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Kafagi AH, Li AS, Jayne D, Brix SR. Anti-GBM disease in pregnancy. BMJ Case Rep 2024; 17:e257767. [PMID: 38688578 PMCID: PMC11085961 DOI: 10.1136/bcr-2023-257767] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
We present the case of a pregnant woman in her 20s who presented in her second trimester with severe pulmonary haemorrhage and dialysis-dependent acute kidney failure due to antiglomerular basement membrane (GBM) disease. Responding to therapy, she recovered kidney function and delivered a baby. During her pregnancy, she developed cytomegalovirus viraemia, gestational diabetes and pre-eclampsia. Here, we report the first combined use of cyclophosphamide, rituximab and intensified plasma exchange in anti-GBM disease in pregnancy, allowing minimal exposure to cytotoxic medication, resulting in live birth and dialysis independence.
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Affiliation(s)
| | - Anna S Li
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | | | - Silke R Brix
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
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2
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Brix SR. The Challenge of Assessing Remission and Relapse in ANCA Kidney Disease. J Am Soc Nephrol 2024; 35:395-397. [PMID: 38557787 PMCID: PMC11000735 DOI: 10.1681/asn.0000000000000331] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Silke R Brix
- Renal, Transplantation and Urology Unit, Manchester University Hospitals NHS Foundation Trust, and Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, United Kingdom
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3
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Bate S, McGovern D, Costigliolo F, Tan PG, Kratky V, Scott J, Chapman GB, Brown N, Floyd L, Brilland B, Martín-Nares E, Aydın MF, Ilyas D, Butt A, Nic an Riogh E, Kollar M, Lees JS, Yildiz A, Hinojosa-Azaola A, Dhaygude A, Roberts SA, Rosenberg A, Wiech T, Pusey CD, Jones RB, Jayne DR, Bajema I, Jennette JC, Stevens KI, Augusto JF, Mejía-Vilet JM, Dhaun N, McAdoo SP, Tesar V, Little MA, Geetha D, Brix SR. The Improved Kidney Risk Score in ANCA-Associated Vasculitis for Clinical Practice and Trials. J Am Soc Nephrol 2024; 35:335-346. [PMID: 38082490 PMCID: PMC10914211 DOI: 10.1681/asn.0000000000000274] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024] Open
Abstract
SIGNIFICANCE STATEMENT Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. More than 1500 patients were collated in an international longitudinal study to revise the ANCA kidney risk score. The score showed satisfactory performance, mimicking the original study (Harrell's C=0.779). In the development cohort of 959 patients, no additional parameters aiding the tool were detected, but replacing the GFR with creatinine identified an additional cutoff. The parameter interstitial fibrosis and tubular atrophy was modified to allow wider access, risk points were reweighted, and a fourth risk group was created, improving predictive ability (C=0.831). In the validation, the new model performed similarly well with excellent calibration and discrimination ( n =480, C=0.821). The revised score optimizes prognostication for clinical practice and trials. BACKGROUND Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. A retrospective international longitudinal cohort was collated to revise the ANCA renal risk score. METHODS The primary end point was ESKD with patients censored at last follow-up. Cox proportional hazards were used to reweight risk factors. Kaplan-Meier curves, Harrell's C statistic, receiver operating characteristics, and calibration plots were used to assess model performance. RESULTS Of 1591 patients, 1439 were included in the final analyses, 2:1 randomly allocated per center to development and validation cohorts (52% male, median age 64 years). In the development cohort ( n =959), the ANCA renal risk score was validated and calibrated, and parameters were reinvestigated modifying interstitial fibrosis and tubular atrophy allowing semiquantitative reporting. An additional cutoff for kidney function (K) was identified, and serum creatinine replaced GFR (K0: <250 µ mol/L=0, K1: 250-450 µ mol/L=4, K2: >450 µ mol/L=11 points). The risk points for the percentage of normal glomeruli (N) and interstitial fibrosis and tubular atrophy (T) were reweighted (N0: >25%=0, N1: 10%-25%=4, N2: <10%=7, T0: none/mild or <25%=0, T1: ≥ mild-moderate or ≥25%=3 points), and four risk groups created: low (0-4 points), moderate (5-11), high (12-18), and very high (21). Discrimination was C=0.831, and the 3-year kidney survival was 96%, 79%, 54%, and 19%, respectively. The revised score performed similarly well in the validation cohort with excellent calibration and discrimination ( n =480, C=0.821). CONCLUSIONS The updated score optimizes clinicopathologic prognostication for clinical practice and trials.
