1
|
Zhu Y, Chen J, Zhang Y, Wang X, Wang J. Immunosuppressive agents for frequently relapsing/steroid-dependent nephrotic syndrome in children: a systematic review and network meta-analysis. Front Immunol 2024; 15:1310032. [PMID: 38464533 PMCID: PMC10920238 DOI: 10.3389/fimmu.2024.1310032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Aim This study aimed to systematically compare the efficacy of various immunosuppressive agents in treating pediatric frequently relapsing or steroid-dependent nephrotic syndrome (FRSDNS). Methods We conducted systematic searches of PubMed, Embase, the Cochrane Library, and the Web of Science up to May 23, 2023. Outcome measures included relapses within 1 year, mean cumulative exposure to corticosteroids, patients with treatment failure at 1 year, relapse-free survival during 1 year, and adverse events. The quality of the included studies was evaluated using the modified Jadad scale, the Methodological Index for Non-Randomized Studies (MINORS), and the modified Newcastle-Ottawa Scale (NOS). Results Rituximab was found to be the most likely (92.44%) to be associated with the fewest relapses within 1 year and was also most likely (99.99%) to result in the lowest mean cumulative exposure to corticosteroids. Rituximab had the highest likelihood (45.98%) of being associated with the smallest number of patients experiencing treatment failure at 1 year. CsA was most likely (57.93%) to achieve the highest relapse-free survival during 1 year, followed by tacrolimus (26.47%) and rituximab (30.48%). Rituximab showed no association with serious side effects and had comparable adverse effects to ofatumumab and tacrolimus. Conclusion Rituximab may be the most favorable immunosuppressive agent for treating pediatric FRSDNS. Nephrologists should consider this drug, along with their clinical experience, patient characteristics, and cost considerations, when choosing a treatment approach.
Collapse
Affiliation(s)
- Yu Zhu
- Department of Traditional Chinese Medicine, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Junyi Chen
- Department of Nephrology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Yao Zhang
- Department of Traditional Chinese Medicine, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Xiaoai Wang
- Department of Traditional Chinese Medicine, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Jingjing Wang
- Department of Nephrology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| |
Collapse
|
2
|
Odler B, Tieu J, Artinger K, Chen-Xu M, Arnaud L, Kitching RA, Terrier B, Thiel J, Cid MC, Rosenkranz AR, Kronbichler A, Jayne DRW. The plethora of immunomodulatory drugs: opportunities for immune-mediated kidney diseases. Nephrol Dial Transplant 2023; 38:ii19-ii28. [PMID: 37816674 DOI: 10.1093/ndt/gfad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Indexed: 10/12/2023] Open
Abstract
In recent decades, insights into the molecular pathways involved in disease have revolutionized the treatment of autoimmune diseases. A plethora of targeted therapies have been identified and are at varying stages of clinical development in renal autoimmunity. Some of these agents, such as rituximab or avacopan, have been approved for the treatment of immune-mediated kidney disease, but kidney disease lags behind more common autoimmune disorders in new drug development. Evidence is accumulating as to the importance of adaptive immunity, including abnormalities in T-cell activation and signaling, and aberrant B-cell function. Furthermore, innate immunity, particularly the complement and myeloid systems, as well as pathologic responses in tissue repair and fibrosis, play a key role in disease. Collectively, these mechanistic studies in innate and adaptive immunity have provided new insights into mechanisms of glomerular injury in immune-mediated kidney diseases. In addition, inflammatory pathways common to several autoimmune conditions exist, suggesting that the repurposing of some existing drugs for the treatment of immune-mediated kidney diseases is a logical strategy. This new understanding challenges the clinical investigator to translate new knowledge into novel therapies leading to better disease outcomes. This review highlights promising immunomodulatory therapies tested for immune-mediated kidney diseases as a primary indication, details current clinical trials and discusses pathways that could be targeted in the future.
Collapse
Affiliation(s)
- Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Johanna Tieu
- Faculty of Health and Medical Sciences, University of Adelaide; Adelaide, Australia
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia
- Rheumatology Unit, Lyell McEwin Hospital, Adelaide, Australia
| | - Katharina Artinger
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Chen-Xu
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Laurent Arnaud
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
| | - Richard A Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
- Departments of Nephrology and Paediatric Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Benjamin Terrier
- Department of Internal Medicine, National Reference Center for Autoimmune Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| | - Jens Thiel
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alexander R Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
3
|
Vivarelli M, Gibson K, Sinha A, Boyer O. Childhood nephrotic syndrome. Lancet 2023; 402:809-824. [PMID: 37659779 DOI: 10.1016/s0140-6736(23)01051-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 09/04/2023]
Abstract
Idiopathic nephrotic syndrome is the most common glomerular disease in children. Corticosteroids are the cornerstone of its treatment, and steroid response is the main prognostic factor. Most children respond to a cycle of oral steroids, and are defined as having steroid-sensitive nephrotic syndrome. Among the children who do not respond, defined as having steroid-resistant nephrotic syndrome, most respond to second-line immunosuppression, mainly with calcineurin inhibitors, and children in whom a response is not observed are described as multidrug resistant. The pathophysiology of nephrotic syndrome remains elusive. In cases of immune-mediated origin, dysregulation of immune cells and production of circulating factors that damage the glomerular filtration barrier have been described. Conversely, up to a third of cases of steroid-resistant nephrotic syndrome have a monogenic origin. Multidrug resistant nephrotic syndrome often leads to kidney failure and can cause relapse after kidney transplant. Although steroid-sensitive nephrotic syndrome does not affect renal function, most children with steroid-sensitive nephrotic syndrome have a relapsing course that requires repeated steroid cycles with significant side-effects. To minimise morbidity, some patients require steroid-sparing immunosuppressive agents, including levamisole, mycophenolate mofetil, calcineurin inhibitors, anti-CD20 monoclonal antibodies, and cyclophosphamide. Close monitoring and preventive measures are warranted at onset and during relapse to prevent acute complications (eg, hypovolaemia, acute kidney injury, infections, and thrombosis), whereas long-term management requires minimising treatment-related side-effects. A subset of patients have active disease into adulthood.
Collapse
Affiliation(s)
- Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
| | - Keisha Gibson
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, NC, USA
| | - Aditi Sinha
- Division of Nephrology, Indian Council of Medical Research Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Olivia Boyer
- Néphrologie Pédiatrique, Centre de Référence Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Hôpital Necker - Enfants Malades, Assistance Publique Hôpitaux de Paris, Inserm U1163, Institut Imagine, Université Paris Cité, Paris, France
| |
Collapse
|
4
|
Barry A, McNulty MT, Jia X, Gupta Y, Debiec H, Luo Y, Nagano C, Horinouchi T, Jung S, Colucci M, Ahram DF, Mitrotti A, Sinha A, Teeninga N, Jin G, Shril S, Caridi G, Bodria M, Lim TY, Westland R, Zanoni F, Marasa M, Turudic D, Giordano M, Gesualdo L, Magistroni R, Pisani I, Fiaccadori E, Reiterova J, Maringhini S, Morello W, Montini G, Weng PL, Scolari F, Saraga M, Tasic V, Santoro D, van Wijk JAE, Milošević D, Kawai Y, Kiryluk K, Pollak MR, Gharavi A, Lin F, Simœs E Silva AC, Loos RJF, Kenny EE, Schreuder MF, Zurowska A, Dossier C, Ariceta G, Drozynska-Duklas M, Hogan J, Jankauskiene A, Hildebrandt F, Prikhodina L, Song K, Bagga A, Cheong H, Ghiggeri GM, Vachvanichsanong P, Nozu K, Lee D, Vivarelli M, Raychaudhuri S, Tokunaga K, Sanna-Cherchi S, Ronco P, Iijima K, Sampson MG. Multi-population genome-wide association study implicates immune and non-immune factors in pediatric steroid-sensitive nephrotic syndrome. Nat Commun 2023; 14:2481. [PMID: 37120605 PMCID: PMC10148875 DOI: 10.1038/s41467-023-37985-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/10/2023] [Indexed: 05/01/2023] Open
Abstract
Pediatric steroid-sensitive nephrotic syndrome (pSSNS) is the most common childhood glomerular disease. Previous genome-wide association studies (GWAS) identified a risk locus in the HLA Class II region and three additional independent risk loci. But the genetic architecture of pSSNS, and its genetically driven pathobiology, is largely unknown. Here, we conduct a multi-population GWAS meta-analysis in 38,463 participants (2440 cases). We then conduct conditional analyses and population specific GWAS. We discover twelve significant associations-eight from the multi-population meta-analysis (four novel), two from the multi-population conditional analysis (one novel), and two additional novel loci from the European meta-analysis. Fine-mapping implicates specific amino acid haplotypes in HLA-DQA1 and HLA-DQB1 driving the HLA Class II risk locus. Non-HLA loci colocalize with eQTLs of monocytes and numerous T-cell subsets in independent datasets. Colocalization with kidney eQTLs is lacking but overlap with kidney cell open chromatin suggests an uncharacterized disease mechanism in kidney cells. A polygenic risk score (PRS) associates with earlier disease onset. Altogether, these discoveries expand our knowledge of pSSNS genetic architecture across populations and provide cell-specific insights into its molecular drivers. Evaluating these associations in additional cohorts will refine our understanding of population specificity, heterogeneity, and clinical and molecular associations.
