biol 2021; 98:32-48. [PMID: 34015468 DOI: 10.1016/j.matbio.2021.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 12/11/2022]
Abstract
The sphingosine 1-phosphate (S1P) is a bioactive sphingolipid that is now appreciated as key regulatory factor for various cellular functions in the kidney, including matrix remodeling. It is generated by two sphingosine kinases (Sphk), Sphk1 and Sphk2, which are ubiquitously expressed, but have distinct enzymatic activities and subcellular localizations. In this study, we have investigated the role of Sphk2 in podocyte function and its contribution to diabetic nephropathy. We show that streptozotocin (STZ)-induced nephropathy and albuminuria in mice is prevented by genetic depletion of Sphk2. This protection correlated with an increased protein expression of the transcription factor Wilm's tumor suppressor gene 1 (WT1) and its target gene nephrin, and a reduced macrophage infiltration in immunohistochemical renal sections of STZ-treated Sphk2-/- mice compared to STZ-treated wildtype mice. To investigate changes on the cellular level, we used an immortalized human podocyte cell line and generated a stable knockdown of Sphk2 (Sphk2-kd) by a lentiviral transduction method. These Sphk2-kd cells accumulated sphingosine as a consequence of the knockdown, and showed enhanced nephrin and WT1 mRNA and protein expressions similar to the finding in Sphk2 knockout mice. Treatment of wildtype podocytes with the highly selective Sphk2 inhibitor SLM6031434 caused a similar upregulation of nephrin and WT1 expression. Furthermore, exposing cells to the profibrotic mediator transforming growth factor β (TGFβ) resulted on the one side in reduced nephrin and WT1 expression, but on the other side, in upregulation of various profibrotic marker proteins, including connective tissue growth factor (CTGF), fibronectin (FN) and plasminogen activator inhibitor (PAI) 1. All these effects were reverted by Sphk2-kd and SLM6031434. Mechanistically, the protection by Sphk2-kd may depend on accumulated sphingosine and inhibited PKC activity, since treatment of cells with exogenous sphingosine not only reduced the phosphorylation pattern of PKC substrates, but also increased WT1 protein expression. Moreover, the selective stable knockdown of PKCδ increased WT1 expression, suggesting the involvement of this PKC isoenzyme in WT1 regulation. The glucocorticoid dexamethasone, which is a treatment option in many glomerular diseases and is known to mediate a nephroprotection, not only downregulated Sphk2 and enhanced cellular sphingosine, but also enhanced WT1 and nephrin expressions, thus, suggesting that parts of the nephroprotective effect of dexamethasone is mediated by Sphk2 downregulation. Altogether, our data demonstrated that loss of Sphk2 is protective in diabetes-induced podocytopathy and can prevent proteinuria, which is a hallmark of many glomerular diseases. Thus, Sphk2 could serve as a new attractive pharmacological target to treat proteinuric kidney diseases.
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Affiliation(s)
- Faik Imeri
- Institute of Pharmacology, University of Bern, Inselspital, INO-F, Bern CH-3010, Switzerland
| | | | - Stephanie Schwalm
- Institute of Pharmacology and Toxicology, Goethe University, Frankfurt am Main D-60590, Germany
| | - Sarbari Saha
- Institute of Pharmacology and Toxicology, Goethe University, Frankfurt am Main D-60590, Germany
| | - Jinyang Zeng-Brouwers
- Institute of Pharmacology and Toxicology, Goethe University, Frankfurt am Main D-60590, Germany
| | - Herrmann Pavenstädt
- Medizinische Klinik D, University Hospital Münster, Münster D-48149, Germany
| | - Josef Pfeilschifter
- Institute of Pharmacology and Toxicology, Goethe University, Frankfurt am Main D-60590, Germany
| | - Liliana Schaefer
- Institute of Pharmacology and Toxicology, Goethe University, Frankfurt am Main D-60590, Germany.
| | - Andrea Huwiler
- Institute of Pharmacology, University of Bern, Inselspital, INO-F, Bern CH-3010, Switzerland.
