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Liu Y, Wu Y, Wei W, Yang L, Liu C, Li J, Huang Y, Wang B, Yang Y, Zhang L, Fu P, Zhao Y. Plasmapheresis, immunosuppressive therapy and anti-GBM disease prognosis: a cohort study of 107 patients. Ren Fail 2024; 46:2400539. [PMID: 39258391 PMCID: PMC11391867 DOI: 10.1080/0886022x.2024.2400539] [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: 04/30/2024] [Revised: 08/04/2024] [Accepted: 08/30/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Anti-glomerular basement membrane (anti-GBM) disease presents with rapidly progressive glomerulonephritis and alveolar hemorrhage, requiring urgent management. In this study, we analyzed the relationship between plasmapheresis strategy, immunosuppressive therapy and the prognosis of anti-GBM disease patients. METHOD We screened newly diagnosed anti-GBM disease patients at West China Hospital of Sichuan University from 2010 to 2021. The primary outcome was a composite endpoint of in-hospital death or dialysis dependency upon discharge. RESULTS This study enrolled 107 anti-GBM disease patients. The use of plasmapheresis was independently associated with a reduced risk of primary outcome (OR: 0.179, 95% Cl: 0.051-0.630, p = 0.007), better 2-year (HR: 0.146; 95% CI: 0.038-0.553; p = 0.005) and 8-year patient survival (HR: 0.309; 95% CI: 0.112-0.850; p = 0.023). Restricted cubic spline regression suggested that patients with 5-10 sessions of plasmapheresis had already achieved maximum risk reduction in the primary outcome. Patients who started plasmapheresis at lower serum creatinine (42.9% vs. 96.2%, p < 0.001) or lower anti-GBM antibody levels (44.4% vs. 93.3%, p = 0.030) had lower risk of primary outcome than those at higher levels. Use of high-dose methylprednisolone (p = 0.505), pulsed cyclophosphamide (p = 0.343) or ANCA positivity (p = 0.115) were not related to primary outcome in anti-GBM disease. CONCLUSION Plasmapheresis was protective for both in-hospital outcome and long-term survival in anti-GBM disease. Patients who initiated plasmapheresis early had a better prognosis and might only need 5-10 plasmapheresis sessions to achieve maximal risk reduction. Use of high-dose methylprednisolone or cyclophosphamide pulses was not related to improved short- or long-term outcomes in anti-GBM disease.
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Affiliation(s)
- Ying Liu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yiting Wu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Wei
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Letian Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Caihong Liu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yongxiu Huang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yingying Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Fu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yuliang Zhao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Klaus R, Kanzelmeyer N, Haffner D, Lange-Sperandio B. Outcome of rituximab treatment in children with non-dialysis-dependent anti-GBM disease. Pediatr Nephrol 2024:10.1007/s00467-024-06512-4. [PMID: 39320552 DOI: 10.1007/s00467-024-06512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/13/2024] [Accepted: 08/19/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Anti-GBM disease is a rare vasculitis mediated by pathogenic antibodies against collagen IV. Anti-GBM disease presents with rapid progressive glomerulonephritis and leads to kidney failure if untreated. KDIGO recommends plasma exchanges (PEX) for antibody elimination and steroids plus cyclophosphamide (CTX) to suppress antibody production. CTX is associated with severe side effects including gonadal toxicity. Rituximab (RTX) and mycophenolate mofetil (MMF) might be a less toxic but equally efficient alternative to CTX. Studies in pediatric anti-GBM disease patients receiving RTX and MMF instead of CTX are lacking. METHODS A retrospective survey in 8 tertiary German centers was performed. The clinical data of patients diagnosed between 2014 and 2022 were collected and analyzed. RESULTS Five adolescent patients treated with PEX and RTX and/or MMF due to anti-GBM disease were analyzed. All patients had anti-GBM antibodies, hematuria, glomerular proteinuria, and pulmonary hemorrhage. eGFR was 124 ml/min/1.73 m2 (range 47-162), and all patients were non-dialysis-dependent but with relevant histological kidney affection (mean crescents on kidney biopsy 77%). Antibody clearance was achieved after 13 PEX cycles (range 6-31). Four out of 5 patients received methylprednisolone pulses. All patients received oral prednisolone and MMF, and four patients received a median of 4 RTX doses (range 2-4). After a mean follow-up of 27 months, 4/5 patients had conserved or improved kidney function, while one patient (20%) developed kidney failure. CONCLUSIONS In this small series of pediatric non-dialysis-dependent anti-GBM disease patients, first-line treatment with RTX and MMF showed a favorable kidney outcome in 4/5 cases and had an acceptable side effect profile.
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Affiliation(s)
- Richard Klaus
- Department of Pediatrics, Dr. v. Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nele Kanzelmeyer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Bärbel Lange-Sperandio
- Department of Pediatrics, Dr. v. Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany.
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Ge Y, Zhu J, Yang G, Liu K, Yu X, Sun B, Zhang B, Yuan Y, Zeng M, Wang N, Xing C, Mao H. Clinical characteristics and outcome of double-seropositive patients with anti-glomerular basement membrane antibodies and anti-neutrophil cytoplasmic antibodies. Int Immunopharmacol 2024; 138:112607. [PMID: 38981222 DOI: 10.1016/j.intimp.2024.112607] [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: 03/27/2024] [Revised: 06/24/2024] [Accepted: 06/29/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE To explore the clinical characteristics of double-seropositive patients (DPPs) with anti-glomerular basement membrane (Anti-GBM) antibodies and anti-neutrophil cytoplasmic antibodies (ANCA). METHODS We collected patients with both ANCA and anti-GBM positive glomerulonephritis who were hospitalized in the Department of Nephrology at the First Affiliated Hospital of Nanjing Medical University from January 2010 to August 2022. Retrospective analysis of the baseline clinical characteristics of patients and follow-up to explore relevant factors affecting renal and patient survival. RESULTS A total of 386 patients, including 69 ANCA negative anti-GBM glomerulonephritis patients, 296 anti-GBM negative ANCA associated vasculitis (AAV) patients, and 21 DPPs were enrolled in this study. Among the 21 DPPs aged 68.0 years (59.5, 74.0), there were 11 males and 10 females. The median serum creatinine at diagnosis was 629.0 (343.85, 788.75) μmol/L, and the median eGFR (CKD-EPI) was 7.58 (4.74, 13.77) mL/min. Fifteen cases (71.4 %) underwent initial RRT. After a follow-up of 40.0 (11.0, 73.0) months, 13 out of 21 DPPs (61.9 %) received maintenance RRT, while 49 out of 69 (71.0 %) ANCA negative anti-GBM-GN patients and 124 out of 296 (41.9 %) anti-GBM negative AAV patients received maintenance RRT (P < 0.001). Kaplan-Meier survival analysis showed that DPPs and ANCA negative anti-GBM-GN patients were more likely to progress to ESRD than anti-GBM negative AAV patients (P = 0.001). Among the 21 patients with DPPs, renal survival was significantly better in patients with better initial renal function, including those who did not receive initial RRT (P = 0.003), with lower serum creatinine levels (Cr < 629.0 μmol/L, P = 0.004) and higher eGFR levels (eGFR ≥ 7.60 ml/min, P = 0.005) than those with poor initial renal function. At the end of follow-up, 14 out of 21 DPPs (66.7 %) survived. Survival analysis showed no significant difference among patients in DPPs group, ANCA negative anti-GBM-GN group, and anti-GBM negative AAV group. CONCLUSIONS DPPs and ANCA negative anti-GBM-GN patients were more likely to progress to ESRD than anti-GBM negative AAV patients. In DPPs, the poor renal function at diagnosis might be a risk factor associated with poor renal survival.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Jinxing Zhu
- Pulmonary and Critical Care Medicine, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China.
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, Jiangsu Province, China.
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Sallee M, Resseguier N, Crepin T, Bertin D, Bertrand D, Bobot M, Krummel T, Maillard N, Moussi-Frances J, Pelletier M, Poullin P, Rafat C, Robert T, Terrier B, Rostaing L, Faguer S, Jourde-Chiche N. Immunoadsorption and Plasma Exchange are Comparable in Anti-Neutrophil Cytoplasmic Antibodies or Anti-Glomerular Basement Membrane Removal Kinetics. Kidney Int Rep 2024; 9:2767-2773. [PMID: 39291196 PMCID: PMC11403088 DOI: 10.1016/j.ekir.2024.06.031] [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: 03/15/2024] [Revised: 06/07/2024] [Accepted: 06/17/2024] [Indexed: 09/19/2024] Open
Abstract
Introduction Apheresis allows the fast removal of autoantibodies in anti-glomerular basement membrane (anti-GBM) disease, and in severe antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis. The CINEVAS study tested whether immunoadsorption (IA) allowed a faster removal of ANCA and/or anti-GBM antibodies than plasma exchanges (PEx). Methods CINEVAS was a prospective multicenter study comparing IA to PEx in consecutive patients with ANCA and/or anti-GBM vasculitides. The primary objective was the reduction rate in autoantibody titers between the beginning of the first and the end of the seventh apheresis session. Secondary objectives were number of sessions needed to obtain desired reduction rates; reduction rates of total Ig levels; tolerance of sessions; and patients' outcome. Results The results of 38 patients (16 treated with IA and 22 with PEx), and 43 autoantibodies, were analyzed. There was no difference in the reduction rates in autoantibody titers between IA and PEx over 7 sessions (respectively 98% vs. 96%, P = 0.39). The numbers of sessions needed to obtain undetectable autoantibodies, or 50%, 75%, or 90% reductions, did not differ between techniques. Greater reduction rates of autoantibodies were observed when plasma was separated by filtration compared to centrifugation, with IA and PEx. IA allowed a greater reduction in total IgG levels, and better preservation of total IgA and IgM levels than PEx. PEx sessions required higher volumes of plasma, IA sessions higher volumes of citrate; IA sessions were longer. Conclusions IA and PEx were comparable in ANCA or anti-GBM removal kinetics, despite a faster reduction in total IgG with IA.