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Affiliation(s)
- Sebastian Bate
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Population Health, Health Services Research, and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Dominic McGovern
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Francesca Costigliolo
- Division of Nephrology, Dialysis and Transplantation, University of Genova, Genova, Italy
- Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Pek Ghe Tan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Renal Unit, Northern Health, Victoria, Australia
| | - Vojtech Kratky
- 1st Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, General University Hospital, Prague, Czechia
| | - Jennifer Scott
- Trinity Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Gavin B. Chapman
- University/BHF Centre for Cardiovascular Science, University of Edinburgh and Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nina Brown
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Lauren Floyd
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, CHU d’Angers, Angers, France
| | - Eduardo Martín-Nares
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Duha Ilyas
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Arslan Butt
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | | | - Marek Kollar
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jennifer S. Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Abdülmecit Yildiz
- Division of Nephrology, Bursa Uludağ University School of Medicine, Bursa, Turkey
| | - Andrea Hinojosa-Azaola
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Stephen A. Roberts
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Population Health, Health Services Research, and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thorsten Wiech
- University Medical Center Hamburg-Eppendorf, Institute of Pathology, Hamburg, Germany
| | - Charles D. Pusey
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Rachel B. Jones
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - David R.W. Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ingeborg Bajema
- Department of Pathology, Groningen University Medical Center, Groningen, The Netherlands
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kate I. Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | | | - Juan Manuel Mejía-Vilet
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Neeraj Dhaun
- University/BHF Centre for Cardiovascular Science, University of Edinburgh and Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Stephen P. McAdoo
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Vladimir Tesar
- 1st Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, General University Hospital, Prague, Czechia
| | - Mark A. Little
- Trinity Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Duruvu Geetha
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Silke R. Brix
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, United Kingdom
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4
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Rodziewicz M, Dyball S, Achieng S, Brix SR, Parker B, Bruce IN. An imperfect world: assessing safety of biological treatments in systemic lupus erythematosus. Comment on the article by Materne et al. Arthritis Rheumatol 2024; 76:315-316. [PMID: 37653671 DOI: 10.1002/art.42689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Affiliation(s)
| | | | | | - Silke R Brix
- Manchester Academic Health Science Centre, Manchester, UK
| | - Ben Parker
- Manchester Academic Health Science Centre, Manchester, UK
| | - Ian N Bruce
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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5
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Bate S, Brix SR. From Prediction Tools to Precision Medicine in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. J Rheumatol 2023; 50:583-585. [PMID: 36921970 DOI: 10.3899/jrheum.230115] [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: 03/17/2023]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are multiorgan autoimmune disorders resulting in irreversible organ damage. Left untreated, AAVs are fatal, and aggressive immunosuppressive treatment has transformed them into chronic relapsing conditions.
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Affiliation(s)
- Sebastian Bate
- S. Bate, MMath, Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, and Centre for Biostatistics, Division of Population Health, Health Services Research, and Primary Care, University of Manchester
| | - Silke R Brix
- S.R. Brix, MD, Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, University of Manchester, Manchester, and Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, UK
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6
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Floyd L, Bate S, Hadi Kafagi A, Brown N, Scott J, Srikantharajah M, Myslivecek M, Reid G, Aqeel F, Frausova D, Kollar M, Kieu PL, Khurshid B, Pusey CD, Dhaygude A, Tesar V, McAdoo S, Little MA, Geetha D, Brix SR. Risk Stratification to Predict Renal Survival in Anti-Glomerular Basement Membrane Disease. J Am Soc Nephrol 2023; 34:505-514. [PMID: 36446430 PMCID: PMC10103284 DOI: 10.1681/asn.2022050581] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 12/03/2022] Open
Abstract
SIGNIFICANCE STATEMENT Most patients with anti-glomerular basement membrane (GBM) disease present with rapidly progressive glomerulonephritis, and more than half develop ESKD. Currently, no tools are available to aid in the prognostication or management of this rare disease. In one of the largest assembled cohorts of patients with anti-GBM disease (with 174 patients included in the final analysis), the authors demonstrated that the renal risk score for ANCA-associated vasculitis is transferable to anti-GBM disease and the renal histology is strongly predictive of renal survival and recovery. Stratifying patients according to the percentage of normal glomeruli in the kidney biopsy and the need for RRT at the time of diagnosis improves outcome prediction. Such stratification may assist in the management of anti-GBM disease. BACKGROUND Prospective randomized trials investigating treatments and outcomes in anti-glomerular basement membrane (anti-GBM) disease are sparse, and validated tools to aid prognostication or management are lacking. METHODS In a retrospective, multicenter, international cohort study, we investigated clinical and histologic parameters predicting kidney outcome and sought to identify patients who benefit from rescue immunosuppressive therapy. We also explored applying the concept of the renal risk score (RRS), currently used to predict renal outcomes in ANCA-associated vasculitis, to anti-GBM disease. RESULTS The final analysis included 174 patients (out of a total of 191). Using Cox and Kaplan-Meier methods, we found that the RRS was a strong predictor for ESKD. The 36-month renal survival was 100%, 62.4%, and 20.7% in the low-risk, moderate-risk, and high-risk groups, respectively. The need for renal replacement therapy (RRT) at diagnosis and the percentage of normal glomeruli in the biopsy were independent predictors of ESKD. The best predictor for renal recovery was the percentage of normal glomeruli, with a cut point of 10% normal glomeruli providing good stratification. A model with the predictors RRT and normal glomeruli ( N ) achieved superior discrimination for significant differences in renal survival. Dividing patients into four risk groups led to a 36-month renal survival of 96.4% (no RRT, N ≥10%), 74.0% (no RRT, N <10%), 42.3% (RRT, N ≥10%), and 14.1% (RRT, N <10%), respectively. CONCLUSIONS These findings demonstrate that the RRS concept is transferrable to anti-GBM disease. Stratifying patients according to the need for RRT at diagnosis and renal histology improves prediction, highlighting the importance of normal glomeruli. Such stratification may assist in the management of anti-GBM disease. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3.
