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Yu S, Sun J. A review of progress on complement and primary membranous nephropathy. Medicine (Baltimore) 2024; 103:e38990. [PMID: 39029058 PMCID: PMC11398747 DOI: 10.1097/md.0000000000038990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Primary membranous nephropathy (PMN) is a predominant cause of adult nephrotic syndrome, with its incidence witnessing a progressive surge over time. Approximately 35% to 47% of patients progress to renal failure within 10 years, causing a huge social burden. Within China, the proportion of PMN in primary glomerular disease exhibits a gradual ascension. Recent studies have shown that the 3 activation pathways of complement: the classical pathway, mannose-binding lectin pathway, and alternative pathway, are all involved in the pathogenesis of PMN. Despite historical limitations in detecting C1q deposits on the glomeruli of PMN in the past, recent studies have confirmed the classical pathway is implicated in patients with PMN. Considering the dysregulation of the complement system has been observed in PMN, complement inhibitors become increasingly promising. Several clinical trials are presently underway to evaluate the efficacy of complement inhibitors, such as MASP2 antagonists (OMS721), C3 and C3b antagonists (APL2), FD inhibitors (BCX9930), C3aR antagonists (SB290157 and JR14a), FB inhibitors (LNP023). This article reviews the recent research progress on the role of the complement pathway in the pathogenesis of PMN, and underscores the importance of continued research into the complement pathway and its inhibitors, which may pave the way for groundbreaking advancements in the management of PMN.
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Affiliation(s)
- Shanshen Yu
- Department of Nephrology, First People's Hospital of Linping District, Hangzhou, China
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2
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Wang M, Yang J, Fang X, Lin W, Yang Y. Membranous nephropathy: pathogenesis and treatments. MedComm (Beijing) 2024; 5:e614. [PMID: 38948114 PMCID: PMC11214595 DOI: 10.1002/mco2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 07/02/2024] Open
Abstract
Membranous nephropathy (MN), an autoimmune disease, can manifest at any age and is among the most common causes of nephrotic syndrome in adults. In 80% of cases, the specific etiology of MN remains unknown, while the remaining cases are linked to drug use or underlying conditions like systemic lupus erythematosus, hepatitis B virus, or malignancy. Although about one-third of patients may achieve spontaneous complete or partial remission with conservative management, another third face an elevated risk of disease progression, potentially leading to end-stage renal disease within 10 years. The identification of phospholipase A2 receptor as the primary target antigen in MN has brought about a significant shift in disease management and monitoring. This review explores recent advancements in the pathophysiology of MN, encompassing pathogenesis, clinical presentations, diagnostic criteria, treatment options, and prognosis, with a focus on emerging developments in pathogenesis and therapeutic strategies aimed at halting disease progression. By synthesizing the latest research findings and clinical insights, this review seeks to contribute to the ongoing efforts to enhance our understanding and management of this challenging autoimmune disorder.
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Affiliation(s)
- Mengqiong Wang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Jingjuan Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Xin Fang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Weiqiang Lin
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Yi Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
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Zanoni F, Abinti M, Belingheri M, Castellano G. Present and Future of IgA Nephropathy and Membranous Nephropathy Immune Monitoring: Insights from Molecular Studies. Int J Mol Sci 2023; 24:13134. [PMID: 37685941 PMCID: PMC10487514 DOI: 10.3390/ijms241713134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
IgA Nephropathy (IgAN) and Membranous Nephropathy (MN) are primary immune-mediated glomerular diseases with highly variable prognosis. Current guidelines recommend that greater immunologic activity and worse prognosis should guide towards the best treatment in an individualized approach. Nevertheless, proteinuria and glomerular filtration rate, the current gold standards for prognosis assessment and treatment guidance in primary glomerular diseases, may be altered with chronic damage and nephron scarring, conditions that are not related to immune activity. In recent years, thanks to the development of new molecular technologies, among them genome-wide genotyping, RNA sequencing techniques, and mass spectrometry, we have witnessed an outstanding improvement in understanding the pathogenesis of IgAN and MN. In addition, recent genome-wide association studies have suggested potential targets for immunomodulating agents, stressing the need for the identification of specific biomarkers of immune activity. In this work, we aim to review current evidence and recent progress, including the more recent use of omics techniques, in the identification of potential biomarkers for immune monitoring in IgAN and MN.
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Affiliation(s)
- Francesca Zanoni
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
| | - Matteo Abinti
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Mirco Belingheri
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
| | - Giuseppe Castellano
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
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4
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Dantas M, Silva LBB, Pontes BTM, dos Reis MA, de Lima PSN, Moysés M. Membranous nephropathy. J Bras Nefrol 2023; 45:229-243. [PMID: 37527529 PMCID: PMC10627124 DOI: 10.1590/2175-8239-jbn-2023-0046en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.
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Affiliation(s)
- Márcio Dantas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
| | | | | | - Marlene Antônia dos Reis
- Universidade Federal do Triângulo Mineiro, Patologia Geral, Centro
de Pesquisa em Rim, Uberaba, MG, Brazil
| | | | - Miguel Moysés
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
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Batal I, Khairallah P, Weins A, Andeen NK, Stokes MB. The role of HLA antigens in recurrent primary focal segmental glomerulosclerosis. Front Immunol 2023; 14:1124249. [PMID: 36911713 PMCID: PMC9995699 DOI: 10.3389/fimmu.2023.1124249] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Primary focal segmental glomerulosclerosis (FSGS), typically characterized by diffuse podocyte foot process effacement and nephrotic syndrome (diffuse podocytopathy), is generally attributed to a circulating permeability factor. Primary FSGS can recur after transplantation where it manifests as diffuse foot process effacement in the early stages, with subsequent evolution of segmental sclerotic lesions. Previous published literature has been limited by the lack of stringent selection criteria to define primary FSGS. Although immunogenetic factors play an important role in many glomerular diseases, their role in recurrent primary FSGS post-transplantation has not been systematically investigated. To address this, we retrospectively studied a multicenter cohort of 74 kidney allograft recipients with end stage kidney disease due to primary FSGS, confirmed by clinical and histologic parameters. After adjusting for race/ethnicity, there was a numeric higher frequency of HLA-A30 antigen in primary FSGS (19%) compared to each of 22,490 healthy controls (7%, adjusted OR=2.0, P=0.04) and 296 deceased kidney donors (10%, OR=2.1, P=0.03). Within the group of transplant patients with end stage kidney disease due to primary FSGS, donor HLA-A30 was associated with recurrent disease (OR=9.1, P=0.02). Multivariable time-to-event analyses revealed that recipients who self-identified as Black people had lower risk of recurrent disease, probably reflecting enrichment of these recipients with APOL1 high-risk genotypes. These findings suggest a role for recipient and donor immunogenetic makeup in recurrent primary FSGS post-transplantation. Further larger studies in well-defined cohorts of primary FSGS that include high-resolution HLA typing and genome-wide association are necessary to refine these hereditary signals.
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Affiliation(s)
- Ibrahim Batal
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
| | - Pascale Khairallah
- Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, United States
| | - Astrid Weins
- Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nicole K Andeen
- Pathology, Oregon Health & Science University, Portland, OR, United States
| | - Michael B Stokes
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
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Nieto-Gañán I, Iturrieta-Zuazo I, Rita C, Carrasco-Sayalero Á. Revisiting immunological and clinical aspects of membranous nephropathy. Clin Immunol 2022; 237:108976. [PMID: 35276323 DOI: 10.1016/j.clim.2022.108976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/16/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
Idiopathic or primary membranous nephropathy (IMN) is one of the most frequent causes of nephrotic syndrome in adults and the elderly. It is characterized by a thickening of the wall of the glomerular capillaries due to the presence of immune complex deposits. 85% of membranous nephropathy cases are classified as primary or idiopathic (IMN). The rest are of secondary origin (SMN), caused by autoimmune conditions or malignant tumors as lung cancer, colon and melanomas. It is an organ-specific autoimmune disease in which the complement system plays an important role with the formation of the membrane attack complex (MAC; C5b-9), which produces an alteration of the podocyte structure. The antigen responsible for 70-80% of IMN is a podocyte protein called M-type phospholipase A2 receptor (PLA2R). More recently, another podocyte antigen has been identified, the "Thrombospondin type-1 domain-containing 7A" (THSD7A), which is responsible for 10% of the cases of negative IMN for anti- PLA2R.