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Affiliation(s)
- Marion Sallee
- AP-HM, Hôpital de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Univ, C2VN, INSERM, INRAE, Marseille, France
| | - Noémie Resseguier
- Aix-Marseille Univ, CEReSS/UR 3279 - Health Services and Quality of Life Research, Marseille, France
- APHM, Methodological Support Unit for Clinical and Epidemiological Research, Marseille, France
| | - Thomas Crepin
- CHU de Besançon, Service de Néphrologie, Besançon, France
| | - Daniel Bertin
- AP-HM, Hôpital de la Timone, Laboratoire d'Immunologie, Marseille, France
| | | | - Mickaël Bobot
- AP-HM, Hôpital de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Univ, C2VN, INSERM, INRAE, Marseille, France
| | - Thierry Krummel
- CHU de Strasbourg, Service de Néphrologie, Strasbourg, France
| | - Nicolas Maillard
- CHU de Saint-Etienne, Service de Néphrologie, Saint-Etienne, France
| | | | - Marion Pelletier
- AP-HM, Hôpital de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Pascale Poullin
- AP-HM, Hôpital de la Conception, Service d'Aphérèses, Marseille, France
| | - Cédric Rafat
- AP-HP, Hôpital Tenon, Service de Néphrologie, Paris, France
| | - Thomas Robert
- AP-HM, Hôpital de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Benjamin Terrier
- AP-HP, Hôpital Cochin, Service de Médecine interne, Paris, France
| | | | | | - Noémie Jourde-Chiche
- AP-HM, Hôpital de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Univ, C2VN, INSERM, INRAE, Marseille, France
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5
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Chauveau B, Gibier JB, Olagne J, Morel A, Aydin S, McAdoo SP, Viallet N, Perrochia H, Pambrun E, Royal V, Demoulin N, Kemeny JL, Philipponnet C, Hertig A, Boffa JJ, Plaisier E, Domenger C, Brochériou I, Deltombe C, Duong Van Huyen JP, Buob D, Roufosse C, Hellmark T, Audard V, Mihout F, Nasr SH, Renaudin K, Moktefi A, Rabant M. Atypical Anti-Glomerular Basement Membrane Nephritis: A Case Series From the French Nephropathology Group. Am J Kidney Dis 2024; 83:713-728.e1. [PMID: 38171412 DOI: 10.1053/j.ajkd.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/06/2023] [Accepted: 11/02/2023] [Indexed: 01/05/2024]
Abstract
RATIONALE & OBJECTIVE Atypical anti-glomerular basement membrane (GBM) nephritis is characterized by a bright linear immunoglobulin staining along the GBM by immunofluorescence without a diffuse crescentic glomerulonephritis nor serum anti-GBM antibodies by conventional enzyme-linked immunosorbent assay (ELISA). We characterized a series of patients with atypical anti-GBM disease. STUDY DESIGN Case series. SETTING & PARTICIPANTS Patients identified by the French Nephropathology Group as having atypical anti-GBM nephritis between 2003 and 2022. FINDINGS Among 38 potential cases, 25 were included, of whom 14 (56%) were female and 23 (92%) had hematuria. The median serum creatinine at diagnosis was 150 (IQR, 102-203) μmol/L and median urine protein-creatinine ratio (UPCR) was 2.4 (IQR, 1.3-5.2) g/g. Nine patients (36%) had endocapillary proliferative glomerulonephritis (GN), 4 (16%) had mesangial proliferative GN, 4 (16%) had membranoproliferative GN, 2 (8%) had pure and focal crescentic GN, 1 (4%) had focal segmental glomerulosclerosis, and 5 had glomeruli that were unremarkable on histopathology. Nine patients (36%) had crescents, involving a median of 9% of glomeruli. Bright linear staining for IgG was seen in 22 cases (88%) and for IgA in 3 cases (12%). The 9 patients (38%) who had a monotypic staining pattern tended to be older with less proteinuria and rarely had crescents. Kidney survival rate at 1 year was 83% and did not appear to be associated with the light chain restriction. LIMITATIONS Retrospective case series with a limited number of biopsies including electron microscopy. CONCLUSIONS Compared with typical anti-GBM disease, atypical anti-GBM nephritis frequently presents with an endocapillary or mesangial proliferative glomerulonephritis pattern and appears to have a slower disease progression. Further studies are needed to fully characterize its pathophysiology and associated clinical outcomes. PLAIN-LANGUAGE SUMMARY Atypical anti-glomerular basement membrane (GBM) nephritis is characterized histologically by bright linear immunoglobulin staining along the GBM without diffuse crescentic glomerulonephritis or circulating anti-GBM antibodies. We report a case series of 25 atypical cases of anti-GBM nephritis in collaboration with the French Nephropathology Group. Compared with typical anti-GBM disease, we observed a slower disease progression. Patients frequently presented with heavy proteinuria and commonly had evidence of endocapillary or mesangial proliferative glomerulonephritis. About half of the patients displayed a monotypic immune staining pattern; they tended to be older, with less proteinuria, and commonly without glomerular crescents in biopsy specimens. No concomitant circulating monoclonal gammopathy was detected. Further studies are needed to fully characterize its pathophysiology and associated clinical outcomes.
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Affiliation(s)
- Bertrand Chauveau
- Department of Pathology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France; CNRS UMR 5164, ImmunoConcEpT, University of Bordeaux, Bordeaux, France.
| | - Jean-Baptiste Gibier
- UMR9020-U1277, CANTHER, Cancer Heterogeneity Plasticity and Resistance to Therapies, University of Lille, Lille, France; Institute of Pathology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jérôme Olagne
- Department of Nephrology and Transplantation, Strasbourg University Hospital, Strasbourg, France; Department of Pathology, Strasbourg University Hospital, Strasbourg, France
| | - Antoine Morel
- Nephrology and Renal Transplantation Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Henri Mondor Hospital University, Rare Disease Center "Idiopathic Nephrotic Syndrome," Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", Créteil, France
| | - Selda Aydin
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Pathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Nicolas Viallet
- Department of Nephrology-Transplantation, Centre Hospitalier Universitaire de la Réunion Felix Guyon, Saint Denis, Réunion, France
| | - Hélène Perrochia
- Pathology Department, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Emilie Pambrun
- Department of Nephrology Dialysis Apheresis, Nîmes University Hospital, Nîmes, France
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, University of Montreal, Quebec, Canada
| | - Nathalie Demoulin
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Louis Kemeny
- Pathology Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Carole Philipponnet
- Nephrology, Dialysis, and Transplantation Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | | | - Jean-Jacques Boffa
- Department of Nephrology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Emmanuelle Plaisier
- Department of Nephrology, Association pour l'Utilisation du Rein Artificiel Paris Plaisance, Paris, France; Unité Mixte de Recherche S1155, Sorbonne Université and Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Camille Domenger
- Department of Nephrology, Dialysis and Transplantation, Polynésie Française Hospital, Pirae, Tahiti
| | - Isabelle Brochériou
- INSERM UMR S1155, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France; Department of Pathology, Pitié-Salpêtrière Hospital, Paris, France
| | - Clément Deltombe
- Nephrology and Transplantation Department, Department of Nephrology and Immunology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jean-Paul Duong Van Huyen
- Department of Pathology, Centre Hospitalier Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - David Buob
- INSERM UMR S1155, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France; Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Thomas Hellmark
- Nephrology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Vincent Audard
- Nephrology and Renal Transplantation Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Henri Mondor Hospital University, Rare Disease Center "Idiopathic Nephrotic Syndrome," Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", Créteil, France; Institut Mondor de Recherche Biomédicale, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Université Paris-Est Créteil, Créteil, France
| | - Fabrice Mihout
- Department of Nephrology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Karine Renaudin
- Department of Pathology, Centre Hospitalier Universitaire de Nantes, Nantes, France; Centre de Recherche en Transplantation et en Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France
| | - Anissa Moktefi
- Institut Mondor de Recherche Biomédicale, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Université Paris-Est Créteil, Créteil, France; Department of Pathology, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Marion Rabant
- Department of Pathology, Centre Hospitalier Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1151, CNRS UMR 8253, Institut Necker-Enfants Malades, Département Croissance et Signalisation, University of Paris Cité, Paris, France
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Bharati J, Jhaveri KD, Salama AD, Oni L. Anti-Glomerular Basement Membrane Disease: Recent Updates. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:206-215. [PMID: 39004460 DOI: 10.1053/j.akdh.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 04/01/2024] [Accepted: 04/24/2024] [Indexed: 07/16/2024]
Abstract
Anti-glomerular basement membrane disease is a small-vessel vasculitis involving the kidneys (∼90%) and the lungs (∼60%). Antibodies against the glomerular basement membrane are directly pathogenic in anti-glomerular basement membrane disease; however, recent research has highlighted the critical role of T cells. Novel autoantigens within the glomerular basement membrane are also now recognized. Atypical forms of the disease are reported along with preceding triggers, such as immune checkpoint inhibitors, immunomodulatory drugs, and vaccines. Kidney outcomes in anti-glomerular basement membrane disease remain poor despite significant improvement in patient survival in the last 2 to 3 decades. Treatment typically relies on combined plasmapheresis with intensive immunosuppression. Dialysis dependency at presentation is a dominant predictor of kidney outcome. Histologically, a low (<10%) percentage of normal glomeruli, 100% crescents, together with dialysis dependency at presentation, is associated with poor kidney outcomes. In such cases, an individualized approach weighing the risks and benefits of treatment is recommended. There is a need for better ways to stop the toxic inflammatory activity associated with this disease. In this narrative review, we discuss recent updates on the pathogenesis and management of anti-glomerular basement membrane disease relevant to patients of all ages.
