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Dember LM, Hung A, Mehrotra R, Hsu JY, Raj DS, Charytan DM, Mc Causland FR, Regunathan-Shenk R, Landis JR, Kimmel PL, Kliger AS, Himmelfarb J, Ikizler TA. A randomized controlled pilot trial of anakinra for hemodialysis inflammation. Kidney Int 2022; 102:1178-1187. [PMID: 35863559 PMCID: PMC9588554 DOI: 10.1016/j.kint.2022.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/02/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022]
Abstract
Chronic inflammation is highly prevalent among patients receiving maintenance hemodialysis and is associated with morbidity and mortality. Inhibiting inflammation with anti-cytokine therapy has been proposed but not well studied in this population. Therefore, we conducted the ACTION trial, a pilot, multicenter, randomized, placebo-controlled trial of an IL-1 receptor antagonist, anakinra, to evaluate safety, tolerability, and feasibility, and explore efficacy. Eighty hemodialysis patients with plasma concentrations of high sensitivity C-reactive protein (hsCRP) 2 mg/L and above were randomized 1:1 to placebo or anakinra 100 mg, three times per week via the hemodialysis circuit for 24 weeks, with an additional 24 weeks of post-treatment safety monitoring. Efficacy outcomes included changes in hsCRP (primary), cytokines, and patient-reported outcomes. Rates of serious adverse events and deaths were similar with anakinra and placebo (serious adverse events: 2.71 vs 2.74 events/patient-year; deaths: 0.12 vs 0.22 events/patient-year). The rate of adverse events of interest (including infections and cytopenias) was significantly lower with anakinra than placebo (0.48 vs 1.40 events/patient-year). Feasibility was demonstrated by attaining the enrollment target, a retention rate of 80%, and administration of 72% of doses. The median decrease in hsCRP from baseline to Week 24 was 41% in the anakinra group and 6% in the placebo group, a between-group difference that was not statistically significant. For IL-6, the median decreases were significant: 25% and 0% in the anakinra and placebo groups, respectively. An effect of anakinra on patient-reported outcomes was not evident. Thus, anakinra was well tolerated and did not increase infections or cytopenias. The promising safety data and potential efficacy on CRP and IL-6 provide support for conducting definitive trials of IL-1 inhibition to improve outcomes in hemodialysis patients.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adriana Hung
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Kidney Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA; Division of Nephrology, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC, USA
| | - David M Charytan
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Renu Regunathan-Shenk
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC, USA
| | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alan S Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Yale New Haven Health System, New Haven, Connecticut, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Kidney Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA.
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Latt KZ, Heymann J, Jessee JH, Rosenberg AZ, Berthier CC, Arazi A, Eddy S, Yoshida T, Zhao Y, Chen V, Nelson GW, Cam M, Kumar P, Mehta M, Kelly MC, Kretzler M, Ray PE, Moxey-Mims M, Gorman GH, Lechner BL, Regunathan-Shenk R, Raj DS, Susztak K, Winkler CA, Kopp JB. Urine Single-Cell RNA Sequencing in Focal Segmental Glomerulosclerosis Reveals Inflammatory Signatures. Kidney Int Rep 2021; 7:289-304. [PMID: 35155868 PMCID: PMC8821042 DOI: 10.1016/j.ekir.2021.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction Individuals with focal segmental glomerular sclerosis (FSGS) typically undergo kidney biopsy only once, which limits the ability to characterize kidney cell gene expression over time. Methods We used single-cell RNA sequencing (scRNA-seq) to explore disease-related molecular signatures in urine cells from subjects with FSGS. We collected 17 urine samples from 12 FSGS subjects and captured these as 23 urine cell samples. The inflammatory signatures from renal epithelial and immune cells were evaluated in bulk gene expression data sets of FSGS and minimal change disease (MCD) (The Nephrotic Syndrome Study Network [NEPTUNE] study) and an immune single-cell data set from lupus nephritis (Accelerating Medicines Partnership). Results We identified immune cells, predominantly monocytes, and renal epithelial cells in the urine. Further analysis revealed 2 monocyte subtypes consistent with M1 and M2 monocytes. Shed podocytes in the urine had high expression of marker genes for epithelial-to-mesenchymal transition (EMT). We selected the 16 most highly expressed genes from urine immune cells and 10 most highly expressed EMT genes from urine podocytes as immune signatures and EMT signatures, respectively. Using kidney biopsy transcriptomic data from NEPTUNE, we found that urine cell immune signature and EMT signature genes were more highly expressed in FSGS biopsies compared with MCD biopsies. Conclusion The identification of monocyte subsets and podocyte expression signatures in the urine samples of subjects with FSGS suggests that urine cell profiling might serve as a diagnostic and prognostic tool in nephrotic syndrome. Furthermore, this approach may aid in the development of novel biomarkers and identifying personalized therapies targeting particular molecular pathways in immune cells and podocytes.
