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Ryu J, Baek E, Son HE, Ryu JY, Jeong JC, Kim S, Na KY, Chae DW, Kim SP, Kim SH, Jhee JH, Chang TI, Choi BS, Chin HJ. Comparison of dominant and nondominant C3 deposition in primary glomerulonephritis. Kidney Res Clin Pract 2023; 42:98-108. [PMID: 36747358 PMCID: PMC9902730 DOI: 10.23876/j.krcp.22.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/19/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Alternative complement pathway dysregulation plays a key role in glomerulonephritis (GN) and is associated with C3 deposition. Herein, we examined pathological and clinical differences between cases of primary GN with C3-dominant (C3D-GN) and nondominant (C3ND-GN) deposition. METHODS We extracted primary GN data from the Korean GlomeruloNEphritis sTudy (KoGNET). C3D-GN was defined as C3 staining two grades greater than C1q, C4, and immunoglobulin via immunofluorescence analysis. To overcome a large difference in the number of patients between the C3D-GN and C3ND-GN groups (31 vs. 9,689), permutation testing was used for analysis. RESULTS The C3D-GN group exhibited higher serum creatinine (p ≤ 0.001), a greater prevalence of estimated glomerular filtration rate of <60 mL/min/1.72 m2 (p ≤ 0.001), higher (but not significantly so) C-reactive protein level, and lower serum C3 level (p ≤ 0.001). Serum albumin, urine protein/creatinine ratio, number of patients who progressed to end-stage renal disease, and all-cause mortality were comparable between groups. Interstitial fibrosis and mesangial cellularity were greater in the C3D-GN group (p = 0.04 and p = 0.01, respectively) than in the C3ND-GN group. C3 deposition was dominant in the former group (p < 0.001), in parallel with increased subendothelial deposition (p ≤ 0.001). CONCLUSION Greater progression of renal injury and higher mortality occurred in patients with C3D-GN than with C3ND-GN, along with pathologic differences in interstitial and mesangial changes.
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Affiliation(s)
- Jiwon Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eunji Baek
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyung-Eun Son
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Seong Pyo Kim
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Su Hwan Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea,Correspondence: Ho Jun Chin Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
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Detsika MG, Theochari E, Palamaris K, Gakiopoulou H, Lianos EA. Effect of Heme Oxygenase-1 Depletion on Complement Regulatory Proteins Expression in the Rat. Antioxidants (Basel) 2022; 12:61. [PMID: 36670923 PMCID: PMC9854825 DOI: 10.3390/antiox12010061] [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: 11/15/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Heme oxygenase has been implicated in the regulation of various immune responses including complement activation. Using a transgenic rat model of HO-1 depletion, the present study assessed the effect of HO-1 absence on the expression of complement regulatory proteins: decay accelerating factor (DAF), CR1-related gene/protein Y (Crry) and CD59, which act to attenuate complement activation. Protein expression was assessed by immunohistochemistry in kidney, liver, lung and spleen tissues. DAF protein was reduced in all tissues retrieved from rats lacking HO-1 (Hmox1-/-) apart from spleen tissue sections. Crry protein was also reduced, but only in Hmox1-/- kidney and liver tissue. C3b staining was augmented in the kidney and spleen from Hmox1-/- rats, suggesting that the decrease of DAF and Crry was sufficient to increase C3b deposition. The observations support an important role of HO-1 as a regulator of the complement system.
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Affiliation(s)
- Maria G. Detsika
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens, 10675 Athens, Greece
| | - Eirini Theochari
- Department of Pathology, School of Medicine, University of Athens, 11527 Athens, Greece
| | - Kostas Palamaris
- Department of Pathology, School of Medicine, University of Athens, 11527 Athens, Greece
| | - Harikleia Gakiopoulou
- Department of Pathology, School of Medicine, University of Athens, 11527 Athens, Greece
| | - Elias A. Lianos
- Veterans Affairs Medical Center and Virginia Tech, Carilion School of Medicine, Salem, VA 24153, USA
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Karunnaya AV, Dobronravov VA. Remissions and progression of C3 glomerulopathy. TERAPEVT ARKH 2022; 94:718-724. [DOI: 10.26442/00403660.2022.06.201564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/04/2022] [Indexed: 11/22/2022]
Abstract
Aim. To analyze the outcomes of C3-glomerulopathy (C3-GP) and determine the associated factors.
Materials and methods. A retrospective single-center study included 60 patients with newly diagnosed C3-GP (with primary C3-GP pC3-GP 82%). Of these, 48 (80%) patients had clinical data to assess the following disease outcomes: development of remission and disease progression (by a composite endpoint that included initiation of chronic dialysis or a decrease in estimated glomerular filtration rate eGFR 15 mL/min/1.73 m2 or a decrease in eGFR30% of baseline at the time of renal biopsy). The median follow-up period was 25 (7; 52) months.