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Affiliation(s)
- Joyita Bharati
- Glomerular Center, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck
| | - Kenar D Jhaveri
- Glomerular Center, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck
| | - Alan D Salama
- University College London (UCL) Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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7
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Kuang H, Jiang N, Jia XY, Cui Z, Zhao MH. Epidemiology, clinical features, risk factors, and outcomes in anti-glomerular basement membrane disease: A systematic review and meta-analysis. Autoimmun Rev 2024; 23:103531. [PMID: 38493958 DOI: 10.1016/j.autrev.2024.103531] [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: 03/04/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/19/2024]
Abstract
Anti-glomerular basement membrane (GBM) disease is a small-vessel vasculitis that represents the most aggressive form of autoimmune glomerulonephritis. The study aimed to investigate the prevalence, clinical characteristics, risk factors, and outcomes of anti-GBM disease through a systematic review and meta-analysis involving 47 studies with 2830 patients. The overall incidence of anti-GBM disease ranged from 0.60 to 1.79 per million population per annum. In rapidly progressive glomerulonephritis and crescentic glomerulonephritis, the pooled incidence rates were 8.0% and 12.8%, respectively. The pooled prevalence rates of anti-GBM antibodies, antineutrophil cytoplasmic antibodies (ANCA), and lung hemorrhage were 88.8%, 27.4%, and 32.6%, respectively. Patients with combined ANCA positivity demonstrated a prognosis comparable to those patients with only anti-GBM antibodies, though with differing clinical features. The pooled one-year patient and kidney survival rates were 76.2% and 30.2%, respectively. Kidney function on diagnosis and normal glomeruli percentage were identified as strong prognostic factors. This study represents the first comprehensive meta-analysis on anti-GBM disease, providing insights into its management. However, caution is warranted in interpreting some results due to the observational nature of the included studies and high heterogeneity.
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Affiliation(s)
- Huang Kuang
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Jiang
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Yu Jia
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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8
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Jacobs JW, Villalba CAF, Stendahl K, Tormey CA, Abels E. Immunity in the balance: Fatal disseminated adenovirus infection in a patient undergoing plasma exchange and immunosuppressive chemotherapy for anti-glomerular basement membrane disease. J Clin Apher 2023; 38:770-777. [PMID: 37698143 DOI: 10.1002/jca.22088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/31/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
Anti-glomerular basement membrane (anti-GBM) disease (formerly known as Goodpasture's syndrome) is a rare autoinflammatory condition that affects the renal and/or pulmonary capillaries. The standard therapeutic regimen for anti-GBM disease involves therapeutic plasma exchange (TPE), cyclophosphamide, and corticosteroids to rapidly remove and inhibit autoantibody production and reduce organ inflammation. Herein we report an 82-year-old female who developed anti-GBM disease but expired despite therapy, secondary to multi-organ failure in the setting of disseminated adenovirus disease. We discuss the utility and potential adverse effect of daily TPE for a protracted course (ie, 10-14 days), the recommended TPE intensity in the 2023 American Society for Apheresis guidelines, updated from every-other-day TPE in the 2019 guidelines, despite no new data. We also highlight the potential for unusual infections to occur in these patients due to the profound immunosuppression, and discuss the importance of balancing immunosuppression to treat the disease with close surveillance of any potential opportunistic infections.
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Affiliation(s)
- Jeremy W Jacobs
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kristin Stendahl
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth Abels
- Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
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9
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Yamashita M, Takayasu M, Maruyama H, Hirayama K. The Immunobiological Agents for Treatment of Antiglomerular Basement Membrane Disease. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2014. [PMID: 38004064 PMCID: PMC10673378 DOI: 10.3390/medicina59112014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
Combination therapy with glucocorticoids, cyclophosphamide, and plasmapheresis is recommended as the standard treatment for anti-glomerular basement membrane (anti-GBM) disease, but the prognosis of this disease remains poor. Several immunobiological agents have been administered or are expected to be useful for anti-GBM disease in light of refractory disease or the standard treatments' tolerability. Many data regarding the use of biologic agents for anti-GBM disease have accumulated, verifying the effectiveness and potential of biologic agents as a new treatment option for anti-GBM disease. Tumor necrosis factor (TNF) inhibitors were shown to be useful in animal studies, but these agents have no clinical use and were even shown to induce anti-GBM disease in several cases. Although the efficacy of the TNF-receptor antagonist has been observed in animal models, there are no published case reports of its clinical use. There are also no published reports of animal or clinical studies of anti-B-cell-activating factor, which is a member of the TNF family of agents. Anti-interleukin (IL)-6 antibodies have been demonstrated to have no effect on or to exacerbate nephritis in animal models. Anti-C5 inhibitor was observed to be useful in a few anti-GBM disease cases. Among the several immunobiological agents, only rituximab has been demonstrated to be useful in refractory or poor-tolerance patients or small uncontrolled studies. Rituximab is usually used in combination with steroids and plasma exchange and is used primarily as an alternative to cyclophosphamide, but there is insufficient evidence regarding the efficacy of rituximab for anti-GBM disease, and thus, randomized controlled studies are required.
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Affiliation(s)
| | | | | | - Kouichi Hirayama
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami 300-0395, Ibaraki, Japan; (M.Y.); (M.T.); (H.M.)
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10
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Watanabe H, Yamana H, Okada A, Matsui H, Fushimi K, Yasunaga H. Therapeutic plasma exchange for anti-glomerular basement membrane disease with dialysis-dependent kidney failure without diffuse alveolar hemorrhage. J Nephrol 2023; 36:2317-2325. [PMID: 37354278 PMCID: PMC10638153 DOI: 10.1007/s40620-023-01695-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 05/30/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Anti-glomerular basement membrane (anti-GBM) disease is treated with immunosuppressive medications and plasma exchange. However, whether plasma exchange, in addition to pulse glucocorticoid therapy, would benefit patients with anti-GBM disease with dialysis-dependent kidney failure without diffuse alveolar hemorrhage remains unclear. METHODS Using the Japanese Diagnosis Procedure Combination database, we identified patients diagnosed with anti-GBM disease with dialysis-dependent kidney failure and without diffuse alveolar hemorrhage from July 2010 to March 2020. We compared in-hospital mortality within 10 days of hospitalization between patients who received therapeutic plasma exchange in addition to pulse glucocorticoid therapy and those who received pulse glucocorticoid therapy alone. Overlap weighting based on propensity score was performed to adjust for potential confounders. RESULTS We identified 207 eligible patients; 168 patients received therapeutic plasma exchange plus pulse glucocorticoid therapy, while 39 patients received pulse glucocorticoid therapy alone. The mean dose of therapeutic plasma exchange was 52.2 ml/kg/day of albumin and/or fresh frozen plasma. Therapeutic plasma exchange in addition to pulse glucocorticoid therapy was associated with a lower in-hospital mortality risk in the unweighted (10.7% versus 28.2%; risk difference, 17.5%; 95% confidence interval, 2.6-32.4%; P = 0.02) and weighted analyses (11.5% versus 28.4%; risk difference, 17.0%; 95% confidence interval, 1.5-32.5%; P = 0.03) than pulse glucocorticoid therapy alone. CONCLUSIONS This retrospective cohort study using a national database suggests that therapeutic plasma exchange may improve the in-hospital prognosis of anti-GBM disease with dialysis-dependent kidney failure and without diffuse alveolar hemorrhage.
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Affiliation(s)
- Hideaki Watanabe
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, 7-3-1, Hongo, Bunkyo, Tokyo, 1130033, Japan.
| | - Hayato Yamana
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, 7-3-1, Hongo, Bunkyo, Tokyo, 1130033, Japan
- Data Science Center, Jichi Medical University, Shimotsuke, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, 7-3-1, Hongo, Bunkyo, Tokyo, 1130033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, 7-3-1, Hongo, Bunkyo, Tokyo, 1130033, Japan
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11
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Mansour I, Murugapandian S, Tanriover B, Thajudeen B. Contemporary Monoclonal Antibody Utilization in Glomerular Diseases. Mayo Clin Proc Innov Qual Outcomes 2023; 7:276-290. [PMID: 37448529 PMCID: PMC10338194 DOI: 10.1016/j.mayocpiqo.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Therapeutic monoclonal antibodies (MAbs) have been one of the fastest growing drug classes in the past 2 decades and are indicated in the treatment of cancer, autoimmune disorders, solid organ transplantation, and glomerular diseases. The Food and Drug Administration has approved 100 MAbs between 1986 and 2021, and MAbs account for 20% of Food and Drug Administration's new drug approval every year. MAbs are preferred over traditional immunosuppressive agents because of their high specificity, reduced number of drug-drug interactions, and low toxicity, which make them a prime example of personalized medicine. In this review article, we provide an overview of the taxonomy, pharmacology, and therapeutic applications of MAbs in glomerular diseases. We searched the literature through PubMed using the following search terms: monoclonal antibodies, glomerular diseases, pharmacokinetics, pharmacodynamics, immunoglobulin, murine, chimeric,humanized, and fully human, and limited our search to years 2018-2023. We selected peer-reviewed journal articles with an evidence-based approach, prioritizing randomized control trials in specific glomerular diseases, if available. Advances in the MAb field have resulted in a significant paradigm shift in targeted treatment of immune-mediated glomerular diseases, and multiple randomized control trials are currently being conducted. Increased recognition is critical to expand their use in experimental research and personalized medicine.