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Affiliation(s)
- Lauren Floyd
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Sebastian Bate
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Abdul Hadi Kafagi
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Nina Brown
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Jennifer Scott
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Dublin, Ireland
| | | | - Marek Myslivecek
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Graeme Reid
- Renal Pathology, Adult Histopathology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Faten Aqeel
- Department of Medicine, John Hopkins University, Baltimore, Maryland
| | - Doubravka Frausova
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Marek Kollar
- Centre of Clinical and Transplant Pathology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Phuong Le Kieu
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Bilal Khurshid
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Charles D. Pusey
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Vladimir Tesar
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Stephen McAdoo
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Mark A. Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Dublin, Ireland
| | - Duvuru Geetha
- Department of Medicine, John Hopkins University, Baltimore, Maryland
| | - Silke R. Brix
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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7
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Brix SR, Tesař V. Rituximab in the Frail and Elderly with Severe ANCA-Associated GN. Clin J Am Soc Nephrol 2022; 17:1546-1548. [PMID: 35918105 PMCID: PMC9528265 DOI: 10.2215/cjn.04760422] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Silke R. Brix
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, United Kingdom of Great Britain, and Northern Ireland
- Renal, Transplantation and Urology Unit, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom of Great Britain, and Northern Ireland
| | - Vladimir Tesař
- Department of Nephrology, Charles University and General University Hospital in Prague, Prague, Czech Republic
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8
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Rutherford MA, Scott J, Karabayas M, Antonelou M, Gopaluni S, Gray D, Barrett J, Brix SR, Dhaun N, McAdoo SP, Smith RM, Geddes C, Jayne D, Luqmani R, Salama AD, Little MA, Basu N. Risk Factors for Severe Outcomes in Patients With Systemic Vasculitis and COVID-19: A Binational, Registry-Based Cohort Study. Arthritis Rheumatol 2021; 73:1713-1719. [PMID: 33750043 PMCID: PMC8251299 DOI: 10.1002/art.41728] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/04/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE COVID-19 is a novel infectious disease with a broad spectrum of clinical severity. Patients with systemic vasculitis have an increased risk of serious infections and may be at risk of severe outcomes following COVID-19. We undertook this study to establish the risk factors for severe COVID-19 outcomes in these patients, including the impact of immunosuppressive therapies. METHODS A multicenter cohort was developed through the participation of centers affiliated with national UK and Ireland vasculitis registries. Clinical characteristics and outcomes are described. Logistic regression was used to evaluate associations between potential risk factors and a severe COVID-19 outcome, defined as a requirement for advanced oxygen therapy, a requirement for invasive ventilation, or death. RESULTS The cohort included 65 patients with systemic vasculitis who developed COVID-19 (median age 70 years, 49% women), of whom 25 patients (38%) experienced a severe outcome. Most patients (55 of 65 [85%]) had antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Almost all patients required hospitalization (59 of 65 [91%]), 7 patients (11%) were admitted to intensive care, and 18 patients (28%) died. Background glucocorticoid therapy was associated with severe outcomes (adjusted odds ratio [OR] 3.7 [95% confidence interval 1.1-14.9]; P = 0.047), as was comorbid respiratory disease (adjusted OR 7.5 [95% confidence interval 1.9-38.2]; P = 0.006). Vasculitis disease activity and nonglucocorticoid immunosuppressive therapy were not associated with severe outcomes. CONCLUSION In patients with systemic vasculitis, glucocorticoid use at presentation and comorbid respiratory disease were associated with severe outcomes in COVID-19. These data can inform clinical decision-making relating to the risk of severe COVID-19 in this vulnerable patient group.
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Affiliation(s)
| | | | | | | | | | | | | | - Silke R. Brix
- Manchester University NHS Foundation Trust and University of ManchesterManchesterUK
| | | | | | | | | | | | | | - Alan D. Salama
- University College London and Royal Free HospitalLondonUK
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9
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Salas A, Kant S, Floyd L, Kratky V, Brix SR, Prendecki M, Schönermarck U, Scott J, Saha M, Gauckler P, Li T, Sharma PD, Ayoub I, Morris AD, Dhaygude AP, Hruskova Z, Tesar V, McAdoo SP, Little MA, Derebail VK, Poulton CJ, Seo P, Kronbichler A, Geetha D. ANCA Vasculitis Induction Management During the COVID-19 Pandemic. Kidney Int Rep 2021; 6:2903-2907. [PMID: 34426797 PMCID: PMC8373584 DOI: 10.1016/j.ekir.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Antonio Salas
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sam Kant
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lauren Floyd
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Vojtěch Kratky
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Silke R Brix
- Renal, Urology and Transplantation Unit, Manchester University Hospitals, Manchester, UK
| | - Maria Prendecki
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
| | | | - Jennifer Scott
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
| | - Manish Saha
- Division of Nephrology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Tingting Li
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Purva D Sharma
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Isabelle Ayoub
- Department of Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adam D Morris
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ajay P Dhaygude
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
| | - Vimal K Derebail
- Division of Nephrology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Caroline J Poulton
- Division of Nephrology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Philip Seo
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Duvuru Geetha
- Division of Nephrology and Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Brix SR, Jones RB, Jayne DRW. Glomerular basement membrane nephritis: crescentic renal inflammation and immunosuppressive intervention in the time of the severe acute respiratory syndrome coronavirus 2 pandemic. Kidney Int 2021; 99:1234-1235. [PMID: 33581197 PMCID: PMC7875705 DOI: 10.1016/j.kint.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 01/15/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Silke R Brix
- Renal, Urology and Transplantation Unit, Manchester University Hospitals, Manchester, UK.