Collapse
Affiliation(s)
- Alexandra Barry
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Michelle T McNulty
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Xiaoyuan Jia
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine (NCGM), Tokyo, Japan
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yask Gupta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Hanna Debiec
- Sorbonne Université, UPMC Paris 06, Institut National de la Santé et de la Recherde Médicale, Unité Mixte de Rechereche, S 1155, Paris, France
| | - Yang Luo
- Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom
- Center for Data Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Divisions of Genetics and Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - China Nagano
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seulgi Jung
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Dina F Ahram
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Adele Mitrotti
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Aditi Sinha
- Department of Pediatrics, AIIMS, New Delhi, India
| | - Nynke Teeninga
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gina Jin
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shirlee Shril
- Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Gianluca Caridi
- Laboratory on Molecular Nephrology, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Monica Bodria
- Department of Nephrology and Renal Transplantation, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Tze Y Lim
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Rik Westland
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Francesca Zanoni
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Maddalena Marasa
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Daniel Turudic
- Department of Pediatric Nephrology, Dialysis and Transplantation, Clinical Hospital Hospital Center Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Mario Giordano
- Division of Nephrology and Pediatric Dialysis, Bari Polyclinic Giovanni XXIII Children's Hospital, Bari, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Riccardo Magistroni
- Department of Nephrology, Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Isabella Pisani
- Unità Operativa Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- Unità Operativa Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Jana Reiterova
- Department of Nephrology, Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | | | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Patricia L Weng
- Department of Pediatric Nephrology, UCLA Medical Center and UCLA Medical Center-Santa Monica, Los Angeles, CA, USA
| | - Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Division of Nephrology and Dialysis, University of Brescia and ASST Spedali Civili of Brescia, Brescia, Italy
| | - Marijan Saraga
- Department of Pediatrics, University of Split, Split, Croatia
| | - Velibor Tasic
- Department of Pediatric Nephrology, University Children's Hospital, Skopje, Macedonia
| | - Domenica Santoro
- Division of Nephrology and Dialysis Unit, University of Messina, Sicily, Italy
| | - Joanna A E van Wijk
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Danko Milošević
- Department of Pediatric Nephrology, Dialysis and Transplantation, Clinical Hospital Hospital Center Zagreb, University of Zagreb Medical School, Zagreb, Croatia
- Croatian Academy of Medical Sciences, Praska 2/III p.p. 27, 10000, Zagreb, Croatia
| | - Yosuke Kawai
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine (NCGM), Tokyo, Japan
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Martin R Pollak
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pediatric, Division of Pediatric Nephrology, Columbia University Irving Medical Center New York-Presbyterian Morgan Stanley Children's Hospital in New York, New York, NY, USA
| | - Ali Gharavi
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Fangmin Lin
- Department of Pediatric, Division of Pediatric Nephrology, Columbia University Irving Medical Center New York-Presbyterian Morgan Stanley Children's Hospital in New York, New York, NY, USA
| | - Ana Cristina Simœs E Silva
- Department of Pediatrics, Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eimear E Kenny
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Genomic Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aleksandra Zurowska
- Department of Pediatrics, Nephrology and Hypertension, Medical University Gdansk, Gdansk, Poland
| | - Claire Dossier
- AP-HP, Pediatric Nephrology Department, Hôpital Robert-Debré, Paris, France
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | - Julien Hogan
- AP-HP, Pediatric Nephrology Department, Hôpital Robert-Debré, Paris, France
| | - Augustina Jankauskiene
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Friedhelm Hildebrandt
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Larisa Prikhodina
- Research and Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University, Taldomskava St, 2, Moscow, Russia
| | - Kyuyoung Song
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Arvind Bagga
- Department of Pediatrics, AIIMS, New Delhi, India
| | - Hae Cheong
- Department of Pediatrics, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, Korea
| | - Gian Marco Ghiggeri
- Department of Nephrology and Renal Transplantation, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Prayong Vachvanichsanong
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, 90110, Thailand
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Dongwon Lee
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Marina Vivarelli
- Division of Nephrology, and Dialysis, Department of Pediatric Subspecialities, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Soumya Raychaudhuri
- Center for Data Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Divisions of Genetics and Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Centre for Genetics and Genomics Versus Arthritis, University of Manchester, Manchester, UK
| | - Katsushi Tokunaga
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine (NCGM), Tokyo, Japan
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Simone Sanna-Cherchi
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Pierre Ronco
- Sorbonne Université, UPMC Paris 06, Institut National de la Santé et de la Recherde Médicale, Unité Mixte de Rechereche, S 1155, Paris, France
- Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Matthew G Sampson
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA.
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
5
|
Liu J, Shen Q, Xie L, Wang J, Li Y, Chen J, Fang X, Tang X, Qian B, Xu H. Protocol for an open-label, single-arm, multicentre clinical study to evaluate the efficacy and safety of rituximab in the first episode of paediatric idiopathic nephrotic syndrome. BMJ Open 2022; 12:e064216. [PMID: 36223961 PMCID: PMC9562314 DOI: 10.1136/bmjopen-2022-064216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Rituximab (RTX) effectively prevents relapses in patients with complicated steroid-sensitive nephrotic syndrome (SSNS). The 1-year relapse-free survival rate is approximately 30% in children after the first episode of SSNS treated with standardised corticosteroids. Whether the benefits of RTX extend to the first relapse are unknown. The efficacy and safety of RTX in the first episode of paediatric idiopathic nephrotic syndrome (RTXFIRPedINS) trial (NCT04783675) will assess its effect on the risk of subsequent relapse. METHODS AND ANALYSIS RTXFIRPedINS is an open-label, single-arm, multicentre trial targeting patients aged 1-18 years with a first episode of SSNS. All patients will receive standardised corticosteroid treatment for 12 weeks. A sample size of 44 patients provides 80% power to detect a 20% increase in the 1-year relapse-free rate, assuming a dropout rate of 10%. After obtaining informed consent and screening, eligible patients will be treated with a single intravenous infusion of 375 mg/m2 RTX within 1 week after achieving remission. Trimethoprim-sulfamethoxazole will be administered for 3 months after RTX administration to prevent Pneumocystis carinii infection. The follow-up period will be 1 year. The primary outcome is the 1-year relapse-free survival rate after RTX infusion. The secondary study outcomes are the number of days from the infusion of RTX to the occurrence of the first relapse, 6-month relapse-free survival rate, the B cell recovery time and treatment-related adverse events. Immunological factors will be studied as predictors of response. ETHICS AND DISSEMINATION This trial was approved by the Ethics Committee of the Children's Hospital of Fudan University and seven local ethics committees. We will publish our study results in peer-reviewed journals and present them at international scientific meetings. TRIAL REGISTRATION NUMBER NCT04783675.