Results. At early follow-up (median 4 [3; 9] months) remission was registered in 35% of patients; at the end of follow-up, in 48% (for pC3-GP, 32 and 41%). Disease progression occurred in 17 patients. In the overall group the likelihood of achieving early remission was higher with treatment (Exp=6.4, 95% confidence interval CI 1.429.3; p=0.017). Early remission was associated with the presence of remission at the end of follow-up (Exp=6.3, 95% CI 2.218.4; p=0.001). Specific treatment (Exp=0.308, 95% CI 0.1080.881; p=0.028) and late remission (Exp=0.079, 95% CI 0.0170.368; p=0.001) were associated with reduced risk of disease progression in multivariable models (adjusted for eGFR, mean blood pressure). The same results were obtained for the group of patients with pC3-GP.
Conclusion. C3-GP is a variant of severe complement-mediated glomerular damage with unfavorable renal prognosis, which requires timely personalized expert-level diagnostics with clarification of etiopathogenesis of the disease followed by therapy aimed at achieving remission to improve outcomes.
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4
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Loeven MA, Maciej-Hulme ML, Yanginlar C, Hubers MC, Kellenbach E, de Graaf M, van Kuppevelt TH, Wetzels J, Rabelink TJ, Smith RJH, van der Vlag J. Selective Binding of Heparin/Heparan Sulfate Oligosaccharides to Factor H and Factor H-Related Proteins: Therapeutic Potential for C3 Glomerulopathies. Front Immunol 2021; 12:676662. [PMID: 34489931 PMCID: PMC8416517 DOI: 10.3389/fimmu.2021.676662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/02/2021] [Indexed: 11/26/2022] Open
Abstract
Complement dysregulation is characteristic of the renal diseases atypical hemolytic uremic syndrome (aHUS) and complement component 3 glomerulopathy (C3G). Complement regulatory protein Factor H (FH) inhibits complement activity, whereas FH-related proteins (FHRs) lack a complement regulatory domain. FH and FHRs compete for binding to host cell glycans, in particular heparan sulfates (HS). HS is a glycosaminoglycan with an immense structural variability, where distinct sulfation patterns mediate specific binding of proteins. Mutations in FH, FHRs, or an altered glomerular HS structure may disturb the FH : FHRs balance on glomerular endothelial cells, thereby leading to complement activation and the subsequent development of aHUS/C3G. In this study, we aimed to identify specific HS structures that could specifically compete off FHRs from HS glycocalyx (HSGlx), without interfering with FH binding. FH/FHR binding to human conditionally immortalized glomerular endothelial cells (ciGEnCs) and HSGlx purified from ciGEnC glycocalyx was assessed. HS modifications important for FH/FHR binding to HSGlx were analyzed using selectively desulfated heparins in competition with purified HSGlx. We further assessed effects of heparinoids on FHR1- and FHR5-mediated C3b deposition on ciGEnCs. In the presence of C3b, binding of FH, FHR1 and FHR5 to ciGEnCs was significantly increased, whereas binding of FHR2 was minimal. FHR1 and 5 competitively inhibited FH binding to HSGlx, leading to alternative pathway dysregulation. FHR1 and FHR5 binding was primarily mediated by N-sulfation while FH binding depended on N-, 2-O- and 6-O-sulfation. Addition of 2-O-desulfated heparin significantly reduced FHR1- and FHR5-mediated C3b deposition on ciGEnCs. We identify 2-O-desulfated heparin derivatives as potential therapeutics for C3G and other diseases with dysregulated complement.
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Affiliation(s)
- Markus A Loeven
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marissa L Maciej-Hulme
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Cansu Yanginlar
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Melanie C Hubers
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Mark de Graaf
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Toin H van Kuppevelt
- Department of Biochemistry, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jack Wetzels
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ton J Rabelink
- Department of Nephrology and Einthoven Laboratory for Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Richard J H Smith
- Departments of Internal Medicine and Otolaryngology, Carver College of Medicine, Iowa City, IA, United States
| | - Johan van der Vlag
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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5
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Medjeral-Thomas NR, Cook HT, Pickering MC. Complement activation in IgA nephropathy. Semin Immunopathol 2021; 43:679-690. [PMID: 34379175 PMCID: PMC8551128 DOI: 10.1007/s00281-021-00882-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/23/2021] [Indexed: 11/25/2022]
Abstract
IgA nephropathy pathogenesis is incompletely understood, and this limits the development of disease-specific biomarkers and effective therapies. Evidence of complement activity in IgA nephropathy is well established. However, a growing body of research indicates complement activity is an important contributor to IgA nephropathy pathology. In particular, multiple associations have been identified between complement alternative, lectin and terminal pathway proteins and IgA nephropathy severity. Recently, we have also gained insight into possible mechanisms that could link glomerular IgA deposition, complement activity, glomerular inflammation and disease severity. Ongoing clinical trials of therapeutic complement inhibitors will provide insight into the importance of complement activity to IgA nephropathy pathogenesis. Further research into mechanisms of complement activity is essential to improving our understanding and management of patients with IgA nephropathy.