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Affiliation(s)
- Israel Nieto-Gañán
- Immunology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Ignacio Iturrieta-Zuazo
- Immunology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Claudia Rita
- Immunology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Liu X, Xu W, Yu C, Wang M, Liu R, Xie R. Associations between m-type phospholipase A2 receptor,human leukocyte antigen gene polymorphisms and idiopathic membranous nephropathy. Bioengineered 2021; 12:8833-8844. [PMID: 34607530 PMCID: PMC8806941 DOI: 10.1080/21655979.2021.1987080] [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] [Indexed: 11/17/2022] Open
Abstract
Primary membranous nephropathy, also known as idiopathic membranous nephropathy, is an autoimmune disease. As an autoimmune disease, genetic factors are essential in the pathogenesis of IMN. People pay more and more attention to genetics and bioinformatics. With the continuous improvement and development of high-throughput gene sequencing and genotyping technology, it has been confirmed that many genes and their single nucleotide polymorphisms are strongly correlated with IMN disease susceptibility. However, there are few studies on HLA-DQA1 and PLA2R gene polymorphisms and IMN susceptibility in China. The purpose of this study was to investigate whether PLA2R rs2715928 and rs16844715 are related to IMN, the correlation between five SNP loci of PLA2R and HLA-DQA1 and IMN, and the effect of gene-gene interaction among different genotypes of each locus on disease. In this study, 86 patients with IMN confirmed by renal biopsy in the first hospital of Harbin Medical University and 90 healthy controls were selected. All subjects were excluded from secondary membranous nephropathy, pregnant or breastfeeding women, severe primary disease of vital organs, severe infection, major surgery, and severe trauma. Seven selected SNP loci were genotyped using the IMLDR multiple SNP typing kit. Chi-square test and logistic regression were used to analyze the correlation between each SNP and IMN. The general clinical data and laboratory indicators of each subject were recorded, and the relationship between different genotypes and clinical manifestations was analyzed. Among the 7 SNP loci included in the study, except HLA-DQA1 rs2187668, the other 6 loci all met Hardy-Weiberg equilibrium test (P > 0.05). The allele distribution of PLA2R rs2715928 and rs16844715 was significantly different between the IMN group and the healthy control group, and it was closely related to IMN (P < 0.05). There was no statistical difference in the distribution of alleles of rs2715918 between the IMN group and the control group (P* > 0.05), and there was also statistical difference in the distribution of alleles of rs35771982, rs3749117, and rs4664308 between the IMN group and the healthy control group (P < 0.05).The C allele of rs16844715 (OR = 2.03, 95%CI: 1.29–3.19, P* = 0.0140) and the A allele of rs2715928 (OR = 3.18, 95%CI: 1.94–5.24, P* = 3.54E-5), G allele of rs35771982 (OR = 4.07, 95%CI: 2.34–7.08, P* = 4.96E-6), T allele of rs3749117 (OR = 4.07, 95%CI: 2.34–7.08, P* = 4.96E-6), the A allele of rs4664308 (OR = 2.63, 95%CI: 1.54–4.49, P* = 0.0028) was the risk gene of IMN.Through the establishment of different genetic models, we found that,in the additive model, the three SNPs of PLA2R rs2715928 (OR = 5.40, 95%CI: 1.77–16.50, P* = 0.0217) and rs35771982 (OR = 15.15, 95%CI: 2.92–78.48, P* = 0.0084), rs3749117 (OR = 15.15, 95%CI: 2.92–78.48, P* = 0.0084) had a strong correlation with IMN. In the stealth model,homozygous gene risk type of the five SNPs,PLA2R rs16844715 (OR = 2.52, 95%CI: 1.38–4.61, P* = 0.0189) and rs2715928 (OR = 4.30, 95%CI: 2.31–8.03, P* = 3.14E-5), rs35771982 (OR = 4.85, 95%CI: 5.53–9.31, P* = 1.42E-5), rs3749117 (OR = 4.85, 95%CI: 5.53–9.31, P* = 1.42E-5) and rs4664308 (OR = 3.16, 95%CI: 1.67–5.97, P* = 0.0028) had a strong correlation with IMN. The distribution of GT haplotypes and CC haplotypes of rs35771982 and rs3749117 and CA haplotypes and TG haplotypes of rs16844715 and rs4664308 were significantly different between IMN group and control group (P < 0.05). When GMDR software was used to establish a model to analyze the interaction between various SNP sites, it was found that the combination of GG genotype at rs35771982 and AA genotype at rs2715928 was the highest risk of disease. The risk genotypes of rs16844715, rs2715928 and rs4664308 had no effect on the clinical manifestations of IMN (P > 0.05). PLA2R rs2715928 and rs16844715 are associated with susceptibility to IMN. The C allele of rs16844715, the A allele of rs2715928, the G allele of rs35771982, the T allele of rs3749117, and the A allele of rs4664308 are the dangerous genes of IMN. The combination of GG genotype at rs35771982 and AA genotype at rs2715928 poses the greatest risk of disease. Haplotype may affect susceptibility to IMN. The risk genotype had no effect on the clinical manifestations of IMN.
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Affiliation(s)
- Xiaogang Liu
- Department of Nephrology, Shenzhen Hengsheng Hospital, 20 Yintian Rd, Shenzhen, Guangdong, People's Republic of China
| | - Weixi Xu
- Department of Nephrology, The 2nd Affiliated of Chengdu Medical College Nuclear Industry 416 Hospital, Chengdu, China
| | - Chengyuan Yu
- Department of Geriatric, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; the First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Mingao Wang
- Department of Nephrology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ruichan Liu
- Department of Nephrology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rujuan Xie
- Department of Nephrology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Abstract
Membranous nephropathy (MN) is a glomerular disease that can occur at all ages. In adults, it is the most frequent cause of nephrotic syndrome. In ~80% of patients, there is no underlying cause of MN (primary MN) and the remaining cases are associated with medications or other diseases such as systemic lupus erythematosus, hepatitis virus infection or malignancies. MN is an autoimmune disease characterized by a thickening of the glomerular capillary walls due to immune complex deposition. Identification of the phospholipase A2 receptor (PLA2R) as the major antigen in adults in 2009 induced a paradigm shift in disease diagnosis and monitoring and several other antigens have since been characterized. Disease outcome is difficult to predict and around one-third of patients will undergo spontaneous remission. In those at high risk of progression, immunosuppressive therapy with cyclophosphamide plus corticosteroids has substantially reduced the need for kidney replacement therapy. Owing to carcinogenic risk, other treatments (calcineurin inhibitors and CD20-targeted B cell depletion therapy (rituximab)) have been developed. However, disease relapses are frequent when calcineurin inhibitors are stopped and the remission rate with rituximab is lower than with cyclophosphamide, particularly in patients with high PLA2R antibody titres. Other new drugs are already available and antigen-specific immunotherapies are being developed.
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A Novel Insight into the Role of PLA2R and THSD7A in Membranous Nephropathy. J Immunol Res 2021; 2021:8163298. [PMID: 34337081 PMCID: PMC8298181 DOI: 10.1155/2021/8163298] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/20/2021] [Accepted: 07/03/2021] [Indexed: 12/22/2022] Open
Abstract
Membranous nephropathy (MN) is an organ-restricted autoimmune disease mainly caused by circulating autoantibodies against podocyte antigens, including the M-type phospholipase A2 receptor (PLA2R) and thrombospondin domain-containing 7A (THSD7A). Antibodies against PLA2R are present in 70%-80% and against THSD7A in 2% of adult patients, which provides a paradigm shift in molecular diagnosis and management monitoring. Both antigens share some similar characteristics: they are expressed by podocytes and have wide tissue distributions; they are bound by autoantibodies only under nonreducing conditions, and the subtype of most autoantibodies is IgG4. However, the factors triggering autoantibody production as well as the association among air pollution, malignancy, and the pathogenesis of MN remain unclear. In this review, we discuss the similarity between the pathological mechanisms triggered by disparate antigens and their associated diseases. Furthermore, we demonstrated the possibility that PM2.5, malignancy, and gene expression specifically induce exposure of these antigens through conformational changes, molecular mimicry, or increased expression eliciting autoimmune responses. Thus, this review provides novel insights into the pathological mechanism of MN.
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Batal I, Vasilescu ER, Dadhania DM, Adel AA, Husain SA, Avasare R, Serban G, Santoriello D, Khairallah P, Patel A, Moritz MJ, Latulippe E, Riopel J, Khallout K, Swanson SJ, Bomback AS, Mohan S, Ratner L, Radhakrishnan J, Cohen DJ, Appel GB, Stokes MB, Markowitz GS, Seshan SV, De Serres SA, Andeen N, Loupy A, Kiryluk K, D'Agati VD. Association of HLA Typing and Alloimmunity With Posttransplantation Membranous Nephropathy: A Multicenter Case Series. Am J Kidney Dis 2020; 76:374-383. [PMID: 32359820 PMCID: PMC7483441 DOI: 10.1053/j.ajkd.2020.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/07/2020] [Indexed: 12/20/2022]
Abstract
RATIONALE & OBJECTIVES Posttransplantation membranous nephropathy (MN) represents a rare complication of kidney transplantation that can be classified as recurrent or de novo. The clinical, pathologic, and immunogenetic characteristics of posttransplantation MN and the differences between de novo and recurrent MN are not well understood. STUDY DESIGN Multicenter case series. SETTING & PARTICIPANTS We included 77 patients from 5 North American and European medical centers with post-kidney transplantation MN (27 de novo and 50 recurrent). Patients with MN in the native kidney who received kidney allografts but did not develop recurrent MN were used as nonrecurrent controls (n = 43). To improve understanding of posttransplantation MN, we compared de novo MN with recurrent MN and then contrasted recurrent MN with nonrecurrent controls. FINDINGS Compared with recurrent MN, de novo MN was less likely to be classified as primary MN (OR, 0.04; P < 0.001) and had more concurrent antibody-mediated rejection (OR, 12.0; P < 0.001) and inferior allograft survival (HR for allograft failure, 3.2; P = 0.007). HLA-DQ2 and HLA-DR17 antigens were more common in recipients with recurrent MN compared with those with de novo MN; however, the frequency of these recipient antigens in recurrent MN was similar to that in nonrecurrent MN controls. Among the 93 kidney transplant recipients with native kidney failure attributed to MN, older recipient age (HR per each year older, 1.03; P = 0.02), recipient HLA-A3 antigen (HR, 2.5; P = 0.003), steroid-free immunosuppressive regimens (HR, 2.84; P < 0.001), and living related allograft (HR, 1.94; P = 0.03) were predictors of MN recurrence. LIMITATIONS Retrospective case series, limited sample size due to rarity of the disease, nonstandardized nature of data collection and biopsies. CONCLUSIONS De novo and recurrent MN likely represent separate diseases. De novo MN is associated with humoral alloimmunity and guarded outcome. Potential predisposing factors for recurrent MN include recipients who are older, recipient HLA-A3 antigen, steroid-free immunosuppressive regimen, and living related donor kidney.
