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Steinberg AG, Fox LC, Bender S, Batrouney A, Juneja S, Sirac C, Touchard G, Blombery P, Finlay MJ, Bridoux F, Barbour TD. Proliferative Glomerulonephritis With Fibrils, Monoclonal κ Light Chain, and C3 Deposits. Am J Kidney Dis 2021; 78:459-463. [PMID: 33774080 DOI: 10.1053/j.ajkd.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/06/2020] [Accepted: 01/07/2021] [Indexed: 11/11/2022]
Abstract
There is increasing recognition of monoclonal gammopathy as a cause of proliferative glomerulonephritis (GN), including cases in which glomerular deposition of monoclonal immunoglobulin is demonstrated. Recently, proliferative GN with monoclonal immunoglobulin deposits (PGNMID) has incorporated a light chain variant of the disease (termed PGNMID-LC). Intriguingly, glomerular co-deposition of C3 is found in addition to monotypic light chain, implying complement activation via the alternative pathway (AP). We present a unique case of proliferative GN in a 42-year-old man who presented with nephrotic syndrome and was found to have κ light chain multiple myeloma. Immune staining of the glomerulus was positive only for κ light chain and C3, with the striking appearance of nonamyloid fibrils on electron microscopy. Following clonally targeted therapy for myeloma, the renal clinical abnormalities resolved completely. We present detailed molecular studies for light chain and complement and consider local mechanisms whereby monoclonal κ light chain fibrils may have triggered AP activation within the glomerulus.
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Affiliation(s)
- Adam G Steinberg
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Lucy C Fox
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Sebastien Bender
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Ahida Batrouney
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Surender Juneja
- Department of Hematology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christophe Sirac
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Guy Touchard
- Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Piers Blombery
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Moira J Finlay
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Frank Bridoux
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France; Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Sutu B, Tio SY, Fox LC, Sasadeusz J, Blombery P, Finlay MJ, Barbour TD. Cat-Scratch Disease Masquerading as C3 Glomerulonephritis. Kidney Int Rep 2020; 5:2388-2392. [PMID: 33305138 PMCID: PMC7710836 DOI: 10.1016/j.ekir.2020.09.034] [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] [Received: 06/11/2020] [Revised: 08/25/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Benjamin Sutu
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Shio Yen Tio
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lucy C Fox
- Department of Hematology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Joseph Sasadeusz
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Piers Blombery
- Department of Hematology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Moira J Finlay
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Flavell AL, Fullinfaw RO, Smith ER, Holt SG, Finlay MJ, Barbour TD. Noninfectious mixed cryoglobulinaemic glomerulonephritis and monoclonal gammopathy of undetermined significance: a coincidental association? BMC Nephrol 2020; 21:293. [PMID: 32703171 PMCID: PMC7376917 DOI: 10.1186/s12882-020-01941-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Cryoglobulins are cold-precipitable immunoglobulins that may cause systemic vasculitis including cryoglobulinaemic glomerulonephritis (CGN). Type 1 cryoglobulins consist of isolated monoclonal immunoglobulin (mIg), whereas mixed cryoglobulins are typically immune complexes comprising either monoclonal (type 2) or polyclonal (type 3) Ig with rheumatoid activity against polyclonal IgG. Only CGN related to type 1 cryoglobulins has been clearly associated with monoclonal gammopathy of undetermined significance (MGUS) using the conventional serum-, urine- or tissue-based methods of paraprotein detection. Case presentation We present four patients with noninfectious mixed (type 2 or 3) CGN and MGUS. Two patients had type 2 cryoglobulinaemia, one had type 3 cryoglobulinaemia, and one lacked definitive typing of the serum cryoprecipitate. The serum monoclonal band was IgM-κ in all four cases. Treatments included corticosteroids, cyclophosphamide, plasma exchange, and rituximab. At median 3.5 years’ follow-up, no patient had developed a haematological malignancy or advanced chronic kidney disease. Other potential causes of mixed cryoglobulinaemia were also present in our cohort, notably primary Sjögren’s syndrome in three cases. Conclusion Our study raises questions regarding the current designation of type 2 CGN as a monoclonal gammopathy of renal significance, and the role of clonally directed therapies for noninfectious mixed CGN outside the setting of haematological malignancy.
