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Zhang Q, Bin S, Budge K, Petrosyan A, Villani V, Aguiari P, Vink C, Wetzels J, Soloyan H, La Manna G, Podestà MA, Molinari P, Sedrakyan S, Lemley KV, De Filippo RE, Perin L, Cravedi P, Da Sacco S. C3aR-initiated signaling is a critical mechanism of podocyte injury in membranous nephropathy. JCI Insight 2024; 9:e172976. [PMID: 38227377 PMCID: PMC11143932 DOI: 10.1172/jci.insight.172976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 01/11/2024] [Indexed: 01/17/2024] Open
Abstract
The deposition of antipodocyte autoantibodies in the glomerular subepithelial space induces primary membranous nephropathy (MN), the leading cause of nephrotic syndrome worldwide. Taking advantage of the glomerulus-on-a-chip system, we modeled human primary MN induced by anti-PLA2R antibodies. Here we show that exposure of primary human podocytes expressing PLA2R to MN serum results in IgG deposition and complement activation on their surface, leading to loss of the chip permselectivity to albumin. C3a receptor (C3aR) antagonists as well as C3AR gene silencing in podocytes reduced oxidative stress induced by MN serum and prevented albumin leakage. In contrast, inhibition of the formation of the membrane-attack-complex (MAC), previously thought to play a major role in MN pathogenesis, did not affect permselectivity to albumin. In addition, treatment with a C3aR antagonist effectively prevented proteinuria in a mouse model of MN, substantiating the chip findings. In conclusion, using a combination of pathophysiologically relevant in vitro and in vivo models, we established that C3a/C3aR signaling plays a critical role in complement-mediated MN pathogenesis, indicating an alternative therapeutic target for MN.
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Affiliation(s)
- Qi Zhang
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
| | - Sofia Bin
- Translational Transplant Research Center and Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Kelly Budge
- Translational Transplant Research Center and Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Astgik Petrosyan
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Valentina Villani
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
| | - Paola Aguiari
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
| | - Coralien Vink
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hasmik Soloyan
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Manuel Alfredo Podestà
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paolo Molinari
- Translational Transplant Research Center and Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sargis Sedrakyan
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevin V. Lemley
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Roger E. De Filippo
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Laura Perin
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Paolo Cravedi
- Translational Transplant Research Center and Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stefano Da Sacco
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Saban Research Institute, Division of Urology, Children’s Hospital Los Angeles (CHLA), Los Angeles, California, USA
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Petr V, Thurman JM. The role of complement in kidney disease. Nat Rev Nephrol 2023; 19:771-787. [PMID: 37735215 DOI: 10.1038/s41581-023-00766-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
The complement cascade comprises soluble and cell surface proteins and is an important arm of the innate immune system. Once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammatory, vasoactive and metabolic responses. Although complement is crucial to host defence and homeostasis, its inappropriate or uncontrolled activation can also drive tissue injury. For example, the complement system has been known for more than 50 years to be activated by glomerular immune complexes and to contribute to autoimmune kidney disease. Notably, the latest research shows that complement is also activated in kidney diseases that are not traditionally thought of as immune-mediated, including haemolytic-uraemic syndrome, diabetic kidney disease and focal segmental glomerulosclerosis. Several complement-targeted drugs have been approved for the treatment of kidney disease, and additional anti-complement agents are being investigated in clinical trials. These drugs are categorically different from other immunosuppressive agents and target pathological processes that are not effectively inhibited by other classes of immunosuppressants. The development of these new drugs might therefore have considerable benefits in the treatment of kidney disease.