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Affiliation(s)
- Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY.
| | - Elena-Rodica Vasilescu
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Darshana M Dadhania
- Department of Medicine, Nephrology, Weill Cornell Medical College, New York, NY
| | | | - S Ali Husain
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Rupali Avasare
- Department of Medicine, Nephrology, Oregon Health & Science University, Portland, OR
| | - Geo Serban
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Pascale Khairallah
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Ankita Patel
- Department of Medicine, Nephrology, Hackensack University Medical Center, Hackensack, NJ
| | - Michael J Moritz
- Department of Surgery, Lehigh Valley Health Network, Allentown, PA
| | - Eva Latulippe
- Department of Pathology, University Health Center of Quebec, Laval University, Québec, QC, Canada
| | - Julie Riopel
- Department of Pathology, University Health Center of Quebec, Laval University, Québec, QC, Canada
| | - Karim Khallout
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | | | - Andrew S Bomback
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Sumit Mohan
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Lloyd Ratner
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Jai Radhakrishnan
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - David J Cohen
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Gerald B Appel
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Michael B Stokes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Surya V Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Sacha A De Serres
- Renal Division, Department of Medicine, University Health Center of Quebec, Laval University, Québec, QC, Canada
| | - Nicole Andeen
- Department of Pathology, Oregon Health & Science University, Portland, OR
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - Krzysztof Kiryluk
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
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11
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Cravedi P, Jarque M, Angeletti A, Favà À, Cantarelli C, Bestard O. Immune-Monitoring Disease Activity in Primary Membranous Nephropathy. Front Med (Lausanne) 2019; 6:241. [PMID: 31788474 PMCID: PMC6856075 DOI: 10.3389/fmed.2019.00241] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/14/2019] [Indexed: 01/03/2023] Open
Abstract
Primary membranous nephropathy (MN) is a glomerular disease mediated by autoreactive antibodies, being the main cause of nephrotic syndrome among adult patients. While the pathogenesis of MN is still controversial, the detection of autoantibodies against two specific glomerular antigens, phospholipase A2 receptor (PLA2R) and thrombospondin type 1 domain containing 7A (THSD7A), together with the beneficial effect of therapies targeting B cells, have highlighted the main role of autoreactive B cells driving this renal disease. In fact, the detection of PLA2R-specific IgG4 antibodies has resulted in a paradigm shift regarding the diagnosis as well as a better prediction of the progression and recurrence of primary MN. Nevertheless, some patients do not show remission of the nephrotic syndrome or do rapidly recur after immunosuppression withdrawal, regardless the absence of detectable anti-PLA2R antibodies, thus highlighting the need of other immune biomarkers for MN risk-stratification. Notably, the exclusive evaluation of circulating antibodies may significantly underestimate the magnitude of the global humoral memory immune response since it may exclude the role of antigen-specific memory B cells. Therefore, the assessment of PLA2R-specific B-cell immune responses using novel technologies in a functional manner may provide novel insight on the pathogenic mechanisms of B cells triggering MN as well as refine current immune-risk stratification solely based on circulating autoantibodies.
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Affiliation(s)
- Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Marta Jarque
- Experimental Nephrology Laboratory, Biomedical Research Institute of Bellvitge (IDIBELL), Barcelona, Spain
| | - Andrea Angeletti
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Àlex Favà
- Experimental Nephrology Laboratory, Biomedical Research Institute of Bellvitge (IDIBELL), Barcelona, Spain
| | - Chiara Cantarelli
- UO Nefrologia, Dipartimento di Medicina e Chirurgia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Oriol Bestard
- Experimental Nephrology Laboratory, Biomedical Research Institute of Bellvitge (IDIBELL), Barcelona, Spain.,Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona University, Biomedical Research Institute of Bellvitge (IDIBELL), Barcelona, Spain
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12
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Ronco P, Debiec H. Molecular Pathogenesis of Membranous Nephropathy. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2019; 15:287-313. [PMID: 31622560 DOI: 10.1146/annurev-pathol-020117-043811] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Membranous nephropathy is a noninflammatory autoimmune disease of the kidney glomerulus, characterized by the formation of immune deposits, complement-mediated proteinuria, and risk of renal failure. Considerable advances in understanding the molecular pathogenesis have occurred with the identification of several antigens [neutral endopeptidase, phospholipase A2 receptor (PLA2R), thrombospondin domain-containing 7A (THSD7A)] in cases arising from the neonatal period to adulthood and the characterization of antibody-binding domains (that is, epitopes). Immunization against PLA2R occurs in 70% to 80% of adult cases. The development of highly specific and sensitive assays of circulating antibodies has induced a paradigm shift in diagnosis and treatment monitoring. In addition, several interacting loci in HLA-DQ, HLA-DR, and PLA2R1, as well as classical human leukocyte antigen (HLA)-D alleles have been identified as being risk factors, depending on a patient's ethnicity. Additionally, mechanisms of antibody pathogenicity and pathways of complement activation are now better understood. Further research is mandatory for designing new therapeutic strategies, including the identifying triggering events, the molecular bases of remission and progression, and the T cell epitopes involved.
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Affiliation(s)
- Pierre Ronco
- Rare and Common Kidney Diseases: From Molecular Mechanisms to Personalized Medicine Unit, INSERM UMRS 1155, Sorbonne Université, 75020 Paris, France;
| | - Hanna Debiec
- Rare and Common Kidney Diseases: From Molecular Mechanisms to Personalized Medicine Unit, INSERM UMRS 1155, Sorbonne Université, 75020 Paris, France;
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13
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van de Logt AE, Fresquet M, Wetzels JF, Brenchley P. The anti-PLA2R antibody in membranous nephropathy: what we know and what remains a decade after its discovery. Kidney Int 2019; 96:1292-1302. [PMID: 31611068 DOI: 10.1016/j.kint.2019.07.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/08/2019] [Accepted: 07/05/2019] [Indexed: 12/21/2022]
Abstract
The discovery in 2009 of the M-type phospholipase A2 receptor (PLA2R) as the primary target in membranous nephropathy (MN) greatly advanced basic and clinical research. Primary MN is now considered a renal-limited autoimmune disease, with antibodies against PLA2R (aPLA2Rab) identified in 70-80 % of patients of various ethnic groups. Although the use of aPLA2Rab as a diagnostic and prognostic biomarker is now widely accepted, many questions related to the development of the auto-immune response, the role of IgG subclasses and antigenic epitopes, and the pathways to podocyte injury remain unresolved. PLA2R-associated MN most likely develops governed by factors such as genetic susceptibility, loss of tolerance, alterations in antigen expression with a role for environmental factors like air pollution, smoking, and infections. More detailed knowledge of genetic factors, the relevant B- and T-cell epitopes, and the mechanisms of podocyte injury is needed to identify patients at risk for disease progression and to develop optimized, targeted treatment strategies. In this review we highlight unresolved issues, addressing initiation of antibody formation, the timeline of antibody production, the role of IgG subclass, and the pathogenicity of the antibodies in concert with complement to produce glomerular pathology and proteinuria.
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Affiliation(s)
- Anne-Els van de Logt
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
| | - Maryline Fresquet
- Wellcome Centre for Cell-Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Jack F Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Brenchley
- Institute of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
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14
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Abstract
PURPOSE OF REVIEW Despite major advances in since the discovery of the phospholipase A2 receptor (PLA2R) as the major autoantigen on podocytes in primary membranous nephropathy, there are still several unanswered questions as highlighted here. RECENT FINDINGS A substantial body of literature, included in more than 680 articles since 2009, has documented genetic susceptibility to primary membranous nephropathy involving PLA2R1 and class II MHC alleles, the clinical value of anti-PLA2R assays, the significance of epitope spreading of the anti-PLA2R response, discovery of thrombospondin type I domain-containing 7A (THSD7A) as a minor antigen in primary membranous nephropathy, and the ability to transfer disease into mice by infusion of anti-THSD7A sera. However, the normal physiology and pathophysiology of PLA2R and THSD7A in podocytes is still unknown and the genetic influence on disease susceptibility is unexplained. We still do not know what causes loss of self-tolerance to PLA2R and THSD7A or how the autoantibodies, which are predominantly of the IgG4 subclass, cause podocyte injury and proteinuria. Complement deposits are prominent in membranous nephropathy but we are still uncertain how the complement system is activated and whether or not it plays a role in podocyte damage. Notwithstanding the advances over the past decade, our treatments have not changed substantially. SUMMARY This review identifies opportunities to extend the advances that have been made to better understand the immunopathogenesis and genetic basis of primary membranous nephropathy and apply the knowledge to design more specific therapies.