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Affiliation(s)
- Adam L Flavell
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.
| | - Robert O Fullinfaw
- Department of Chemical Pathology, The Royal Melbourne Hospital, Parkville, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Moira J Finlay
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Anatomical Pathology, The Royal Melbourne Hospital, Parkville, Australia
| | - Thomas D Barbour
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
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Yo JH, Barbour TD, Nicholls K. Management of refractory lupus nephritis: challenges and solutions. Open Access Rheumatol 2019; 11:179-188. [PMID: 31372070 PMCID: PMC6636187 DOI: 10.2147/oarrr.s166303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/13/2019] [Indexed: 12/15/2022] Open
Abstract
Refractory lupus nephritis, broadly defined as failure to attain clinical remission after appropriate induction immunosuppressive therapy, is associated with an increased risk of progression to end-stage kidney disease and mortality. This is a challenging issue in clinical practice, as modern induction therapy despite proven efficacy can still be associated with treatment failure. Moreover, newer therapies have failed in recent years to displace or even match existing protocols for effective induction of remission. Refractory disease is generally assessed on the basis of clinical parameters, which may be unreliable, and renal biopsy, which is often not performed in a standard or timely fashion. Persisting histological inflammation in 30%–50% of patients who have attained clinical remission highlights the disparity between clinical and immunological response to therapy. The lack of an international consensus regarding what constitutes refractory lupus nephritis compounds clinician indecision regarding optimal management for these patients. Moreover, non-adherence to prescribed therapy versus primary treatment failure can be challenging to discriminate, and the time point at which non-response becomes treatment failure is unclear. In this review, we assess the key published evidence for the treatment of refractory lupus nephritis and provide practical recommendations based around the use of adjunctive therapies. These agents include rituximab and calcineurin inhibitors, with evidence consisting largely of observational or uncontrolled studies, as well as some of the biologic therapies currently under investigation through prospective clinical trials. The poor prognosis of refractory lupus nephritis demands regular review of patient response and the flexibility to switch or augment therapy.
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Affiliation(s)
- J H Yo
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - T D Barbour
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - K Nicholls
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Intern Med J 2018; 48:624-636. [DOI: 10.1111/imj.13804] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C. Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J. Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y. Kausman
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology; Monash Health; Melbourne Victoria Australia
- School of Clinical Sciences, Monash Health; Monash University; Melbourne Victoria Australia
| | - Peter D. Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology; Monash Health; Melbourne Victoria Australia
| | - Nicole M. Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D. Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Nephrology (Carlton) 2018; 23:507-517. [DOI: 10.1111/nep.13234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y Kausman
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
- School of Clinical Sciences; Monash Health, Monash University; Melbourne Victoria Australia
| | - Peter D Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
| | - Nicole M Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology, Immunology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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Barbour TD, Ling GS, Ruseva MM, Fossati-Jimack L, Cook HT, Botto M, Pickering MC. Complement receptor 3 mediates renal protection in experimental C3 glomerulopathy. Kidney Int 2016; 89:823-32. [PMID: 26924054 PMCID: PMC4869622 DOI: 10.1016/j.kint.2015.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 11/16/2015] [Accepted: 11/19/2015] [Indexed: 12/14/2022]
Abstract
C3 glomerulopathy is a complement-mediated renal disease that is frequently associated with abnormalities in regulation of the complement alternative pathway. Mice with deficiency of factor H (Cfh–/–), a negative alternative pathway regulator, are an established experimental model of C3 glomerulopathy in which complement C3 fragments including iC3b accumulate along the glomerular basement membrane. Here we show that deficiency of complement receptor 3 (CR3), the main receptor for iC3b, enhances the severity of spontaneous renal disease in Cfh–/– mice. This effect was found to be dependent on CR3 expression on bone marrow–derived cells. CR3 also mediated renal protection outside the setting of factor H deficiency, as shown by the development of enhanced renal injury in CR3-deficient mice during accelerated nephrotoxic nephritis. The iC3b–CR3 interaction downregulated the proinflammatory cytokine response of both murine and human macrophages to lipopolysaccharide stimulation in vitro, suggesting that the protective effect of CR3 on glomerular injury was mediated via modulation of macrophage-derived proinflammatory cytokines. Thus, CR3 has a protective role in glomerulonephritis and suggests that pharmacologic potentiation of the macrophage CR3 interaction with iC3b could be therapeutically beneficial.