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Affiliation(s)
- Vojtech Petr
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua M Thurman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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Wooden B, Tarragon B, Navarro-Torres M, Bomback AS. Complement inhibitors for kidney disease. Nephrol Dial Transplant 2023; 38:ii29-ii39. [PMID: 37218685 DOI: 10.1093/ndt/gfad079] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Indexed: 05/24/2023] Open
Abstract
A refined understanding of the role of complement in the pathogenesis of glomerular and other kidney diseases has, over the past two decades, been matched by the development of novel, complement-targeting therapies. As we increasingly recognize the important role that complement activation across all three pathways-classical, lectin and alternative-plays in glomerular lesions both rare (e.g. C3 glomerulopathy) and common (e.g. immunoglobulin A nephropathy), we can identify avenues for precise, targeted approaches to modifying the natural history of these kidney diseases. In this review, we survey the evidence on using complement inhibition from the earliest, small-scale studies focusing on C5-targeting agents to more recent, large, multicenter, randomized trials utilizing complement blockade higher up in the complement pathway at the level of C3. We conclude by examining where the field of complement targeting therapy may be headed in light of these studies.
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Affiliation(s)
- Benjamin Wooden
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Blanca Tarragon
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariela Navarro-Torres
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
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Cheung CK, Dormer JP, Barratt J. The role of complement in glomerulonephritis-are novel therapies ready for prime time? Nephrol Dial Transplant 2023; 38:1789-1797. [PMID: 36307926 DOI: 10.1093/ndt/gfac296] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Indexed: 08/01/2023] Open
Abstract
The complement system plays a key pathogenic role in glomerular diseases with a diverse range of aetiologies, including C3 glomerulopathy, immunoglobulin A nephropathy, membranous nephropathy, ANCA-associated vasculitis and lupus nephritis. Several novel therapies targeting complement activity have recently been developed, which have now been approved or are in the late stages of clinical development. In this review, potential benefits and challenges of targeting the complement system in glomerular disease are discussed. We summarize current understanding of the role of complement, and the novel targeted therapies that are being developed for the treatment of glomerular disease.
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Affiliation(s)
- Chee Kay Cheung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - John P Dormer
- Department of Histopathology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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Rizk DV, Rovin BH, Zhang H, Kashihara N, Maes B, Trimarchi H, Perkovic V, Meier M, Kollins D, Papachristofi O, Charney A, Barratt J. Targeting the Alternative Complement Pathway With Iptacopan to Treat IgA Nephropathy: Design and Rationale of the APPLAUSE-IgAN Study. Kidney Int Rep 2023; 8:968-979. [PMID: 37180505 PMCID: PMC10166738 DOI: 10.1016/j.ekir.2023.01.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/06/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction Targeting the alternative complement pathway (AP) is an attractive therapeutic strategy because of its role in immunoglobulin A nephropathy (IgAN) pathophysiology. Iptacopan (LNP023), a proximal complement inhibitor that specifically binds to factor B and inhibits the AP, reduced proteinuria and attenuated AP activation in a Phase 2 study of patients with IgAN, thereby supporting the rationale for its evaluation in a Phase 3 study. Methods APPLAUSE-IgAN (NCT04578834) is a multicenter, randomized, double-blind, placebo-controlled, parallel-group, Phase 3 study enrolling approximately 450 adult patients (aged ≥18 years) with biopsy-confirmed primary IgAN at high risk of progression to kidney failure despite optimal supportive treatment. Eligible patients receiving stable and maximally tolerated doses of angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) will be randomized 1:1 to either iptacopan 200 mg or placebo twice daily for a 24-month treatment period. A prespecified interim analysis (IA) will be performed when approximately 250 patients from the main study population complete the 9-month visit. The primary objective is to demonstrate superiority of iptacopan over placebo in reducing 24-hour urine protein-to-creatinine ratio (UPCR) at the IA and demonstrate the superiority of iptacopan over placebo in slowing the rate of estimated glomerular filtration rate (eGFR) decline (total eGFR slope) estimated over 24 months at study completion. The effect of iptacopan on patient-reported outcomes, safety, and tolerability will be evaluated as secondary outcomes. Conclusions APPLAUSE-IgAN will evaluate the benefits and safety of iptacopan, a novel targeted therapy for IgAN, in reducing complement-mediated kidney damage and thus slowing or preventing disease progression.