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15
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Liu D, Zhang J, Shi Y, Liu Z. Gene polymorphism and risk of idiopathic membranous nephropathy. Life Sci 2019; 229:124-131. [DOI: 10.1016/j.lfs.2019.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 01/09/2023]
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16
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Tang W, Wang Z, Cao Y, Zhang D, Mi X. Bioinformatic Analysis Reveals Novel Immune-Associated Hub Genes in Human Membranous Nephropathy. Genet Test Mol Biomarkers 2019; 23:23-31. [PMID: 30526079 DOI: 10.1089/gtmb.2018.0137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Wanxin Tang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Zheng Wang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yiling Cao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Dongmei Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Xuhua Mi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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17
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Robson KJ, Ooi JD, Holdsworth SR, Rossjohn J, Kitching AR. HLA and kidney disease: from associations to mechanisms. Nat Rev Nephrol 2018; 14:636-655. [DOI: 10.1038/s41581-018-0057-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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Zhang XD, Cui Z, Zhao MH. The Genetic and Environmental Factors of Primary Membranous Nephropathy: An Overview from China. KIDNEY DISEASES 2018; 4:65-73. [PMID: 29998121 DOI: 10.1159/000487136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/18/2018] [Indexed: 01/10/2023]
Abstract
Background Primary membranous nephropathy (pMN) is the most common cause of nephrotic syndrome in adults. The discovery of the 2 autoantigens, M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A), has defined pMN as an autoimmune disease. A remarkable increase in the frequency of pMN in primary glomerular disease was witnessed in China. The genetic and environmental contributors to disease susceptibility have been investigated in these patients. Summary We reviewed recent publications in genetic and environmental studies of pMN, focusing mainly on those undertaken in China. Following a genome-wide association study, the gene-gene interaction between the 2 most significant risk factors, PLA2R1 and DQA1, was validated in Chinese patients with MN. Fine mapping on human leukocyte antigen (HLA) locus found that DRB1*1501 and DRB1*0301 were risk alleles. Three amino acid residues on positions 13 and 71 of HLA-DRβ1 chain may confer the susceptibility to pMN by presenting T-cell epitopes on PLA2R. Another study found that DRB3*0202 was the most likely culprit allele for the signal at DRB1*0301. One environmental risk factor for pMN has been identified as the long-term exposure to high levels of PM2.5 in Chinese patients with MN. Each 10 μg/m3 increase in PM2.5 concentration was associated with 14% higher odds for pMN in the regions with PM2.5 above 70 μg/m3. Key Message A gene-environment interaction is suspected as an underlying mechanism for the increasing trend of pMN in China.
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Affiliation(s)
- Xiao-Dan Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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19
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Lal S, Luger A, Hashefi M, Ross G. De novo Membranous Glomerulopathy in a Renal Transplant Patient Treated with FK 506. The First Reported Case. Int J Artif Organs 2018. [DOI: 10.1177/039139889702000705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We describe a case of de novo membranous glomerulopathy in the renal allograft of a diabetic patient, treated with the newer immunosuppressive agent FK 506. Twenty-two months later this patient developed nephrotic range proteinuria.
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Affiliation(s)
- S.M. Lal
- Departments of Internal Medicine Columbia, Missouri - USA
| | - A.M. Luger
- Pathology and, University of Missouri Health Sciences Center, Columbia, Missouri - USA
| | - M. Hashefi
- Departments of Internal Medicine Columbia, Missouri - USA
| | - G. Ross
- Surgery, University of Missouri Health Sciences Center, Columbia, Missouri - USA
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20
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Membranous Nephropathy and Anti-Podocytes Antibodies: Implications for the Diagnostic Workup and Disease Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6281054. [PMID: 29511687 PMCID: PMC5817285 DOI: 10.1155/2018/6281054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/31/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
The discovery of circulating antibodies specific for native podocyte antigens has transformed the diagnostic workup and greatly improved management of idiopathic membranous nephropathy (iMN). In addition, their identification has clearly characterized iMN as a largely autoimmune disorder. Anti-PLA2R1 antibodies are detected in approximately 70% to 80% and anti-THSD7A antibodies in only 2% of adult patients with iMN. The presence of anti-THSD7A antibodies is associated with increased risk of malignancy. The assessment of PLA2R1 and THSD7A antigen expression in glomerular immune deposits has a better sensitivity than measurement of the corresponding autoantibodies. Therefore, in the presence of circulating anti-podocytes autoantibodies and/or enhanced expression of PLA2R1 and THSD7A antigens MN should be considered as primary MN (pMN). Anti-PLA2R1 or anti-THSD7A autoantibodies have been proposed as biomarkers of autoimmune disease activity and their blood levels should be regularly monitored in pMN to evaluate disease activity and predict outcomes. We propose a revised clinical workup flow for patients with MN that recommends assessment of kidney biopsy for PLA2R1 and THSD7A antigen expression, screening for circulating anti-podocytes antibodies, and assessment for secondary causes, especially cancer, in patients with THSD7A antibodies. Persistence of anti-podocyte antibodies for 6 months or their increase in association with nephrotic proteinuria should lead to the introduction of immunosuppressive therapies. Recent data have reported the efficacy and safety of new specific therapies targeting B cells (anti-CD20 antibodies, inhibitors of proteasome) in pMN which should lead to an update of currently outdated treatment guidelines.
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21
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Qin XS, Liu JH, Lyu GT, Peng ML, Yang FN, Qin DC, Li YZ, Liu Y. Variants in the Promoter Region of HLA-DQA1 were Associated with Idiopathic Membranous Nephropathy in a Chinese Han Population. Chin Med J (Engl) 2017; 130:1677-1682. [PMID: 28685717 PMCID: PMC5520554 DOI: 10.4103/0366-6999.209884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Idiopathic membranous nephropathy (IMN) is an autoimmune disease and the leading cause of adult nephritic syndrome. HLA-DQA1 had been identified to be associated with IMN in Europeans and the result was replicated in Chinese Han population. In this study, six single nucleotide polymorphisms (SNPs) in the promoter of HLA-DQA1 and other two SNPs with IgA nephropathy were included for the association analysis. Methods: The SNPs were genotyped in 509 patients and 601 controls by the MassArray iPLEX. The quantification of anti-phospholipase A2 receptor (PLA2R) antibodies in sera of IMN patients was performed by anti-PLA2R ELISA (IgG) kit. Results: After analysis, four SNPs were significantly associated with IMN, with rs2187668 and rs28383345 as the top two signals (P = 8.42×10-5 and 2.48×10-5, respectively). Even under dominant model, the two SNPs were still significantly associated with IMN (P = 3.50×10-3 for rs28383345 and P = 6.55×10-5 for rs2187668). After conditional study with rs2187668, rs28383345 was the only variant significantly correlated with IMN after Bonferroni correction (P = 0.016). The minor alleles of the two SNPs were also mutually exclusive in our cohort. This indicated that the two SNPs were independently associated with IMN in Chinese Han population. Levels of anti-PLA2R autoantibodies were correlated with the genotypes of the two SNPs, but not significantly (P>0.05). Conclusions: Our results revealed that a novel independent variant in the promoter of HLA-DQA1 was associated with IMN in Chinese Han population. The locus possessed regulatory role according to the data of RegulomeDB. The exact role of the SNPs on the expression of HLA-DQA1 needs further investigation.