Collapse
Affiliation(s)
- Jialu Liu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Clinical Research Promotion and Development Centre, Shanghai Hospital Development Centre, Shanghai, China
| | - Jiyang Wang
- Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Yaxuan Li
- Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xiaoyan Fang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xiaoshan Tang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Biyun Qian
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Clinical Research Promotion and Development Centre, Shanghai Hospital Development Centre, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| |
Collapse
|
6
|
KIAA0101 and IL2RA Were Identified as Core Genes in Hormone-Resistant Nephropathy. DISEASE MARKERS 2022; 2022:6545266. [PMID: 36164371 PMCID: PMC9509277 DOI: 10.1155/2022/6545266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022]
Abstract
Objectives To analyze the tissue heterogeneity of hormone-sensitive and drug-resistant nephrotic syndrome genes using a bioinformatics approach and to analyze gene-related functional pathways. Methods The limma package of R software was used to screen differential genes from the nephropathy datasets GSE145969 and GSE189734. The differential genes were analyzed for functional and pathway enrichment in terms of biological processes, cellular components, and molecular functions. The Metascape tool was used to construct protein networks for the differential genes, and the results were imported into Cytoscape software for visualization. The genes were identified as key modules and genes using the MCODE plug-in. Gene set enrichment analysis was performed for the HALLMARK analysis of the two microarray key genes to obtain the relevant pathways. Results GSE145969 screened 351 differential genes, 168 upregulated genes, and 183 downregulated genes. The differential genes were enriched in biological processes, cellular components, and molecular functions, such as myocardial contraction, intracellular nonmembrane organelles, and structural molecular activities. The protein-protein interaction (PPI) network contained 140 nodes, with the highest-scoring module containing seven genes, and the MCODE plug-in calculated the downseed. The key gene was KIAA0101, whose HALLMARK pathway was significantly enriched in the mTORC1 signaling pathway. A total of 263 differential genes were screened by GSE189734, and they were enriched in biological processes, molecular functions, and cellular components, such as immune system processes, signaling receptor binding, and the cytoplasmic matrix. The PPI network contained 253 nodes, with the highest-scoring module containing 37 genes. The seed gene obtained through the MCODE plug-in calculation was IL2RA, whose HALLMARK pathway was significantly enriched in the KRAS signaling pathway. Conclusion By analyzing the gene sets of different tissues in nephropathy, two key genes, namely KIAA0101 and IL2RA, were obtained. Their gene function enrichment is related to cell growth, development, and reproduction. Therefore, IL2RA and KIAA0101 can be used as diagnostic markers for hormone-resistant nephropathy.
Collapse
|
7
|
Al Salloum AA, Al Herbish AJ, Al Hissi MA, Abdalla MS, Salim SB, Farhat AH, Shagal RA, Othman A, Alshaiban A, Temsah MHA, Al-Eyadhy AA, Alhasan KA. The outcome of rituximab in treating steroid dependent nephrotic syndrome.: Histopathology and immunosuppressive drugs as predicting factors. Saudi Med J 2022; 43:760-764. [PMID: 35830996 PMCID: PMC9749693 DOI: 10.15537/smj.2022.43.7.20210727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To present our experience of treating steroid-dependent nephrotic syndrome (SDNS) in children with repeated doses of rituximab (RTX) with a relatively long follow-up, and to discuss the role of the histopathology type and previous immune-suppressor (IS) drugs on the outcome of these patients. METHODS The patients included in this prospective study were children with SDNS who were in remission on a high-dose steroid or with additional IS drugs. All patients underwent renal biopsy before RTX treatment. Intravenous RTX was administered monthly at 375 mg/m2 for 4 doses. Response to treatment was defined as maintaining remission with no steroid-sparing agents or prednisone for one year. RESULTS Seventeen (14 males) patients were enrolled. Approximately 76% had minimal change disease (MCD) and 3 (18%) patients had immunoglobulin M (IgM) nephropathy. Approximately 85% of MCD and 33% of IgM nephropathy showed complete response to RTX. CONCLUSION Compared to other IS used to treat SDNS, RTX showed a significant decrease in relapse rate with fewer side effects. The dose and interval should be modified according to the patient's characteristics, such as medical history, pathology type, and previous IS agents.
Collapse
Affiliation(s)
- Abdullah A. Al Salloum
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Adi J. Al Herbish
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Mohammed A. Al Hissi
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Mohammed S. Abdalla
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Suha B. Salim
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Afrah H. Farhat
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Reem A. Shagal
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Abduldafaee Othman
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Abdulelah Alshaiban
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Mohamad-Hani A. Temsah
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Ayman A. Al-Eyadhy
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Khalid A. Alhasan
- From the Department of Pediatrics (Al Salloum, Al Herbish, Al Hissi, Abdallah, Salim, Farhat, Shagal, Othman, Alshiban, Temsah, Al-Eyadhy, Alhasan), College of Medicine, King Saud University, King Saud University Medical City, and from the Department of Pediatric Kidney Transplant (Alhasan), Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
- Address correspondence and reprints request to: Dr. Khalid A. Alhasan, Department of Pediatrics, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail: ORCID ID: https://orcid.org/0000-0002-42918536
| |
Collapse
|
8
|
PARMAKSIZ G. Tedavisi zor nefrotik sendromlu çocuklarda rituksimab tedavisi. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1038641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amaç: Rituksimab (RTX), tedavisi zor nefrotik sendromlu (sık tekrarlayan, steroide bağımlı ve steroide dirençli) hastalar için kurtarma tedavisi olarak önerilmektedir. Amacımız zor nefrotik sendromlu çocuklarda RTX tedavisinin etkinliğini ve uzun dönem sonuçlarını değerlendirmek ve deneyimlerimizi paylaşmaktır.
Gereç ve Yöntem: RTX ile tedavi edilen zor nefrotik sendromlu çocukların tıbbi kayıtları geriye dönük olarak değerlendirildi. Oniki ayda nükssüz sağkalım oranı ve B hücre deplesyonun izlemi değerlendirildi.
Bulgular: Çalışmaya 8'i steroide bağımlı (SBNS), 6'sı sık tekrarlayan (STNS) ve 6'sı steroide dirençli nefrotik sendromlu (SDNS) 20 çocuk dahil edildi. RTX tedavisi alan STNS/SBNS hastalarının tedavi öncesi ve sonrası 1 yıllık ortalama nüks sayısı karşılaştırıldı. Ortalama nüks sayısı 2 (1-4)’den 0 (0-1) kez/yıla geriledi. RTX tedavisi sonrası ortalama takip süresi 23 ay (12-59) ve 8 hastada nüks gelişti. RTX tedavisi sonrası nüks eden 5 hastaya, tekrarlayan dozlarda RTX uygulandı. Bu hastalarda, CD19+B hücreleri remisyon sırasında yeniden ortaya çıkarken, hafıza B hücrelerinin deplesyonu devam etti.
Sonuç: RTX tedavisi, STNS/SBNS hastalarında remisyon süresini uzattı, ancak SDNS hastalarında etkisiz kaldı. Bu hastalarda remisyonun idamesi için RTX dozunun tekrarlanabileceği ve tekrarlama dozlarının zamanlamasında en iyi hafıza B hücre sayısının yardımcı olabileceği saptandı.