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Jørgensen HS, David K, Salam S, Evenepoel P. Traditional and Non-traditional Risk Factors for Osteoporosis in CKD. Calcif Tissue Int 2021; 108:496-511. [PMID: 33586002 DOI: 10.1007/s00223-020-00786-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
Osteoporosis is a state of bone fragility with reduced skeletal resistance to trauma, and consequently increased risk of fracture. A wide range of conditions, including traditional risk factors, lifestyle choices, diseases and their treatments may contribute to bone fragility. It is therefore not surprising that the multi-morbid patient with chronic kidney disease (CKD) is at a particularly high risk. CKD is associated with reduced bone quantity, as well as impaired bone quality. Bone fragility in CKD is a composite of primary osteoporosis, accumulation of traditional and uremia-related risk factors, assaults brought on by systemic disease, and detrimental effects of drugs. Some risk factors are modifiable and represent potential targets for intervention. This review provides an overview of the heterogeneity of bone fragility in CKD.
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Affiliation(s)
- Hanne Skou Jørgensen
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karel David
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
- Academic Unit of Bone Metabolism and 3 Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, UK
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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Ghosh S, Das S, Mukherjee J, Abdullah S, Mondal R, Sultana S, Sehgal A, Behl T. Enumerating the role of properdin in the pathogenesis of IgA nephropathy and its possible therapies. Int Immunopharmacol 2021; 93:107429. [PMID: 33571820 DOI: 10.1016/j.intimp.2021.107429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) has become the most prevalent form of glomerulonephritis affecting almost 1.3% of the total population worldwide. It is an autoimmune disorder where the host autoantibody forms an immune complex with the defective galactose-deficient IgA1 and gets deposited at the mesangium and endocapillary region of glomeruli. IgA has the capability to activate alternative and lectin complement cascades which even aggravates the condition. Properdin is directly associated with IgAN by activating and stabilising the alternative complement pathway at the mesangium, thereby causing progressive renal damage. OBJECTIVE The present review mainly focuses on correlating the influence of properdin in activating the complement cascade at glomeruli which is the major cause of disease exacerbation. Secondly, we have described the probable therapies and new targets that are under trials to check their efficacy in IgAN. METHODS An in-depth research was carried out from different peer-reviewed articles till December 2020 from several renowned databases like PubMed, Frontier, and MEDLINE, and the information was analysed and written in a simplified manner. RESULTS Co-deposition of properdin is observed along with IgA and C3 in 75%-100% of the patients. It is not yet fully understood whether properdin inhibition can attenuate IgAN, as many conflicting reports have revealed worsening of IgAN after impeding properdin. CONCLUSION With no specific cure still available, the treatment strategies are of great concern to find a better target to restrict the disease progression. More research and clinical trials are required to find out a prominent target to combat IgAN.
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Affiliation(s)
- Srijit Ghosh
- Guru Nanak Institute of Pharmaceutical Science and Technology, Panihati, Kolkata 700114, West Bengal, India
| | - Srijita Das
- Guru Nanak Institute of Pharmaceutical Science and Technology, Panihati, Kolkata 700114, West Bengal, India
| | - Joy Mukherjee
- Bengal School of Technology, Sugandha, Hooghly 712102, West Bengal, India
| | - Salik Abdullah
- Guru Nanak Institute of Pharmaceutical Science and Technology, Panihati, Kolkata 700114, West Bengal, India
| | - Rupsa Mondal
- Guru Nanak Institute of Pharmaceutical Science and Technology, Panihati, Kolkata 700114, West Bengal, India
| | - Shirin Sultana
- Guru Nanak Institute of Pharmaceutical Science and Technology, Panihati, Kolkata 700114, West Bengal, India
| | - Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Patiala 140401, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Patiala 140401, Punjab, India.