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Affiliation(s)
- Nicholas R Medjeral-Thomas
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, W12 0NN, UK.
| | - H Terence Cook
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, W12 0NN, UK
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, W12 0NN, UK
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Gyapon-Quast F, Goicoechea de Jorge E, Malik T, Wu N, Yu J, Chai W, Feizi T, Liu Y, Pickering MC. Defining the Glycosaminoglycan Interactions of Complement Factor H-Related Protein 5. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 207:534-541. [PMID: 34193601 PMCID: PMC8313009 DOI: 10.4049/jimmunol.2000072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/06/2021] [Indexed: 01/09/2023]
Abstract
Complement activation is an important mediator of kidney injury in glomerulonephritis. Complement factor H (FH) and FH-related protein 5 (FHR-5) influence complement activation in C3 glomerulopathy and IgA nephropathy by differentially regulating glomerular complement. FH is a negative regulator of complement C3 activation. Conversely, FHR-5 in vitro promotes C3 activation either directly or by competing with FH for binding to complement C3b. The FH-C3b interaction is enhanced by surface glycosaminoglycans (GAGs) and the FH-GAG interaction is well-characterized. In contrast, the contributions of carbohydrates to the interaction of FHR-5 and C3b are unknown. Using plate-based and microarray technologies we demonstrate that FHR-5 interacts with sulfated GAGs and that this interaction is influenced by the pattern and degree of GAG sulfation. The FHR-5-GAG interaction that we identified has functional relevance as we could show that the ability of FHR-5 to prevent binding of FH to surface C3b is enhanced by surface kidney heparan sulfate. Our findings are important in understanding the molecular basis of the binding of FHR-5 to glomerular complement and the role of FHR-5 in complement-mediated glomerular disease.
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Affiliation(s)
- Frederick Gyapon-Quast
- Glycosciences Laboratory, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom;,Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom; and
| | - Elena Goicoechea de Jorge
- Department of Immunology, Complutense University and Research Institute Hospital 12 de Octubre, Madrid, Spain
| | - Talat Malik
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom; and
| | - Nian Wu
- Glycosciences Laboratory, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Jin Yu
- Glycosciences Laboratory, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Wengang Chai
- Glycosciences Laboratory, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Ten Feizi
- Glycosciences Laboratory, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Yan Liu
- Glycosciences Laboratory, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Matthew C. Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom; and
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7
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Steinberg AG, Fox LC, Bender S, Batrouney A, Juneja S, Sirac C, Touchard G, Blombery P, Finlay MJ, Bridoux F, Barbour TD. Proliferative Glomerulonephritis With Fibrils, Monoclonal κ Light Chain, and C3 Deposits. Am J Kidney Dis 2021; 78:459-463. [PMID: 33774080 DOI: 10.1053/j.ajkd.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 01/07/2021] [Indexed: 11/11/2022]
Abstract
There is increasing recognition of monoclonal gammopathy as a cause of proliferative glomerulonephritis (GN), including cases in which glomerular deposition of monoclonal immunoglobulin is demonstrated. Recently, proliferative GN with monoclonal immunoglobulin deposits (PGNMID) has incorporated a light chain variant of the disease (termed PGNMID-LC). Intriguingly, glomerular co-deposition of C3 is found in addition to monotypic light chain, implying complement activation via the alternative pathway (AP). We present a unique case of proliferative GN in a 42-year-old man who presented with nephrotic syndrome and was found to have κ light chain multiple myeloma. Immune staining of the glomerulus was positive only for κ light chain and C3, with the striking appearance of nonamyloid fibrils on electron microscopy. Following clonally targeted therapy for myeloma, the renal clinical abnormalities resolved completely. We present detailed molecular studies for light chain and complement and consider local mechanisms whereby monoclonal κ light chain fibrils may have triggered AP activation within the glomerulus.