Collapse
|
9
|
Funatogawa T, Narita Y, Tamura A, Mii K, Sugitani Y, Uchida T. Use of mycophenolate mofetil in patients with pediatric and adult primary nephrotic syndrome: information from a Japanese hospital claims database. Clin Exp Nephrol 2022; 26:1005-1013. [PMID: 35579722 PMCID: PMC9481489 DOI: 10.1007/s10157-022-02233-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/25/2022] [Indexed: 11/24/2022]
Abstract
Background Current treatment for frequently relapsing, steroid-dependent, or steroid-resistant nephrotic syndrome focuses on immunosuppressive therapies. Although the clinical guideline suggests the use of mycophenolate mofetil (MMF), limited information is available on patients with primary nephrotic syndrome who receive off-label treatment with MMF in Japan. Method The dose, treatment duration, previous treatment, and characteristics of primary nephrotic syndrome patients receiving MMF were investigated using data from a Japanese hospital claims database (April 2008–September 2021). Results Data on 424 primary nephrotic syndrome patients receiving MMF (146 patients < 18 years old; 278 patients ≥ 18 years old) were captured. The most common initial daily doses of MMF capsules (% of patients < 18 and ≥ 18 years old) were 1000 mg (31.9%, 36.8%), 1500 mg (16.0%, 23.8%), and 500 mg (23.6%, 17.3%), and the most common maximum daily doses were 1000 mg (43.8%, 32.9%), 1500 mg (23.6%, 28.9%), and 2000 mg (6.3%, 16.2%). Most patients (97.9%, 99.3%) were treated with a daily dose of 2000 mg or less. Among patients < 18 years old, the younger the patient, the lower the dose. MMF was used for more than 1 year in 30.8% of patients < 18 years old and in 28.8% of patients ≥ 18 years old. Conclusions Our study suggested that off-label use of MMF for primary nephrotic syndrome has increased since 2012 in Japan. The dose of MMF used in patients with primary nephrotic syndrome was generally within the approved dose range for lupus nephritis and transplant-related diseases in Japan.
Collapse
Affiliation(s)
- Takashi Funatogawa
- Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, 103-8324, Japan.
| | - Yusuke Narita
- Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, 103-8324, Japan
| | - Aya Tamura
- Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, 103-8324, Japan
| | - Kazuma Mii
- Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, 103-8324, Japan
| | - Yasuo Sugitani
- Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, 103-8324, Japan
| | - Tomoaki Uchida
- Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, 103-8324, Japan
| |
Collapse
|
10
|
Second and Third Generational Advances in Therapies of the Immune-Mediated Kidney Diseases in Children and Adolescents. CHILDREN 2022; 9:children9040536. [PMID: 35455580 PMCID: PMC9030090 DOI: 10.3390/children9040536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
Therapy of immune-mediated kidney diseases has evolved during recent decades from the non-specific use of corticosteroids and antiproliferative agents (like cyclophosphamide or azathioprine), towards the use of more specific drugs with measurable pharmacokinetics, like calcineurin inhibitors (cyclosporine A and tacrolimus) and mycophenolate mofetil, to the treatment with biologic drugs targeting detailed specific receptors, like rituximab, eculizumab or abatacept. Moreover, the data coming from a molecular science revealed that several drugs, which have been previously used exclusively to modify the upregulated adaptive immune system, may also exert a local effect on the kidney microstructure and ameliorate the functional instability of podocytes, reducing the leak of protein into the urinary space. The innate immune system also became a target of new therapies, as its specific role in different kidney diseases has been de novo defined. Current therapy of several immune kidney diseases may now be personalized, based on the detailed diagnostic procedures, including molecular tests. However, in most cases there is still a space for standard therapies based on variable protocols including usage of steroids with the steroid-sparing agents. They are used as a first-line treatment, while modern biologic agents are selected as further steps in cases of lack of the efficacy or toxicity of the basic therapies. In several clinical settings, the biologic drugs are effective as the add-on therapy.
Collapse
|
11
|
The horizon of the 21st century in pediatric nephrology: Clinical trials and personalized medicine. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:81-82. [DOI: 10.1016/j.anpede.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/30/2021] [Indexed: 11/21/2022] Open
|
12
|
Iijima K, Sako M, Oba M, Tanaka S, Hamada R, Sakai T, Ohwada Y, Ninchoji T, Yamamura T, Machida H, Shima Y, Tanaka R, Kaito H, Araki Y, Morohashi T, Kumagai N, Gotoh Y, Ikezumi Y, Kubota T, Kamei K, Fujita N, Ohtsuka Y, Okamoto T, Yamada T, Tanaka E, Shimizu M, Horinochi T, Konishi A, Omori T, Nakanishi K, Ishikura K, Ito S, Nakamura H, Nozu K. Mycophenolate Mofetil after Rituximab for Childhood-Onset Complicated Frequently-Relapsing or Steroid-Dependent Nephrotic Syndrome. J Am Soc Nephrol 2022; 33:401-419. [PMID: 34880074 PMCID: PMC8819987 DOI: 10.1681/asn.2021050643] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 11/21/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Rituximab is the standard therapy for childhood-onset complicated frequently relapsing or steroid-dependent nephrotic syndrome (FRNS/SDNS). However, most patients redevelop FRNS/SDNS after peripheral B cell recovery. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial to examine whether mycophenolate mofetil (MMF) administration after rituximab can prevent treatment failure (FRNS, SDNS, steroid resistance, or use of immunosuppressive agents or rituximab). In total, 39 patients (per group) were treated with rituximab, followed by either MMF or placebo until day 505 (treatment period). The primary outcome was time to treatment failure (TTF) throughout the treatment and follow-up periods (until day 505 for the last enrolled patient). RESULTS TTFs were clinically but not statistically significantly longer among patients given MMF after rituximab than among patients receiving rituximab monotherapy (median, 784.0 versus 472.5 days, hazard ratio [HR], 0.59; 95% confidence interval [95% CI], 0.34 to 1.05, log-rank test: P=0.07). Because most patients in the MMF group presented with treatment failure after MMF discontinuation, we performed a post-hoc analysis limited to the treatment period and found that MMF after rituximab prolonged the TTF and decreased the risk of treatment failure by 80% (HR, 0.20; 95% CI, 0.08 to 0.50). Moreover, MMF after rituximab reduced the relapse rate and daily steroid dose during the treatment period by 74% and 57%, respectively. The frequency and severity of adverse events were similar in both groups. CONCLUSIONS Administration of MMF after rituximab may sufficiently prevent the development of treatment failure and is well tolerated, although the relapse-preventing effect disappears after MMF discontinuation.