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Affiliation(s)
- Khun Zaw Latt
- Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Correspondence: Khun Zaw Latt, Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, 3N114, Bethesda, Maryland 20892-1268, USA.
| | - Jurgen Heymann
- Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph H. Jessee
- Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Avi Z. Rosenberg
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Celine C. Berthier
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Arnon Arazi
- The Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sean Eddy
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Teruhiko Yoshida
- Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Yongmei Zhao
- Advanced Biomedical and Computational Sciences, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., National Cancer Institute, Frederick, Maryland, USA
| | - Vicky Chen
- Advanced Biomedical and Computational Sciences, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., National Cancer Institute, Frederick, Maryland, USA
| | - George W. Nelson
- Advanced Biomedical and Computational Sciences, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., National Cancer Institute, Frederick, Maryland, USA
| | - Margaret Cam
- Advanced Biomedical and Computational Sciences, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., National Cancer Institute, Frederick, Maryland, USA
| | - Parimal Kumar
- Center for Cancer Research Sequencing Facility, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, Maryland, USA
| | - Monika Mehta
- Center for Cancer Research Sequencing Facility, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, Maryland, USA
| | - Michael C. Kelly
- Cancer Research Technology Program, Single-Cell Analysis Facility, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, Maryland, USA
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | | | - Patricio E. Ray
- Department of Pediatrics, Child Health Research Center, University of Virginia, Charlottesville, Virginia, USA
| | - Marva Moxey-Mims
- Division of Nephrology, Children’s National Hospital, Washington, District of Columbia, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Gregory H. Gorman
- Section on Pediatric Nephrology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland, USA
| | - Brent L. Lechner
- Section on Pediatric Nephrology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland, USA
| | - Renu Regunathan-Shenk
- Division of Kidney Disease and Hypertension, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Dominic S. Raj
- Division of Kidney Disease and Hypertension, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Katalin Susztak
- Department of Medicine, Renal Electrolyte and Hypertension Division, Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cheryl A. Winkler
- Basic Research Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jeffrey B. Kopp
- Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Pathak V, Venkatesan M, Regunathan-Shenk R. Low-dose Rituximab Monotherapy or in Combination with Tacrolimus Is Effective in Primary Membranous Nephropathy. Kidney360 2021; 2:336-338. [PMID: 35373023 PMCID: PMC8741002 DOI: 10.34067/kid.0004672020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/15/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Vivek Pathak
- Nephrology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Madhav Venkatesan
- Nephrology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
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Raj DS, Sohn MB, Charytan DM, Himmelfarb J, Ikizler TA, Mehrotra R, Ramezani A, Regunathan-Shenk R, Hsu JY, Landis JR, Li H, Kimmel PL, Kliger AS, Dember LM. The Microbiome and p-Inulin in Hemodialysis: A Feasibility Study. Kidney360 2021; 2:445-455. [PMID: 35369018 PMCID: PMC8786005 DOI: 10.34067/kid.0006132020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/14/2021] [Indexed: 02/08/2023]
Abstract