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A rare case report of reversible acute kidney injury due to hyperuricemia alone. Int Urol Nephrol 2021; 53:2189-2190. [PMID: 33389502 PMCID: PMC8463400 DOI: 10.1007/s11255-020-02743-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/02/2020] [Indexed: 11/08/2022]
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Perico L, Benigni A, Casiraghi F, Ng LFP, Renia L, Remuzzi G. Immunity, endothelial injury and complement-induced coagulopathy in COVID-19. Nat Rev Nephrol 2021; 17:46-64. [PMID: 33077917 PMCID: PMC7570423 DOI: 10.1038/s41581-020-00357-4] [Citation(s) in RCA: 359] [Impact Index Per Article: 119.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 01/08/2023]
Abstract
In December 2019, a novel coronavirus was isolated from the respiratory epithelium of patients with unexplained pneumonia in Wuhan, China. This pathogen, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes a pathogenic condition that has been termed coronavirus disease 2019 (COVID-19) and has reached pandemic proportions. As of 17 September 2020, more than 30 million confirmed SARS-CoV-2 infections have been reported in 204 different countries, claiming more than 1 million lives worldwide. Accumulating evidence suggests that SARS-CoV-2 infection can lead to a variety of clinical conditions, ranging from asymptomatic to life-threatening cases. In the early stages of the disease, most patients experience mild clinical symptoms, including a high fever and dry cough. However, 20% of patients rapidly progress to severe illness characterized by atypical interstitial bilateral pneumonia, acute respiratory distress syndrome and multiorgan dysfunction. Almost 10% of these critically ill patients subsequently die. Insights into the pathogenic mechanisms underlying SARS-CoV-2 infection and COVID-19 progression are emerging and highlight the critical role of the immunological hyper-response - characterized by widespread endothelial damage, complement-induced blood clotting and systemic microangiopathy - in disease exacerbation. These insights may aid the identification of new or existing therapeutic interventions to limit the progression of early disease and treat severe cases.
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Affiliation(s)
- Luca Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Lisa F P Ng
- Infectious Diseases Horizontal Technology Centre (ID HTC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Laurent Renia
- Infectious Diseases Horizontal Technology Centre (ID HTC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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Fan K, Zeng L, Guo J, Xie S, Yu Y, Chen J, Cao J, Xiang Q, Zhang S, Luo Y, Deng Q, Zhou Q, Zhao Y, Hao L, Wang Z, Zhong L. Visualized podocyte-targeting and focused ultrasound responsive glucocorticoid nano-delivery system against immune-associated nephropathy without glucocorticoid side effect. Am J Cancer Res 2021; 11:2670-2690. [PMID: 33456566 PMCID: PMC7806481 DOI: 10.7150/thno.53083] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022] Open
Abstract
Glucocorticoids are widely used in the treatment of nephritis, however, its dose-dependent side effects, such as the increased risk of infection and metabolic disturbances, hamper its clinical use. This study reports a visualized podocyte-targeting and focused ultrasound responsive glucocorticoid nano-delivery system (named as Dex/PFP@LIPs-BMS-α), which specific delivers dexamethasone (Dex) to podocyte targets and reduces systemic side effects. Methods: The glucocorticoid nano-delivery system was synthesized by a lipid thin film and a simple facile acoustic-emulsification method. This glucocorticoid nano-delivery system used BMS-470539 (BMS-α), a synthetic compound, as a “navigator” to specifically identify and target the melanocortin-1 receptor (MC-1R) on podocytes. The loaded perfluoropentane (PFP) realizes the directed "explosion effect" through ultrasound-targeted microbubble destruction (UTMD) technology under the coordination of low intensity focused ultrasound (LIFU) to completely release Dex. Results: Both in vitro and in vivo experiments have demonstrated that Dex/PFP@LIPs-BMs-α accurately gathered to podocyte targets and improved podocyte morphology. Moreover, in vivo, proteinuria and serum creatinine levels were significantly reduced in the group treated with Dex/PFP@LIPs-BMS-α, and no severe side effects were detected. Furthermore, Dex/PFP@LIPs-BMS-α, with capabilities of ultrasound, photoacoustic and fluorescence imaging, provided individualized visual guidance and the monitoring of treatment. Conclusion: This study provides a promising strategy of Dex/PFP@LIPs-BMS-α as effective and safe against immune-associated nephropathy.