Collapse
Affiliation(s)
- Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan,Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Mayumi Sako
- Department of Clinical Research Promotion, National Center for Child Health and Development, Tokyo, Japan
| | - Mari Oba
- Department of Medical Statistics, Toho University, Tokyo, Japan
| | - Seiji Tanaka
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children’s Medical Center, Fuchu, Japan
| | - Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Yoko Ohwada
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Machida
- Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama City, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan,Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yoshinori Araki
- Department of Pediatrics, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Tamaki Morohashi
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Naonori Kumagai
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshimitsu Gotoh
- Department of Pediatrics, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Yohei Ikezumi
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University, Suita, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Naoya Fujita
- Department of Nephrology, Aichi Children's Health and Medical Center, Obu, Japan
| | | | - Takayuki Okamoto
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Yamada
- Department of Pediatrics, Niigata University Medical and Dental Hospital, Niigata City, Japan
| | - Eriko Tanaka
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaki Shimizu
- Department of Pediatrics, Kanazawa University, Kanazawa, Japan
| | - Tomoko Horinochi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akihide Konishi
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Takashi Omori
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Hidefumi Nakamura
- Department of Research and Development Supervision, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | | |
Collapse
|
13
|
El horizonte del siglo xxi en nefrología pediátrica: ensayos clínicos y medicina personalizada. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
14
|
Liu D, Zhou Z, Wang M, Nie S, Li J, Hu B, He W, Wang G, Ai J. Extended infusion of rituximab combined with steroids is effective in inducing remission and reducing relapse in adult minimal change disease. BMC Nephrol 2021; 22:242. [PMID: 34210283 PMCID: PMC8247102 DOI: 10.1186/s12882-021-02437-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background Minimal change disease is a common cause of nephrotic syndrome in adults. Higher relapse rate put patients at risk of steroids toxicity due to long-term exposure. Rituximab has been suggested to maintain long time remission and withdraw steroids and other immunosuppressants with fewer adverse events. However, optimal dose and dosing interval have not been explored. Methods Twenty-five patients were enrolled from 2017-10 to 2020-03 in Nanfang Hospital in China. Clinical and biological data were extracted from medical records and laboratory databases. Therapy composed of 375mg/m2 rituximab once three weeks for 3 dose and corticosteroid was applied. Complete remission was defined as reduction of proteinuria to 0.3g/d. Remission rate, relapse rate, steroids used before and after rituximab therapy and adverse effects were documented at a mean time of 14.71 months. Results Twenty-two patients achieved complete remission for an average of 3.26 months and only 3 patients experienced one relapse respectively during the follow-up period. The mean remission maintenance time was 11.6 months, and was 5 months after steroids withdrawal. Steroids dose at last follow-up was 6.09mg/d, which was significantly reduced compared to 28.15mg/d before rituximab. Relapse rate before and after rituximab was 1.43 and 0.1, respectively. Only four minor adverse events were recorded. Conclusions Therapy consisted of 375mg/m2 rituximab once three weeks for 3 dose combined with corticosteroid is effective in inducing remission in adult patients with minimal change disease. Both of the relapse rate and dose of steroids used are significantly decreased with fewer side effects. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02437-4.
Collapse
Affiliation(s)
- Diankun Liu
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhanmei Zhou
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mengyi Wang
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng Nie
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Li
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bianxiang Hu
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenjuan He
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guobao Wang
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China. .,Renal Division, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, 510515, China.
| | - Jun Ai
- National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China. .,Renal Division, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, 510515, China.
| |
Collapse
|
15
|
Kobayashi M, Kageyama Y, Ando T, Sakamoto J, Kimura S. All-case Japanese post-marketing surveillance of the real-world safety and efficacy of rituximab treatment in patients with refractory nephrotic syndrome. Clin Exp Nephrol 2021; 25:854-864. [PMID: 33796934 PMCID: PMC8260412 DOI: 10.1007/s10157-021-02035-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rituximab is conditionally approved in Japan for use in patients with refractory nephrotic syndrome. To meet the conditions of approval, an all-case post-marketing surveillance study was conducted to confirm the real-world safety and efficacy of rituximab in patients of all ages with refractory nephrotic syndrome. METHODS All patients scheduled to receive rituximab treatment for refractory nephrotic syndrome were eligible to register (registration: August 29, 2014 through April 15, 2016); the planned observation period was 2 years from the initiation of rituximab treatment (intravenous infusion, 375 mg/m2 once weekly for four doses). The study was conducted at 227 hospitals throughout Japan. Adverse drug reactions (ADRs) were collected for safety outcomes. The efficacy outcomes were relapse-free period and the degree of growth in pediatric (< 15 years) patients. RESULTS In total, 997 (447 pediatric) patients were registered; 981 (445) were included in the safety analysis set; 852 (402) completed the 2-year observation period; and 810 (429) were included in the efficacy analysis set. Refractory nephrotic syndrome had developed in childhood for 85.0% of patients, and 54.6% were aged ≥15 years. ADRs were observed in 527 (53.7%) patients, treatment-related infection/infestation in 235 (24.0%) patients, and infusion reactions in 313 (31.9%) patients. The relapse-free period was 580 days (95% confidence interval, 511-664). There was a significant change in height standard deviation score (pediatric patients; mean change, 0.093; standard deviation, 0.637; P = 0.009). CONCLUSION The safety and efficacy of rituximab treatment in patients with refractory nephrotic syndrome were confirmed in the real-world setting. CLINICAL TRIAL REGISTRATION UMIN000014997.
Collapse
Affiliation(s)
- Mana Kobayashi
- Pharmacovigilance and Quality Assurance Department, Zenyaku Kogyo Co., Ltd, 6-15, Otsuka 5-Chome, Bunkyo-ku, Tokyo, 112-8650, Japan
| | - Yutaro Kageyama
- Pharmacovigilance and Quality Assurance Department, Zenyaku Kogyo Co., Ltd, 6-15, Otsuka 5-Chome, Bunkyo-ku, Tokyo, 112-8650, Japan
| | - Takashi Ando
- Pharmacovigilance and Quality Assurance Department, Zenyaku Kogyo Co., Ltd, 6-15, Otsuka 5-Chome, Bunkyo-ku, Tokyo, 112-8650, Japan.
| | - Junko Sakamoto
- Pharmacovigilance and Quality Assurance Department, Zenyaku Kogyo Co., Ltd, 6-15, Otsuka 5-Chome, Bunkyo-ku, Tokyo, 112-8650, Japan
| | - Shohji Kimura
- Pharmacovigilance and Quality Assurance Department, Zenyaku Kogyo Co., Ltd, 6-15, Otsuka 5-Chome, Bunkyo-ku, Tokyo, 112-8650, Japan
| |
Collapse
|
16
|
Sanjad SA, Ulinski T, Aoun B. Editorial: Nephrotic Syndrome in Children. Front Pediatr 2021; 9:803923. [PMID: 34900881 PMCID: PMC8651990 DOI: 10.3389/fped.2021.803923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sami A Sanjad
- Department of Pediatrics/Nephrology, American University of Beirut Med Center, Beirut, Lebanon
| | - Tim Ulinski
- Department of Pediatric Nephrology, Armand Trousseau Hospital, Paris, France
| | - Bilal Aoun
- Department of Pediatrics/Nephrology, American University of Beirut Med Center, Beirut, Lebanon
| |
Collapse
|
17
|
Lee JM, Kronbichler A, Shin JI, Oh J. Current understandings in treating children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2021; 36:747-761. [PMID: 32086590 PMCID: PMC7910243 DOI: 10.1007/s00467-020-04476-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Steroid-resistant nephrotic syndrome (SRNS) remains a challenge for paediatric nephrologists. SRNS is viewed as a heterogeneous disease entity including immune-based and monogenic aetiologies. Because SRNS is rare, treatment strategies are individualized and vary among centres of expertise. Calcineurin inhibitors (CNI) have been effectively used to induce remission in patients with immune-based SRNS; however, there is still no consensus on treating children who become either CNI-dependent or CNI-resistant. Rituximab is a steroid-sparing agent for patients with steroid-sensitive nephrotic syndrome, but its efficacy in SRNS is controversial. Recently, several novel monoclonal antibodies are emerging as treatment option, but their efficacy remains to be seen. Non-immune therapies, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, have been proven efficacious in children with SRNS and are recommended as adjuvant agents. This review summarizes and discusses our current understandings in treating children with idiopathic SRNS.