Background The intestinal microbiome is an appealing target for interventions in ESKD because of its likely contribution to uremic toxicity. Before conducting clinical trials of microbiome-altering treatments, it is necessary to understand the within-person and between-person variability in the composition and function of the gut microbiome in patients with ESKD. Methods We conducted a multicenter, nonrandomized, crossover feasibility study of patients on maintenance hemodialysis consisting of three phases: pretreatment (8 weeks); treatment, during which the prebiotic, p-inulin, was administered at a dosage of 8 g twice daily (12 weeks); and post-treatment (8 weeks). Stool samples were collected 1-2 times per week and blood was collected weekly for 28 weeks. The gut microbiome was characterized using 16S ribosomal-RNA sequencing and metabolomic profiling. Results A total of 11 of the 13 participants completed the 28-week study. Interparticipant variability was greater than intraparticipant variability for microbiome composition (P<0.001 by UniFrac distances) and metabolomic composition (P<0.001 by Euclidean distances). p-Inulin was well tolerated by 12 of 13 participants. Adherence to the frequent sample collection and self-aliquoting of stool samples were both 96%. A change in the microbiome composition from pretreatment to post-treatment was evident by the overall shifts in weighted UniFrac distances (P=0.004) and a progressive decrease in prevalence of high intraclass correlations, indicating an increase in intraparticipant microbiome diversity during and after p-inulin treatment. An effect of p-inulin on the metabolomic profile was not evident. Conclusions The intraparticipant stability of the gut microbiome under no-treatment conditions, the tolerability of p-inulin, the signals of increased diversity of the microbiome with p-inulin treatment, and the willingness of participants to provide stool samples all support the feasibility of a larger trial to investigate interventions targeting the gut microbiome in patients with ESKD. Whether or not p-inulin has sufficient efficacy as an intervention requires evaluation in larger studies. Clinical Trial registry name and registration number Gut Microbiome and p-Inulin in Hemodialysis, NCT02572882.
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Affiliation(s)
- Dominic S. Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Michael B. Sohn
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
| | - David M. Charytan
- Division of Nephrology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Jonathan Himmelfarb
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
| | - T. Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ali Ramezani
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Renu Regunathan-Shenk
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J. Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hongzhe Li
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alan S. Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Laura M. Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Oxalate is a metabolite consumed in nuts, beans and leaves, and excreted in urine. Oxalosis can cause nephropathy. We describe a rare case of a high-oxalate diet intended for irritable bowel syndrome (IBS) treatment causing oxalate nephropathy. A 59-year-old woman with a history of controlled hypertension presented with creatinine 1.8 mg/dL, increased from baseline 1.3 mg/dL. She denied recent illness, urinary stones, medication adjustments, herbal supplements and non-steroidal anti-inflammatory drugs use. Diet included six tablespoons of chia seeds and five handfuls of almonds daily to manage IBS symptoms. Her electrolytes, urinalysis and renal ultrasound were unremarkable. Her 24-hour urine output revealed increased oxalate and low citrate. Renal biopsy showed glomerulosclerosis, fibrosis and calcium oxalate deposition. She switched to a low-oxalate diet, with improvement in laboratory markers. An earlier dietary history could have raised concern for oxalosis prior to renal biopsy. Providers should be trained to identify at-risk patients and provide appropriate dietary counselling.
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Affiliation(s)
- Victoria Garland
- Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Leal Herlitz
- Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Renu Regunathan-Shenk
- Division of Kidney Disease and Hypertension, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Raj D, Gao B, Barrows E, Jagadeesan M, Amdur R, Collins A, Regunathan-Shenk R, Kincaid D, Omar B, Siddiqi M. SO046REGULATION OF GUT MICROBIOTA AND HOST CO-METABOLISM BY POTASSIUM HOMEOSTASIS IN PATIENTS ON HEMODIALYSIS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa139.so046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Gut microbiota composition is dysregulated in hemodialysis patients. However, the impact of potassium homeostasis on the gut microbiota and their metabolites has not been studied. Patiromer is a potassium binding polymer that exchanges calcium for potassium in the gastrointestinal (GI) tract, thereby increasing fecal potassium excretion and reducing serum potassium levels.
