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Barratt J, Liew A, Yeo SC, Fernström A, Barbour SJ, Sperati CJ, Villanueva R, Wu MJ, Wang D, Borodovsky A, Badri P, Yureneva E, Bhan I, Cattran D. Phase 2 Trial of Cemdisiran in Adult Patients with IgA Nephropathy: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2024; 19:452-462. [PMID: 38214599 PMCID: PMC11020434 DOI: 10.2215/cjn.0000000000000384] [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: 07/27/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND IgA nephropathy is the most common primary GN. Clinical features of IgA nephropathy include proteinuria, which is the strongest known surrogate of progression to kidney failure. Complement pathway activation is a critical driver of inflammation and tissue injury in IgA nephropathy. Cemdisiran is an investigational RNA interference therapeutic that suppresses hepatic production of complement component 5 (C5), thereby potentially reducing proteinuria in IgA nephropathy. We evaluated the efficacy and safety of cemdisiran in adult patients with IgA nephropathy at high risk of kidney disease progression. METHODS In this phase 2, 36-week, double-blind study, adult patients with IgA nephropathy and urine protein ≥1 g/24 hours were randomized (2:1) to subcutaneous cemdisiran 600 mg or placebo every 4 weeks in combination with the standard of care. The primary end point was percentage change from baseline at week 32 in urine protein-to-creatinine ratio (UPCR) measured by 24-hour urine collection. Additional end points included change from baseline in UPCR measured by spot urine, serum C5 level, and safety assessments. RESULTS Thirty-one patients were randomized (cemdisiran, N =22; placebo, N =9). Cemdisiran-treated patients had a placebo-adjusted geometric mean change in 24-hour UPCR of -37.4% (cemdisiran-adjusted geometric mean ratio to baseline [SEM], 0.69 [0.10]) at week 32. Spot UPCR was consistent with 24-hour UPCR placebo-adjusted change of -45.8% (cemdisiran-adjusted geometric mean ratio to baseline [SEM], 0.73 [0.11]). Mean (SD) change in serum C5 level from baseline at week 32 was -98.7% (1.2) with cemdisiran and 25.2% (57.7) with placebo. Over 36 weeks, most adverse events were mild or moderate and transient; the most common adverse event after cemdisiran treatment was injection-site reaction (41%). CONCLUSIONS These findings indicate that treatment with cemdisiran resulted in a reduction of proteinuria at week 32 and was well tolerated.
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Affiliation(s)
- Jonathan Barratt
- Department of Cardiovascular Medicine, University of Leicester, Leicester, United Kingdom
| | - Adrian Liew
- Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - See Cheng Yeo
- Renal Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anders Fernström
- Department of Nephrology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Sean J. Barbour
- University of British Columbia, Division of Nephrology, Vancouver, British Columbia, Canada
| | - C. John Sperati
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ming-Ju Wu
- Department of Internal Medicine, Taichung Veterans General Hospital and Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Dazhe Wang
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
| | | | | | | | - Ishir Bhan
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
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Koubar SH, Garcia-Rivera A, Mohamed MMB, Hall JE, Hall ME, Hassanein M. Underlying Mechanisms and Treatment of Hypertension in Glomerular Diseases. Curr Hypertens Rep 2024; 26:119-130. [PMID: 37982994 DOI: 10.1007/s11906-023-01287-9] [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] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the underlying mechanisms that lead to hypertension in glomerular diseases and the advancements in treatment strategies and to provide clinicians with valuable insights into the pathophysiological mechanisms and evidence-based therapeutic approaches for managing hypertension in patients with glomerular diseases. RECENT FINDINGS In recent years, there have been remarkable advancements in our understanding of the immune and non-immune mechanisms that are involved in the pathogenesis of hypertension in glomerular diseases. Furthermore, this review will encompass the latest data on management strategies, including RAAS inhibition, endothelin receptor blockers, SGLT2 inhibitors, and immune-based therapies. Hypertension (HTN) and cardiovascular diseases are leading causes of mortality in glomerular diseases. The latter are intricately related with hypertension and share common pathophysiological mechanisms. Hypertension in glomerular disease represents a complex and multifaceted interplay between kidney dysfunction, immune-mediated, and non-immune-mediated pathology. Understanding the complex mechanisms involved in this relationship has evolved significantly over the years, shedding light on the pathophysiological processes underlying the development and progression of glomerular disease-associated HTN, and is crucial for developing effective therapeutic strategies and improving patients' outcomes.
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Affiliation(s)
- Sahar H Koubar
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alejandro Garcia-Rivera
- Department of Nephrology. Hospital General Regional 46, Instituto Mexicano del Seguro Social, Guadalajara, Mexico
| | - Muner M B Mohamed
- Department of Nephrology, Ochsner Health System, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - John E Hall
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
- Mississippi Center for Obesity Research, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael E Hall
- Division of Cardiovascular Disease, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohamed Hassanein
- Division of Nephrology and Hypertension, Department of Medicine, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, USA.