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Affiliation(s)
- Adam G Steinberg
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Lucy C Fox
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Sebastien Bender
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Ahida Batrouney
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Surender Juneja
- Department of Hematology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christophe Sirac
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Guy Touchard
- Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Piers Blombery
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Moira J Finlay
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Frank Bridoux
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France; Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW In this review, we discuss recent studies showing the importance of the complement pathway in kidney disease. RECENT FINDINGS Recent findings in C3 glomerulopathy (C3G) include: acute postinfectious glomerulonephritis is characterised by the presence of antifactor B antibodies; human leukocyte antigen type, but not rare complement gene variation, is associated with primary immunoglobulin-associated membranoproliferative GN and C3G. Immunohistochemistry in C3G shows that factor H related protein 5 (FHR5) is the most prevalent complement protein and correlates with kidney function. A multicentre study supported the use of mycophenolate mofetil (MMF) in C3G even after a propensity matching analysis. In immunoglobulin A nephropathy (IgAN) several studies have emphasised the importance of complement. Imbalances of circulating FH and FHR1 and FHR5, which interfere with the regulatory functions of FH, associate with IgAN. Immunohistochemistry has shown associations between glomerular FHR5 deposition and C3 activation; glomerular FHR5 associated with clinical markers of IgAN severity. Data also suggest the lectin complement pathway contributes to IgAN severity. We also discuss complement activation in thrombotic microangiopathy and other kidney diseases. SUMMARY Complement activity can be detected in a wide range of kidney diseases and this provides pathogenic insight and potential for therapy with the ongoing development of several drugs directed at complement activation.
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Trutin I, Oletić L, Galešić Ljubanović D, Turudić D, Milošević D. A CHILD WITH DENSE DEPOSIT DISEASE AND DECREASED CLASSIC COMPLEMENT PATHWAY ACTIVITY. Acta Clin Croat 2021; 60:141-145. [PMID: 34588735 PMCID: PMC8305348 DOI: 10.20471/acc.2021.60.01.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/08/2020] [Indexed: 11/24/2022] Open
Abstract
We report a rare case of nephritic syndrome underlying dense deposit disease (DDD) with alternative complement pathway dysfunction explained with both C3 nephritic factor (C3NeF) antibodies and DDD associated polymorphism of factor H. An 8-year-old boy presented with macroscopic hematuria, hypertension and periorbital edema followed by persistently low C3 during the 8-week follow-up. Positive C3 staining on immunofluorescence microscopy, supported by dense deposits within the glomerular basement membrane on electron microscopy, confirmed the diagnosis of DDD. Preliminary tests for complement activation showed decreased classic pathway and deficient alternative complement pathway, as well as slightly positive C3NeF, supporting the diagnosis of DDD. Genetic analysis revealed a polymorphism of the complement factor H gene with an increased risk of developing DDD. Supportive therapy led to satisfactory recovery of renal function and normalization of C3. Given the poor prognosis of the disease, proper approach to such specific glomerulopathy is important to avoid or at least slow down progression to end-stage renal disease.
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Affiliation(s)
| | - Lea Oletić
- 1Department of Pediatrics, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Division of Renal Pathology and Electron Microscopy, Department of Pathology, Dubrava University Hospital, ZagrebCroatia; 3University of Zagreb, School of Medicine, Zagreb, Croatia; 4Zagreb University Hospital Centre, Zagreb, Croatia
| | - Danica Galešić Ljubanović
- 1Department of Pediatrics, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Division of Renal Pathology and Electron Microscopy, Department of Pathology, Dubrava University Hospital, ZagrebCroatia; 3University of Zagreb, School of Medicine, Zagreb, Croatia; 4Zagreb University Hospital Centre, Zagreb, Croatia
| | - Daniel Turudić
- 1Department of Pediatrics, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Division of Renal Pathology and Electron Microscopy, Department of Pathology, Dubrava University Hospital, ZagrebCroatia; 3University of Zagreb, School of Medicine, Zagreb, Croatia; 4Zagreb University Hospital Centre, Zagreb, Croatia
| | - Danko Milošević
- 1Department of Pediatrics, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Division of Renal Pathology and Electron Microscopy, Department of Pathology, Dubrava University Hospital, ZagrebCroatia; 3University of Zagreb, School of Medicine, Zagreb, Croatia; 4Zagreb University Hospital Centre, Zagreb, Croatia
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Devalaraja-Narashimha K, Meagher K, Luo Y, Huang C, Kaplan T, Muthuswamy A, Halasz G, Casanova S, O'Brien J, Peyser Boiarsky R, McWhirter J, Gartner H, Bai Y, MacDonnell S, Liu C, Hu Y, Latuszek A, Wei Y, Prasad S, Huang T, Yancopoulos G, Murphy A, Olson W, Zambrowicz B, Macdonald L, Morton LG. Humanized C3 Mouse: A Novel Accelerated Model of C3 Glomerulopathy. J Am Soc Nephrol 2021; 32:99-114. [PMID: 33288630 PMCID: PMC7894673 DOI: 10.1681/asn.2020050698] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/16/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND C3 glomerulopathy (C3G) is characterized by the alternative-pathway (AP) hyperactivation induced by nephritic factors or complement gene mutations. Mice deficient in complement factor H (CFH) are a classic C3G model, with kidney disease that requires several months to progress to renal failure. Novel C3G models can further contribute to understanding the mechanism behind this disease and developing therapeutic approaches. METHODS A novel, rapidly progressing, severe, murine model of C3G was developed by replacing the mouse C3 gene with the human C3 homolog using VelociGene technology. Functional, histologic, molecular, and pharmacologic assays characterize the presentation of renal disease and enable useful pharmacologic interventions in the humanized C3 (C3hu/hu) mice. RESULTS The C3hu/hu mice exhibit increased morbidity early in life and die by about 5-6 months of age. The C3hu/hu mice display elevated biomarkers of kidney dysfunction, glomerulosclerosis, C3/C5b-9 deposition, and reduced circulating C3 compared with wild-type mice. Administration of a C5-blocking mAb improved survival rate and offered functional and histopathologic benefits. Blockade of AP activation by anti-C3b or CFB mAbs also extended survival and preserved kidney function. CONCLUSIONS The C3hu/hu mice are a useful model for C3G because they share many pathologic features consistent with the human disease. The C3G phenotype in C3hu/hu mice may originate from a dysregulated interaction of human C3 protein with multiple mouse complement proteins, leading to unregulated C3 activation via AP. The accelerated disease course in C3hu/hu mice may further enable preclinical studies to assess and validate new therapeutics for C3G.