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Affiliation(s)
- Xiao-Song Qin
- Department of Medical Laboratory, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110011, China
| | - Jian-Hua Liu
- Department of Medical Laboratory, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110011, China
| | - Guan-Ting Lyu
- Department of Blood Transfusion, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710038, China
| | - Meng-Le Peng
- Department of Medical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Fu-Ning Yang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100005, China
| | - Dong-Chun Qin
- Department of Medical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Yong-Zhe Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100005, China
| | - Yong Liu
- Department of Medical Laboratory, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110011, China
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22
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Mladkova N, Kiryluk K. Genetic Complexities of the HLA Region and Idiopathic Membranous Nephropathy. J Am Soc Nephrol 2017; 28:1331-1334. [PMID: 28396523 PMCID: PMC5407745 DOI: 10.1681/asn.2017030283] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Nikol Mladkova
- Division of Nephrology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
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23
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Cattran DC, Brenchley PE. Membranous nephropathy: integrating basic science into improved clinical management. Kidney Int 2017; 91:566-574. [PMID: 28065518 DOI: 10.1016/j.kint.2016.09.048] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/26/2016] [Accepted: 09/08/2016] [Indexed: 02/08/2023]
Abstract
Idiopathic membranous nephropathy (INM) remains a common cause of the nephrotic syndrome in adults. The autoimmune nature of IMN was clearly delineated in 2009 with the identification of the glomerular-deposited IgG to be a podocyte receptor, phospholipase A2 receptor (PLA2R) in 70% to 75% of cases. This anti-PLA2R autoantibody, predominantly the IgG4 subclass, has been quantitated in serum using an enzyme-linked immunosorbent assay and has been used to aid diagnosis and monitor response to immunosuppressive therapy. In 2014, a second autoantigen, thrombospondin type 1 domain-containing 7A (THSD7A), was identified. Immunostaining of biopsy specimens has further detected either PLA2R or THSD7A antigen in the deposited immune complexes in 5% to 10% of cases autoantibody seronegative at the time of biopsy. Therefore, the term IMN should now be superseded by the term primary or autoimmune MN (AMN) (anti-PLA2R or anti-THSD7A positive) classifying ∼80% to 90% of cases previously designated IMN. Cases of secondary MN associated with other diseases show much lower association with these autoantibodies, but their true incidence in secondary cases still needs to be defined. How knowledge of the autoimmune mechanism and the sequential measurement of these autoantibodies is likely to change the clinical management and trajectory of AMN by more precisely defining its diagnosis, prognosis, and treatment is discussed. Their application early in the disease course to new and old therapies will provide additional precision to AMN management. We also review innovative therapeutic approaches on the horizon that are expected to lead to our ultimate goal of improved patient care in A(I)MN.
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Affiliation(s)
- Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada.
| | - Paul E Brenchley
- Renal Research Labs, Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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24
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Le WB, Shi JS, Zhang T, Liu L, Qin HZ, Liang S, Zhang YW, Zheng CX, Jiang S, Qin WS, Zhang HT, Liu ZH. HLA-DRB1*15:01 and HLA-DRB3*02:02 in PLA2R-Related Membranous Nephropathy. J Am Soc Nephrol 2016; 28:1642-1650. [PMID: 28028136 DOI: 10.1681/asn.2016060644] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/20/2016] [Indexed: 01/15/2023] Open
Abstract
Idiopathic membranous nephropathy (MN) is associated with HLA; however, the HLA allele involved remains unknown. To identify the HLA risk alleles associated with phospholipase A2 receptor (PLA2R)-related MN in the Chinese population, we sequenced the entire MHC region in DNA samples from 99 patients with PLA2R-related MN, 50 patients with PLA2R-unrelated MN, and 100 healthy subjects. Two HLA risk alleles, HLA-DRB1*15:01 and HLA-DRB3*02:02, independently and strongly associated with an increased risk of PLA2R-related MN. After adjusting for HLA-DRB1*15:01 and HLA-DRB3*02:02, no other alleles showed significant association with PLA2R-related MN. A replication study in an independent cohort of 293 participants with PLA2R-related MN and 285 healthy controls validated these findings. In a joint analysis, a multivariate logistic regression model confirmed that HLA-DRB1*15:01 (odds ratio [OR], 24.9; 95% confidence interval [95% CI], 15.3 to 42.6; P=2.3×10-35) and HLA-DRB3*02:02 (OR, 17.7; 95% CI, 11.0 to 30.3; P=8.0×10-29) independently and strongly associated with PLA2R-related MN. As many as 98.7% of patients with PLA2R-related MN, compared with 43.9% of control subjects, carried at least one HLA risk allele. Subjects with either risk allele had higher odds of developing PLA2R-related MN than those without a risk allele (OR, 98.9; 95% CI, 44.4 to 281.7; P=2.5×10-23). These HLA risk alleles also associated with the age at disease onset in patients with PLA2R-related MN. In conclusion, our findings provide clear evidence that the HLA-DRB1*15:01 and HLA-DRB3*02:02 alleles independently and strongly associate with PLA2R-related MN in the Chinese population.
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Affiliation(s)
- Wei-Bo Le
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - Jing-Song Shi
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | | | - Lei Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - Hua-Zhang Qin
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - ShaoShan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | | | - Cun-Xia Zheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - Song Jiang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - Wei-Song Qin
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - Hai-Tao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and
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25
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Cui Z, Xie LJ, Chen FJ, Pei ZY, Zhang LJ, Qu Z, Huang J, Gu QH, Zhang YM, Wang X, Wang F, Meng LQ, Liu G, Zhou XJ, Zhu L, Lv JC, Liu F, Zhang H, Liao YH, Lai LH, Ronco P, Zhao MH. MHC Class II Risk Alleles and Amino Acid Residues in Idiopathic Membranous Nephropathy. J Am Soc Nephrol 2016; 28:1651-1664. [PMID: 27852637 DOI: 10.1681/asn.2016020114] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 09/21/2016] [Indexed: 11/03/2022] Open
Abstract
Epitopes of phospholipase A2 receptor (PLA2R), the target antigen in idiopathic membranous nephropathy (iMN), must be presented by the HLA-encoded MHC class II molecules to stimulate autoantibody production. A genome-wide association study identified risk alleles at HLA and PLA2R loci, with the top variant rs2187668 within HLA-DQA1 showing a risk effect greater than that of the top variant rs4664308 within PLA2R1. How the HLA risk alleles affect epitope presentation by MHC class II molecules in iMN is unknown. Here, we genotyped 261 patients with iMN and 599 healthy controls at the HLA-DRB1, HLA-DQA1, HLA-DQB1, and HLA-DPB1 loci with four-digit resolution and extracted the encoded amino acid sequences from the IMGT/HLA database. We predicted T cell epitopes of PLA2R and constructed MHC-DR molecule-PLA2R peptide-T cell receptor structures using Modeler. We identified DRB1*1501 (odds ratio, 4.65; 95% confidence interval [95% CI], 3.39 to 6.41; P<0.001) and DRB1*0301 (odds ratio, 3.96; 95% CI, 2.61 to 6.05; P<0.001) as independent risk alleles for iMN and associated with circulating anti-PLA2R antibodies. Strong gene-gene interaction was noted between rs4664308(AA) and HLA-DRB1*1501/DRB1*0301. Amino acid positions 13 (P<0.001) and 71 (P<0.001) in the MHC-DRβ1 chain independently associated with iMN. Structural models showed that arginine13 and alanine71, encoded by DRB1*1501, and lysine71, encoded by DRB1*0301, facilitate interactions with T cell epitopes of PLA2R. In conclusion, we identified two risk alleles of HLA class II genes and three amino acid residues on positions 13 and 71 of the MHC-DRβ1 chain that may confer susceptibility to iMN by presenting T cell epitopes on PLA2R.
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Affiliation(s)
- Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li-Jun Xie
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Renal Division, Department of Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Fang-Jin Chen
- State Key Laboratory for Structural Chemistry of Unstable and Stable Species, Beijing National Laboratory for Molecular Sciences, College of Chemistry and Molecular Engineering and Center for Theoretical Biology, Peking University, Beijing, China
| | | | | | - Zhen Qu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Jing Huang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Qiu-Hua Gu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Yi-Miao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Xin Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Fang Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li-Qiang Meng
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Gang Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Xu-Jie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li Zhu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Ji-Cheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Fan Liu
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomic, Chinese Academy of Science, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Yun-Hua Liao
- Renal Division, Department of Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lu-Hua Lai
- State Key Laboratory for Structural Chemistry of Unstable and Stable Species, Beijing National Laboratory for Molecular Sciences, College of Chemistry and Molecular Engineering and Center for Theoretical Biology, Peking University, Beijing, China
| | - Pierre Ronco
- Sorbonne Universités, Université Pierre et Marie Curie Univ Paris 06, Paris, France.,Institut National de la Santé et la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France.,Assistance Publique-Hôpitaux de Paris, Service de Néphrologie et Dialyses, Hôpital Tenon, Paris, France; and
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; .,Peking-Tsinghua Center for Life Sciences, Beijing, China
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Francis JM, Beck LH, Salant DJ. Membranous Nephropathy: A Journey From Bench to Bedside. Am J Kidney Dis 2016; 68:138-47. [PMID: 27085376 PMCID: PMC4921260 DOI: 10.1053/j.ajkd.2016.01.030] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/31/2016] [Indexed: 12/28/2022]
Abstract
Lessons from an animal model that faithfully resembles human membranous nephropathy (MN) have informed our understanding of the pathogenesis of this organ-specific autoimmune disease and common cause of nephrotic syndrome. After it was established that the subepithelial immune deposits that characterize experimental MN form in situ when circulating antibodies bind to an intrinsic podocyte antigen, it was merely a matter of time before the human antigen was identified. The M-type phospholipase A2 receptor 1 (PLA2R) represents the major target antigen in primary MN, and thrombospondin type 1 domain-containing 7A (THSD7A) was more recently identified as a minor antigen. Serologic tests for anti-PLA2R and kidney biopsy specimen staining for PLA2R show >90% specificity and 70% to 80% sensitivity for the diagnosis of primary MN in most populations. The assays distinguish most cases of primary MN from MN associated with other systemic diseases, and sequential anti-PLA2R titers are useful to monitor treatment response. A positive pretransplantation test result for anti-PLA2R is also helpful for predicting the risk for posttransplantation recurrence. Identification of target epitopes within PLA2R and the genetic association of primary MN with class II major histocompatibility and PLA2R1 variants are 2 additional examples of our evolving understanding of this disease.