Method
In this non-randomized, open label, 3-period crossover trial with repeated measures within each period, we investigated the effect of 12 weeks of treatment with patiromer on the microbiome profile and microbiota-related metabolites in 27 hemodialysis patients using multi-omics integration of data from shotgun metagenomic sequencing and untargeted and targeted metabolomic profiling. Data from hemodialysis patients at baseline was first compared with individuals without kidney disease (n=20).
Results
We found that 18 bacterial species and 49 plasma chemical clusters were significantly different between patients and controls. Serum potassium decreased significantly from baseline (5.62±0.65 mEq/L) with patiromer treatment (4.80±0.46 meq/L) and increased during the post-treatment phase (5.45 ± 0.67 meq/L), (p<0.001). Three bacterial species and one bacterial pathway were altered by patiromer. We identified 52 serum metabolites, which were significantly different in patients at baseline compared with controls, and were partially reversed with patiromer treatment. Specifically, the serum levels of polyphenols such as vanillic acid, gallic acid and benzoic acid, and other microbiota-related metabolites such as 2,6-diaminopimelic acid, 2-ketogluconic acid, indole-3-carboxaldehyde and 3-hydroxyphenylacetic acid were reduced by patiromer treatment.
Conclusion
Our study suggests that control of hyperkalemia by patiromer alters the gut microbial composition and host co-metabolism in hemodialysis patients.
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Affiliation(s)
- Dominic Raj
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
| | - Bei Gao
- University of California, Department of Medicine, United States of America
| | | | - Muralidharan Jagadeesan
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
| | - Richard Amdur
- George Washington Medical Faculty Associates, Department of Surgery, Washington, United States of America
| | - Ashte Collins
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
| | - Renu Regunathan-Shenk
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
| | - Danielle Kincaid
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
| | - Badryah Omar
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
| | - Muhammad Siddiqi
- George Washington Medical Faculty Associates, Division of Renal Diseases and Hypertension, Washington D.C., United States of America
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Regunathan-Shenk R, Avasare RS, Ahn W, Canetta PA, Cohen DJ, Appel GB, Bomback AS. Kidney Transplantation in C3 Glomerulopathy: A Case Series. Am J Kidney Dis 2018; 73:316-323. [PMID: 30413277 DOI: 10.1053/j.ajkd.2018.09.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 09/03/2018] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE C3 glomerulopathy (C3G), a form of glomerulonephritis associated with dysregulation of the alternative complement pathway, occurs either as dense deposit disease (DDD) or C3 glomerulonephritis (C3GN). Few studies have reported outcomes of patients with C3G after transplantation since its formal classification and the advent of complement-targeting therapies such as eculizumab. STUDY DESIGN Case series of C3G. SETTING & PARTICIPANTS We reviewed laboratory testing, native and allograft biopsy reports, and clinical charts of the 19 patients (12, C3GN; and 7, DDD) from our C3G registry who underwent transplantation between 1999 and 2016. RESULTS During a median follow-up of 76 months, 16 patients had recurrent disease (10 of 12, C3GN; and 6 of 7, DDD), with median time to recurrence of 14 months in C3GN versus 15 months in DDD. Graft failure was more frequent in patients with DDD (6 of 7) than in patients with C3GN (3 of 12), occurred at a median time of 42 months posttransplantation, and was attributed to recurrent disease in half the failures. A rare genetic variant or autoantibody associated with alternative complement pathway abnormalities was detected in 9 of 10 screened patients. Treatment of 7 patients (8 allografts) with eculizumab was associated with variable clinical outcomes. LIMITATIONS Incomplete testing for complement pathway abnormalities and genetic defects, incomplete records of HLA antigen matching, lack of centralized biopsy review, and limited sample size. CONCLUSIONS In a case series of C3G transplant recipients, the proportion of disease recurrence was high in both C3GN and DDD, although graft loss appeared to occur more frequently in DDD. In a small subset of study patients, eculizumab therapy was not consistently followed by salutary outcomes.
