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Luo MN, Pan Q, Ye T, Li S, Yang L, Liu HF, Xu Y. Efficacy and safety of sequential immunosuppressive treatment for severe IgA nephropathy: A retrospective study. Front Pharmacol 2023; 14:1093442. [PMID: 36998610 PMCID: PMC10043386 DOI: 10.3389/fphar.2023.1093442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
Background: This study compared the efficacy and safety of sequential immunosuppressive therapy in patients with non-end-stage IgA nephropathy (IgAN) with Lee’s classification of IV ∼ V and provided evidence for the use of immunotherapy in patients with severe IgAN.Methods: We retrospectively analyzed the clinical data of patients with Lee’s IV ∼ V non-end-stage IgA nephropathy.Results: 436 patients were diagnosed with IgAN, and 98 patients who met the inclusion criteria were included in this retrospective study. Of these, 17 were in the supportive care group, 20 in the P group (prednisone-only), 35 in P + CTX group (the prednisone combined with cyclophosphamide followed by mycophenolate mofetil), and 26 in the P + MMF group (prednisone combined with mycophenolate mofetil). The four groups showed differences in the segmental glomerulosclerosis score and the proportion of patients with Lee’s grade IV (p < 0.05), but no differences in other indicators. Compared with the baseline values, urine protein-to-creatinine ratio (PCR) significantly decreased and serum albumin increased (p < 0.05), but there was no significant difference between the groups. The estimated Glomerular Filtration Rate (eGFR) of the P, P + MMF, and P + CTX groups were higher than that of the supportive care group at the 6th and 24th month after treatment (all p < 0.05). At the 24th month, the eGFR in the P + CTX group was higher than that in the P + MMF group (p < 0.05). The effective remission rate of the P + CTX group was higher than that of the supportive care group (p < 0.05). At 12 months, the effective remission rate of the P group was higher than that of the supportive care group (p < 0.05). At the 24th month, there was no significant difference in the effective remission rates among the three groups (P, P + MMF, and P + CTX). Nine patients with severe IgA nephropathy reached the endpoint.Conclusion: This study showed that immunosuppressive therapy insevere IgAN patient scan effectively reduce urinary protein, increase albumin, and protect renal function in the early stages of IgAN. P + CTX is the most commonly used, which has a high effective remission rate of urine protein and a low incidence of end-point events.
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Affiliation(s)
- Mian-Na Luo
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-Communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Qingjun Pan
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-Communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Ting Ye
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Shangmei Li
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-Communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Lawei Yang
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-Communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Hua-Feng Liu
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-Communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yongzhi Xu
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- *Correspondence: Yongzhi Xu,
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Luo MN, Yin Y, Li S, Hao J, Yao C, Xu YZ, Liu HF, Yang L. Podocytes are likely the therapeutic target of IgA nephropathy with isolated hematuria: Evidence from repeat renal biopsy. Front Pharmacol 2023; 14:1148553. [PMID: 37089927 PMCID: PMC10119397 DOI: 10.3389/fphar.2023.1148553] [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: 01/20/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Background: The present study aimed to prove the progression of immunoglobulin A nephropathy (IgAN) patients with isolated hematuria based on repeat renal biopsy data for the first time. Methods: 29 IgAN patients with isolated hematuria who received repeat renal biopsies were analyzed retrospectively, while 29 non-isolated hematuria IgAN patients with similar age and background were randomly selected as the control group. Clinical parameters were collected at the time of biopsy. The treatment strategies (conservative treatment with RASS blocker or immunosuppressive treatment) were choosen according to the pathological results at the first renal biopsy. The activity and chronicity indexes of renal lesions were evaluated. Markers of cell inflammation and proliferation were tseted by immunochemistry. The ultrastructure of podocytes was observed by transmission electron microscopy (TEM). Podocyte and oxidative stress marker (NPHS2 and 4-HNE) were detected by immunofluorescence. Results: The IgAN patients with isolated hematuria had better clinical indicators than those with no-isolated hematuria, such as better renal function, higher albumin and lower uric acid. The interval between two biopsies in IgAN patients with isolated hematuria was 630 (interquartile range, 409.5-1,171) days. The hematuria of the patients decreased significantly from 30 (IQR, 4.00-35.00) RBC/ul in the first biopsy to 11 (IQR, 2.50-30.00) RBC/ul in the repeated biopsy (p < 0.05). The level of triglyceride decreased significantly (p < 0.05). The other clinical indicators were not statistically significant (p > 0.05). Deposits of IgA and C3 in the glomerulus were persistent. The activity index decreased, especially cellular crescent formation, while the chronicity index increased. The ultrastructure of podocytes was improved after treatment. The oxidative stress products of podocytes reduced after treatment. Conclusion: Although the clinical indicators of the IgAN patients with isolated hematuria were in the normal range, various acute and chronic pathological changes have occurred, and irreversible chronic changes have been progressing. Cell inflammation and proliferation persisted. Oxidative stress of podocytes was likely to be the therapeutic target. This study provided a strong basis for the progress of IgAN with isolated hematuria through pathological changes before and after treatment. This study will help clinicians recognize the harm of hematuria, change the traditional treatment concept, and help such patients get early treatment.