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Affiliation(s)
- Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brad H. Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, People’s Republic of China
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Hernán Trimarchi
- Nephrology Service and Kidney Transplantation Unit, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | - Alan Charney
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester and The John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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Evaluating the clinical utility of measuring levels of factor H and the related proteins. Mol Immunol 2022; 151:166-182. [PMID: 36162225 DOI: 10.1016/j.molimm.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 11/21/2022]
Abstract
After years of disappointing clinical results, the tide has finally changed and complement targeted-therapies have become a validated and accepted treatment option for several diseases. These accomplishments have revitalized the field and brought renewed attention to the prospects that complement therapeutics can offer. Streamlining diagnostics and therapeutics is imperative in this new era of clinical use of complement therapeutics. However, the incredible success in therapeutics has not been accompanied by the development of novel standardized tools for complement testing. Complement biomarkers can assist in the risk assessment and diagnosis of diseases as well as the prediction of disease progression and treatment response. Recently, a group of complement proteins has been suggested to be highly relevant in various complement-associated disorders, namely the human factor H (FH) protein family. This family of closely related proteins consists of FH, FH-like protein 1, and five factor H-related proteins, and they have been linked to eye, kidney, infectious, vascular, and autoimmune diseases as well as cancer. The goal of this review is to provide a comprehensive overview of the available data on circulating levels of FH and its related proteins in different pathologies. In addition, we examined the current literature to determine the clinical utility of measuring levels of the FH protein family in health and disease. Finally, we discuss future steps that are needed to make their clinical translation a reality.
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Bomback AS, Kavanagh D, Vivarelli M, Meier M, Wang Y, Webb NJ, Trapani AJ, Smith RJ. Alternative Complement Pathway Inhibition With Iptacopan for the Treatment of C3 Glomerulopathy-Study Design of the APPEAR-C3G Trial. Kidney Int Rep 2022; 7:2150-2159. [PMID: 36217526 PMCID: PMC9546729 DOI: 10.1016/j.ekir.2022.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/15/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Complement 3 glomerulopathy (C3G) is a rare kidney disease characterized by dysregulation of the alternative pathway (AP) of the complement system. About 50% of patients with C3G progress to kidney failure within 10 years of diagnosis. Currently, there are no approved therapeutic agents for C3G. Iptacopan is an oral, first-in-class, potent, and selective inhibitor of factor B, a key component of the AP. In a Phase II study, treatment with iptacopan was associated with a reduction in proteinuria and C3 deposit scores in C3G patients with native and transplanted kidneys, respectively. Methods APPEAR-C3G (NCT04817618) is a randomized, double-blind, and placebo-controlled Phase III study to evaluate the efficacy and safety of iptacopan in C3G patients, enrolling 68 adults with biopsy-confirmed C3G, reduced C3 (<77 mg/dl), proteinuria ≥1.0 g/g, and estimated glomerular filtration rate (eGFR) ≥30 ml/min per 1.73 m2. All patients will receive maximally tolerated angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and vaccination against encapsulated bacteria. Patients with any organ transplantation, progressive crescentic glomerulonephritis (GN), monoclonal gammopathy of undetermined significance, or kidney biopsy with >50% interstitial fibrosis/tubular atrophy, will be excluded. Patients will be randomized 1:1 to receive either iptacopan 200 mg twice daily or placebo for 6 months, followed by open-label treatment with iptacopan 200 mg twice daily for all patients for 6 months. The primary objective is to evaluate the efficacy of iptacopan versus placebo on proteinuria reduction urine protein:creatinine ratio (UPCR) (24 h urine). Key secondary endpoints will assess kidney function measured by eGFR, histological disease total activity score, and fatigue. Conclusion This study aims to demonstrate the clinical benefits of AP inhibition with iptacopan in C3G.