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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11
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Brix SR, Stahl RAK, Wiech T. The authors reply. Kidney Int 2021; 99:489-490. [PMID: 33509361 DOI: 10.1016/j.kint.2020.11.005] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Silke R Brix
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Renal Department, Manchester University Hospital, Manchester, UK.
| | - Rolf A K Stahl
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Wiech
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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12
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Brix SR, Geetha D. Keeping Up with the Times. Clin J Am Soc Nephrol 2020; 15:1078-1080. [PMID: 32723806 PMCID: PMC7409759 DOI: 10.2215/cjn.09600620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Silke R. Brix
- Division of Cardiovascular Science, University of Manchester, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester Royal Infirmary, Manchester University Hospitals National Health Service Foundation Trust, Manchester, United Kingdom
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Brix SR, Huber TB, Waldherr R, Hopfer H, Stahl RA, Wiech T. The authors reply. Kidney Int 2019; 96:245-246. [DOI: 10.1016/j.kint.2019.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 11/29/2022]
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14
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Li AS, Saleh C, Denley H, Patel M, Brix SR. ANCA renal risk score predicts outcome in the Manchester cohort. Kidney Int 2019; 96:246-247. [DOI: 10.1016/j.kint.2019.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
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15
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Person F, Rinschen MM, Brix SR, Wulf S, Noriega MDLM, Fehrle W, Schmitz J, Schwarz A, Ivanyi P, Steinmetz OM, Reinhard L, Hoxha E, Zipfel PF, Bräsen JH, Wiech T. Bevacizumab-associated glomerular microangiopathy. Mod Pathol 2019; 32:684-700. [PMID: 30552416 DOI: 10.1038/s41379-018-0186-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 11/09/2022]
Abstract
Bevacizumab is a humanized monoclonal IgG1 antibody, which neutralizes vascular endothelial growth factor and is used for treating multiple cancer types. As a known and frequent adverse event, this therapy can lead to renal damage including proteinuria and nephrotic syndrome. In a retrospective approach, we analyzed 17 renal biopsies from patients receiving bevacizumab treatment. We observed a distinctive histopathological pseudothrombotic pattern different from the previously reported thrombotic microangiopathy. Since this pattern includes some features similar to acute and chronic thrombotic microangiopathy, focal segmental glomerulosclerosis and cryoglobulinemic membranoproliferative glomerulonephritis, biopsies with these diagnoses were included for comparison. Clinical, laboratory, light microscopic, immunohistochemical (including a proximity ligation assay), proteomic and electron microscopic features were assessed. Nephrotic syndrome was present in 15 of the 17 bevacizumab-treated patients. All 17 displayed a patchy pattern of variably PAS-positive hyaline pseudothrombi occluding markedly dilated glomerular capillaries in their biopsies. Mass spectrometry-based proteome analysis revealed a special protein pattern demonstrating some features of thrombotic microangiopathy and some of cryoglobulinemic glomerulonephritis, including a strong accumulation of IgG in the pseudothrombi. Proximity ligation assay did not show interaction of IgG with C1q, arguing for accumulation without classic pathway complement activation. In contrast to thrombi in thrombotic microangiopathy cases, the hyaline pseudothrombi did not contain clusters of CD61-positive platelets. Electron microscopy of bevacizumab cases did not show fibrin polymers or extensive loss of podocyte foot processes. Even though cases of bevacizumab-associated microangiopathy share some features with thrombotic microangiopathy, its overall histopathological pattern is quite different from acute or chronic thrombotic microangiopathy cases. We conclude that bevacizumab therapy can lead to a unique hyaline occlusive glomerular microangiopathy, likely arising from endothelial leakage followed by subendothelial accumulation of serum proteins. It can be diagnosed by light microscopy and is an important differential diagnosis in cancer patients with nephrotic syndrome.
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Affiliation(s)
- Fermin Person
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Markus M Rinschen
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Silke R Brix
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sonia Wulf
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Wilfried Fehrle
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Anke Schwarz
- Clinic for Nephrology, Hannover Medical School, Hannover, Germany
| | - Philipp Ivanyi
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Oliver M Steinmetz
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Reinhard
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter F Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Jan Hinrich Bräsen
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Thorsten Wiech
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany.