Collapse
Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, South Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752 South Korea ,Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul, South Korea ,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Oh
- Department of Pediatrics Nephrology, University Hamburg-Eppendorf, Martinistrasse, 52 20246, Hamburg, Germany.
| |
Collapse
|
18
|
Current Therapies in Nephrotic Syndrome: HDAC inhibitors, an Emerging Therapy for Kidney Diseases. CURRENT RESEARCH IN BIOTECHNOLOGY 2021. [DOI: 10.1016/j.crbiot.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
|
19
|
Podestà MA, Ponticelli C. Autoimmunity in Focal Segmental Glomerulosclerosis: A Long-Standing Yet Elusive Association. Front Med (Lausanne) 2020; 7:604961. [PMID: 33330569 PMCID: PMC7715033 DOI: 10.3389/fmed.2020.604961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/26/2020] [Indexed: 01/17/2023] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a histological term that describes a pathologic renal entity affecting both adults and children, with a wide array of possible underlying etiologies. Podocyte damage with scarring, the hallmark of this condition, leads to altered permeability of the glomerular barrier, which may result in massive proteinuria and relentless renal function deterioration. A definite cause of focal segmental glomerulosclerosis can be confirmed in a minority of cases, while most forms have been traditionally labeled as primary or idiopathic. Despite this definition, increasing evidence indicates that primary forms are a heterogenous group rather than a single disease entity: several circulating factors that may affect glomerular permeability have been proposed as potential culprits, and both humoral and cellular immunity have been implicated in the pathogenesis of the disease. Consistently, immunosuppressive drugs are considered as the cornerstone of treatment for primary focal segmental glomerulosclerosis, but response to these agents and long-term outcomes are highly variable. In this review we provide a summary of historical and recent advances on the pathogenesis of primary focal segmental glomerulosclerosis, focusing on implications for its differential diagnosis and treatment.
Collapse
|
20
|
Xue C, Yang B, Xu J, Zhou C, Zhang L, Gao X, Dai B, Yu S, Mao Z, Mei C, Xu C. Efficacy and safety of rituximab in adult frequent-relapsing or steroid-dependent minimal change disease or focal segmental glomerulosclerosis: a systematic review and meta-analysis. Clin Kidney J 2020; 14:1042-1054. [PMID: 34094516 PMCID: PMC8173623 DOI: 10.1093/ckj/sfaa191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Indexed: 12/11/2022] Open
Abstract
Background The efficacy and safety of rituximab (RTX) in adult frequent-relapsing (FR) or steroid-dependent (SD) nephrotic syndrome (NS), including minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS), are still inconclusive. Methods We performed a systematic review and meta-analysis registered in PROSPERO (CRD42019148102) by pooling data of cohort studies or case series on adult patients with difficult-to-treat NS. Steroid-resistant NS was excluded. The primary outcomes were the complete remission (CR) rate and the relapse rate. Partial remission (PR) rate, no response (NR) rate and adverse events were the secondary outcomes. A random-effects model was performed for all the outcomes. Results We included 21 studies involving 382 adult MCD/FSGS subjects with a median follow-up duration from 12 to 43 months. RTX treatment induced a pooled 84.2% CR rate [95% confidence interval (CI): 67.7–96.3%], while MCD patients had a high 91.6% CR rate and FSGS patients a moderate 43% CR rate. However, 27.4% (95% CI 20.7–34.5%) of the patients relapsed during the follow-up. The pooled PR and NR rates were 5.8% (95% CI 1.2–12.5%) and 5.2% (95% CI 0.0–15.0%), respectively. RTX was associated with trivial adverse events and good tolerance. Conclusions In summary, by pooling results of current pilot studies, RTX may be an effective and relatively safe alternative for most adult FR or SD MCD/FSGS to displace calcineurin inhibitors or prednisone in the hierarchy of treatment. More clinical trials comparing RTX with other immunosuppressants and concerning the long-term adverse events are needed.
Collapse
Affiliation(s)
- Cheng Xue
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Nephrology, the Third Affiliated Hospital of Second Military Medical University, Shanghai, China
| | - Bo Yang
- Department of Nephrology, Naval Medical Center of PLA (People's Liberation Army), Shanghai, China
| | - Jing Xu
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chenchen Zhou
- Outpatient Department, Yangpu Third Military Retreat, Shanghai, China
| | - Liming Zhang
- Department of Nephrology, Zhabei Central Hospital of Jing'an District, Shanghai, China
| | - Xiang Gao
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bing Dai
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Shengqiang Yu
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhiguo Mao
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Changlin Mei
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chenggang Xu
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Nephrology, the Third Affiliated Hospital of Second Military Medical University, Shanghai, China
| |
Collapse
|
21
|
Liu GW, Pippin JW, Eng DG, Lv S, Shankland SJ, Pun SH. Nanoparticles exhibit greater accumulation in kidney glomeruli during experimental glomerular kidney disease. Physiol Rep 2020; 8:e14545. [PMID: 32786069 PMCID: PMC7422806 DOI: 10.14814/phy2.14545] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/26/2022] Open
Abstract
Loss and dysfunction of glomerular podocytes result in increased macromolecule permeability through the glomerular filtration barrier and nephrotic syndrome. Current therapies can induce and maintain disease remission, but cause serious and chronic complications. Nanoparticle drug carriers could mitigate these side effects by delivering drugs to the kidneys more efficiently than free drug through tailoring of carrier properties. An important extrinsic factor of nanoparticle biodistribution is local pathophysiology, which may drive greater nanoparticle deposition in certain tissues. Here, we hypothesized that a "leakier" filtration barrier during glomerular kidney disease would increase nanoparticle distribution into the kidneys. We examined the effect of nanoparticle size and disease state on kidney accumulation in male BALB/c mice. The effect of size was tested using a panel of fluorescent polystyrene nanoparticles of size 20-200 nm, due to the relevance of this size range for drug delivery applications.Experimental focal segmental glomerulosclerosis was induced using an anti-podocyte antibody that causes abrupt podocyte depletion. Nanoparticles were modified with carboxymethyl-terminated poly(ethylene glycol) for stability and biocompatibility. After intravenous injection, fluorescence from nanoparticles of size 20 and 100 nm, but not 200 nm, was observed in kidney glomeruli and peritubular capillaries. During conditions of experimental focal segmental glomerulosclerosis, the number of fluorescent nanoparticle punctae in kidney glomeruli increased by 1.9-fold for 20 and 100 nm nanoparticles compared to normal conditions. These findings underscore the importance of understanding and leveraging kidney pathophysiology in engineering new, targeted drug carriers that accumulate more in diseased glomeruli to treat glomerular kidney disease.
Collapse
Affiliation(s)
- Gary W. Liu
- Department of Bioengineering and Molecular Engineering & Sciences InstituteUniversity of WashingtonSeattleWAUSA
| | - Jeffrey W. Pippin
- Department of MedicineDivision of NephrologyUniversity of Washington School of MedicineSeattleWAUSA
| | - Diana G. Eng
- Department of MedicineDivision of NephrologyUniversity of Washington School of MedicineSeattleWAUSA
| | - Shixian Lv
- Department of Bioengineering and Molecular Engineering & Sciences InstituteUniversity of WashingtonSeattleWAUSA
| | - Stuart J. Shankland
- Department of Bioengineering and Molecular Engineering & Sciences InstituteUniversity of WashingtonSeattleWAUSA
| | - Suzie H. Pun
- Department of Bioengineering and Molecular Engineering & Sciences InstituteUniversity of WashingtonSeattleWAUSA
| |
Collapse
|
22
|
Abstract
BACKGROUND Glomerulosclerosis represents the final stage of glomerular injury during the course of kidney disease and can result from a primary disturbance in disorders like focal segmental glomerulosclerosis or a secondary response to tubulointerstitial disease. Overall, primary focal glomerulosclerosis (FSGS), the focus of this review, accounts for 10-20% of patients of all ages who progress to end stage kidney disease. There are no FDA approved therapeutic options that effectively prevent or delay the onset of kidney failure. AREAS COVERED Current immunosuppressive therapy and conservative management including inhibitors of the renin-angiotensin-aldosterone axis and sodium-glucose cotransporter are reviewed. FSGS is now recognized to represent a heterogeneous entity with multiple underlying disease mechanisms. Therefore, novel approaches targeting the podocyte cytoskeleton, immunological, inflammatory, hemodynamic and metabolic pathways are highlighted. EXPERT OPINION A number of factors are driving the development of drugs to treat focal segmental glomerulosclerosis in particular and glomerulosclerosis in general including growing awareness of the burden of chronic kidney disease, improved scientific understanding of the mechanism of injury, and the development of noninvasive profiles to identify subgroups of patients with discrete mechanisms of glomerular injury.