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Affiliation(s)
- Renu Regunathan-Shenk
- Division of Kidney Disease and Hypertension, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Rupali S Avasare
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Wooin Ahn
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Regunathan-Shenk R, Radhakrishnan J. Pathogenesis of SLE Nephritis in the Era of Precision Medicine. Curr Rheumatol Rev 2018; 14:140-144. [PMID: 27426406 DOI: 10.2174/1573397112666160614080121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 04/28/2016] [Accepted: 06/09/2016] [Indexed: 11/22/2022]
Abstract
Systemic Lupus Erythematosis (SLE) is a heterogeneous and complex disease produced by diverse pathogenic events in the innate and adaptive immune system. Lupus nephritis affects over half of all patients with lupus and leads to substantial morbidity and mortality. This review presents our current understanding of the development of lupus nephritis and examines the role of genetics and epigenetics in further elucidating the pathogenesis of the disease. Advancements in genomics are leading the way to better understanding and novel biologic therapies for SLE.
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Affiliation(s)
- Renu Regunathan-Shenk
- Columbia College of Physicians & Surgeons - Medicine-Nephrology, New York, NY, United States
| | - Jai Radhakrishnan
- Columbia College of Physicians & Surgeons - Medicine-Nephrology, New York, NY, United States
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Ramezani A, Nolin TD, Barrows IR, Serrano MG, Buck GA, Regunathan-Shenk R, West RE, Latham PS, Amdur R, Raj DS. Gut Colonization with Methanogenic Archaea Lowers Plasma Trimethylamine N-oxide Concentrations in Apolipoprotein e-/- Mice. Sci Rep 2018; 8:14752. [PMID: 30283097 PMCID: PMC6170401 DOI: 10.1038/s41598-018-33018-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/20/2018] [Indexed: 01/19/2023] Open
Abstract
A mechanistic link between trimethylamine N-oxide (TMAO) and atherogenesis has been reported. TMAO is generated enzymatically in the liver by the oxidation of trimethylamine (TMA), which is produced from dietary choline, carnitine and betaine by gut bacteria. It is known that certain members of methanogenic archaea (MA) could use methylated amines such as trimethylamine as growth substrates in culture. Therefore, we investigated the efficacy of gut colonization with MA on lowering plasma TMAO concentrations. Initially, we screened for the colonization potential and TMAO lowering efficacy of five MA species in C57BL/6 mice fed with high choline/TMA supplemented diet, and found out that all five species could colonize and lover plasma TMAO levels, although with different efficacies. The top performing MA, Methanobrevibacter smithii, Methanosarcina mazei, and Methanomicrococcus blatticola, were transplanted into Apoe−/− mice fed with high choline/TMA supplemented diet. Similar to C57BL/6 mice, following initial provision of the MA, there was progressive attrition of MA within fecal microbial communities post-transplantation during the initial 3 weeks of the study. In general, plasma TMAO concentrations decreased significantly in proportion to the level of MA colonization. In a subsequent experiment, use of antibiotics and repeated transplantation of Apoe−/− mice with M. smithii, led to high engraftment levels during the 9 weeks of the study, resulting in a sustained and significantly lower average plasma TMAO concentrations (18.2 ± 19.6 μM) compared to that in mock-transplanted control mice (120.8 ± 13.0 μM, p < 0.001). Compared to control Apoe−/− mice, M. smithii-colonized mice also had a 44% decrease in aortic plaque area (8,570 μm [95% CI 19587–151821] vs. 15,369 μm [95% CI [70058–237321], p = 0.34), and 52% reduction in the fat content in the atherosclerotic plaques (14,283 μm [95% CI 4,957–23,608] vs. 29,870 μm [95% CI 18,074–41,666], p = 0.10), although these differences did not reach significance. Gut colonization with M. smithii leads to a significant reduction in plasma TMAO levels, with a tendency for attenuation of atherosclerosis burden in Apoe−/− mice. The anti-atherogenic potential of MA should be further tested in adequately powered experiments.