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Saleh C, Li A, Patel M, Denley H, Brix SR. 112. VALIDATION OF RENAL ANCA SCORE. Rheumatology (Oxford) 2019. [DOI: 10.1093/rheumatology/kez058.052] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Anna Li
- Manchester University Hospitals Manchester Royal Infirmary Manchester, United Kingdom
| | - Mumtaz Patel
- Manchester University Hospitals Manchester Royal Infirmary Manchester, United Kingdom
| | - Helen Denley
- Manchester University Hospitals Manchester Royal Infirmary Manchester, United Kingdom
| | - Silke R Brix
- Manchester University Hospitals Manchester Royal Infirmary Manchester, United Kingdom
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17
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Brix SR, Noriega M, Tennstedt P, Vettorazzi E, Busch M, Nitschke M, Jabs WJ, Özcan F, Wendt R, Hausberg M, Sellin L, Panzer U, Huber TB, Waldherr R, Hopfer H, Stahl RA, Wiech T. Development and validation of a renal risk score in ANCA-associated glomerulonephritis. Kidney Int 2018; 94:1177-1188. [DOI: 10.1016/j.kint.2018.07.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/14/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
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18
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Brix SR, Noriega M, Herden EM, Goldmann B, Langbehn U, Busch M, Jabs WJ, Steinmetz OM, Panzer U, Huber TB, Stahl RAK, Wiech T. Organisation of lymphocytic infiltrates in ANCA-associated glomerulonephritis. Histopathology 2018; 72:1093-1101. [PMID: 29453894 DOI: 10.1111/his.13487] [Citation(s) in RCA: 12] [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] [Received: 11/21/2017] [Accepted: 02/12/2018] [Indexed: 12/17/2022]
Abstract
AIMS Renal involvement in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis contributes to significant morbidity and mortality in patients. In chronic inflammation, B cells are recruited to the inflamed tissue and organised lymphoid structures have been described in several autoimmune diseases. The aim of this study was to correlate the lymphoid organisation in renal biopsies with renal outcome in ANCA-associated glomerulonephritis (GN). METHODS AND RESULTS We investigated 112 renal biopsies from patients with newly diagnosed ANCA-associated necrotising GN. We identified four different levels of the intrarenal organisation of lymphocytes: T cells without B cells, scattered B and T cells, clustered lymphocytic infiltrates and nodular compartmentally arranged B and T cell aggregates. Almost half the patients showed clusters of B and T lymphocytes in their biopsies. In 15 of these biopsies, a higher degree of organisation with lymphocytic compartments was detected. Inflammatory cell organisation was associated with renal failure, but not with tubular atrophy and interstitial fibrosis. Patients with organised lymphocytic infiltrates in their biopsy had worse renal function during follow-up and were more likely to develop end stage renal disease. CONCLUSIONS In the present study, we show that the renal lymphocytic organisation is associated with renal outcome in ANCA-associated GN. The organisation of the lymphocytic infiltrate may be a morphological correlate of a perpetual and exaggerated inflammation in renal ANCA disease. Classifying the lymphocytic infiltrate could help to predict renal outcome, and might therefore be used for individualised adjustments in the intensity and duration of immunosuppressive therapy.
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Affiliation(s)
- Silke R Brix
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Mercedes Noriega
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Elisabeth M Herden
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Birgit Goldmann
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike Langbehn
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Busch
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Jena, Germany
| | - Wolfram J Jabs
- Klinik für Nephrologie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Oliver M Steinmetz
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Panzer
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias B Huber
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf A K Stahl
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Wiech
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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19
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Krohn S, Nies JF, Kapffer S, Schmidt T, Riedel JH, Kaffke A, Peters A, Borchers A, Steinmetz OM, Krebs CF, Turner JE, Brix SR, Paust HJ, Stahl RAK, Panzer U. IL-17C/IL-17 Receptor E Signaling in CD4 + T Cells Promotes T H17 Cell-Driven Glomerular Inflammation. J Am Soc Nephrol 2018; 29:1210-1222. [PMID: 29483158 DOI: 10.1681/asn.2017090949] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022] Open
Abstract
The IL-17 cytokine family and the cognate receptors thereof have a unique role in organ-specific autoimmunity. Most studies have focused on the founding member of the IL-17 family, IL-17A, as the central mediator of diseases. Indeed, although pathogenic functions have been ascribed to IL-17A and IL-17F in the context of immune-mediated glomerular diseases, the specific functions of the other IL-17 family members in immunity and inflammatory kidney diseases is largely unknown. Here, we report that compared with healthy controls, patients with acute Anti-neutrophil cytoplasmatic antibody (ANCA)-associated crescentic glomerulonephritis (GN) had significantly elevated serum levels of IL-17C (but not IL-17A, F, or E). In mouse models of crescentic GN (nephrotoxic nephritis) and pristane-induced lupus nephritis, deficiency in IL-17C significantly ameliorated the course of GN in terms of renal tissue injury and kidney function. Deficiency of the unique IL-17C receptor IL-17 receptor E (IL-17RE) provided similar protection against crescentic GN. These protective effects associated with a reduced TH17 response. Bone marrow transplantation experiments revealed that IL-17C is produced by tissue-resident cells, but not by lymphocytes. Finally, IL-17RE was highly expressed by CD4+ TH17 cells, and loss of this expression prevented the TH17 responses and subsequent tissue injury in crescentic GN. Our findings indicate that IL-17C promotes TH17 cell responses and immune-mediated kidney disease via IL-17RE expressed on CD4+ TH17 cells. Targeting the IL-17C/IL-17RE pathway may present an intriguing therapeutic strategy for TH17-induced autoimmune disorders.