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Affiliation(s)
- Thomas D Barbour
- Centre for Complement and Inflammation Research, Imperial College, London, UK
| | - Guang Sheng Ling
- Centre for Complement and Inflammation Research, Imperial College, London, UK
| | - Marieta M Ruseva
- Centre for Complement and Inflammation Research, Imperial College, London, UK
| | - Liliane Fossati-Jimack
- Centre for Complement and Inflammation Research, Imperial College, London, UK; Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK
| | - H Terence Cook
- Centre for Complement and Inflammation Research, Imperial College, London, UK
| | - Marina Botto
- Centre for Complement and Inflammation Research, Imperial College, London, UK
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College, London, UK.
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Nichols EM, Barbour TD, Pappworth IY, Wong EKS, Palmer JM, Sheerin NS, Pickering MC, Marchbank KJ. An extended mini-complement factor H molecule ameliorates experimental C3 glomerulopathy. Kidney Int 2015. [PMID: 26221753 PMCID: PMC4650264 DOI: 10.1038/ki.2015.233] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [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] [Indexed: 11/09/2022]
Abstract
Abnormal regulation of the complement alternative pathway is associated with C3 glomerulopathy. Complement factor H is the main plasma regulator of the alternative pathway and consists of 20 short consensus repeat (SCR) domains. Although recombinant full-length factor H represents a logical treatment for C3 glomerulopathy, its production has proved challenging. We and others have designed recombinant mini-factor H proteins in which ‘non-essential' SCR domains have been removed. Here, we report the in vitro and in vivo effects of a mini-complement factor H protein, FH1–5^18–20, using the unique factor H–deficient (Cfh−/−) mouse model of C3 glomerulopathy. FH1–5^18–20 is comprised of the key complement regulatory domains (SCRs 1–5) linked to the surface recognition domains (SCRs 18–20). Intraperitoneal injection of FH1–5^18–20 in Cfh−/− mice reduced abnormal glomerular C3 deposition, similar to full-length factor H. Systemic effects on plasma alternative pathway control were comparatively modest, in association with a short half-life. Thus, FH1–5^18–20 is a potential therapeutic agent for C3 glomerulopathy and other renal conditions with alternative pathway-mediated tissue injury.
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Affiliation(s)
- Eva-Maria Nichols
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas D Barbour
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | - Isabel Y Pappworth
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Edwin K S Wong
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy M Palmer
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | - Kevin J Marchbank
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
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Barbour TD, Crosthwaite A, Chow K, Finlay MJ, Better N, Hughes PD, Cohney SJ. Antiphospholipid syndrome in renal transplantation. Nephrology (Carlton) 2014; 19:177-85. [PMID: 24548061 DOI: 10.1111/nep.12217] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2014] [Indexed: 12/19/2022]
Abstract
Antiphospholipid syndrome (APS) may occur in isolation or in association with systemic lupus erythematosus (SLE), with the potential to cause renal failure via several distinct pathologies. Renal transplantation in the presence of APS carries a risk of early graft loss from arterial or venous thrombosis, or thrombotic microangiopathy (TMA). Whilst perioperative anticoagulation reduces the risk of large vessel thrombosis, it may result in significant haemorrhage, and its efficacy in preventing post-transplant TMA is uncertain. Here, we report a patient with end-stage kidney disease (ESKD) due to lupus nephritis and APS, in whom allograft TMA developed soon after transplantation despite partial anticoagulation. TMA resolved with plasma exchange-based therapy albeit with some irreversible graft damage and renal impairment. We discuss the differential diagnosis of post-transplant TMA, and current treatment options.