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11
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Skerka C, Pradel G, Halder LD, Zipfel PF, Zipfel SLH, Strauß O. Factor H-related protein 1: a complement regulatory protein and guardian of necrotic-type surfaces. Br J Pharmacol 2020; 178:2823-2831. [PMID: 33085794 DOI: 10.1111/bph.15290] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/21/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022] Open
Abstract
Factor H-related protein 1 (FHR-1) is a member of the factor H protein family, which is involved in regulating innate immune complement reactions. Genetic modification of the encoding gene, CFHR1 on human chromosome 1, is involved in diseases such as age-related macular degeneration, C3 glomerulopathy and atypical haemolytic uraemic syndrome, indicating an important role for FHR-1 in human health. Recent research data demonstrate that FHR-1 levels increase in IgA nephropathy and anti-neutrophilic cytoplasmic autoantibodies (ANCA) vasculitis and that FHR-1 induces strong inflammation in monocytes on necrotic-type surfaces, suggesting a complement-independent role. These new results increase our knowledge about the role of this complement protein in pathology and provide a new therapeutic target, particularly in the context of inflammatory diseases induced by necrosis. This review summarizes current knowledge about FHR-1 and discusses its role in complement reactions and inflammation. LINKED ARTICLES: This article is part of a themed issue on Canonical and non-canonical functions of the complement system in health and disease. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.14/issuetoc.
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Affiliation(s)
- Christine Skerka
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | - Gabriele Pradel
- Division of Cellular and Applied Infection Biology, RWTH Aachen University, Aachen, Germany
| | - Luke D Halder
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | - Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | - Svante L H Zipfel
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Olaf Strauß
- Experimental Ophthalmology, Charité University Medicine, Campus Virchow Clinic, Berlin, Germany
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12
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Abstract
Community-acquired acute kidney injury (CA-AKI) is the dominant form of AKI encountered in developing countries in Asia. Economic disparities, variations in access to health care services, geographic conditions, environmental risk factors, and sociocultural circumstances shape the causes and outcomes of CA-AKI. Infections, drugs, plant and chemical toxins, envenomations, and obstetric complications are common causes of CA-AKI. Previously healthy young individuals who often work outdoors in fields or farms are exposed to a wide variety of work-related or environmental risk factors for CA-AKI. Improving disease definitions, better data, and evolving host-pathogen interactions have changed disease descriptions and presentations over the past 20 years. Among infections, although the incidence of malaria has decreased, the number of cases with dengue and scrub typhus have increased sharply. The recognition of AKI in relation to Plasmodium knowlesi, Plasmodium vivax, scrub typhus, and leptospirosis in areas not traditionally considered at risk, association of infections with the future development of chronic kidney disease, and the role of complement dysregulation in infection-associated AKI are important new findings. Snake-bite-related toxic envenomation continues to be an important cause of AKI in some counties and is a neglected public health problem. On the other hand, significant decreases in the incidence of AKI related to acute diarrheal illness or obstetric causes are signs of hope. Coordinated efforts between administrative stakeholders, society, and health care delivery services at all levels have the potential to propel research and improve outcomes in CA-AKI.
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Affiliation(s)
- Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India; School of Public Health, Imperial College, London, UK; Manipal Academy of Higher Education, Manipal, India.