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Affiliation(s)
- Jean M Francis
- Department of Medicine, Boston University Medical Center, Boston, MA
| | - Laurence H Beck
- Department of Medicine, Boston University Medical Center, Boston, MA
| | - David J Salant
- Department of Medicine, Boston University Medical Center, Boston, MA.
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Idiopathic membranous nephropathy and IgG4: an interesting relationship. Clin Nephrol 2014; 82:7-15. [PMID: 23380389 PMCID: PMC4928035 DOI: 10.5414/cn107768] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2014] [Indexed: 12/24/2022] Open
Abstract
Idiopathic membranous nephropathy (iMN) is a single-organ autoimmune disease characterized by subepithelial deposition of immune complexes containing IgG4 resulting in proteinuria, nephrotic syndrome, and, in some, end-stage renal disease. The pathogenesis involves a chronic IgG4 response against specific podocyte antigens which have now been at least partially defined in the neonatal, early childhood, and adult varieties. More has recently been learned about the genetic predisposition as well. This review discusses the pathophysiology of iMN in light of these discoveries and what is known about the genesis and potential clinical ramifications of an antigen-specific IgG4 response.
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Immunopathogenesis of membranous nephropathy: an update. Semin Immunopathol 2014; 36:381-97. [PMID: 24715030 DOI: 10.1007/s00281-014-0423-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
Abstract
Membranous nephropathy (MN) is a non-inflammatory organ-specific autoimmune disease which affects the kidney glomerulus, resulting in the formation of immune deposits on the outer aspect of the glomerular basement membrane, complement-mediated proteinuria, and severe renal failure in 30% of patients. In the last 10 years, substantial advances have been made in the understanding of the molecular bases of MN, with the identification of several antigens and predisposing genes in children and adults. These ground-breaking findings already have a major impact on diagnosis and monitoring and to some extent on therapies. However, there is evidence that the disease is more complex and involves a variety of antigen-antibody systems and genes involved in immune response, progression, recovery, and protective mechanisms. We herein review these recent findings which open new perspectives of research. Understanding the complex pathogenesis of MN will offer many opportunities for future therapeutic interventions and will hopefully have a major impact on patient care. New insights into the molecular mechanisms of MN may also enlighten the pathogenesis of organ-specific autoimmune diseases.
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Bullich G, Ballarín J, Oliver A, Ayasreh N, Silva I, Santín S, Díaz-Encarnación MM, Torra R, Ars E. HLA-DQA1 and PLA2R1 polymorphisms and risk of idiopathic membranous nephropathy. Clin J Am Soc Nephrol 2013; 9:335-43. [PMID: 24262501 DOI: 10.2215/cjn.05310513] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Single nucleotide polymorphisms (SNPs) within HLA complex class II HLA-DQ α-chain 1 (HLA-DQA1) and M-type phospholipase A2 receptor (PLA2R1) genes were identified as strong risk factors for idiopathic membranous nephropathy (IMN) development in a recent genome-wide association study. Copy number variants (CNVs) within the Fc gamma receptor III (FCGR3) locus have been associated with several autoimmune diseases, but their role in IMN has not been studied. This study aimed to validate the association of HLA-DQA1 and PLA2R1 risk alleles with IMN in a Spanish cohort, test the putative association of FCGR3A and FCGR3B CNVs with IMN, and assess the use of these genetic factors to predict the clinical outcome of the disease. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS A Spanish cohort of 89 IMN patients and 286 matched controls without nephropathy was recruited between October of 2009 and July of 2012. Case-control studies for SNPs within HLA-DQA1 (rs2187668) and PLA2R1 (rs4664308) genes and CNVs for FCGR3A and FCGR3B genes were performed. The contribution of these polymorphisms to predict clinical outcome and renal function decline was analyzed. RESULTS This study validated the association of these HLA-DQA1 and PLA2R1 SNPs with IMN in a Spanish cohort and its increased risk when combining both risk genotypes. No significant association was found between FCGR3 CNVs and IMN. These results revealed that HLA-DQA1 and PLA2R1 genotype combination adjusted for baseline proteinuria strongly predicted response to immunosuppressive therapy. HLA-DQA1 genotype adjusted for proteinuria was also linked with renal function decline. CONCLUSION This study confirms that HLA-DQA1 and PLA2R1 genotypes are risk factors for IMN, whereas no association was identified for FCGR3 CNVs. This study provides, for the first time, evidence of the contribution of these HLA-DQA1 and PLA2R1 polymorphisms in predicting IMN response to immunosuppressors and disease progression. Future studies are needed to validate and identify prognostic markers.
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Affiliation(s)
- Gemma Bullich
- Molecular Biology Laboratory and, †Nephrology Department, Fundació Puigvert, Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona, Red de Investigación Renal, Instituto de Investigación Carlos III, Barcelona, Spain
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Anti-PLA2R antibodies measured by ELISA predict long-term outcome in a prevalent population of patients with idiopathic membranous nephropathy. Kidney Int 2013; 83:940-8. [DOI: 10.1038/ki.2012.486] [Citation(s) in RCA: 223] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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31
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Salant DJ. Genetic variants in membranous nephropathy: perhaps a perfect storm rather than a straightforward conformeropathy? J Am Soc Nephrol 2013; 24:525-8. [PMID: 23492731 DOI: 10.1681/asn.2013020166] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Ronco P, Debiec H. [Pathophysiology of extramembranous glomerulopathies. Fifty years of progress, from laboratory to patient]. Biol Aujourdhui 2013; 207:249-59. [PMID: 24594573 DOI: 10.1051/jbio/2013025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Indexed: 11/15/2022]
Abstract
Membranous nephropathy (MN) is a kidney disease characterized by deposition of immune complexes and complement on the outer aspect of the glomerular capillary wall. It is responsible for a loss of serum proteins in the urine and kidney failure. During the last ten years, considerable progress has occurred in the understanding of the molecular bases of the disease with the description of three distinct mechanisms in humans. In the neonatal allo-immune form, antibodies are directed against neutral endopeptidase (NEP), a podocyte antigen absent in the mothers who become immunized against this antigen expressed by placenta cells during pregnancy. NEP was the first podocyte antigen to be identified in MN. Most adult forms of MN are autoimmune diseases without identified etiology (primary MN), linked to the production of antibodies raised against another podocyte antigen, the type-M phospholipase A2 receptor (PLA2R1). Anti-PLA2R1 antibodies are detected in 70 to 80% of patients before any immunosuppressive treatment, and only occasionally in secondary forms of MN, variants of PLAR1 and HLA-DQA1 genes are very significantly associated with occurrence of primary MN in Caucasians. The third mechanism is characterized by immunization against a foreign protein, cationic bovine serum albumin (BSA), which is involved in rare forms of MN during early childhood. This finding points to a possible role of food and environmental antigens in membranous nephropathy.
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HLA-A, -B, -DR allele group frequencies in 7007 kidney transplant list patients in 27 UK centres. Int J Immunogenet 2012; 40:209-15. [DOI: 10.1111/iji.12000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 07/20/2012] [Accepted: 07/25/2012] [Indexed: 12/01/2022]
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Abstract
Antibodies to neutral endopeptidase, a podocyte protein, are responsible for rare alloimmune neonatal membranous nephropathy that develops in children from neutral endopeptidase-deficient mothers. Neutral endopeptidase was the first podocyte antigen described in human membranous nephropathy. PLA2R1, the type-M receptor of soluble phospholipase A2, is a major target antigen in so-called idiopathic membranous nephropathy in adults. Antibodies to PLA2R1 are detected in 60 to 80% of patients before immunosuppressive treatment, and are only occasionally found in secondary membranous nephropathy. To date, they have not been detected in other pathological conditions and in healthy individuals. PLA2R1 and HLA-DQA1 gene variants defined by single nucleotide polymorphisms are strongly associated with idiopathic membranous nephropathy in patients of white ancestry, and can thus be considered as predisposing genes. In addition to their diagnostic value, anti-PLA2R1 antibodies can be used to monitor treatment. Immunization against cationic bovine serum albumin is a cause of early childhood membranous nephropathy. This finding points to a possible role of food and environmental antigens in membranous nephropathy. The newly identified antigen-antibody systems should be considered as molecular signatures challenging the uniform histological definition and having a major impact on patient care in a near future.