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Affiliation(s)
- Iyad Mansour
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
| | | | - Bekir Tanriover
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
| | - Bijin Thajudeen
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
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12
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Caillard P, Vigneau C, Halimi JM, Hazzan M, Thervet E, Heitz M, Juillard L, Audard V, Rabant M, Hertig A, Subra JF, Vuiblet V, Guerrot D, Tamain M, Essig M, Lobbedez T, Quemeneur T, Legendre M, Ganea A, Peraldi MN, Vrtovsnik F, Daroux M, Makdassi R, Choukroun G, Titeca-Beauport D. Prognostic value of complement serum C3 level and glomerular C3 deposits in anti-glomerular basement membrane disease. Front Immunol 2023; 14:1190394. [PMID: 37475859 PMCID: PMC10354545 DOI: 10.3389/fimmu.2023.1190394] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Background and objectives Activation of the complement system is involved in the pathogenesis of anti-glomerular basement membrane (anti-GBM) disease. Glomerular deposits of complement 3 (C3) are often detected on kidney biopsies. The primary objective of this study was to analyze the prognostic value of the serum C3 level and the presence of C3 glomerular deposits in patients with anti-GBM disease. Methods We conducted a retrospective cohort study of 150 single-positive patients with anti-GBM disease diagnosed between 1997 and 2017. Patients were categorized according to the serum C3 level (forming a low C3 (C3<1.23 g/L) and a high C3 (C3≥1.23 g/L) groups) and positivity for C3 glomerular staining (forming the C3+ and C3- groups). The main outcomes were kidney survival and patient survival. Results Of the 150 patients included, 89 (65%) were men. The median [interquartile range (IQR)] age was 45 [26-64]. At diagnosis, kidney involvement was characterized by a median [IQR] peak serum creatinine (SCr) level of 578 [298-977] µmol/L, and 106 (71%) patients required dialysis. Patients in the low C3 group (72 patients) had more severe kidney disease at presentation, as characterized by higher prevalences of oligoanuria, peak SCr ≥500 µmol/L (69%, vs. 53% in the high C3 group; p=0.03), nephrotic syndrome (42%, vs. 24%, respectively; p=0.02) and fibrous forms on the kidney biopsy (21%, vs. 8%, respectively; p=0.04). Similarly, we observed a negative association between the presence of C3 glomerular deposits (in 52 (41%) patients) and the prevalence of cellular forms (83%, vs. 58% in the C3- group; p=0.003) and acute tubulo-interstitial lesions (60%, vs. 36% in the C3- group; p=0.007). When considering patients not on dialysis at diagnosis, the kidney survival rate at 12 months was poorer in the C3+ group (50% [25-76], vs. 91% [78-100] in the C3- group; p=0.01), with a hazard ratio [95% confidence interval] of 5.71 [1.13-28.85] (p=0.04, after adjusting for SCr). Conclusion In patients with anti-GBM disease, a low serum C3 level and the presence of C3 glomerular deposits were associated with more severe disease and histological kidney involvement at diagnosis. In patients not on dialysis at diagnosis, the presence of C3 deposits was associated with worse kidney survival.
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Affiliation(s)
- Pauline Caillard
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
- Mécanismes Physiopathologiques et Conséquences des Calcifications Cardiovasculaires (MP3CV) laboratory, Centre de Recherche en Santé (CURS), Amiens, France
| | - Cécile Vigneau
- Rennes University Hospital, Inserm, Ecole des hautes études en santé publique (EHESP), Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Jean-Michel Halimi
- Department of Nephrology, Tours University Hospital and EA4245, University of Tours, Tours, France
| | - Marc Hazzan
- Nephrology Department, Lille University Hospital, University of Lille, UMR 995, Lille, France
| | - Eric Thervet
- Department of Nephrology, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris and INSERM UMRS970, Boulogne-Billancourt, France
| | - Morgane Heitz
- Department of Nephrology and Dialysis, Annecy Genevois Hospital, Pringy, France
| | - Laurent Juillard
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Carmen INSERM 1060 and Univ Lyon, Lyon, France
| | - Vincent Audard
- Department of Nephrology and Renal Transplantation, Reference Center-Idiopathic Nephrotic Syndrome, Henri-Mondor Hospital/Albert-Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP) Créteil, INSERMU955, Paris Est Créteil University, Créteil, France
| | - Marion Rabant
- Pathology Department, Necker University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre-Université de Paris, Paris, France
| | - Alexandre Hertig
- Department of Nephrology, Dialysis and Transplantation, Foch Hospital, Paris-Saclay University, Suresnes, France
| | - Jean-François Subra
- Department of Nephrology, Dialysis and Transplantation, University Hospital, Angers and Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCINA), INSERM, Nantes University, Angers University, Angers, France
| | - Vincent Vuiblet
- Department of Nephrology and Renal Transplantation, Reims University Hospital, Reims, France
| | - Dominique Guerrot
- Department of Nephrology, Rouen University Hospital, Rouen and INSERM, U1096 Rouen, France
| | - Mathilde Tamain
- Department of Nephrology and Dialysis, Vichy Hospital, Vichy, France
| | - Marie Essig
- Department of Nephrology, Dialysis, and Renal Transplantation, Ambroise-Paré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris-Saclay University, Boulogne-Billancourt, France
| | - Thierry Lobbedez
- Department of Nephrology, Caen University Hospital, Caen, France and the French Registry of Peritoneal Dialysis, Langue Française, Pontoise, France
| | - Thomas Quemeneur
- Department of Nephrology and Internal Medicine, Valenciennes General Hospital, Valenciennes, France
| | - Mathieu Legendre
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Dijon, France
| | | | - Marie-Noëlle Peraldi
- Department of Nephrology, Dialysis and Renal Transplantation, Necker University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre-Université de Paris, Paris, France
| | - François Vrtovsnik
- Nephrology Department, Bichat-Claude Bernard Hospital, APHP, Paris, France. Faculty of Medicine, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Maïté Daroux
- Department of Nephrology, Duchenne Hospital, Boulogne-Sur-Mer, France
| | - Raïfah Makdassi
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| | - Gabriel Choukroun
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
- Mécanismes Physiopathologiques et Conséquences des Calcifications Cardiovasculaires (MP3CV) laboratory, Centre de Recherche en Santé (CURS), Amiens, France
| | - Dimitri Titeca-Beauport
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
- Mécanismes Physiopathologiques et Conséquences des Calcifications Cardiovasculaires (MP3CV) laboratory, Centre de Recherche en Santé (CURS), Amiens, France
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Douté M, Sannier A, Even G, Tran TT, Gaston AT, Delbosc S, Loyau S, Bruneval P, Witko-Sarsat V, Mouthon L, Nicoletti A, Caligiuri G, Clement M. Thrombopoietin-Dependent Myelo-Megakaryopoiesis Fuels Thromboinflammation and Worsens Antibody-Mediated Chronic Renal Microvascular Injury. J Am Soc Nephrol 2023; 34:1207-1221. [PMID: 37022108 PMCID: PMC10356147 DOI: 10.1681/asn.0000000000000127] [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: 08/20/2022] [Accepted: 03/07/2023] [Indexed: 04/07/2023] Open
Abstract
SIGNIFICANCE STATEMENT Kidney-derived thrombopoietin (TPO) increases myeloid cell and platelet production during antibody-mediated chronic kidney disease (AMCKD) in a mouse model, exacerbating chronic thromobinflammation in microvessels. The effect is mirrored in patients with extracapillary glomerulonephritis associated with thromboinflammation, TGF β -dependent glomerulosclerosis, and increased bioavailability of TPO. Neutralization of TPO in mice normalized hematopoiesis, reduced chronic thromboinflammation, and ameliorated renal disease. The findings suggest that TPO is a relevant biomarker and a promising therapeutic target for patients with CKD and other chronic thromboinflammatory diseases.Neutralization of TPO in mice normalized hematopoiesis, reduced chronic thromboinflammation, and ameliorated renal disease. The findings suggest that TPO is a relevant biomarker and a promising therapeutic target for patients with CKD and other chronic thromboinflammatory diseases. BACKGROUND Chronic thromboinflammation provokes microvascular alterations and rarefaction, promoting organ dysfunction in individuals with various life-threatening diseases. Hematopoietic growth factors (HGFs) released by the affected organ may sustain emergency hematopoiesis and fuel the thromboinflammatory process. METHODS Using a murine model of antibody-mediated chronic kidney disease (AMCKD) and pharmacological interventions, we comprehensively monitored the response to injury in the circulating blood, urine, bone marrow, and kidney. RESULTS Experimental AMCKD was associated with chronic thromboinflammation and the production of HGFs, especially thrombopoietin (TPO), by the injured kidney, which stimulated and skewed hematopoiesis toward myelo-megakaryopoiesis. AMCKD was characterized by vascular and kidney dysfunction, TGF β -dependent glomerulosclerosis, and microvascular rarefaction. In humans, extracapillary glomerulonephritis is associated with thromboinflammation, TGF β -dependent glomerulosclerosis, and increased bioavailability of TPO. Analysis of albumin, HGF, and inflammatory cytokine levels in sera from patients with extracapillary glomerulonephritis allowed us to identify treatment responders. Strikingly, TPO neutralization in the experimental AMCKD model normalized hematopoiesis, reduced chronic thromboinflammation, and ameliorated renal disease. CONCLUSION TPO-skewed hematopoiesis exacerbates chronic thromboinflammation in microvessels and worsens AMCKD. TPO is both a relevant biomarker and a promising therapeutic target in humans with CKD and other chronic thromboinflammatory diseases.