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Affiliation(s)
- Sonja Krohn
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jasper F Nies
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Sonja Kapffer
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Tilman Schmidt
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Hendrik Riedel
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Kaffke
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Anett Peters
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Borchers
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver M Steinmetz
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian F Krebs
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Eric Turner
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Silke R Brix
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Joachim Paust
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf A K Stahl
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Panzer
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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20
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Krebs CF, Paust HJ, Krohn S, Koyro T, Brix SR, Riedel JH, Bartsch P, Wiech T, Meyer-Schwesinger C, Huang J, Fischer N, Busch P, Mittrücker HW, Steinhoff U, Stockinger B, Perez LG, Wenzel UO, Janneck M, Steinmetz OM, Gagliani N, Stahl RAK, Huber S, Turner JE, Panzer U. Autoimmune Renal Disease Is Exacerbated by S1P-Receptor-1-Dependent Intestinal Th17 Cell Migration to the Kidney. Immunity 2017; 45:1078-1092. [PMID: 27851911 PMCID: PMC6381450 DOI: 10.1016/j.immuni.2016.10.020] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/11/2016] [Accepted: 09/27/2016] [Indexed: 12/13/2022]
Abstract
Th17 cells are most abundant in the gut, where their presence depends on the intestinal microbiota. Here, we examined whether intestinal Th17 cells contribute to extra-intestinal Th17 responses in autoimmune kidney disease. We found high frequencies of Th17 cells in the kidneys of patients with antineutrophil cytoplasmatic antibody (ANCA)-associated glomerulonephritis. We utilized photoconversion of intestinal cells in Kaede mice to track intestinal T cell mobilization upon glomerulonephritis induction, and we found that Th17 cells egress from the gut in a S1P-receptor-1-dependent fashion and subsequently migrate to the kidney via the CCL20/CCR6 axis. Depletion of intestinal Th17 cells in germ-free and antibiotic-treated mice ameliorated renal disease, whereas expansion of these cells upon Citrobacter rodentium infection exacerbated pathology. Thus, in some autoimmune settings, intestinal Th17 cells migrate into target organs, where they contribute to pathology. Targeting the intestinal Th17 cell "reservoir" may present a therapeutic strategy for these autoimmune disorders.
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Affiliation(s)
- Christian F Krebs
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Hans-Joachim Paust
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Sonja Krohn
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Tobias Koyro
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Silke R Brix
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Jan-Hendrik Riedel
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Patricia Bartsch
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Thorsten Wiech
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | | | - Jiabin Huang
- Institut für Medizinische Mikrobiologie, Virologie, und Hygiene, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Nicole Fischer
- Institut für Medizinische Mikrobiologie, Virologie, und Hygiene, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Philipp Busch
- Klinik für Allgemeinchirurgie, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Hans-Willi Mittrücker
- Institut für Immunologie, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Ulrich Steinhoff
- Philipps-Universität Marburg, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, 35043 Marburg, Germany
| | | | - Laura Garcia Perez
- I. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Ulrich O Wenzel
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Matthias Janneck
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Oliver M Steinmetz
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Nicola Gagliani
- Klinik für Allgemeinchirurgie, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Rolf A K Stahl
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Samuel Huber
- I. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Jan-Eric Turner
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Ulf Panzer
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, 20251 Hamburg, Germany.
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21
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Riedel JH, Becker M, Kopp K, Düster M, Brix SR, Meyer-Schwesinger C, Kluth LA, Gnirck AC, Attar M, Krohn S, Fehse B, Stahl RAK, Panzer U, Turner JE. IL-33-Mediated Expansion of Type 2 Innate Lymphoid Cells Protects from Progressive Glomerulosclerosis. J Am Soc Nephrol 2017; 28:2068-2080. [PMID: 28154198 DOI: 10.1681/asn.2016080877] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [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: 08/16/2016] [Accepted: 12/22/2016] [Indexed: 12/30/2022] Open
Abstract
Innate lymphoid cells (ILCs) have an important role in the immune system's response to different forms of infectious and noninfectious pathologies. In particular, IL-5- and IL-13-producing type 2 ILCs (ILC2s) have been implicated in repair mechanisms that restore tissue integrity after injury. However, the presence of renal ILCs in humans has not been reported. In this study, we show that ILC populations are present in the healthy human kidney. A detailed characterization of kidney-residing ILC populations revealed that IL-33 receptor-positive ILC2s are a major ILC subtype in the kidney of humans and mice. Short-term IL-33 treatment in mice led to sustained expansion of IL-33 receptor-positive kidney ILC2s and ameliorated adriamycin-induced glomerulosclerosis. Furthermore, the expansion of ILC2s modulated the inflammatory response in the diseased kidney in favor of an anti-inflammatory milieu with a reduction of pathogenic myeloid cell infiltration and a marked accumulation of eosinophils that was required for tissue protection. In summary, kidney-residing ILC2s can be effectively expanded in the mouse kidney by IL-33 treatment and are central regulators of renal repair mechanisms. The presence of ILC2s in the human kidney tissue identifies these cells as attractive therapeutic targets for CKD in humans.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Boris Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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22
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Brix SR, Iking-Konert C, Stahl RAK, Wenzel U. Disseminated Mycobacterium haemophilum infection in a renal transplant recipient. BMJ Case Rep 2016; 2016:bcr-2016-216042. [PMID: 27799227 DOI: 10.1136/bcr-2016-216042] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Opportunistic infections are a major concern in renal and transplant medicine. We present the case of a renal transplant recipient with a generalised Mycobacterium haemophilum infection after an increase in immunosuppressive therapy and treatment with a tumour necrosis factor-α (TNF-α) inhibitor. Infection involved skin and soft tissue, joints and bones, as well as the renal transplant with an interstitial nephritis. Rapid diagnosis using PCR and DNA sequencing allowed early appropriate treatment. Triple antibiotic therapy and reduction in immunosuppression resulted in a slow but sustained recovery. Immunosuppression causes severe opportunistic infections. TNF-α inhibitors are very effective and well tolerated but have an increased susceptibility to infections with mycobacteria. Mycobacterial infections represent a significant clinical risk to transplant recipients because of their aggressive clinical course and the need for complex toxic antibiotic treatments. In these patients, M. haemophilum is a cause of skin infections.