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Affiliation(s)
- Ali Ramezani
- Division of Renal Diseases and Hypertension, The George Washington University School of Medicine, Washington, DC, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Medicine, Renal-Electrolyte Division, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ian R Barrows
- Department of Medicine Georgetown University School of Medicine, Washington, DC, USA
| | - Myrna G Serrano
- Center for the Study of Biological Complexity, Virginia Commonwealth University, Richmond, VA, USA
| | - Gregory A Buck
- Department of Microbiology and Immunology, Medical College of Virginia Campus of Virginia Commonwealth University, Richmond, VA, USA
| | - Renu Regunathan-Shenk
- Division of Renal Diseases and Hypertension, The George Washington University School of Medicine, Washington, DC, USA
| | - Raymond E West
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patricia S Latham
- Departments of Pathology and Medicine, The George Washington University, Washington, DC, USA
| | - Richard Amdur
- Medical Faculty Associates, Department of Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, The George Washington University School of Medicine, Washington, DC, USA.
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Kil BH, Zachariah T, Husain SA, Nestor J, Regunathan-Shenk R, Markowitz GS, Bomback AS. Membranous Nephropathy in a Patient With Common Variable Immune Deficiency. Kidney Int Rep 2018; 3:738-742. [PMID: 29854983 PMCID: PMC5976836 DOI: 10.1016/j.ekir.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Byum Hee Kil
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Teena Zachariah
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jordan Nestor
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Renu Regunathan-Shenk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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11
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Bomback AS, Santoriello D, Avasare RS, Regunathan-Shenk R, Canetta PA, Ahn W, Radhakrishnan J, Marasa M, Rosenstiel PE, Herlitz LC, Markowitz GS, D'Agati VD, Appel GB. C3 glomerulonephritis and dense deposit disease share a similar disease course in a large United States cohort of patients with C3 glomerulopathy. Kidney Int 2018; 93:977-985. [PMID: 29310824 DOI: 10.1016/j.kint.2017.10.022] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/05/2017] [Accepted: 10/20/2017] [Indexed: 11/16/2022]
Abstract
C3 glomerulonephritis (C3GN) and dense deposit disease comprise the two classes of C3 glomerulopathy. Studies from Europe and Asia have aided our understanding of this recently defined disorder, but whether these data apply to a diverse United States patient population remains unclear. We, therefore, reviewed clinical and histopathological data, including generation of a C3 Glomerulopathy Histologic Index to score biopsy activity and chronicity, to determine predictors of progression to end-stage renal disease (ESRD) and advanced chronic kidney disease (CKD) in 111 patients (approximately 35% non-white) with C3 glomerulopathy: 87 with C3GN and 24 with dense deposit disease. Complement-associated gene variants and autoantibodies were detected in 24% and 35% of screened patients, respectively. Our C3 Glomerulopathy Histologic Index denoted higher activity in patients with C3GN and higher chronicity in patients with dense deposit disease. Over an average of 72 months of follow-up, remission occurred in 38% of patients with C3GN and 25% of patients with dense deposit disease. Progression to late-stage CKD and ESRD was common, with no differences between C3GN (39%) and dense deposit disease (42%). In multivariable models, the strongest predictors for progression were estimated glomerular filtration rate at diagnosis (clinical variables model) and tubular atrophy/interstitial fibrosis (histopathology variables model). Using our C3 Glomerulopathy Histologic Index, both total activity and total chronicity scores emerged as the strongest predictors of progression. Thus, in a large, diverse American cohort of patients with C3 glomerulopathy, there is a high rate of progression to CKD and ESRD with no differences between C3GN and dense deposit disease.
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Affiliation(s)
- Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA.