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Affiliation(s)
- Mian-Na Luo
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yanqing Yin
- Department of the First Clinical Medical College, Guangdong Medical University, Zhanjiang, China
| | - Shangmei Li
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Junfeng Hao
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Cuiwei Yao
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yong-Zhi Xu
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- *Correspondence: Yong-Zhi Xu, ; Lawei Yang,
| | - Hua-feng Liu
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Lawei Yang
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-communicable Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- *Correspondence: Yong-Zhi Xu, ; Lawei Yang,
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Jullien P, Laurent B, Berthoux F, Masson I, Dinic M, Claisse G, Thibaudin D, Mariat C, Alamartine E, Maillard N. Repeat renal biopsy improves the Oxford classification-based prediction of immunoglobulin A nephropathy outcome. Nephrol Dial Transplant 2020; 35:1179-1186. [PMID: 30445530 DOI: 10.1093/ndt/gfy341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/23/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The prognosis of IgA nephropathy (IgAN) is very heterogeneous. Predicting the nature and the rate of the disease progression is crucial for refining patient treatment. The aim of this study was to evaluate the prognostic impact of an Oxford classification-based repeat kidney tissue evaluation to predict end-stage renal disease (ESRD). METHODS Patients with biopsy-proven primary IgAN who underwent two renal biopsies at our centre were analyzed retrospectively. Renal biopsies were scored by two pathologists blinded to the clinical data and according to the updated Oxford classification. Cox models were generated to evaluate the prognostic impact considering the Oxford classification elementary lesions from the first (Model 1) or the second (Model 2) biopsy, adjusted on clinical data at time of reevaluation. The prognostic impacts of the dynamic evolution of each elementary lesion between biopsies were also assessed through univariate and multivariate evaluation. RESULTS A total of 168 adult patients were included, with a median follow-up duration of 18 (range 11-24) years. The second biopsy was performed either systematically (n = 112) of for-cause (n = 56), after a median time of 5.4 years. The prognostic performances of Model 2 (second biopsy) were significantly better than Model 1 (first biopsy, analysis of deviance P < 0.0001). The dynamic changes of C and T lesions were significantly associated with the progression toward ESRD after adjustment on variables from Model 2. CONCLUSION Both static and dynamic Oxford-based histological evaluation offered by a repeat biopsy improves the prediction of ESRD in patients with IgAN.