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Affiliation(s)
- Mélodie Douté
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Aurélie Sannier
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Université de Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), Service d'Anatomie et Cytologie Pathologiques, Hôpital Bichat, Paris, France
| | - Guillaume Even
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Thi-Thu Tran
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Ahn-Tu Gaston
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Sandrine Delbosc
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Stéphane Loyau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Patrick Bruneval
- Departments of Nephrology Pathology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Witko-Sarsat
- Laboratoire d'Excellence INFLAMEX, Paris, France
- Université de Paris, INSERM U1016, CNRS UMR 8104, Institut Cochin, Paris, France
| | - Luc Mouthon
- Laboratoire d'Excellence INFLAMEX, Paris, France
- Université de Paris, INSERM U1016, CNRS UMR 8104, Institut Cochin, Paris, France
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares d'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP)-CUP-CUP, Hôpital Cochin, Université Paris Cité, Paris, France
| | - Antonino Nicoletti
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Giuseppina Caligiuri
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Nord Val-de-Seine, Site Bichat, Paris, France
| | - Marc Clement
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
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14
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Chalkia A, Koutsianas C, Stampolliou E, Giannou P, Gakiopoulou H, Vassilopoulos D, Petras D. Pulmonary-Renal Syndrome During COVID-19 Pandemic Revealed a Rare Case of Anti-GBM Disease. Mediterr J Rheumatol 2023; 34:252-256. [PMID: 37654641 PMCID: PMC10466353 DOI: 10.31138/mjr.34.2.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 09/02/2023] Open
Abstract
Anti-GBM disease is a rare, life-threatening small vessel vasculitis caused by circulating anti-GBM antibodies resulting to rapidly progressive glomerulonephritis and/or pulmonary haemorrhage. The gold standard for the diagnosis is the renal biopsy with the pathognomonic finding of linear deposition of IgG along the glomerular capillaries. Early diagnosis and intervention are key determinants of the response to therapy and long-term prognosis of these patients. However, during COVID-19 pandemic recognizing a pulmonary-renal syndrome caused by autoimmune diseases has become challenging. Herein, we aimed to describe a rare case of anti-GBM disease with pulmonary haemorrhage and rapidly progressive glomerulonephritis in a young man in a tertiary referral hospital in Greece, while COVID-19 pandemic was at its peak. Although the patient presented high level of creatinine and crescents, the early diagnosis and start of treatment resulted to favourable renal prognosis.
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Affiliation(s)
- Aglaia Chalkia
- Nephrology Department, Hippokration General Hospital, Athens, Greece
| | - Christos Koutsianas
- 2nd Department of Medicine and Laboratory, Clinical Immunology - Rheumatology Unit, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | | | - Panagiota Giannou
- Nephrology Department, Hippokration General Hospital, Athens, Greece
| | - Harikleia Gakiopoulou
- 1st Department of Pathology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology - Rheumatology Unit, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Petras
- Nephrology Department, Hippokration General Hospital, Athens, Greece
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15
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Floyd L, Bate S, Hadi Kafagi A, Brown N, Scott J, Srikantharajah M, Myslivecek M, Reid G, Aqeel F, Frausova D, Kollar M, Kieu PL, Khurshid B, Pusey CD, Dhaygude A, Tesar V, McAdoo S, Little MA, Geetha D, Brix SR. Risk Stratification to Predict Renal Survival in Anti-Glomerular Basement Membrane Disease. J Am Soc Nephrol 2023; 34:505-514. [PMID: 36446430 PMCID: PMC10103284 DOI: 10.1681/asn.2022050581] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 12/03/2022] Open
Abstract
SIGNIFICANCE STATEMENT Most patients with anti-glomerular basement membrane (GBM) disease present with rapidly progressive glomerulonephritis, and more than half develop ESKD. Currently, no tools are available to aid in the prognostication or management of this rare disease. In one of the largest assembled cohorts of patients with anti-GBM disease (with 174 patients included in the final analysis), the authors demonstrated that the renal risk score for ANCA-associated vasculitis is transferable to anti-GBM disease and the renal histology is strongly predictive of renal survival and recovery. Stratifying patients according to the percentage of normal glomeruli in the kidney biopsy and the need for RRT at the time of diagnosis improves outcome prediction. Such stratification may assist in the management of anti-GBM disease. BACKGROUND Prospective randomized trials investigating treatments and outcomes in anti-glomerular basement membrane (anti-GBM) disease are sparse, and validated tools to aid prognostication or management are lacking. METHODS In a retrospective, multicenter, international cohort study, we investigated clinical and histologic parameters predicting kidney outcome and sought to identify patients who benefit from rescue immunosuppressive therapy. We also explored applying the concept of the renal risk score (RRS), currently used to predict renal outcomes in ANCA-associated vasculitis, to anti-GBM disease. RESULTS The final analysis included 174 patients (out of a total of 191). Using Cox and Kaplan-Meier methods, we found that the RRS was a strong predictor for ESKD. The 36-month renal survival was 100%, 62.4%, and 20.7% in the low-risk, moderate-risk, and high-risk groups, respectively. The need for renal replacement therapy (RRT) at diagnosis and the percentage of normal glomeruli in the biopsy were independent predictors of ESKD. The best predictor for renal recovery was the percentage of normal glomeruli, with a cut point of 10% normal glomeruli providing good stratification. A model with the predictors RRT and normal glomeruli ( N ) achieved superior discrimination for significant differences in renal survival. Dividing patients into four risk groups led to a 36-month renal survival of 96.4% (no RRT, N ≥10%), 74.0% (no RRT, N <10%), 42.3% (RRT, N ≥10%), and 14.1% (RRT, N <10%), respectively. CONCLUSIONS These findings demonstrate that the RRS concept is transferrable to anti-GBM disease. Stratifying patients according to the need for RRT at diagnosis and renal histology improves prediction, highlighting the importance of normal glomeruli. Such stratification may assist in the management of anti-GBM disease. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3.
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Affiliation(s)
- Lauren Floyd
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Sebastian Bate
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Abdul Hadi Kafagi
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Nina Brown
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Jennifer Scott
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Dublin, Ireland
| | | | - Marek Myslivecek
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Graeme Reid
- Renal Pathology, Adult Histopathology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Faten Aqeel
- Department of Medicine, John Hopkins University, Baltimore, Maryland
| | - Doubravka Frausova
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Marek Kollar
- Centre of Clinical and Transplant Pathology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Phuong Le Kieu
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Bilal Khurshid
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Charles D. Pusey
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Vladimir Tesar
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Stephen McAdoo
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Mark A. Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Dublin, Ireland
| | - Duvuru Geetha
- Department of Medicine, John Hopkins University, Baltimore, Maryland
| | - Silke R. Brix
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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16
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Tang M, Zhang J, Xu X, Pan Q, Zhao H. Clinical characteristics and prognosis of pulmonary renal syndrome in West China. Sci Rep 2023; 13:417. [PMID: 36624127 PMCID: PMC9829867 DOI: 10.1038/s41598-023-27559-7] [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: 07/20/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Pulmonary renal syndrome (PRS) is a rare and life-threatening syndrome. Interstitial lung disease (ILD) has been recently considered another phenotype of lung dysfunction in patients with PRS, but there are very limited data. The characteristics of fifty PRS patients were retrospectively reviewed after a 3-year follow-up, and the differences between PRS patients whose lung dysfunction presented as diffuse alveolar hemorrhage (DAH group) and those with interstitial lung disease (ILD group) were also analyzed. The median age at diagnosis of PRS patients was 50.78 ± 17.88 years, and the main symptoms at disease onset were proteinuria (94.00%), hemoptysis (68.00%), dyspnea (32.00%) and fever (12.00%). DAH patients were younger and had significantly lower hemoglobin levels, a higher incidence of hemoptysis, and higher serum creatinine levels at onset than ILD patients. Univariate analyses of PRS patients showed that respiratory failure and the initiation of mechanical ventilation predicted patient death and that the initiation of hemodialysis and higher serum creatinine levels at onset predicted ESRD. Multivariate analyses showed that respiratory failure and anti-GBM antibody positivity could independently predict patient death. Survival analyses showed that 1- and 3-year patient survival rates and ESRD-free survival rate were not significantly different between the two groups. ILD was another important phenotype of lung dysfunction in patients with PRS. Poor outcomes were observed in PRS patients with ILD and in PRS patients with DAH.