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13
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Sutu B, Tio SY, Fox LC, Sasadeusz J, Blombery P, Finlay MJ, Barbour TD. Cat-Scratch Disease Masquerading as C3 Glomerulonephritis. Kidney Int Rep 2020; 5:2388-2392. [PMID: 33305138 PMCID: PMC7710836 DOI: 10.1016/j.ekir.2020.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/25/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Benjamin Sutu
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Shio Yen Tio
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lucy C Fox
- Department of Hematology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Joseph Sasadeusz
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Piers Blombery
- Department of Hematology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Moira J Finlay
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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14
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Pharmacology, Pharmacokinetics and Pharmacodynamics of Eculizumab, and Possibilities for an Individualized Approach to Eculizumab. Clin Pharmacokinet 2020; 58:859-874. [PMID: 30758736 PMCID: PMC6584251 DOI: 10.1007/s40262-019-00742-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Eculizumab is the first drug approved for the treatment of complement-mediated diseases, and current dosage schedules result in large interindividual drug concentrations. This review provides insight into the pharmacokinetic and pharmacodynamic properties of eculizumab, both for reported on-label (paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, generalized myasthenia gravis) and off-label (hematopoietic stem cell transplantation-associated thrombotic microangiopathy) indications. Furthermore, we discuss the potential of therapeutic drug monitoring to individualize treatment and reduce costs.
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15
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Hanna RM, Hou J, Hasnain H, Arman F, Selamet U, Wilson J, Olanrewaju S, Zuckerman JE, Barsoum M, Yabu JM, Kurtz I. Diverse Clinical Presentations of C3 Dominant Glomerulonephritis. Front Med (Lausanne) 2020; 7:293. [PMID: 32695788 PMCID: PMC7338606 DOI: 10.3389/fmed.2020.00293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Abstract
C3 dominant immunofluorescence staining is present in a subset of patients with idiopathic immune complex membranoproliferative glomerulonephritis (iMPGN). It is increasingly recognized that iMPGN may be complement driven, as are cases of "typical" C3 glomerulopathy (C3G). In both iMPGN and C3G, a frequent membranoproliferative pattern of glomerular injury may indicate common pathogenic mechanisms via complement activation and endothelial cell damage. Dysregulation of the alternative complement pathway and mutations in certain regulatory factors are highly implicated in C3 glomerulopathy (which encompasses C3 glomerulonephritis, dense deposit disease, and cases of C3 dominant MPGN). We report three cases that demonstrate that an initial biopsy diagnosis of iMPGN does not exclude complement alterations similar to the ones observed in patients with a diagnosis of C3G. The first patient is a 39-year-old woman with iMPGN and C3 dominant staining, with persistently low C3 levels throughout her course. The second case is a 22-year-old woman with elevated anti-factor H antibodies and C3 dominant iMPGN findings on biopsy. The third case is a 25-year-old woman with C3 dominant iMPGN, dense deposit disease, and a crescentic glomerulonephritis on biopsy. We present the varied phenotypic variations of C3 dominant MPGN and review clinical course, complement profiles, genetic testing, treatment course, and peri-transplantation plans. Testing for complement involvement in iMPGN is important given emerging treatment options and transplant planning.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, UCI School of Medicine, Irvine, CA, United States.,Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Jean Hou
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Huma Hasnain
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Farid Arman
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Umut Selamet
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States.,Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - James Wilson
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Samuel Olanrewaju
- David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory Medicine, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Marina Barsoum
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Julie M Yabu
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Ira Kurtz
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States.,UCLA Brain Research Institute, Los Angeles, CA, United States
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16
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Schena FP, Esposito P, Rossini M. A Narrative Review on C3 Glomerulopathy: A Rare Renal Disease. Int J Mol Sci 2020; 21:ijms21020525. [PMID: 31947692 PMCID: PMC7013756 DOI: 10.3390/ijms21020525] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
In April 2012, a group of nephrologists organized a consensus conference in Cambridge (UK) on type II membranoproliferative glomerulonephritis and decided to use a new terminology, "C3 glomerulopathy" (C3 GP). Further knowledge on the complement system and on kidney biopsy contributed toward distinguishing this disease into three subgroups: dense deposit disease (DDD), C3 glomerulonephritis (C3 GN), and the CFHR5 nephropathy. The persistent presence of microhematuria with or without light or heavy proteinuria after an infection episode suggests the potential onset of C3 GP. These nephritides are characterized by abnormal activation of the complement alternative pathway, abnormal deposition of C3 in the glomeruli, and progression of renal damage to end-stage kidney disease. The diagnosis is based on studying the complement system, relative genetics, and kidney biopsies. The treatment gap derives from the absence of a robust understanding of their natural outcome. Therefore, a specific treatment for the different types of C3 GP has not been established. Recommendations have been obtained from case series and observational studies because no randomized clinical trials have been conducted. Current treatment is based on corticosteroids and antiproliferative drugs (cyclophosphamide, mycophenolate mofetil), monoclonal antibodies (rituximab) or complement inhibitors (eculizumab). In some cases, it is suggested to include sessions of plasma exchange.