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Affiliation(s)
- Perrine Jullien
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France.,EA3064 GIMAP, Université Jean Monnet Saint Etienne, Université de Lyon, Lyon, France
| | - Blandine Laurent
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France
| | - François Berthoux
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France
| | - Ingrid Masson
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France
| | - Miriana Dinic
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France
| | - Guillaume Claisse
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France
| | - Damien Thibaudin
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France
| | - Christophe Mariat
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France.,EA3064 GIMAP, Université Jean Monnet Saint Etienne, Université de Lyon, Lyon, France
| | - Eric Alamartine
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France.,EA3064 GIMAP, Université Jean Monnet Saint Etienne, Université de Lyon, Lyon, France
| | - Nicolas Maillard
- Department of Nephrology, Dialysis and Renal Transplantation, HOPITAL NORD, CHU Saint-Etienne, France.,EA3064 GIMAP, Université Jean Monnet Saint Etienne, Université de Lyon, Lyon, France
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Cambier A, Boyer O, Deschenes G, Gleeson J, Couderc A, Hogan J, Robert T. Steroid therapy in children with IgA nephropathy. Pediatr Nephrol 2020; 35:359-366. [PMID: 30778826 DOI: 10.1007/s00467-018-4189-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 01/14/2023]
Abstract
IgA nephropathy (IgAN) is one the most common primary glomerulonephritis in children and adolescents worldwide, with 20% of children developing end-stage kidney disease (ESKD) within 20 years of diagnosis. There is a need for treatment guidelines, especially for steroids in children with primary IgAN, since the STOP-IgA trial casts doubts on the use of steroids in adults with intermediate risk. Pediatricians are prone to prescribe steroids in addition to renin-angiotensin system blockade (RASB) when proteinuria is > 0.5 g/l, eGFR deteriorates < 70 ml/min/1.73 m2, or when a biopsy sample shows glomerular inflammation. Lack of randomized controlled trials (RCTs) in children with IgAN has led to an absence of consensus on the use of immunosuppressive agents in the treatment of progressive IgAN. This literature review evaluates the available evidence on steroid treatment in children with IgAN.
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Affiliation(s)
- Alexandra Cambier
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France.
| | - Olivia Boyer
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Georges Deschenes
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - James Gleeson
- Université Paris Diderot, Faculté de Médecine, Site Xavier Bichat, INSERM U1149 & CNRS ERL8252, Centre de Recherche sur l'Inflammation, Paris, France
| | - Anne Couderc
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Julien Hogan
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Thomas Robert
- Department of Nephrology, Transplantation and Emergency, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Marseille, France.
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Thompson A, Carroll K, A. Inker L, Floege J, Perkovic V, Boyer-Suavet S, W. Major R, I. Schimpf J, Barratt J, Cattran DC, S. Gillespie B, Kausz A, W. Mercer A, Reich HN, H. Rovin B, West M, Nachman PH. Proteinuria Reduction as a Surrogate End Point in Trials of IgA Nephropathy. Clin J Am Soc Nephrol 2019; 14:469-481. [PMID: 30635299 PMCID: PMC6419287 DOI: 10.2215/cjn.08600718] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IgA nephropathy (IgAN) is an important cause of ESKD for which there are no approved therapies. A challenge for evaluating treatments for IgAN is the usual long time course for progression to ESKD. The aim of this Kidney Health Initiative project was to identify surrogate end points that could serve as reliable predictors of a treatment's effect on long-term kidney outcomes in IgAN and be used as a basis for approval. Proteinuria was identified as the most widely recognized and well studied risk factor for progression to ESKD in IgAN. The workgroup performed a critical review of the data on proteinuria reduction as a surrogate end point for a treatment's effect on progression to ESKD in IgAN. Epidemiologic data indicate a strong and consistent relationship between the level and duration of proteinuria and loss of kidney function. Trial-level analyses of data from 13 controlled trials also show an association between treatment effects on percent reduction of proteinuria and treatment effects on a composite of time to doubling of serum creatinine, ESKD, or death. We conclude that data support the use of proteinuria reduction as a reasonably likely surrogate end point for a treatment's effect on progression to ESKD in IgAN. In the United States, reasonably likely surrogate end points can be used as a basis for accelerated approval of therapies intended to treat serious or life-threatening conditions, such as IgAN. The clinical benefit of products approved under this program would need to be verified in a postmarketing confirmatory trial.
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Affiliation(s)
- Aliza Thompson
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jürgen Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sonia Boyer-Suavet
- Service de Néphrologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Université Nice Sophia-Antipolis, Nice, France; Departments of
| | | | | | - Jonathan Barratt
- Infection, Inflammation and Immunity, University of Leicester, Leicester, UK
| | - Daniel C. Cattran
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Heather N. Reich
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Brad H. Rovin
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Melissa West
- American Society of Nephrology, Washington, DC; and
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
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