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Tang C, Chen P, Si FL, Yao YX, Lv JC, Shi SF, Zhou XJ, Liu LJ, Zhang H. Intensive blood pressure control and the progression of IgA nephropathy: a cohort study using marginal structural models. Nephrol Dial Transplant 2023; 39:55-63. [PMID: 37391382 DOI: 10.1093/ndt/gfad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND In chronic kidney disease, current guidelines recommend systolic blood pressure (SBP) below 120 mmHg. However, the renoprotective effect of intensive blood-pressure (BP) lowering on immunoglobulin A nephropathy (IgAN) remains undetermined. We aimed to determine the effect of intensive BP control on the progression of IgAN. METHODS At Peking University First Hospital, 1530 patients with IgAN were enrolled. An examination of the relationship between baseline and time-updated BP and composite kidney outcomes, defined as development of end-stage kidney disease (ESKD) or a 30% decline in estimated glomerular filtration rate (eGFR), was conducted. Baseline and time-updated BPs were modeled using multivariate causal hazards models and marginal structural models (MSMs). RESULTS In a median follow-up of 43.5 (interquartile range 27.2, 72.7) months, 367 (24.0%) patients experienced the composite kidney outcomes. No significant associations were found between baseline BP and the composite outcomes. Using MSMs with time-updated SBP for analysis, a U-shaped association was found. In reference to SBP 110-119 mmHg, hazard ratios (95% confidence intervals) for the SBP categories <110, 120-129, 130-139 and ≥140 mmHg were 1.48 (1.02-2.17), 1.13 (0.80-1.60), 2.21 (1.54-3.16) and 2.91 (1.94-4.35), respectively. The trend was more prominent in patients with proteinuria ≥1 g/day and eGFR ≥60 mL/min/1.73 m2. After analyzing time-updated diastolic BP, no similar trend was observed. CONCLUSIONS In patients with IgAN, intensive BP control during the treatment period may retard the kidney disease progression, but the potential risk of hypotension still needs to be considered.
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Affiliation(s)
- Chen Tang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Pei Chen
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Feng-Lei Si
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu-Xuan Yao
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xu-Jie Zhou
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Cattran DC, Floege J, Coppo R. Evaluating Progression Risk in Patients With Immunoglobulin A Nephropathy. Kidney Int Rep 2023; 8:2515-2528. [PMID: 38106572 PMCID: PMC10719597 DOI: 10.1016/j.ekir.2023.09.020] [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: 06/06/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 12/19/2023] Open
Abstract
The highly variable rate of decline in kidney function in patients with immunoglobulin A nephropathy (IgAN) provides a major clinical challenge. Predicting which patients will progress to kidney failure, and how quickly, is difficult. Multiple novel therapies are likely to be approved in the short-term, but clinicians lack the tools to identify patients most likely to benefit from specific treatments at the right time. Noninvasive and validated markers for selecting at-risk patients and longitudinal monitoring are urgently needed. This review summarizes what is known about demographic, clinical, and histopathologic prognostic markers in the clinician's toolkit, including the International IgAN Prediction Tool. We also briefly review what is known on these topics in children and adolescents with IgAN. Although helpful, currently used markers leave clinicians heavily reliant on histologic features from the diagnostic kidney biopsy and standard clinical data to guide treatment choice, and very few noninvasive markers reflect treatment efficacy over time. Novel prognostic and predictive markers are under clinical investigation, with considerable progress being made in markers of complement activation. Other areas of research are the interplay between gut microbiota and galactose-deficient IgA1 expression; microRNAs; imaging; artificial intelligence; and markers of fibrosis. Given the rate of therapeutic advancement, the remaining gaps in biomarker research need to be addressed. We finish by describing our route to clinical utility of predictive and prognostic markers in IgAN. This route will provide us with the chance to improve IgAN prognosis by using robust, clinically practical markers to inform patient care.
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Affiliation(s)
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University, Aachen, Germany
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
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Bednarova K, Mjøen G, Hruba P, Modos I, Voska L, Kollar M, Viklicky O. A novel prognostic nomogram predicts premature failure of kidney allografts with IgA nephropathy recurrence. Nephrol Dial Transplant 2023; 38:2627-2636. [PMID: 37202220 PMCID: PMC10660147 DOI: 10.1093/ndt/gfad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Recurrence of immunoglobulin A nephropathy (IgAN) limits graft survival in kidney transplantation. However, predictors of a worse outcome are poorly understood. METHODS Among 442 kidney transplant recipients (KTRs) with IgAN, 83 (18.8%) KTRs exhibited biopsy-proven IgAN recurrence between 1994 and 2020 and were enrolled in the derivation cohort. A multivariable Cox model predicting allograft loss based on clinical data at the biopsy and a web-based nomogram were developed. The nomogram was externally validated using an independent cohort (n = 67). RESULTS Patient age <43 years {hazard ratio [HR] 2.20 [95% confidence interval (CI) 1.41-3.43], P < .001}, female gender [HR 1.72 (95% CI 1.07-2.76), P = .026] and retransplantation status [HR 1.98 (95% CI 1.13-3.36), P = .016] were identified as independent risk factors for IgAN recurrence. Patient age <43 years [HR 2.77 (95% CI 1.17-6.56), P = .02], proteinuria >1 g/24 hours [HR 3.12 (95% CI 1.40-6.91), P = .005] and C4d positivity [HR 2.93 (95% CI 1.26-6.83), P = .013] were found to be associated with graft loss in patients with IgAN recurrence. A nomogram predicting graft loss was constructed based on clinical and histological variables, with a C statistic of 0.736 for the derivation cohort and 0.807 for the external validation cohort. CONCLUSIONS The established nomogram identified patients with recurrent IgAN at risk for premature graft loss with good predictive performance.