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Affiliation(s)
- Silke R Brix
- Medical Clinic, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Rolf A K Stahl
- Medical Clinic, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Wenzel
- Medical Clinic, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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23
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Paust HJ, Riedel JH, Krebs CF, Turner JE, Brix SR, Krohn S, Velden J, Wiech T, Kaffke A, Peters A, Bennstein SB, Kapffer S, Meyer-Schwesinger C, Wegscheid C, Tiegs G, Thaiss F, Mittrücker HW, Steinmetz OM, Stahl RAK, Panzer U. CXCR3+ Regulatory T Cells Control TH1 Responses in Crescentic GN. J Am Soc Nephrol 2015; 27:1933-42. [PMID: 26534920 DOI: 10.1681/asn.2015020203] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [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: 02/24/2015] [Accepted: 09/08/2015] [Indexed: 12/29/2022] Open
Abstract
Chemokines and chemokine receptors are implicated in regulatory T cell (Treg) trafficking to sites of inflammation and suppression of excessive immune responses in inflammatory and autoimmune diseases; however, the specific requirements for Treg migration into the inflamed organs and the positioning of these cells within the tissue are incompletely understood. Here, we report that Tregs expressing the TH1-associated chemokine receptor CXCR3 are enriched in the kidneys of patients with ANCA-associated crescentic GN and colocalize with CXCR3(+) effector T cells. To investigate the functional role of CXCR3(+) Tregs, we generated mice that lack CXCR3 in Tregs specifically (Foxp3(eGFP-Cre) × Cxcr3(fl/fl)) and induced experimental crescentic GN. Treg-specific deletion of CXCR3 resulted in reduced Treg recruitment to the kidney and an overwhelming TH1 immune response, with an aggravated course of the nephritis that was reversible on anti-IFNγ treatment. Together, these findings show that a subset of Tregs expresses CXCR3 and thereby, acquires trafficking properties of pathogenic CXCR3(+) TH1 cells, allowing Treg localization and control of excessive TH1 responses at sites of inflammation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gisa Tiegs
- Institut für Experimentelle Immunologie und Hepatologie, and
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Brix SR, Stege G, Disteldorf E, Hoxha E, Krebs C, Krohn S, Otto B, Klätschke K, Herden E, Heymann F, Lira SA, Tacke F, Wolf G, Busch M, Jabs WJ, Özcan F, Keller F, Beige J, Wagner K, Helmchen U, Noriega M, Wiech T, Panzer U, Stahl RAK. CC Chemokine Ligand 18 in ANCA-Associated Crescentic GN. J Am Soc Nephrol 2015; 26:2105-17. [PMID: 25762060 DOI: 10.1681/asn.2014040407] [Citation(s) in RCA: 31] [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] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 10/10/2014] [Indexed: 11/03/2022] Open
Abstract
ANCA-associated vasculitis is the most frequent cause of crescentic GN. To define new molecular and/or cellular biomarkers of this disease in the kidney, we performed microarray analyses of renal biopsy samples from patients with ANCA-associated crescentic GN. Expression profiles were correlated with clinical data in a prospective study of patients with renal ANCA disease. CC chemokine ligand 18 (CCL18), acting through CC chemokine receptor 8 (CCR8) on mononuclear cells, was identified as the most upregulated chemotactic cytokine in patients with newly diagnosed ANCA-associated crescentic GN. Macrophages and myeloid dendritic cells in the kidney were detected as CCL18-producing cells. The density of CCL18(+) cells correlated with crescent formation, interstitial inflammation, and impairment of renal function. CCL18 protein levels were higher in sera of patients with renal ANCA disease compared with those in sera of patients with other forms of crescentic GN. CCL18 serum levels were higher in patients who suffered from ANCA-associated renal relapses compared with those in patients who remained in remission. Using a murine model of crescentic GN, we explored the effects of the CCL18 murine functional analog CCL8 and its receptor CCR8 on kidney function and morphology. Compared with wild-type mice, Ccr8(-/-) mice had significantly less infiltration of pathogenic mononuclear phagocytes. Furthermore, Ccr8(-/-) mice maintained renal function better and had reduced renal tissue injury. In summary, our data indicate that CCL18 drives renal inflammation through CCR8-expressing cells and could serve as a biomarker for disease activity and renal relapse in ANCA-associated crescentic GN.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Felix Heymann
- Medizinische Klinik III, Uniklinik Rheinisch Westfälische Technische Hochschule, Aachen, Germany
| | - Sergio A Lira
- Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frank Tacke
- Medizinische Klinik III, Uniklinik Rheinisch Westfälische Technische Hochschule, Aachen, Germany
| | - Gunter Wolf
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Jena, Germany
| | - Martin Busch
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Jena, Germany
| | - Wolfram J Jabs
- Klinik für Innere Medizin, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Fedai Özcan