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Affiliation(s)
- Francesco Paolo Schena
- Department of Emergency and Organ Transplantation, Renal Unit, University of Bari, 70124 Bari, Italy;
- Schena Foundation, European Center for the Study of Renal Diseases, 70010 Valenzano, Italy
- Correspondence:
| | - Pasquale Esposito
- Department of Internal Medicine, Division of Nephrology, Dialysis and Transplantation, University of Genoa and IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Michele Rossini
- Department of Emergency and Organ Transplantation, Renal Unit, University of Bari, 70124 Bari, Italy;
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17
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Frangou E, Varnavidou-Nicolaidou A, Petousis P, Soloukides A, Theophanous E, Savva I, Michael N, Toumasi E, Georgiou D, Stylianou G, Mean R, Anastasiadou N, Athanasiou Y, Zavros M, Kyriacou K, Deltas C, Hadjianastassiou V. Clinical course and outcome after kidney transplantation in patients with C3 glomerulonephritis due to CFHR5 nephropathy. Nephrol Dial Transplant 2019; 34:1780-1788. [PMID: 30844074 DOI: 10.1093/ndt/gfz021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/17/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Complement factor H-related protein 5 (CFHR5) nephropathy is an inherited renal disease characterized by microscopic and synpharyngitic macroscopic haematuria, C3 glomerulonephritis and renal failure. It is caused by an internal duplication of exons 2-3 within the CFHR5 gene resulting in dysregulation of the alternative complement pathway. The clinical characteristics and outcomes of transplanted patients with this rare familial nephropathy remain unknown. METHODS This is a retrospective case series study of 17 kidney transplant patients with the established founder mutation, followed-up over a span of 30 years. RESULTS The mean (±SD) age of patients at the time of the study and at transplantation was 58.6 ± 9.9 and 46.7 ± 8.8 years, respectively. The 10- and 15-year patient survival rates were 100 and 77.8%, respectively. Proteinuria was present in 33.3% and microscopic haematuria in 58.3% of patients with a functional graft. Serum complement levels were normal in all. 'Confirmed' and 'likely' recurrence of CFHR5 nephropathy were 16.6 and 52.9%, respectively; however, 76.5% of patients had a functional graft after a median of 120 months post-transplantation. Total recurrence was not associated with graft loss (P = 0.171), but was associated with the presence of microscopic haematuria (P = 0.001) and proteinuria (P = 0.018). Graft loss was associated with the presence of proteinuria (P = 0.025). CONCLUSIONS We describe for the first time the clinical characteristics and outcome of patients with CFHR5 nephropathy post-transplantation. Despite the recurrence of CFHR5 nephropathy, we provide evidence for a long-term favourable outcome and support the continued provision of kidney transplantation as a renal replacement option in patients with CFHR5 nephropathy.
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Affiliation(s)
- Eleni Frangou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus.,Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | | | | | - Andreas Soloukides
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Elena Theophanous
- Department of Histopathology, Nicosia General Hospital, Nicosia, Cyprus
| | - Isavella Savva
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Molecular Medicine Research Center, Department of Biological Sciences, University of Cyprus, Nicosia, Cyprus
| | - Nicos Michael
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Nicosia, Nicosia, Cyprus
| | - Elpida Toumasi
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Dora Georgiou
- Histocompatibility and Immunogenetics Laboratory, Nicosia General Hospital, Nicosia, Cyprus
| | - Galatia Stylianou
- Histocompatibility and Immunogenetics Laboratory, Nicosia General Hospital, Nicosia, Cyprus
| | - Richard Mean
- Histocompatibility and Immunogenetics Laboratory, Nicosia General Hospital, Nicosia, Cyprus
| | | | - Yiannis Athanasiou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Michalis Zavros
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus
| | - Kyriacos Kyriacou
- Department of Electron Microscopy, Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Constantinos Deltas
- Molecular Medicine Research Center, Department of Biological Sciences, University of Cyprus, Nicosia, Cyprus
| | - Vassilis Hadjianastassiou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Nicosia, Nicosia, Cyprus
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18
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Maugeri A, Barchitta M, Mazzone MG, Giuliano F, Agodi A. Complement System and Age-Related Macular Degeneration: Implications of Gene-Environment Interaction for Preventive and Personalized Medicine. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7532507. [PMID: 30225264 PMCID: PMC6129329 DOI: 10.1155/2018/7532507] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/18/2018] [Indexed: 12/14/2022]
Abstract
Age-related macular degeneration (AMD) is the most common cause of visual loss in developed countries, with a significant economic and social burden on public health. Although genome-wide and gene-candidate studies have been enabled to identify genetic variants in the complement system associated with AMD pathogenesis, the effect of gene-environment interaction is still under debate. In this review we provide an overview of the role of complement system and its genetic variants in AMD, summarizing the consequences of the interaction between genetic and environmental risk factors on AMD onset, progression, and therapeutic response. Finally, we discuss the perspectives of current evidence in the field of genomics driven personalized medicine and public health.