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Stanescu HC, Arcos-Burgos M, Medlar A, Bockenhauer D, Kottgen A, Dragomirescu L, Voinescu C, Patel N, Pearce K, Hubank M, Stephens HAF, Laundy V, Padmanabhan S, Zawadzka A, Hofstra JM, Coenen MJH, den Heijer M, Kiemeney LALM, Bacq-Daian D, Stengel B, Powis SH, Brenchley P, Feehally J, Rees AJ, Debiec H, Wetzels JFM, Ronco P, Mathieson PW, Kleta R. Risk HLA-DQA1 and PLA(2)R1 alleles in idiopathic membranous nephropathy. N Engl J Med 2011; 364:616-26. [PMID: 21323541 DOI: 10.1056/nejmoa1009742] [Citation(s) in RCA: 356] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Idiopathic membranous nephropathy is a major cause of the nephrotic syndrome in adults, but its etiologic basis is not fully understood. We investigated the genetic basis of biopsy-proven cases of idiopathic membranous nephropathy in a white population. METHODS We performed independent genomewide association studies of single-nucleotide polymorphisms (SNPs) in patients with idiopathic membranous nephropathy from three populations of white ancestry (75 French, 146 Dutch, and 335 British patients). The patients were compared with racially matched control subjects; population stratification and quality controls were carried out according to standard criteria. Associations were calculated by means of a chi-square basic allele test; the threshold for significance was adjusted for multiple comparisons (with the Bonferroni method). RESULTS In a joint analysis of data from the 556 patients studied (398 men), we identified significant alleles at two genomic loci associated with idiopathic membranous nephropathy. Chromosome 2q24 contains the gene encoding M-type phospholipase A(2) receptor (PLA(2)R1) (SNP rs4664308, P=8.6×10(-29)), previously shown to be the target of an autoimmune response. Chromosome 6p21 contains the gene encoding HLA complex class II HLA-DQ alpha chain 1 (HLA-DQA1) (SNP rs2187668, P=8.0×10(-93)). The association with HLA-DQA1 was significant in all three populations (P=1.8×10(-9), P=5.6×10(-27), and P=5.2×10(-36) in the French, Dutch, and British groups, respectively). The odds ratio for idiopathic membranous nephropathy with homozygosity for both risk alleles was 78.5 (95% confidence interval, 34.6 to 178.2). CONCLUSIONS An HLA-DQA1 allele on chromosome 6p21 is most closely associated with idiopathic membranous nephropathy in persons of white ancestry. This allele may facilitate an autoimmune response against targets such as variants of PLA2R1. Our findings suggest a basis for understanding this disease and illuminate how adaptive immunity is regulated by HLA.
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Affiliation(s)
- Horia C Stanescu
- Centre for Nephrology, Royal Free Hospital, University College London, London, United Kingdom
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Sivaramakrishnan R, Kaul B, Jain SB, Mandonca S, Gupta S. Multiple sclerosis in a patient with membranous glomerulopathy: is vitamin D deficiency the culprit in the presence of HLA DRB1*1501 allele? Mult Scler 2011; 17:254. [DOI: 10.1177/1352458510383149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- R Sivaramakrishnan
- Department of Nephrology, All India Institute of Medical Sciences, Delhi, India
| | - Bhavna Kaul
- Department of Neurology, All India Institute of Medical Sciences, Delhi, India
| | - Sheel Badhra Jain
- Department of Nephrology, All India Institute of Medical Sciences, Delhi, India
| | - Sathish Mandonca
- Department of Nephrology, All India Institute of Medical Sciences, Delhi, India
| | - Sanjay Gupta
- Department of Nephrology, All India Institute of Medical Sciences, Delhi, India
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Abstract
Gold salts have been used in the treatment of patients with rheumatoid arthritis since 1927 [1]. After a controlled study, the Empire Rheumatism Council [2], confirmed the effectiveness of gold salts for the treatment of rheumatoid arthritis. Even today, chrysotherapy has remained one of the major therapeutic modalities in the second line treatment of progressive rheumatoid arthritis. Gold salts are also used in the treatment of pemphigus vulgaris [3] and bronchial asthma [4]. Before the introduction of an orally administered gold compound, auranofin (triethylphosphine gold tetra-acetyl glycopyranoside), to clinical use [5-7], parenterally administered gold salts, such as sodium aurothiomalate and gold thioglucose comprised chrysotherapy. The frequency and severity of the side effects for patients treated with parenteral gold versus those given oral gold preparations are significantly different [8-10]. With introduction of newer parental DMARDs, toxicity has been reduced using combination therapy [10a, 10b].
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Shin GT, Yim H, Park J, Kim H. Membranous Nephropathy Associated With Fluconazole Treatment. Am J Kidney Dis 2007; 49:318-22. [PMID: 17261435 DOI: 10.1053/j.ajkd.2006.11.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 11/09/2006] [Indexed: 11/11/2022]
Abstract
About 6% to 9% of cases of membranous nephropathy develop secondary to exposure to drugs. Fluconazole is a widely used antifungal agent that was never implicated in the development of membranous nephropathy. We report the case of a patient found to have membranous nephropathy secondary to fluconazole treatment. This patient had recurrent episodes of nephrotic syndrome caused by readministration of fluconazole. This is the first reported case of membranous nephropathy caused by fluconazole treatment and the first case report of the clinical course of recurrent membranous nephropathy caused by reexposure to this medication.
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Affiliation(s)
- Gyu-Tae Shin
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea.
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40
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Affiliation(s)
- Antonio Mutti
- Laboratory of Industrial ToxicologyUniversity of Parma Medical School
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41
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Bhimma R, Hammond MG, Coovadia HM, Adhikari M, Connolly CA. HLA class I and II in black children with hepatitis B virus-associated membranous nephropathy. Kidney Int 2002; 61:1510-5. [PMID: 11918759 DOI: 10.1046/j.1523-1755.2002.00287.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The pathogenetic mechanisms by which individuals with chronic hepatitis B virus (HBV) infection develop membranous nephropathy (MN) are probably dependent on interactions between viral, host and environmental factors; some evidence suggests a genetic predisposition. HBVMN constitutes a major etiological group in black children with nephrotic syndrome. We therefore explored the HLA associations in black children with HBVMN. METHOD Thirty black children, age range 2 to 16 years, with biopsy-proven HBVMN, were the subjects of the study. HBV status was determined using third generation ELISA. HLA A, B and C antigens were determined using a two-stage lymphocytotoxic test. HLA DRB1* and DQB1* typing was done using sequence-specific primers. HLA class 1 and II antigen frequencies of the study subjects were compared to controls that were randomly chosen healthy blood donors from the same population. RESULTS HLA DQB1*0603 was increased in patients with HBVMN compared to controls (chi2 = 13.65, RR = 4.3). DRB1*07 and DQB1*02 were increased in frequency in the study subjects but failed to reach statistical significance. There was no significant difference in the frequencies of class 1 antigens in the study group compared to controls. CONCLUSION To our knowledge, this is the first report of HLA associations in black patients with HBVMN in whom Class 1 and 11 antigens were determined using molecular methodology. There was a high frequency of DQB1*0603 in subjects compared to controls, suggesting a possible genetic predisposition to the development of HBVMN.
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Affiliation(s)
- Rajendra Bhimma
- Department of Paediatrics & Child Health, University of Natal, Nelson R. Mandela School of Medicine, Natal, South Africa.
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Teixeira e Costa F, Pinto JR, Carvalho F, Galvão MJ. An early case of de novo membranous nephropathy in a renal transplant patient. Transplant Proc 2002; 34:364. [PMID: 11959328 DOI: 10.1016/s0041-1345(01)02803-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Vaughan RW, Zurowska A, Moszkowska G, Kondeatis E, Clark AG. HLA-DRB and -DQB1 alleles in Polish patients with hepatitis B associated membranous nephropathy. TISSUE ANTIGENS 1998; 52:130-4. [PMID: 9756401 DOI: 10.1111/j.1399-0039.1998.tb02276.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We have studied the HLA-DRB and -DQB1 alleles of 42 paediatric patients who have suffered from membranous nephropathy associated with a hepatitis B infection (HBVMN). These patients were all from the Gdansk area of Northern Poland and the disease was diagnosed by light and electron microscopy. The control population consisted of 55 healthy children, approximately age matched, from schools in Gdansk. In addition we have also analysed 40 patients chronically infected with hepatitis B, without any renal involvement, as hepatitis B disease controls. The HLA alleles were defined using PCR/SSP. As idiopathic membranous nephropathy and low responsiveness to hepatitis B vaccine have been found to be associated with DR3 in Caucasoids, our hypothesis was that the HBVMN patients would show an increase in DR3. Our results indicate that, although there is a small increase in the frequency of DRBl*0301 in the HBVMN patients (16/42 38%) when compared to the healthy controls (15/55 31%), this does not approach significance. There is a significant increase in the frequency of DQB1*0303 in the HBVMN patients vs the healthy controls, after correction for the number of antigens detected (Pc)(13/42 vs 2/55, RR=11.6, P=0.0007, Pc=0.02). A similar increase in DQB1*0303 is seen in the HBVMN patients when compared to the hepatitis controls (13/42 vs 4/40) but this is only significant before correction (RR=4.3, P=0.04).