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Podestà MA, Ponticelli C. Autoimmunity in Focal Segmental Glomerulosclerosis: A Long-Standing Yet Elusive Association. Front Med (Lausanne) 2020; 7:604961. [PMID: 33330569 PMCID: PMC7715033 DOI: 10.3389/fmed.2020.604961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/26/2020] [Indexed: 01/17/2023] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a histological term that describes a pathologic renal entity affecting both adults and children, with a wide array of possible underlying etiologies. Podocyte damage with scarring, the hallmark of this condition, leads to altered permeability of the glomerular barrier, which may result in massive proteinuria and relentless renal function deterioration. A definite cause of focal segmental glomerulosclerosis can be confirmed in a minority of cases, while most forms have been traditionally labeled as primary or idiopathic. Despite this definition, increasing evidence indicates that primary forms are a heterogenous group rather than a single disease entity: several circulating factors that may affect glomerular permeability have been proposed as potential culprits, and both humoral and cellular immunity have been implicated in the pathogenesis of the disease. Consistently, immunosuppressive drugs are considered as the cornerstone of treatment for primary focal segmental glomerulosclerosis, but response to these agents and long-term outcomes are highly variable. In this review we provide a summary of historical and recent advances on the pathogenesis of primary focal segmental glomerulosclerosis, focusing on implications for its differential diagnosis and treatment.
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Mohammadi L, Mosayyebi B, Imani M, Rahmati M. Dexamethasone Reduces Cell Adhesion and Migration of T47D Breast Cancer Cell Line. Anticancer Agents Med Chem 2020; 22:2494-2501. [PMID: 33319693 DOI: 10.2174/1871520621666201214150427] [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: 08/18/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Aberrant expression of cell adhesion molecules and matrix metalloproteinase (MMPs) plays a pivotal role in tumor biological processes including progression and metastasis of cancer cells. Targeting these processes and detailed understanding of their underlying molecular mechanism is an essential step in cancer treatment. Dexamethasone (Dex) is a type of synthetic corticosteroid hormone used as adjuvant therapy in combination with current cancer treatments such as chemotherapy in order to alleviate its side effects like acute nausea and vomiting. Recent evidences have suggested that Dex may have antitumor characteristics. OBJECTIVE Dex affects the migration and adhesion of T47D breast cancer cells as well as cell adhesion molecules e.g., cadherin and integrin, and MMPs by regulating the expression levels of associated genes. METHODS In this study, we evaluated the cytotoxicity of Dex on the T47D breast cancer cell line through MTT assay. Cell adhesion assay and wound healing assay were performed to determine the impact of Dex on cell adhesion and cell migration, respectively. Moreover, real-time PCR was used to measure the levels of α and β integrin, E-cadherin, N-cadherin, MMP-2, and MMP-9. RESULTS Dex decreased the viability of T47D cells in a time and dose-dependent manner. Cell adhesion and migration of T47D cells were reduced upon Dex treatment. The expression of α and β integrin, E-cadherin, N-cadherin, MMP-2, and MMP-9 were altered in response to the Dex treatment. CONCLUSION Our findings demonstrated that Dex may have a role in the prevention of metastasis in this cell line.