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Affiliation(s)
- Maozhi Tang
- grid.412461.40000 0004 9334 6536Urinary Nephropathy Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
| | - Jun Zhang
- grid.410570.70000 0004 1760 6682Department of Kidney, The First Affiliated Hospital of Army Medical University, Gaotanyan Zhengjie, Shapingba District, Chongqing, 400038 China
| | - Xiaosong Xu
- grid.410570.70000 0004 1760 6682Department of Kidney, The First Affiliated Hospital of Army Medical University, Gaotanyan Zhengjie, Shapingba District, Chongqing, 400038 China
| | - Qianguang Pan
- grid.410570.70000 0004 1760 6682Department of Kidney, The First Affiliated Hospital of Army Medical University, Gaotanyan Zhengjie, Shapingba District, Chongqing, 400038 China
| | - Hongwen Zhao
- Department of Kidney, The First Affiliated Hospital of Army Medical University, Gaotanyan Zhengjie, Shapingba District, Chongqing, 400038, China.
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17
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Ponticelli C, Calatroni M, Moroni G. Anti-glomerular basement membrane vasculitis. Autoimmun Rev 2023; 22:103212. [PMID: 36252931 DOI: 10.1016/j.autrev.2022.103212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022]
Abstract
Antiglomerular basement membrane disease (anti-GBM) is a rare life-threatening autoimmune vasculitis that involves small vessels and it is characterized by circulating autoantibodies directed against type IV collagen antigens expressed in glomerular and alveolar basement membrane. The typical clinical manifestations are the rapidly progressive glomerulonephritis and the alveolar hemorrhage. The diagnosis is usually confirmed by the detection of anti-GBM circulating antibodies. If not rapidly recognized, anti-GBM disease can lead to end stage kidney disease (ESKD). An early diagnosis and prompt treatment with immunosuppressive therapies and plasmapheresis are crucial to prevent a poor outcome. In this review, we discuss the primary form of anti-GBM (the so called Goodpasture syndrome) but also cases associated with other autoimmune diseases such as antineutrophil-cytoplasmic-antibody (ANCA) vasculitis, membranous nephropathy, IgA nephritis and systemic lupus erythematosus (SLE), as well as the few cases of anti-GBM vasculitis complicating kidney transplantation in the Alport syndrome.
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Affiliation(s)
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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18
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Ge Y, Liu K, Yang G, Yu X, Sun B, Zhang B, Yuan Y, Zeng M, Wang N, Xing C, Mao H. Clinicopathological characteristics and outcome predictors of anti-glomerular basement membrane glomerulonephritis. Ren Fail 2022; 44:2037-2045. [PMID: 36408940 PMCID: PMC9683053 DOI: 10.1080/0886022x.2022.2147673] [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] [Indexed: 11/22/2022] Open
Abstract
Objective To explore the clinicopathological features of anti-glomerular basement membrane (anti-GBM) glomerulonephritis (anti-GBM-GN) and the prognostic values of clinical and laboratory indicators at diagnosis on renal and patient survival. Methods A total of 76 patients (34 males and 42 females) with anti-GBM-GN who were hospitalized in the First Affiliated Hospital of Nanjing Medical University between January 2010 and June 2021 were included in this study. The baseline clinical features, histopathological data from renal biopsies, and predictors of renal and patient survival were retrospectively analyzed. Results Among the 76 patients, the median serum creatinine at diagnosis was 618.0 (350.98, 888.25) μmol/L and the median estimated glomerular filtration rate (eGFR) was 6.62 (4.39, 14.41) mL/min. Of these 76 patients, 55 (72.4%) received initial kidney replacement therapy (KRT) and 39 (51.3%) received plasma exchange or double-filtered plasmapheresis (DFPP). During a median follow-up duration of 28.5 (6.0, 71.8) months, 53 (69.7%) patients progressed to kidney failure with replacement therapy (KFRT) and received maintenance dialysis. Initial KRT (HR = 3.48, 95% CI = 1.22–9.97, p = 0.020) was a significant risk factor for renal survival. During the follow-up, 49 (64.5%) of 76 patients survived. Age (≥60 years, HR = 4.13, 95% CI = 1.65–10.38, p = 0.003) and initial KRT (HR = 2.87, 95% CI = 1.01–8.14, p = 0.047) were predictive of patient survival. Conclusions Among patients with anti-GBM-GN, initial KRT at presentation was predictive of KFRT while older age and initial KRT were associated with higher all-cause mortality.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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19
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A unique case of anti-GBM disease with concomitant anti-PLA2R positivity. BMC Nephrol 2022; 23:337. [PMID: 36271343 PMCID: PMC9587597 DOI: 10.1186/s12882-022-02941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Concomitant occurrence of anti-GBM disease and anti-PLA2R positive membranous nephropathy have been previously described. However, to the best of our knowledge, this is the first case report that documents the co-occurrence of the diseases proven by both serologic and histologic methods. CASE PRESENTATION A 51-year-old woman presented to hospital with nausea, bilateral lower extremity edema, dyspnea, dark urine, and then anuria. Symptoms developed one month after an upper respiratory tract infection. Laboratory results showed acute kidney injury, and hypoalbuminemia. Immunologic examination revealed both anti-GBM and anti-PLA2R positivity. Kidney biopsy demonstrated the histological features of Goodpasture's disease and anti-PLA2R positive membranous nephropathy. Steroid, cyclophosphamide, and plasmapheresis were commenced. Despite the combined immunosuppressive, the patient remained on renal replacement therapy. CONCLUSIONS Microbial kidney injury can trigger multiple autoimmune diseases. The simultaneous occurrence of anti-glomerular basement (anti-GBM) disease and membranous nephropathy is extremely rare. Delayed recognition leads to delayed treatment, causing worse renal and patient outcomes, as well as increased financial costs.
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20
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Martin K, Deleveaux S, Cunningham M, Ramaswamy K, Thomas B, Lerma E, Madariaga H. The presentation, etiologies, pathophysiology, and treatment of pulmonary renal syndrome: A review of the literature. Dis Mon 2022; 68:101465. [PMID: 36008166 DOI: 10.1016/j.disamonth.2022.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Pulmonary renal syndrome (PRS) is a constellation of different disorders that cause both rapidly progressive glomerulonephritis and diffuse alveolar hemorrhage. While antineutrophil cytoplasmic antibody associated vasculitis and anti-glomerular basement membrane disease are the predominant causes of PRS, numerous other mechanisms have been shown to cause this syndrome, including thrombotic microangiopathies, drug exposures, and infections, among others. This syndrome has high morbidity and mortality, and early diagnosis and treatment is imperative to improve outcomes. Treatment generally involves glucocorticoids and immunosuppressive agents, but treatment targeted to the underlying disorder can improve outcomes and mitigate side effects. Familiarity with the wide range of possible causes of PRS can aid the clinician in workup, diagnosis and early initiation of treatment. This review provides a summary of the clinical presentation, etiologies, pathophysiology, and treatment of PRS.
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Affiliation(s)
| | | | | | | | - Beje Thomas
- Medstar Georgetown University Hospital, United States
| | - Edgar Lerma
- Advocate Christ Medical Center, United States
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21
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Dowsett T, Oni L. Anti-glomerular basement membrane disease in children: a brief overview. Pediatr Nephrol 2022; 37:1713-1719. [PMID: 34767075 PMCID: PMC8586640 DOI: 10.1007/s00467-021-05333-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 01/04/2023]
Abstract
Anti-glomerular basement membrane disease (Anti-GBM), previously known as Goodpasture syndrome, is an extremely rare cause of rapidly progressive glomerulonephritis and chronic kidney disease stage 5 (CKD5) in children. It is associated with acute pulmonary haemorrhage and it has a poor prognosis. It is classified as an autoimmune, small-vessel vasculitis caused by autoantibody formation against the alpha-3 chain in type IV collagen found in the glomerular basement membrane. Evidence of anti-GBM antibodies in serum or histologically are required for diagnosis. Treatment in children is based on very limited adult data and often involves the use of acute apheresis to rapidly remove circulating factors coupled with intensive immunosuppression such as cyclophosphamide and intravenous corticosteroids. There is also an emerging role for the use of biologic agents such as B cell depletion. The evidence base in children with anti-GBM disease is extremely limited. Multi-centre international collaboration is required to provide insight into this disease, better describe its prognosis and work towards improving outcomes. This review article summarises the key features of this disease in children, highlights treatment options and considers areas of unmet need.
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Affiliation(s)
- Thomas Dowsett
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP, UK.
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Eaton Road, Liverpool, L12 2AP, UK.