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Affiliation(s)
- Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Abstract
C3 glomerulopathy refers to a disease process in which abnormal control of complement activation, degradation or deposition results in predominant C3 fragment deposition within the glomerulus and glomerular damage. Recent studies have improved our understanding of its pathogenesis. The key abnormality is uncontrolled C3b amplification in the circulation and/or along the glomerular basement membrane. Family studies in which disease segregates with structurally abnormal complement factor H-related (CFHR) proteins demonstrate that abnormal CFHR proteins are important in some types of C3 glomerulopathy. This is currently thought to be due to the ability of these proteins to antagonize the major negative regulator of C3 activation, complement factor H (CFH), a process termed ‘CFH de-regulation’. Recent clinicopathological cohort studies have led to further refinements in case definition, culminating in a 2013 consensus report, which provides recommendations regarding investigation and treatment. Early clinical experience with complement-targeted therapeutics, notably C5 inhibitors, has also now been published. Here, we summarize the latest developments in C3 glomerulopathy.
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Affiliation(s)
- Thomas D Barbour
- Centre for Complement and Inflammation Research (CCIR), Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London W12 0NN, UK
| | - Marieta M Ruseva
- Centre for Complement and Inflammation Research (CCIR), Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London W12 0NN, UK
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research (CCIR), Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London W12 0NN, UK
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Abstract
C3 glomerulopathy refers to those renal lesions characterized histologically by predominant C3 accumulation within the glomerulus, and pathogenetically by aberrant regulation of the alternative pathway of complement. Dense deposit disease is distinguished from other forms of C3 glomerulopathy by its characteristic appearance on electron microscopy. The extent to which dense deposit disease also differs from other forms of C3 glomerulopathy in terms of clinical features, natural history, and outcomes of treatment including renal transplantation is less clear. We discuss the pathophysiology of C3 glomerulopathy, with evidence for alternative pathway dysregulation obtained from affected individuals and complement factor H (Cfh)-deficient animal models. Recent linkage studies in familial C3 glomerulopathy have shown genomic rearrangements in the Cfh-related genes, for which the novel pathophysiologic concept of Cfh deregulation has been proposed.
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Affiliation(s)
- Thomas D Barbour
- Kidney Research UK, Centre for Complement and Inflammation Research, Imperial College London, London, United Kingdom.
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Abstract
‘C3 glomerulopathy’ is a recent disease classification comprising several rare types of glomerulonephritis (GN), including dense deposit disease (DDD), C3 glomerulonephritis (C3GN) and CFHR5 nephropathy. These disorders share the key histological feature of isolated complement C3 deposits in the glomerulus. A common aetiology involving dysregulation of the alternative pathway (AP) of complement has been elucidated in the past decade, with genetic defects and/or autoantibodies able to be identified in a proportion of patients. We review the clinical and histological features of C3 glomerulopathy, relating these to underlying molecular mechanisms. The role of uncontrolled C3 activation in pathogenesis is emphasized, with important lessons from animal models. Methods, advantages and limitations of gene testing in the assessment of individuals or families with C3 glomerulopathy are discussed. While no therapy has yet been shown consistently effective, clinical evaluation of agents targeting specific components of the complement system is ongoing. However, limits to current knowledge regarding the natural history and the appropriate timing and duration of proposed therapies need to be addressed.
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Affiliation(s)
- Thomas D Barbour
- Centre for Complement & Inflammation Research (CCIR), Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London W12 0NN, UK
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