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Affiliation(s)
- Leila Mohammadi
- Student Research Committee, Tabriz University of Medical Science, Tabriz. Iran
| | - Bashir Mosayyebi
- Department of Medical Biotechnology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz. Iran
| | - Mahsa Imani
- Department of Medical Biotechnology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz. Iran
| | - Mohammad Rahmati
- Department of Medical Biotechnology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz. Iran
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Schwalm S, Beyer S, Hafizi R, Trautmann S, Geisslinger G, Adams DR, Pyne S, Pyne N, Schaefer L, Huwiler A, Pfeilschifter J. Validation of highly selective sphingosine kinase 2 inhibitors SLM6031434 and HWG-35D as effective anti-fibrotic treatment options in a mouse model of tubulointerstitial fibrosis. Cell Signal 2020; 79:109881. [PMID: 33301900 DOI: 10.1016/j.cellsig.2020.109881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 01/17/2023]
Abstract
Renal fibrosis is characterized by chronic inflammation and excessive accumulation of extracellular matrix and progressively leads to functional insufficiency and even total loss of kidney function. In this study we investigated the anti-fibrotic potential of two highly selective and potent SK2 inhibitors, SLM6031434 and HWG-35D, in unilateral ureter obstruction (UUO), a model for progressive renal fibrosis, in mice. In both cases, treatment with SLM6031434 or HWG-35D resulted in an attenuated fibrotic response to UUO in comparison to vehicle-treated mice as demonstrated by reduced collagen accumulation and a decreased expression of collagen-1 (Col1), fibronectin-1 (FN-1), connective tissue growth factor (CTGF), and α-smooth muscle actin (α-SMA). Similar to our previous study in Sphk2-/- mice, we found an increased protein expression of Smad7, a negative regulator of the pro-fibrotic TGFβ/Smad signalling cascade, accompanied by a strong accumulation of sphingosine in SK2 inhibitor-treated kidneys. Treatment of primary renal fibroblasts with SLM6031434 or HWG-35D dose-dependently increased Smad7 expression and ameliorated the expression of Col1, FN-1 and CTGF. In summary, these data prove the anti-fibrotic potential of SK2 inhibition in a mouse model of renal fibrosis, thereby validating SK2 as pharmacological target for the treatment of fibrosis in chronic kidney disease.
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Affiliation(s)
- Stephanie Schwalm
- Pharmazentrum Frankfurt/ZAFES, Institute of General Pharmacology and Toxicology, Universitätsklinikum and Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.
| | - Sandra Beyer
- Pharmazentrum Frankfurt/ZAFES, Institute of General Pharmacology and Toxicology, Universitätsklinikum and Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Redona Hafizi
- Institute of Pharmacology, University of Bern, Inselspital INO-F, CH-3010 Bern, Switzerland
| | - Sandra Trautmann
- Pharmazentrum Frankfurt/ZAFES, Institute of Clinical Pharmacology, Universitätsklinikum and Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Gerd Geisslinger
- Pharmazentrum Frankfurt/ZAFES, Institute of Clinical Pharmacology, Universitätsklinikum and Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - David R Adams
- School of Engineering & Physical Sciences, Heriot-Watt University, Edinburgh, UK
| | - Susan Pyne
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Nigel Pyne
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Liliana Schaefer
- Pharmazentrum Frankfurt/ZAFES, Institute of General Pharmacology and Toxicology, Universitätsklinikum and Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Andrea Huwiler
- Institute of Pharmacology, University of Bern, Inselspital INO-F, CH-3010 Bern, Switzerland
| | - Josef Pfeilschifter
- Pharmazentrum Frankfurt/ZAFES, Institute of General Pharmacology and Toxicology, Universitätsklinikum and Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Abdul-Hamid M, Moustafa N, El-Nesr KA, Abukhadra AM. Ameliorative effect of alpha lipoic acid and royal jelly against the side effects of cyclophosphamide in liver of albino rats. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2020. [DOI: 10.1186/s43088-020-00042-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Background
Cyclophosphamide (CP) is a cytotoxic anticancer drug used for the treatment of neoplastic diseases. The present study aimed to examine biochemical, histological, and ultrastructural effects of CP on rat liver and determine the hepatoprotective effects of alpha-lipoic acid (LA) or royal jelly (RJ) against CP.