- Klinik für Nephrologie und Notfallmedizin, Klinikum Dortmund, Dortmund, Germany
| | - Frieder Keller
- Abteilung Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
| | - Joachim Beige
- Abteilung Nephrologie, Klinikum St. Georg, Leipzig, Germany; and
| | - Karl Wagner
- IV Medizinische Abteilung, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Udo Helmchen
- Pathologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - Mercedes Noriega
- Pathologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - Thorsten Wiech
- Pathologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
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25
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Kluger MA, Luig M, Wegscheid C, Goerke B, Paust HJ, Brix SR, Yan I, Mittrücker HW, Hagl B, Renner ED, Tiegs G, Wiech T, Stahl RAK, Panzer U, Steinmetz OM. Stat3 programs Th17-specific regulatory T cells to control GN. J Am Soc Nephrol 2014; 25:1291-302. [PMID: 24511136 DOI: 10.1681/asn.2013080904] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A pathogenic role for Th17 cells in inflammatory renal disease is well established. The mechanisms underlying their counter-regulation are, however, largely unknown. Recently, Th17 lineage-specific regulatory T cells (Treg17) that depend on activation of the transcription factor Stat3 were identified. We studied the function of Treg17 in the nephrotoxic nephritis (NTN) model of crescentic GN. The absence of Treg17 cells in Foxp3(Cre)×Stat3(fl/fl) mice resulted in the aggravation of NTN and skewing of renal and systemic immune responses toward Th17. Detailed analysis of Stat3-deficient Tregs revealed that the survival, activation, proliferation, and suppressive function of these cells remained intact. However, Tregs from Foxp3(Cre)×Stat3(fl/fl) mice lacked surface expression of the chemokine receptor CCR6, which resulted in impaired renal trafficking. Furthermore, aggravation of NTN was reversible in the absence of Th17 responses, as shown in CD4(Cre)×Stat3(fl/fl) mice lacking both Treg17 and Th17 cells, suggesting that Th17 cells are indeed the major target of Treg17 cells. Notably, immunohistochemistry revealed CCR6-bearing Treg17 cells in kidney biopsy specimens of patients with GN. CCR6 expression on human Treg17 cells also appears dependent on STAT3, as shown by analysis of Tregs from patients with dominant-negative STAT3 mutations. Our data indicate the presence and involvement of Stat3/STAT3-dependent Treg17 cells that specifically target Th17 cells in murine and human crescentic GN, and suggest the kidney-specific action of these Treg17 cells is regulated by CCR6-directed migration into areas of Th17 inflammation.
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Affiliation(s)
| | | | - Claudia Wegscheid
- Institut für Experimentelle Hepatologie und Immunologie, Universitätsklinikum Eppendorf, Hamburg, Germany; and
| | | | | | | | | | | | - Beate Hagl
- University Children's Hospital, Ludwig Maximilians University, Munich, Germany
| | - Ellen D Renner
- University Children's Hospital, Ludwig Maximilians University, Munich, Germany
| | - Gisa Tiegs
- Institut für Experimentelle Hepatologie und Immunologie, Universitätsklinikum Eppendorf, Hamburg, Germany; and
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26
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Krebs CF, Kapffer S, Paust HJ, Schmidt T, Bennstein SB, Peters A, Stege G, Brix SR, Meyer-Schwesinger C, Müller RU, Turner JE, Steinmetz OM, Wolf G, Stahl RAK, Panzer U. MicroRNA-155 drives TH17 immune response and tissue injury in experimental crescentic GN. J Am Soc Nephrol 2013; 24:1955-65. [PMID: 23949802 DOI: 10.1681/asn.2013020130] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
CD4(+) T cells play a pivotal role in the pathogenesis of autoimmune disease, including human and experimental crescentic GN. Micro-RNAs (miRs) have emerged as important regulators of immune cell development, but the impact of miRs on the regulation of the CD4(+) T cell immune response remains to be fully clarified. Here, we report that miR-155 expression is upregulated in the kidneys of patients with ANCA-associated crescentic GN and a murine model of crescentic GN (nephrotoxic nephritis). To elucidate the potential role of miR-155 in T cell-mediated inflammation, nephritis was induced in miR-155(-/-) and wild-type mice. The systemic and renal nephritogenic TH17 immune response decreased markedly in nephritic miR-155(-/-) mice. Consistent with this finding, miR-155-deficient mice developed less severe nephritis, with reduced histologic and functional injury. Adoptive transfer of miR-155(-/-) and wild-type CD4(+) T cells into nephritic recombination activating gene 1-deficient (Rag-1(-/-)) mice showed the T cell-intrinsic importance of miR-155 for the stability of pathogenic TH17 immunity. These findings indicate that miR-155 drives the TH17 immune response and tissue injury in experimental crescentic GN and show that miR-155 is a potential therapeutic target in TH17-mediated diseases.
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Affiliation(s)
- Christian F Krebs
- III Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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