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Affiliation(s)
- R W Vaughan
- South Thames Tissue Typing, Guy's Hospital, London, UK
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Chevrier D, Giral M, Perrichot R, Latinne D, Coville P, Muller JY, Soulillou JP, Bignon JD. Idiopathic and secondary membranous nephropathy and polymorphism at TAP1 and HLA-DMA loci. TISSUE ANTIGENS 1997; 50:164-9. [PMID: 9271826 DOI: 10.1111/j.1399-0039.1997.tb02855.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In a previous study on the effects of TAP1 and TAP2 gene polymorphism in kidney allograft recipients, we found no association between graft outcome and recipient/donor TAP1 and TAP2 allele polymorphism or compatibility, but we observed a surprising increased frequency of the TAP1*0201 allele among kidney recipients. This increase was restricted to patients with glomerulopathy. We now report on a larger cohort of 178 patients with membranous nephropathy who were typed for their HLA-DPB1, -DRB1, -DMA, -DMB, LMP2, LMP, TAP1 and TAP2 genes compared with 100 random ethnically matched and healthy unrelated individuals used as controls. The results show a significant increased frequency of two markers in membranous nephropathy patients as compared with controls: firstly the previously recognized increase in HLA-DR3 (59% vs 18%: Pc < 1 x 10(-9), RR = 6.6), secondly a new association with two TAP1 amino acid variants displaying respectively a valine in amino acid position 333 (TAP1-Val-333) and consequently a glycine in position 637 (TAP1Gly-637) due to its strong linkage disequilibrium with Val-333. No linkage disequilibrium was found between TAP1-Val-333 and HLA-DR3. Moreover, we also noticed a decrease of the DMA*0102 phenotype in membranous nephropathy patients. The other HLA-DPB, -DMB, LMP2, LMP7 and TAP2 phenotype frequencies were roughly similar between patients and controls. These results show that the TAP1-Val-333 like HLA-DR3 phenotype is positively associated with membranous nephropathy and that these two risk factors are not cumulative in membranous nephropathy pathophysiology.
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Affiliation(s)
- D Chevrier
- Etablissement de Transfusion Sanguine 44-85, Laboratoire HLA, Nantes, France
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Cattran DC, Pei Y, Greenwood CM, Ponticelli C, Passerini P, Honkanen E. Validation of a predictive model of idiopathic membranous nephropathy: its clinical and research implications. Kidney Int 1997; 51:901-7. [PMID: 9067928 DOI: 10.1038/ki.1997.127] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although a number of factors have consistently correlated with progression to chronic renal insufficiency (CRI) in idiopathic membranous glomerulonephropathy (IMGN), they appear late, are not quantitative in nature and have not been validated. We have determined that the highest sustained six-month period of proteinuria is an important predictor of progression. Using multiple logistic modelling, the only additional prognostic variables of importance in 184 Canadian patients were the initial creatinine clearance and the rate of change in function over this six-month interval. Independent data from Italy (101 patients) and Finland (78 patients) were obtained for comparison. Sensitivity, specificity, negative and positive predictive values and overall accuracy, as well as Pearson's goodness-of-fit and Harrell's "C" statistic were used to assess the fits of the model. Accuracy of prediction was > or = 85% in all three countries. Pearson's Chi-square goodness-of-fit showed good agreement across the spectrum and Harrell's "C" statistic was > or = 90%. Therefore, a predictive, semiquantitative algorithm in IMGN has been validated. Its relevance in patient management and in clinical trials is illustrated.
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Affiliation(s)
- D C Cattran
- Metropolitan Toronto Glomerulonephritis Registry, University of Toronto, Ontario, Canada
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Abstract
Familial idiopathic membranous nephropathy is rarely reported, despite the striking immunogenetic association of the disease with certain HLA antigens. This report describes a pair of identical male twins who contemporaneously developed idiopathic membranous nephropathy. HLA typing was carried out in the twins and in almost all members of their family. Interestingly, HLA antigens that have been reported to be associated with idiopathic membranous nephropathy, especially DR3, were found not only in the twins, but in the other family members as well. Due to similarities between Heymann nephritis and human membranous nephropathy, we performed a search for anti-brush border and antipodocyte antibodies. The inability to detect these antibodies suggests that they were probably not involved in the pathogenesis of these cases.
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Affiliation(s)
- A Guella
- Department of Urology/Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia
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47
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Yoshida H, Kon V, Ichikawa I. Polymorphisms of the renin-angiotensin system genes in progressive renal diseases. Kidney Int 1996; 50:732-44. [PMID: 8872946 DOI: 10.1038/ki.1996.371] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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48
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Elder G, Perl S, Yong JL, Fletcher J, Mackie J. Progression from Goodpasture's disease to membranous glomerulonephritis. Pathology 1995; 27:233-6. [PMID: 8532389 DOI: 10.1080/00313029500169043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
An unusual case of a patient with Goodpasture's disease presenting with hemoptysis, severe iron deficiency anemia and microscopic hematuria and proteinuria is described. Both circulating and tissue anti-glomerular basement membrane (GBM) antibodies were present, and renal function remained normal throughout. Immunosuppressive therapy was given for subclinical pulmonary hemorrhage with successful resolution of anemia and disappearance of the circulating anti-GBM antibody. Nine months after presentation he developed nephrotic range proteinuria and a repeat renal biopsy revealed membranous glomerulonephritis with no evidence of his original disease. Both the Goodpasture's associated HLA-DR2 and the membranous associated HLA-DR3 class II antigens were present. The association of antibody mediated and immune complex glomerulonephritis is discussed. The simultaneous presence of HLA-DR2 and HLA-DR3 may predispose to this association.
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Affiliation(s)
- G Elder
- Department of Renal Medicine, Concord Hospital, Sydney, Australia
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49
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Vaughan RW, Tighe MR, Boki K, Alexoupolos S, Papadakis J, Lanchbury JS, Welsh KI, Williams DG. An analysis of HLA class II gene polymorphism in British and Greek idiopathic membranous nephropathy patients. EUROPEAN JOURNAL OF IMMUNOGENETICS : OFFICIAL JOURNAL OF THE BRITISH SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS 1995; 22:179-86. [PMID: 7605775 DOI: 10.1111/j.1744-313x.1995.tb00228.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Fifty-two British and 29 Greek idiopathic membranous nephropathy (IMN) patients were analysed for DRB, DQA1, DQB1 and DPB1 gene polymorphism using second exon amplification and sequence-specific oligonucleotides (SSO). In addition 100 British and 92 Greek controls were analysed. A highly significant increased frequency of the DRB1*0301 allele was found in IMN patients from Britain (80%), when compared to controls (27%, OR 10.6, P = 0.000004). A lower frequency of DRB1*0301 was observed in Greek IMN patients (33%), but this was just significant before correction, when compared to Greek controls (15%, OR 3, P = 0.02). The DRB3 allele most often associated with DRB1*0301 was DRB3*0101 (OR 4.2, P = 0.00025) in British patients and DRB3*0201/2 (OR 11, P = 0.006) in Greek patients. In Greek IMN patients a decrease in DR16 was found (OR 0.08, P = 0.004), and the overall incidence of DR2 was significantly lowered when both sets of IMN patients were combined (OR 0.21, chi 2 17.6, P = 0.00013). The incidence of DQA1*0501 was raised in both Greek (96% vs. 66%, OR 9.7, chi 2 6.9, P = 0.009) and British IMN (85% vs. 45%, OR 7.4, chi 2 20, P = 0.00007) patients. This gives some support to a proposal for a major role for this allele in IMN.(ABSTRACT TRUNCATED AT 250 WORDS)
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Zhang L, Jayne DR, Zhao MH, Lockwood CM, Oliveira DB. Distribution of MHC class II alleles in primary systemic vasculitis. Kidney Int 1995; 47:294-8. [PMID: 7731160 DOI: 10.1038/ki.1995.37] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Previous studies have shown a number of different associations between major histocompatibility complex (MHC) alleles and primary systemic vasculitis. Disease heterogeneity and the lack of specificity of certain MHC typing techniques may have contributed to the lack of consistency in those studies. We therefore studied a relatively homogeneous group of 94 patients with Wegener's granulomatosis, microscopic polyangiitis, or renal-limited vasculitis using molecular techniques that allow more precise assignment of MHC genotype. DNA was prepared from peripheral blood and DRB1 genotype determined by Taq restriction fragment length polymorphism. DQB1 and DPB1 genotype were assigned by polymerase chain reaction amplification followed by probing with allele-specific oligonucleotides. Specificity of associated anti-neutrophil cytoplasm antibodies (ANCA) was determined where possible by solid phase immunoassays using purified proteinase 3 (PR3) and myeloperoxidase (MPO). After correction for multiple comparisons there were no significant differences in the distribution of DRB1, DQB1 and DPB1 alleles between a local control group (N = 90 for DRB1, N = 50 for DQB1 and DPB1) and the patient group as a whole (N = 94) or two a priori defined subgroups (anti-PR3 positive, N = 35; anti-MPO positive, N = 22). We have therefore found no significant association between primary systemic vasculitis and any MHC class II allele. This, together with the fact that previous smaller studies have shown no consistent association, suggests that any such association is very weak, if it exists at all.
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Affiliation(s)
- L Zhang
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, England, United Kingdom
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