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22
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Uhlin F, Szpirt W, Kronbichler A, Bruchfeld A, Soveri I, Rostaing L, Daugas E, Lionet A, Kamar N, Rafat C, Mysliveček M, Tesař V, Fernström A, Kjellman C, Elfving C, McAdoo S, Mölne J, Bajema I, Sonesson E, Segelmark M. Endopeptidase Cleavage of Anti-Glomerular Basement Membrane Antibodies in vivo in Severe Kidney Disease: An Open-Label Phase 2a Study. J Am Soc Nephrol 2022; 33:829-838. [PMID: 35260419 PMCID: PMC8970456 DOI: 10.1681/asn.2021111460] [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: 11/12/2021] [Accepted: 02/01/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The prognosis for kidney survival is poor in patients presenting with circulating anti-glomerular basement membrane (GBM) antibodies and severe kidney injury. It is unknown if treatment with an endopeptidase that cleaves circulating and kidney bound IgG can alter the prognosis. METHODS An investigator-driven phase 2a one-arm study (EudraCT 2016-004082-39) was performed in 17 hospitals in five European countries. A single dose of 0.25 mg/kg of imlifidase was given to 15 adults with circulating anti-GBM antibodies and an eGFR <15 ml/min per 1.73m2. All patients received standard treatment with cyclophosphamide and corticosteroids, but plasma exchange only if autoantibodies rebounded. The primary outcomes were safety and dialysis independency at 6 months. RESULTS At inclusion, ten patients were dialysis dependent and the other five had eGFR levels between 7 and 14 ml/min per 1.73m2. The median age was 61 years (range 19-77), six were women, and six were also positive for anti-neutrophil cytoplasmic antibodies. Then 6 hours after imlifidase infusion, all patients had anti-GBM antibodies levels below the reference range of a prespecified assay. At 6 months 67% (ten out of 15) were dialysis independent. This is significantly higher compared with 18% (nine out of 50) in a historical control cohort (P<0.001, Fisher's exact test). Eight serious adverse events (including one death) were reported, none assessed as probably or possibly related to the study drug. CONCLUSIONS In this pilot study, the use of imlifidase was associated with a better outcome compared with earlier publications, without major safety issues, but the findings need to be confirmed in a randomized controlled trial.Clinical Trial registration number: EUDRACT 2016-004082-39 https://www.clinicaltrialsregister.eu/ctr-search/trial/2007-001377-28/results.
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Affiliation(s)
- Fredrik Uhlin
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Wladimir Szpirt
- Department of Nephrology P, Københavns universitet, Copenhagen, Denmark
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Annette Bruchfeld
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Inga Soveri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lionel Rostaing
- Department of Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation, EriCHU Grenoble-Alpes, Grenoble, France
| | - Eric Daugas
- Nephrology Service, Hôpital Bichat, Université de Paris, Paris, France
| | - Arnaud Lionet
- Neohrology service, Centre Hospitalier Regional, Lille University, Lille, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Université Paul Sabatier, Toulouse, France
| | - Cédric Rafat
- Urgences Néphrologiques et Transplantation Rénale, Paris, France
| | - Marek Mysliveček
- Department of Nephrology, Charles University and General University Hospital, Prague, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, Charles University and General University Hospital, Prague, Czech Republic
| | - Anders Fernström
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | | | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Johan Mölne
- Department of Laboratory Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Mårten Segelmark
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden .,Department of Clinical Sciences, Lund University, Lund, Sweden
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23
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 787] [Impact Index Per Article: 262.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Zahir Z, Wani AS, Prasad N, Jain M. Clinicopathological characteristics and predictors of poor outcome in anti-glomerular basement membrane disease - a fifteen year single center experience. Ren Fail 2021; 43:79-89. [PMID: 33334228 PMCID: PMC7751384 DOI: 10.1080/0886022x.2020.1854301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Anti-glomerular basement membrane (anti-GBM) disease is a small vessel vasculitis affecting the renal and lung capillary beds. We aim to study the clinicopathological characteristics and predictors of poor outcome of this disease in our population. Materials and methods This is a 15 year retrospective, single center observational study of Indian cohort. Patients with biopsy proven anti-GBM disease were studied. Results Anti-GBM disease was found in 0.5% of the total cases. The mean age at presentation was 46.7 years. Compared to renal limited disease those with pulmonary-renal syndrome had a higher frequency of hypertension, oliguria, percentage of crescents, interstitial inflammation and glomerulosclerosis. Double positive (anti-GBM and ANCA antibodies) patients showed more of glomerulosclerosis, tubular atrophy/interstitial fibrosis (IFTA) as well as periglomerular granulomas on biopsy. Patient survival at one year was 40.4% and death censored renal survival was 9.7%. Factors affecting the dialysis dependency at presentation were oligoanuria (p = .04), creatinine levels >5.7 mg/dl (p = .003), and high mean anti-GBM titers (p = .008). Atypical cases accounted for 8.3% of these patients. Oligoanuria (HR = 5.0, p = .05), high serum creatinine (HR = 1.55, p = .05), severe glomerulosclerosis (HR = 1.09, p = .03), and IFTA (HR = 2, p = .04) were associated with poor renal outcome. Advanced age (HR = 1.92, p = .03), high serum creatinine (HR = 1.9, p = .04) and high anti-GBM titers (HR = 1.01, p = .03) were associated with poor patient survival. Conclusions Anti-GBM is a rare disease with poor prognosis and varied presentations. Patients with pulmonary-renal syndrome showed severe disease whereas double positive had more of chronic changes. The predictors of poor prognosis include advanced age, oliguria, serum anti-GBM levels, serum creatinine levels, degree of glomerulosclerosis and IFTA. Atypical anti-GBM cases should be kept in mind while evaluating renal biopsies.
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Affiliation(s)
- Zafirah Zahir
- PDCC Renal Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Asif Sadiq Wani
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.,Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Narayan Prasad
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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25
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Garcia GE, Lu YJ, Truong LD, Roncal-Jiménez CA, Miyazaki M, Miyazaki-Anzai S, Cara-Fuentes G, Andres-Hernando A, Lanaspa M, Johnson RJ, Leamon CP. A Novel Treatment for Glomerular Disease: Targeting the Activated Macrophage Folate Receptor with a Trojan Horse Therapy in Rats. Cells 2021; 10:2113. [PMID: 34440885 PMCID: PMC8393837 DOI: 10.3390/cells10082113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 02/07/2023] Open
Abstract
Since activated macrophages express a functional folate receptor β (FRβ), targeting this macrophage population with folate-linked drugs could increase selectivity to treat inflammatory diseases. Using a macrophage-mediated anti-glomerular basement membrane (anti-GBM) glomerulonephritis (GN) in WKY rats, we investigated the effect of a novel folic acid-aminopterin (AMT) conjugate (EC2319) designed to intracellularly deliver AMT via the FR. We found that treatment with EC2319 significantly attenuated kidney injury and preserved renal function. Kidney protection with EC2319 was blocked by a folate competitor, indicating that its mechanism of action was specifically FRβ-mediated. Notably, treatment with methotrexate (MTX), another folic acid antagonist related to AMT, did not protect from kidney damage. EC2319 reduced glomerular and interstitial macrophage infiltration and decreased M1 macrophage recruitment but not M2 macrophages. The expression of CCL2 and the pro-fibrotic cytokine TGF-β were also reduced in nephritic glomeruli with EC2319 treatment. In EC2319-treated rats, there was a significant decrease in the deposition of collagens. In nephritic kidneys, FRβ was expressed on periglomerular macrophages and macrophages present in the crescents, but its expression was not observed in normal kidneys. These data indicate that selectively targeting the activated macrophage population could represent a novel means for treating anti-GBM GN and other acute crescentic glomerulonephritis.
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Affiliation(s)
- Gabriela E. Garcia
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Yingjuan J. Lu
- Endocyte, Inc., Novartis Institutes for Biomedical Research, West Lafayette, IN 47906, USA; (Y.J.L.); (C.P.L.)
| | - Luan D. Truong
- Department of Pathology, The Houston Methodist Hospital, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Carlos A. Roncal-Jiménez
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Makoto Miyazaki
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Shinobu Miyazaki-Anzai
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Gabriel Cara-Fuentes
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Ana Andres-Hernando
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Miguel Lanaspa
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Richard J. Johnson
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Christopher P. Leamon
- Endocyte, Inc., Novartis Institutes for Biomedical Research, West Lafayette, IN 47906, USA; (Y.J.L.); (C.P.L.)