Results
The present study revealed that CP-induced significant increase in hepatic marker enzymes (ALT and AST), and elevation in malonaldehyde (MDA) was concomitant with a significant decrease of superoxide dismutase (SOD). It caused histopathological changes in the liver of rat including vacuolation, infiltration, degeneration, and necrosis. Ultrastructurally, the hepatocytes appeared degenerated with multiple small- and medium-sized lipid droplets in the cytoplasm. Kupffer cell showed a shrunken nucleus. Administration of LA and RJ resulted in an obvious improvement in the altered level of ALT, AST, MDA, and SOD activities when compared with the CP-treated group in addition to marked amelioration in histopathology and ultrastructure of the liver.
Conclusions
LA is markedly effective than RJ in protecting rats against CP-induced biochemical, histopathological, and ultrastructural changes. This protection may be due to its antioxidant properties and scavenging abilities against active free radicals.
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Han Y, Huang Z, Zhang H, He L, Sun L, Liu Y, Liu F, Xiao L. Nocardiosis in glomerular disease patients with immunosuppressive therapy. BMC Nephrol 2020; 21:516. [PMID: 33243202 PMCID: PMC7690096 DOI: 10.1186/s12882-020-02179-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 11/19/2020] [Indexed: 01/14/2023] Open
Abstract
Background Glomerular disease patients have a high risk of infection, which contributes to the progression of disease per se and mortality, especially in those with long-term use of glucocorticoids and (or) immunosuppressive agents. Cases of sporadic nocardiosis have been reported in glomerular disease patients, and this observation was conducted to comprehensively understand the manifestations of and treatments for nocardiosis, which is commonly misdiagnosed as pneumonia or tuberculosis or even as lung cancer or metastatic tumors in glomerular disease patients. Methods We reviewed the demographic characteristics, laboratory abnormalities, radiological features, and treatments of 7 patients with nocardiosis and glomerular disease receiving steroids and immunosuppression therapy at the nephrology department of the Second Xiangya Hospital between 2012 and 2019. Results It was found that all 7 patients had been receiving methylprednisolone for renal disease at a median dose of 20 mg per day and a median duration of 4 months before developing nocardiosis. There were 4 males and 3 females, and the median age was 52.14 years. All 7 patients had hypoalbuminemia at the time of admission. In addition, various cystic abscesses in the subcutaneous tissue, with or without lung and brain involvement, were observed in these patients. Encouragingly, body temperatures returned to normal, and subcutaneous abscesses diminished or disappeared with compound sulfamethoxazole treatment alone or in combination with linezolid, imipenem and mezlocillin/sulbactam. Conclusions It was shown that multisite abscesses, including subcutaneous, pulmonary and cerebral abscesses, were the common manifestations of nocardiosis in glomerular disease patients. Sulfonamide was the first-line antibiotic therapy for nocardiosis, and combinations of other antibiotics were also needed in some serious cases.