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Rupali S Avasare
- Department of Medicine, Division of Nephrology, Oregon Health and Science University, Portland, Oregon, USA
| | - Renu Regunathan-Shenk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Pietro A Canetta
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Wooin Ahn
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jai Radhakrishnan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maddalena Marasa
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Paul E Rosenstiel
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Leal C Herlitz
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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12
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Ganda A, Yvan-Charvet L, Zhang Y, Lai EJ, Regunathan-Shenk R, Hussain FN, Avasare R, Chakraborty B, Febus AJ, Vernocchi L, Lantigua R, Wang Y, Shi X, Hsieh J, Murphy AJ, Wang N, Bijl N, Gordon KM, de Miguel MH, Singer JR, Hogan J, Cremers S, Magnusson M, Melander O, Gerszten RE, Tall AR. Plasma metabolite profiles, cellular cholesterol efflux, and non-traditional cardiovascular risk in patients with CKD. J Mol Cell Cardiol 2017; 112:114-122. [PMID: 28478047 DOI: 10.1016/j.yjmcc.2017.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/12/2017] [Accepted: 05/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) experience high rates of atherosclerotic cardiovascular disease and death that are not fully explained by traditional risk factors. In animal studies, defective cellular cholesterol efflux pathways which are mediated by the ATP binding cassette transporters ABCA1 and ABCG1 are associated with accelerated atherosclerosis. We hypothesized that cholesterol efflux in humans would vary in terms of cellular components, with potential implications for cardiovascular disease. METHODS We recruited 120 CKD patients (eGFR<30mL/min/1.73m2) and 120 control subjects (eGFR ≥60mL/min/1.73m2) in order to measure cholesterol efflux using either patients' HDL and THP-1 macrophages or patients' monocytes and a flow cytometry based cholesterol efflux assay. We also measured cell-surface levels of the common β subunit of the IL-3/GM-CSF receptor (IL-3Rβ) which has been linked to defective cholesterol homeostasis and may promote monocytosis. In addition, we measured plasma inflammatory cytokines and plasma metabolite profiles. RESULTS There was a strong positive correlation between cell-surface IL-3Rβ levels and monocyte counts in CKD (P<0.001). ABCA1 mRNA was reduced in CKD vs. control monocytes (P<0.05), across various etiologies of CKD. Cholesterol efflux to apolipoprotein A1 was impaired in monocytes from CKD patients with diabetic nephropathy (P<0.05), but we found no evidence for a circulating HDL-mediated defect in cholesterol efflux in CKD. Profiling of plasma metabolites showed that medium-chain acylcarnitines were both independently associated with lower levels of cholesterol transporter mRNA in CKD monocytes at baseline (P<0.05), and with cardiovascular events in CKD patients after median 2.6years of follow-up. CONCLUSIONS Cholesterol efflux in humans varies in terms of cellular components. We report a cellular defect in ABCA1-mediated cholesterol efflux in monocytes from CKD patients with diabetic nephropathy. Unlike several traditional risk factors for atherosclerotic cardiovascular disease, plasma metabolites inversely associated with endogenous cholesterol transporters predicted cardiovascular events in CKD patients. (Funded by the National Institute of Diabetes and Digestive and Kidney DiseasesK23DK097288 and others.).
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Affiliation(s)
- Anjali Ganda
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States.
| | - Laurent Yvan-Charvet
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Yuan Zhang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Eric J Lai
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Renu Regunathan-Shenk
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Farah N Hussain
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Rupali Avasare
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Bibhas Chakraborty
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, United States; Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Annie J Febus
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Linda Vernocchi
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Rafael Lantigua
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Ying Wang
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Xu Shi
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joanne Hsieh
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Andrew J Murphy
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Nan Wang
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Nora Bijl
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Kristie M Gordon
- Flow Cytometry Shared Resource, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, United States
| | - Maria Hamm de Miguel
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Jessica R Singer
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Jonathan Hogan
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Serge Cremers
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States; Biomarkers Core Laboratory, Irving Institute for Clinical and Translational Research, Columbia University, New York, NY, United States; Department of Pathology and Cell Biology, College of Physicians & Surgeons, Columbia University, New York, NY, United States
| | - Martin Magnusson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Center of Emergency Medicine, Skåne University Hospital, Malmö, Sweden
| | - Robert E Gerszten
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alan R Tall
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, United States
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