Collapse
Affiliation(s)
- Howard Trachtman
- Department of Pediatrics, Division of Nephrology, NYU Langone Health , New York, NY, USA
| |
Collapse
|
23
|
Moorani KN, Zubair AM, Veerwani NR, Hotchandani HJ. Efficacy of Levamisole in children with Frequent Relapsing and Steroid Dependent Nephrotic Syndrome at Tertiary Care Center-Karachi. Pak J Med Sci 2020; 36:1193-1198. [PMID: 32968379 PMCID: PMC7500995 DOI: 10.12669/pjms.36.6.2337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objectives: To determine the effectiveness of levamisole in maintaining remission of proteinuria in children with frequent relapsing and steroid dependent nephrotic syndrome (FR/SDNS). Methods: This observational study on 81 children with FR /SDNS was carried out from June 2007 - June 2017 at The Kidney Center-Postgraduate Training Institute, Karachi-Pakistan. Levamisole (leva) along with low dose prednisolone on alternate day (AD) was used after induction of remission with daily oral prednisolone in children with FR/ SDNS for 6-36 months. Patients with steroid resistance were excluded. Data was analyzed using descriptive statistics. Results: Eighty-one patients with FR (66) or SD (15) received levamisole treatment. Mean age at diagnosis was 3.72 ±2.33 years. Levamisole was used on AD in 59.25% and daily in 40.74% of cases. Twenty-four could not complete six months and were excluded, 57 patients completed treatment duration of 15.68±9.93 months and 51 post-leva follow-up of 11.70±11.23 months. Mean leva-dose was 1.73±0.67 mg/kg/ patient. Mean cumulative prednisolone dose per patient before, on-leva and post-leva was 3389.81±2785.22, 2471.97±2024.98 and 661.37± 905.37 mg respectively. Mean relapse rate per year before leva, on -leva and post -leva was 3.30 ±0.50,0.98± 1.1and 0.79±1.27 respectively. Levamisole was effective in 90% of patients. During post-leva follow up, 76.4% patients, maintained remission, whereas 23.5% behaved as FR/SD and require further immunosuppressive therapy. Conclusions: Levamisole was effective in maintaining remission in 90% while on treatment, whereas it maintained remission after discontinuation in 76.4% cases. Levamisole may be used as first steroid sparing agent before other immunosuppressive therapies in children with FR/SDNS. Further studies are required for optimal duration and dosage schedule.
Collapse
Affiliation(s)
- Khemchand N Moorani
- Khemchand N Moorani, FCPS, MCPS, MBBS. Professor of Pediatric Nephrology, Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute, Karachi Sindh, Pakistan, Department of Pediatric Nephrology, National Institute of Child Health, JSMU, Karachi, Pakistan
| | - Aasia Mohammad Zubair
- Aasia Mohammad Zubair, FCPS, MBBS. Medical Officer, Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute, Karachi Sindh, Pakistan, Department of Pediatric Nephrology, National Institute of Child Health, JSMU, Karachi, Pakistan
| | - Nanga Ram Veerwani
- Nanga Ram Veerwani, FCPS, MBBS. Medical Officer, Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute, Karachi Sindh, Pakistan
| | - Harnam Jaichand Hotchandani
- Harnam Jaichand Hotchandani, MBBS. Senior Medical Officer, Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute, Karachi Sindh, Pakistan
| |
Collapse
|
24
|
Kamei K, Ishikura K, Sako M, Ito S, Nozu K, Iijima K. Rituximab therapy for refractory steroid-resistant nephrotic syndrome in children. Pediatr Nephrol 2020; 35:17-24. [PMID: 30564879 DOI: 10.1007/s00467-018-4166-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/30/2018] [Accepted: 12/03/2018] [Indexed: 12/24/2022]
Abstract
Patients with steroid-resistant nephrotic syndrome (SRNS) who develop resistance to immunosuppressive agents, defined as refractory SRNS, have poor renal outcomes. Although the chimeric anti-CD20 monoclonal antibody rituximab has shown efficacy for frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome, its efficacy for refractory SRNS remains uncertain due to limited data. According to previous case reports, 50.4% of patients with refractory SRNS showed clinical improvements after rituximab treatment. Remission rates in patients with initial steroid resistance and late steroid resistance were 43.9 and 57.7%, respectively, and 41.5 and 63.6% in patients with focal segmental glomerulosclerosis and minor glomerular abnormalities, respectively. However, various factors (race, disease severity, number of rituximab doses, concomitant treatments, and observation period) differed among these observational studies and their consensus may also have been affected by potential publication bias. Rituximab monotherapy may have some degree of efficacy and lead to satisfactory outcomes in a subset of patients with refractory SRNS. However, administration of concomitant treatments during rituximab-mediated B cell depletion, such as methylprednisolone pulse therapy, daily oral prednisolone therapy, and immunosuppressive agents, may lead to better outcomes in these patients. Large-scale, multi-center prospective studies are needed to evaluate the efficacy and safety of such regimens.
Collapse
Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Department of Clinical Research, Center for Clinical Research and Development, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| |
Collapse
|
25
|
Moorani KN, Hotchandani HM, Zubair AM, Lohana NC, Veerwani NR. Immunosuppressive therapy in children with primary nephrotic syndrome: single center experience, Karachi, Pakistan. BMC Nephrol 2019; 20:239. [PMID: 31269922 PMCID: PMC6607530 DOI: 10.1186/s12882-019-1347-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/18/2019] [Indexed: 01/10/2023] Open
Abstract
Background Majority of children with nephrotic syndrome are steroid sensitive, but treatment of difficult to treat nephrotic (frequent relapsing, steroid dependent and steroid resistant) syndrome is challenging. Low dose steroid, levamisole, cyclophosphamide (CPM), mycophenolate mofetil (MMF) and calcineurin inhibitors (CNIs) are the common options of treatment. Objective of the study was to determine the response to steroid and alternative immunosuppressive agents (ISAs) in children with difficult nephrotic syndrome (DNS). Methods This is a retrospective cohort study of 176 children with DNS, managed over 12 years at The Kidney Center-Postgraduate Training Institute, Karachi- Pakistan from 2005 to 2017. Initial episode was treated with daily oral prednisolone (OP) for 4–8 weeks followed by alternate day OP for 12–24 weeks. Subsequently low dose OP, levamisole (Leva)and cyclophosphamide was used for frequent relapsing (FR)/ steroid dependent (SD). All with initial steroid resistance and non- responders to leva and or cyclophosphamide were biopsied and treated with CNIs and MMF. Data was analyzed using descriptive statistics. Results There were 130(73.86%) children with FR/SD and 46(26.13%) with SRNS. All children with SR (46) and 86 with FR/SD were biopsied. Minimal change disease (60.60%) and focal segmental glomerulosclerosis (FSGS 23%) were the two common lesions. Majority (73.86%) received single OP whereas divided doses were administered in 26.13% cases. Daily OP was used for 4, 6 and 8 weeks in 61.36,28.4 and10.22% respectively. Steroids were tapered over 3 (31.81%),4 (52.27%) and 6 months (15.90%). Levamisole, CPM, cyclosporin (CS) and MMF were used sequentially in 45, 54.23, 50 and 20% respectively. Combination of MMF and CS was used in 11.29% of cases. Levamisole was effective in 80%, CPM induced complete remission (CR, 57.77%) or partial remission (PR, 22.22%), CS induced CR 46.59% and PR 39.77%. MMF showed PR and CR 69 and 12.82% respectively. At last follow up, 46% were maintaining remission while off treatment, whereas 35% are maintaining remission on therapy,10.23% lost- to-follow, 5.68% progressed to chronic kidney disease. Mortality was 2.84% and it was due to infection and uremia. Conclusion Majority had steroid sensitive MCD. Levamisole and cyclophosphamide were effective in maintaining remission in FR/ SD. FSGS was responsible for resistance to steroid and alternative ISAs. Cyclosporin was effective in inducing remission in SRNS. Mortality was less than 3%.