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Affiliation(s)
- Yuzhang Han
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zineng Huang
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Huifang Zhang
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Liyu He
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lin Sun
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu Liu
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fuyou Liu
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Xiao
- Department of Nephrology, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Rahbar Saadat Y, Hejazian SM, Nariman-Saleh-Fam Z, Bastami M, Poursheikhani A, M Shoja M, Ardalan M, Zununi Vahed S. Glucocorticoid receptors and their upstream epigenetic regulators in adults with steroid-resistant nephrotic syndrome. Biofactors 2020; 46:995-1005. [PMID: 33031585 DOI: 10.1002/biof.1680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/21/2020] [Accepted: 09/16/2020] [Indexed: 12/15/2022]
Abstract
Steroid-resistant nephrotic syndrome (SRNS) is a clinical challenge with variable clinical outcomes. In patients with SRNS, unsuccessful anti-inflammatory and anti-proteinuric effects of steroids lead to end-stage renal disease (ESRD). Our objective was to define the expression pattern of the glucocorticoid receptors (GR) α and β and their epigenetic regulators (miR-24, miR-30a, and miR-370) in a group of adults with SRNS. In this regard, sixty primary NS patients with focal segmental glomerulosclerosis (FSGS, N = 30) and membranous glomerulonephritis (MGN, N = 30) and also healthy volunteers (N = 24) were enrolled. Real-time PCR was performed to evaluate the expression levels of the aforementioned genes in peripheral blood mononuclear cell (PBMC) samples. Furthermore, an in-silico analysis was performed to understand the signaling pathways and biological procedures that may be targeted by these microRNAs in NS. The decreased and increased levels of GRα and GRβ were not significant, respectively. Statistically significant reduced miR-24 levels were observed between control/MGN (p = .022) and MGN/FSGS (p = .032) groups. Additionally, a decrease was detected in miR-30a between MGN and FSGS (p = .049) groups. There was a significant increase in miR-370 expression level between control and NS groups (p = .029), as well as control/MGN (p = .008), and MGN/FSGS (p = .046). Bioinformatics analysis predicted the possible targets of the studied genes including genes involved in TGF-β, Notch1, and p53 signaling pathways, regulation of gene expression, intracellular signal transduction, negative regulation of response to the stimulus, cell-cell signaling, and cell activation in the pathogenesis of SRNS. Taken all together, dysregulated levels of GRα, GRβ were not attributed to SRNS in our patients. It seems that pharmacokinetics and the genetic variations in podocyte-related genes may be associated with the steroid-resistance in our adult patients with NS rather than GR expression.
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Affiliation(s)
- Yalda Rahbar Saadat
- Nutrition Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyyedeh Mina Hejazian
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ziba Nariman-Saleh-Fam
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Milad Bastami
- Department of Medical Genetics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arash Poursheikhani
- Medical Genetics Research Centre, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammadali M Shoja
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
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50
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Zhao Z, Jia Z, Foster KW, Wei X, Qiao F, Jiang H, Jin Y, Li G, Chen N, Zhao G, Thiele GM, Medlin JL, O'Dell JR, Wang D. Dexamethasone prodrug nanomedicine (ZSJ-0228) treatment significantly reduces lupus nephritis in mice without measurable side effects - A 5-month study. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2020; 31:102302. [PMID: 32980548 DOI: 10.1016/j.nano.2020.102302] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
Abstract
Lupus nephritis (LN) is a major cause of morbidity and mortality among systemic lupus erythematosus patients. Glucocorticoids (GCs) are uniformly used in clinical LN management. Their notorious toxicities, however, have hampered the long-term clinical application. To circumvent GC side effects while maintaining their potent therapeutic efficacy, we have developed a macromolecular prodrug nanomedicine based on dexamethasone (ZSJ-0228). The focus of this study was to investigate its long-term efficacy and, most importantly, safety in the lupus-prone NZB/W F1 mouse. Monthly ZSJ-0228 treatment for five months significantly reduced the incidence of nephritis in NZB/W F1 mice with an improved survival rate. In contrast to treatment with dose equivalent daily free dexamethasone, long-term monthly ZSJ-0228 did not result in any measurable GC-associated side effects. With its outstanding efficacy and exceptional safety, it is anticipated that ZSJ-0228 may be a novel therapy for long-term clinical management of LN.
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Affiliation(s)
- Zhifeng Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Kirk W Foster
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Xin Wei
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Fangfang Qiao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Haochen Jiang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Yan Jin
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Guojuan Li
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Ningrong Chen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Gang Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Geoffrey M Thiele
- Division of Rheumatology and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE; Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jennifer L Medlin
- Division of Rheumatology and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - James R O'Dell
- Division of Rheumatology and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE; Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE.
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