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Affiliation(s)
- Kamila Bednarova
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- 1st Medical Faculty, Charles University, Prague, Czech Republic
| | - Geir Mjøen
- Department of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Istvan Modos
- Department of Informatics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ludek Voska
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marek Kollar
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Abstract
PURPOSE OF REVIEW In the past, the treatment of IgA nephropathy (IgAN), which is the most common glomerulonephritis worldwide, mostly relied on blockade of the renin-angiotensin system as a central component of so-called supportive therapy as well as on high-dose systemic corticosteroid therapy. RECENT FINDINGS The supportive treatment arm has been expanded by the addition of sodium-glucose cotransporter-2 inhibitors, hydroxychloroquine, and, most recently, endothelin A receptor blockers. Treatment with high-dose systemic corticosteroids has become more controversial, with some studies observing no benefit and others documenting the protection of kidney function. However, all recent studies on systemic corticosteroids consistently found significant toxicity. An important novel approach to IgAN, therefore, is therapy with a targeted release formulation of budesonide with preferential release in the distal small intestine, given the mounting evidence for a gut-kidney axis in the pathophysiology of IgAN. In addition, emerging new therapeutic options include a variety of complement inhibitors as well as agents targeting B-cell proliferation and differentiation. SUMMARY In recent years, IgAN has become the focus of a considerable number of clinical studies that will significantly advance the development of new therapy strategies.
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Affiliation(s)
- Uta Kunter
- Division of Nephrology and Rheumatology, RWTH Aachen University Hospital, Aachen, Germany
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Li Y, Jiang S, Gao H, Yang Y, Liu X, Li W. Factors associated with the progression of mesangial lesions in IgA nephropathy: A comparative analysis of renal re-biopsies. Front Endocrinol (Lausanne) 2022; 13:1004289. [PMID: 36479219 PMCID: PMC9719920 DOI: 10.3389/fendo.2022.1004289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES IgA nephropathy (IgAN) is the most common primary glomerular disease, and is the leading cause of chronic renal failure. Because mesangial lesions are the main pathological changes seen in IgAN, we investigated factors associated with the progression of mesangial lesions in IgAN. METHODS We enrolled participants with IgAN who underwent repeat renal biopsies. Based on the progression of mesangial proliferative lesions, the participants were divided into progressive and stable groups. The progression group included participants with a ratio of mesangial cell proliferation score ≥ 1.1 (i.e., proliferation of > 10%) in the second biopsy specimen compared to the first biopsy specimen. The stable group included participants who did not fulfill the aforementioned criteria. We recorded the laboratory parameters, expression of renin-angiotensin system (RAS) receptors (angiotensin II type 1 receptor [AT1R], angiotensin II type 2 receptor [AT2R], Mas receptor [MasR], and the Mas-related G protein-coupled receptor, member D [MrgD]) and mesangial matrix proteins (collagen [Col] IV, fibronectin [FN] and laminin) at the first and second renal biopsies, and the use of immunosuppressive therapy and/or RAS blockers after the first biopsy. RESULTS We enrolled 24 patients with IgAN who underwent repeat renal biopsies. Half of patients showed progression of mesangial lesions on repeat renal biopsy after a median of 4.3 (1-6) years. The progression group had significantly higher expression levels of AT1R and mesangial matrix proteins (Col IV and FN), and significantly lower expression of AT2R and MasR, compared to the stable group. Multivariate analysis showed that the use of RAS blockers (hazard ratio [HR], 0.27; 95% CI, 0.08-0.97; p < 0.05) and the level of proteinuria (HR, 1.8; 95% CI, 1.04-3.12; p < 0.05) were associated with progression of mesangial lesions. Additionally, the progression group exhibited a more rapid decline of renal function compared to the stable group (0.38 and 0.012 ml/min/1.73 m2/month, respectively; p = 0.004). CONCLUSIONS Continuous activation of the intrarenal RAS and massive proteinuria correlate with histological progression of mesangial lesions in IgAN patients, which may further accelerate the deterioration of renal function.
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Affiliation(s)
- Yetong Li
- Department of Nephrology, Beijing Children’s Hospital, National Center for Children’s Health, Capital Medical University, Beijing, China
| | - Shimin Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Hongmei Gao
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Yue Yang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Xiaorong Liu
- Department of Nephrology, Beijing Children’s Hospital, National Center for Children’s Health, Capital Medical University, Beijing, China
- *Correspondence: Xiaorong Liu, ; Wenge Li,
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Xiaorong Liu, ; Wenge Li,
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