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Second and Third Generational Advances in Therapies of the Immune-Mediated Kidney Diseases in Children and Adolescents. CHILDREN 2022; 9:children9040536. [PMID: 35455580 PMCID: PMC9030090 DOI: 10.3390/children9040536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
Therapy of immune-mediated kidney diseases has evolved during recent decades from the non-specific use of corticosteroids and antiproliferative agents (like cyclophosphamide or azathioprine), towards the use of more specific drugs with measurable pharmacokinetics, like calcineurin inhibitors (cyclosporine A and tacrolimus) and mycophenolate mofetil, to the treatment with biologic drugs targeting detailed specific receptors, like rituximab, eculizumab or abatacept. Moreover, the data coming from a molecular science revealed that several drugs, which have been previously used exclusively to modify the upregulated adaptive immune system, may also exert a local effect on the kidney microstructure and ameliorate the functional instability of podocytes, reducing the leak of protein into the urinary space. The innate immune system also became a target of new therapies, as its specific role in different kidney diseases has been de novo defined. Current therapy of several immune kidney diseases may now be personalized, based on the detailed diagnostic procedures, including molecular tests. However, in most cases there is still a space for standard therapies based on variable protocols including usage of steroids with the steroid-sparing agents. They are used as a first-line treatment, while modern biologic agents are selected as further steps in cases of lack of the efficacy or toxicity of the basic therapies. In several clinical settings, the biologic drugs are effective as the add-on therapy.
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Watanabe S, Zheng S, Rashidi A. IgA nephropathy relapse following COVID-19 vaccination treated with corticosteroid therapy: case report. BMC Nephrol 2022; 23:135. [PMID: 35392838 PMCID: PMC8988530 DOI: 10.1186/s12882-022-02769-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background The flare of immune-mediated disease following coronavirus disease of 2019 (COVID-19) vaccination is a rare adverse event following immunization. De novo, as well as relapsing IgA nephropathy (IgAN) cases, have been reported following either mRNA-1273 (Moderna) or BNT162b2 (Pfizer-BioNTech) vaccination. To our knowledge, the majority of IgAN relapses did not result in severe acute kidney injury (AKI) and resolved spontaneously. Case presentation This is a case of a 54-year-old female with a previous diagnosis of IgAN who developed IgAN relapse following the second dose of Moderna vaccine. Gross hematuria developed 2 days after vaccination, which was accompanied by significant AKI. Kidney biopsy showed mild tubular atrophy and IgA staining in mesangium without crescent formation. Significant improvement in serum creatinine (Cr) was observed on day 10 after initiating prednisone. Cr came back to normal within 3 months after initiating corticosteroid. Conclusion COVID-19 vaccination is associated with a flare of IgAN that may cause significant AKI. Steroid therapy is associated with recovery. IgAN flare after COVID-19 vaccination should be closely monitored to elucidate any adverse effect associated with the novel vaccine. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02769-9.
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Affiliation(s)
- Shota Watanabe
- Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Shuling Zheng
- Pathology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Arash Rashidi
- Nephrology, University Hospitals Cleveland Medical Center, Cleveland, USA
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Doi K, Kimura H, Matsunaga YT, Fujii T, Nangaku M. Glomerulus-on-a-Chip: Current Insights and Future Potential Towards Recapitulating Selectively Permeable Filtration Systems. Int J Nephrol Renovasc Dis 2022; 15:85-101. [PMID: 35299832 PMCID: PMC8922329 DOI: 10.2147/ijnrd.s344725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 02/14/2022] [Indexed: 01/27/2023] Open
Affiliation(s)
- Kotaro Doi
- Institute of Industrial Science, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Kimura
- Department of Mechanical Engineering, School of Engineering, Tokai University, Kanagawa, Japan
| | | | | | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
- Correspondence: Masaomi Nangaku, Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan, Tel/Fax +81358009736, Email
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