Collapse
Affiliation(s)
- Khemchand Netaram Moorani
- Department of Pediatric Nephrology, National Institute of Child Health (NICH), Jinnah Sindh Medical University, Karachi, Pakistan. .,Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan.
| | - Harnam Moolchand Hotchandani
- Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| | - Aasia Mohammad Zubair
- Department of Pediatric Nephrology, National Institute of Child Health (NICH), Jinnah Sindh Medical University, Karachi, Pakistan.,Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| | - Neelesh Chander Lohana
- Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| | - Nanga Ram Veerwani
- Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| |
Collapse
|
26
|
Maxted AP, Dalrymple RA, Chisholm D, McColl J, Tse Y, Christian MT, Reynolds BC. Low-dose rituximab is no less effective for nephrotic syndrome measured by 12-month outcome. Pediatr Nephrol 2019; 34:855-863. [PMID: 30564878 PMCID: PMC6424916 DOI: 10.1007/s00467-018-4172-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/03/2018] [Accepted: 12/07/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Rituximab is an effective treatment for children with steroid dependent or frequently relapsing nephrotic syndrome. The optimum dosing schedule for rituximab has not been established. We hypothesized that a single low dose of 375 mg/m2 would have comparable outcomes to higher doses in reducing the frequency of relapse and time to B cell reconstitution. METHODS We conducted a multicenter retrospective observational cohort study of children with steroid-sensitive frequently relapsing nephrotic syndrome. Data were extracted from clinical records including the dates of diagnosis, treatment, relapses, the use of concomitant immunosuppression, and lymphocyte subset profiling. Patients treated earlier received variable doses of rituximab, although typically two doses of 750 mg/m2. Later, patients received the current regimen of a single dose of 375 mg/m2. The primary outcome was an absence of clinically confirmed relapse 12 months following rituximab administration. Secondary outcomes were median time to relapse, probability of being relapse-free at 6 and 24 months and time to reconstitution of CD19+ B cells. RESULTS Sixty patients received 143 courses of rituximab. Seven different dosing regimen strategies were used, ranging between 375 and 750 mg/m2 per dose, with administration of 1-4 doses. There was no significant difference in event-free survival at 12 months between dosing strategies. The median time to reconstitution of B cells was not significantly different between groups. CONCLUSIONS Use of a single low-dose regimen of rituximab in the management of frequently relapsing nephrotic syndrome does not affect the probability of relapse at 12 months or time to B cell reconstitution compared to a conventional higher dose.
Collapse
Affiliation(s)
- Andrew P. Maxted
- Nottingham Children’s Hospital Renal and Urology Unit, Nottingham, UK
| | - Rebecca A. Dalrymple
- Department of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Denise Chisholm
- 0000 0004 4904 7256grid.459561.aGreat North Children’s Hospital, Newcastle Upon Tyne, UK
| | - John McColl
- 0000 0001 2193 314Xgrid.8756.cSchool of Mathematics and Statistics, University of Glasgow, Glasgow, UK
| | - Yincent Tse
- 0000 0004 4904 7256grid.459561.aGreat North Children’s Hospital, Newcastle Upon Tyne, UK
| | | | - Ben C. Reynolds
- Department of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| |
Collapse
|
27
|
Topaloğlu R, Gülhan B, Çelegen K, İnözü M, Hayran M, Düzova A, Ozaltin F. Rituximab for Children With Difficult-to-Treat Nephrotic Syndrome: Its Effects on Disease Progression and Growth. Front Pediatr 2019; 7:313. [PMID: 31417883 PMCID: PMC6682627 DOI: 10.3389/fped.2019.00313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Since the early 2000s rituximab (RTX) has been thought of as an alternative treatment for steroid-sensitive nephrotic syndrome (SSNS) and steroid-resistant nephrotic syndrome (SRNS). Objective: This study aimed to determine the effects of RTX treatment on disease outcome and growth in pediatric SSNS and SRNS patients. Materials and Methods: The medical records of pediatric SSNS and SRNS patients that began RTX treatment at the mean age of 10.8 ± 5.1 years between 2009 and 2017 were retrospectively reviewed. Additionally, the effect of RTX on growth was evaluated based on patient height, weight, and BMI z scores. Results: The study included 41 children, of which 21 had SSNS and 20 had SRNS. Mean age at diagnosis of NS was 5.8 ± 4.7 years. Mean duration of post-RTX treatment follow-up was 2.3 ± 1.6 years. Among the SSNS patients, 6 and 11 patients were steroid free and calcineurin inhibitor free at the last follow-up visit, respectively. The 1-year cumulative steroid and calcineurin inhibitor doses both decreased after RTX treatment, as compared to before RTX (P = 0.001 and P = 0.015, respectively). The median height z-score at the time of RTX initiation was -1.2 and the median height z-score at the last follow-up visit was -0.6 (P = 0.044). The median BMI z-score decreased from 1.6 (IQR; 0.9-3.0) at the time RTX was initiated to 1.1 IQR; [(-0.7)-2.5] at the last follow-up visit (P = 0.007). At the last follow-up visit 4 SRNS patients had complete remission and 4 had partial remission. The 1-year cumulative steroid dosage in the SRNS patients decreased significantly after RTX, as compared to before RTX (P = 0.001). The median height z-score at the time of RTX initiation was -0.8 and the median height z-score at the last follow-up visit was -0.7 (P = 0.81). The median BMI z-score decreased from 0.3 at the time RTX was initiated to -0.1 at the last follow-up visit (P = 0.11). Conclusion: RTX has a more positive effect on disease outcome and growth in SSNS patients than in those with SRNS.
Collapse
Affiliation(s)
- Rezan Topaloğlu
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Bora Gülhan
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Kübra Çelegen
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Mihriban İnözü
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Mutlu Hayran
- Department of Preventive Oncology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Düzova
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Fatih Ozaltin
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Hacettepe University, Ankara, Turkey.,Nephrogenetics Laboratory, School of Medicine, Hacettepe University, Ankara, Turkey.,Center for Biobanking and Genomics, School of Medicine, Hacettepe University, Ankara, Turkey
| |
Collapse
|
28
|
Kemper MJ, Neuhaus TJ. Levamisole in relapsing steroid-sensitive nephrotic syndrome: where do we stand? Kidney Int 2018; 93:310-313. [PMID: 29389398 DOI: 10.1016/j.kint.2017.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 09/13/2017] [Accepted: 09/20/2017] [Indexed: 11/30/2022]
Abstract
Many patients with steroid-sensitive nephrotic syndrome develop a relapsing course; therefore, alternative treatment may be necessary to avoid steroid toxicity. In this issue, a multicenter controlled study in relapsing steroid-sensitive nephrotic syndrome shows the effectiveness of levamisole. Time to first relapse was significantly increased compared with placebo. In addition, possible differential treatment effects were suggested for subgroups: patients with frequent relapses might have a superior response to those with steroid dependency.
Collapse
|