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Shin JI, Geetha D, Szpirt WM, Windpessl M, Kronbichler A. Anti-glomerular basement membrane disease (Goodpasture disease): From pathogenesis to plasma exchange to IdeS. Ther Apher Dial 2021; 26:24-31. [PMID: 34339589 DOI: 10.1111/1744-9987.13718] [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: 06/29/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 12/28/2022]
Abstract
Anti-glomerular basement membrane (GBM) disease (Goodpasture disease) often presents with severe kidney failure and pulmonary hemorrhage. Anti-GBM antibodies are pathogenic, and other autoantibodies such as laminin-521 have been identified recently, potentially indicating a subset with a more severe disease phenotype and poor prognosis. Around 30%-40% of patients are also anti-neutrophil cytoplasmatic antibody (ANCA)-positive and this subset combines features of anti-GBM disease and ANCA-associated vasculitis, with particular impact on long-term treatment. A combination of therapeutic plasma exchange (or immunoadsorption), cyclophosphamide, and glucocorticoids is considered standard of care management, but despite early initiation, patients with poor prognostic factors often remain dialysis dependent. Imlifidase (IdeS), capable to cleave IgG within hours, has been tested in a phase II trial. Among 15 patients, 10 with poor prognosis at baseline (eGFR <15 ml/min/1.73 m2 ) were dialysis independent at 6 months. Further developments are needed to refine treatment approaches in anti-GBM disease.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wladimir M Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
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Philip R, Dumont A, Martin Silva N, de Boysson H, Aouba A, Deshayes S. ANCA and anti-glomerular basement membrane double-positive patients: A systematic review of the literature. Autoimmun Rev 2021; 20:102885. [PMID: 34242834 DOI: 10.1016/j.autrev.2021.102885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Double-positive patients (DPP) exhibiting anti-glomerular basement membrane (GBM) and anti-neutrophil cytoplasmic antibodies (ANCAs) belong to an entity that is newly and poorly described, mainly in short series. We aimed to better characterize the epidemiological features, clinical presentation and therapeutic outcomes of these patients through a systematic review. METHODS We performed a systematic review of English-, German-, Spanish- and French-written publications from February 1987 to March 2020 reporting cases of DPP using the following databases: PubMed, Scielo, ScienceDirect, Google Scholar, The Cochrane Library, Open Grey, The Grey Literature Report, Clinicaltrials.gov and International Clinical Trial Registry Platform of the World Health Organization. RESULTS In total, 538 DPP were identified from 90 articles. Their clinical presentations were often severe, and the majority exhibited acute kidney failure (91.8%) with a median initial serum creatinine level of 873 μmol/L; 50.7% had alveolar haemorrhage. Other manifestations were present in 30.3% of DPP, mainly ear, nose, throat and articular manifestations. ANCAs were predominantly directed against MPO (n = 377/523; 72.1%) compared to PR3 (n = 107/523; 20.5%), with rare cases of triple positivity (n = 15/538; 2.9%). Although most patients received initial immunosuppressive therapy (n = 285/317; 89.9%), the one-year overall, renal and relapse-free survival rates were 64.8%, 38.7% and 71.1%, respectively. CONCLUSION DPP are associated with the characteristics of two eponymous vasculitis types, responsible for a poor overall and renal prognosis. Thus, simultaneous testing of both antibodies and systematic renal biopsy should be recommended in every patient with rapidly progressive glomerulonephritis to recognize this difficult-to-treat and rare disease.
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Affiliation(s)
- Rémi Philip
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France
| | - Anael Dumont
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
| | - Nicolas Martin Silva
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France
| | - Hubert de Boysson
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
| | - Achille Aouba
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France.
| | - Samuel Deshayes
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
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Jia T, Zhang R, Kong F, Zhang Q, Xi Z. The Prognostic Role and Nomogram Establishment of a Novel Prognostic Score Combining with Fibrinogen and Albumin Levels in Patients with WHO Grade II/III Gliomas. Int J Gen Med 2021; 14:2137-2145. [PMID: 34093034 PMCID: PMC8169085 DOI: 10.2147/ijgm.s303733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/14/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose World Health Organization (WHO) Grades II and III gliomas [also known as low grade gliomas (LGGs)] displayed different malignant behaviors and survival outcomes compared to Grade IV gliomas. This study aimed to identify the prognostic predictive value of a novel cumulative prognostic score [combined with fibrinogen and albumin levels (FA score)], establish and validate a point-based nomogram in LGG patients. Patients and Methods A total of 91 patients who underwent total glioma resection at Shengjing Hospital of China Medical University between 2011 and 2013 were enrolled to establish a prognostic nomogram. All patients were histologically diagnosed as grades II/III, and never received radiotherapy or chemotherapy before surgery. Data collection included patient characteristics, clinicopathological factors, and preoperative hematology results. The performance of the nomogram was subsequently validated by the concordance index (c-index), calibration curve, and receiver operating characteristic (ROC) curve. Results The FA score was negatively associated with the overall survival (OS) of LGG patients (p < 0.001). The results of multivariate analysis showed that FA score [p = 0.006, HR = 1.92, 95% confidence interval (CI): 1.21–3.05], age (p = 0.002, HR = 3.014, 95% CI:1.52–5.97), and white blood count (p < 0.001, HR = 4.24, 95% CI: 2.08–8.67) were independent prognostic factors for overall survival (OS). The study established a nomogram to predict OS with a c-index of 0.783 (95% CI, 0.72–0.84). Conclusion FA score might be a potential prognostic biomarker for LGG patients, and a reliable point-based nomogram will help clinicians to decide on the best treatment plans.
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Affiliation(s)
- Tianshu Jia
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Rui Zhang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Fanfei Kong
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Qianjiao Zhang
- Pain Department, The People's Hospital of Liaoning Province, Shenyang, People's Republic of China
| | - Zhuo Xi
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
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Shimamura Y, Maeda T, Abe K, Ogawa Y, Takizawa H. Clinical and immunologic characteristics of Japanese patients with anti-glomerular basement membrane disease: case reports and literature review. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00317-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Clinical studies of anti-glomerular basement membrane (GBM) disease were limited because of the low incidence. We aimed to report the characteristics, treatments, and outcomes of patients with anti-GBM disease at a tertiary reference medical center in Japan and review the literature of mortality in patients with anti-GBM disease.
Case presentation
Case 1 was a 72-year-old Japanese man that was referred with worsening of the serum creatinine (from 1.1 to 27.3 mg/dL). Anti-GBM disease was confirmed by renal biopsy, and treatments with oral prednisolone and plasmapheresis were initiated. Although his anti-GBM antibody decreased (from 476 to 18 units/mL) after the treatments, the patient died from lung abscess. Case 2 was a 32-year-old Japanese man that presented with fever and macroscopic hematuria. At presentation, his serum creatinine was 4.2 mg/dL, and anti-GBM antibody was 265 units/mL. Renal biopsy confirmed the diagnosis of anti-GBM disease, and intensive treatments with plasmapheresis and methyl prednisolone were started, followed by oral prednisolone. Living-donor kidney transplantation was performed because his anti-GBM antibody had remained undetectable for 1 year after diagnosis. In the main text, clinicopathological characteristics of 12 patients with anti-GBM disease at our institution were summarized.
Conclusions
We found that the 1-year survival rate of patients with anti-GBM disease was 88% in our cohort, which was comparable to previous studies. Multicenter, nationwide studies are expected to evaluate prognosis of Japanese patients with this rare entity.
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Abstract
Rapidly progressive glomerulonephritis (RPGN) is a form of glomerulonephritis characterized by loss of renal function within weeks. Although a variety of underlying causes can trigger RPGN, the ultimate pathologic mechanism is the podocyte and epithelial activation leading to the crescent formation. Rituximab has been increasingly and successfully used for autoimmune conditions in recent years. Treatment of RPGN is based on the underlying condition, but specific clinical guidelines are lacking. In this article, we have tried to establish the role of rituximab in the management of patients with RPGN. All the studies we have used were found in the PubMed database, limited to studies involving adults. Animal studies and studies involving the pediatric population were excluded. The currently available literature does not support switching to rituximab as the first-line agent. It has failed to prove consistently superior to other medications. However, combined with other commonly prescribed treatment regimens, namely corticosteroids, with or without cytotoxic drugs, rituximab has shown efficacy in many studies. Therefore, we have concluded that the most prudent use of rituximab in patients with RPGN would be in those with disease refractory to standard management with corticosteroids and cytotoxic drugs or in those who have intolerable side effects. We believe that clinicians should keep reporting any cases of RPGN treated with rituximab so that a more clear pattern emerges and more exact treatment guidelines can be made.
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Affiliation(s)
- Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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31
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Marques C, Plaisier E, Cacoub P, Cadranel J, Saadoun D. [Review on anti-glomerular basement membrane disease or Goodpasture's syndrome]. Rev Med Interne 2019; 41:14-20. [PMID: 31776042 DOI: 10.1016/j.revmed.2019.10.338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/20/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023]
Abstract
Anti-glomerular basement membrane (anti-GBM) disease or Goodpasture's syndrome is a small vessel vasculitis affecting the capillary beds of kidneys and lungs. It is an autoimmune disease mediated by autoantibodies targeting the glomerular and alveolar basement membranes, leading to pneumorenal syndrome. It is a rare, monophasic and severe disease, associating rapidly progressive glomerulonephritis and alveolar hemorrhage. The presence of antineutrophil cytoplasmic antibodies (ANCA) is reported in 20 to 60% of cases. Management should be prompt and combine plasma exchange with systemic corticosteroids and immunosuppressive therapy by cyclophosphamide. The objective of this review is: 1) to describe the pathogenesis, clinical and histological features of the disease; 2) to characterize double-positive anti-GBM/ANCA patients; 3) to highlight the prognostic factors of renal and global survival, and 4) to focus on the treatment of anti-GBM disease.
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Affiliation(s)
- C Marques
- Sorbonne Université, UPMC Université Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), 75005, Paris, France; Inserm, UMR_S 959, 75013, Paris, France; CNRS, FRE3632, 75005, Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France; Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, 94270 Le Kremlin Bicêtre, France.
| | - E Plaisier
- Sorbonne Université, UPMC Université Paris 06, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, 75020 Paris, France
| | - P Cacoub
- Sorbonne Université, UPMC Université Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), 75005, Paris, France; Inserm, UMR_S 959, 75013, Paris, France; CNRS, FRE3632, 75005, Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France; Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, 94270 Le Kremlin Bicêtre, France
| | - J Cadranel
- Chest Department and Constitutive Center for Rare Pulmonary Disease, Hôpital Tenon, AP-HP, Inflammation-Immunopathology-Biotherapy Department (DHU i2B) and Sorbonne Université, 75020 Paris, France
| | - D Saadoun
- Sorbonne Université, UPMC Université Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), 75005, Paris, France; Inserm, UMR_S 959, 75013, Paris, France; CNRS, FRE3632, 75005, Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France; Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, 94270 Le Kremlin Bicêtre, France
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