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Affiliation(s)
- Andrea Maugeri
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Via S. Sofia 87, 95123 Catania, Italy
| | - Martina Barchitta
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Via S. Sofia 87, 95123 Catania, Italy
| | - Maria Grazia Mazzone
- SIFI SpA, Research and Development Department, Via Ercole Patti 36, 95025 Catania, Italy
| | - Francesco Giuliano
- SIFI SpA, Research and Development Department, Via Ercole Patti 36, 95025 Catania, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Via S. Sofia 87, 95123 Catania, Italy
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19
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Moog P, Jost PJ, Büttner-Herold M. Eculizumab as salvage therapy for recurrent monoclonal gammopathy-induced C3 glomerulopathy in a kidney allograft. BMC Nephrol 2018; 19:106. [PMID: 29724174 PMCID: PMC5934889 DOI: 10.1186/s12882-018-0904-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 04/22/2018] [Indexed: 01/14/2023] Open
Abstract
Background Monoclonal gammopathy causes several kinds of renal pathology. A rare and special form is monoclonal gammopathy-induced C3 glomerulopathy (MG-C3G). Like idiopathic C3G, MG-C3G frequently leads to end-stage renal disease. MG-C3G frequently recurs after renal transplantation, leading to graft failure in most of the patients. While there is some evidence for successful treatment of recurrent idiopathic C3 glomerulopathy with eculizumab after renal transplantation, nothing is known about its efficacy in the setting of recurrent MG-C3G. Case presentation We report a patient with recurrent MG-C3G in a renal allograft that was successfully treated with eculizumab in addition to standard immunosuppression. He had early recurrence of MG-C3G 2 months after transplantation. His graft function successively declined despite high dose steroids and plasmapheresis. Only after therapy with three cycles of bortezomib and continuous therapy with eculizumab, his graft function stabilized. He was still in clinical remission after 28 months of follow-up without having experienced major infectious complications. Conclusions Eculizumab may be a safe and effective treatment of recurrent MG-C3G. Because of the high and early recurrence risk, renal transplantation should be reviewed carefully for every individual patient. Subsequent hematopoietic stem cell transplantation may ameliorate long-term renal allograft survival. Eculizumab might serve as a bridging therapy until stem cell transplantation.
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Affiliation(s)
- Philipp Moog
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Philipp J Jost
- III. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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20
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Hirashio S, Satoh A, Arima T, Mandai K, Awaya T, Oshima K, Hara S, Masaki T. Favorable effect of bortezomib in dense deposit disease associated with monoclonal gammopathy: a case report. BMC Nephrol 2018; 19:108. [PMID: 29724182 PMCID: PMC5934801 DOI: 10.1186/s12882-018-0905-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 04/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Complement component 3 (C3) glomerulopathy, which includes dense deposit disease (DDD) and C3 glomerulonephritis, is caused by dysregulation of the alternative complement pathway. In most cases, C3 glomerulopathy manifests pathologically with membranoproliferative glomerulonephritis-like features. An association between C3 glomerulopathy and monoclonal gammopathy was recently reported in several cases, raising the possibility that C3 glomerulopathy is the underlying pathological process in monoclonal gammopathy of renal significance. Case presentation We herein report a case of monoclonal gammopathy-induced DDD that improved histologically and clinically with chemotherapy including bortezomib. Our case is the first in which treatment response can be linked to the histological response. Potential pathological insights are also discussed. Conclusions Rapid and efficient chemotherapy has the potential to limit renal damage in monoclonal gammopathy-associated DDD.
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Affiliation(s)
- Shuma Hirashio
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 7348551, Japan.,Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Ayaka Satoh
- Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Takahiro Arima
- Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Kouichi Mandai
- Department of Diagnostic Pathology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Tadasuke Awaya
- Department of Hematology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kumi Oshima
- Department of Hematology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 7348551, Japan.
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21
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Michelfelder S, Fischer F, Wäldin A, Hörle KV, Pohl M, Parsons J, Reski R, Decker EL, Zipfel PF, Skerka C, Häffner K. The MFHR1 Fusion Protein Is a Novel Synthetic Multitarget Complement Inhibitor with Therapeutic Potential. J Am Soc Nephrol 2018; 29:1141-1153. [PMID: 29335241 DOI: 10.1681/asn.2017070738] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022] Open
Abstract
The complement system is essential for host defense, but uncontrolled complement system activation leads to severe, mostly renal pathologies, such as atypical hemolytic uremic syndrome or C3 glomerulopathy. Here, we investigated a novel combinational approach to modulate complement activation by targeting C3 and the terminal pathway simultaneously. The synthetic fusion protein MFHR1 links the regulatory domains of complement factor H (FH) with the C5 convertase/C5b-9 inhibitory fragment of the FH-related protein 1. In vitro, MFHR1 showed cofactor and decay acceleration activity and inhibited C5 convertase activation and C5b-9 assembly, which prevented C3b deposition and reduced C3a/C5a and C5b-9 generation. Furthermore, this fusion protein showed the ability to escape deregulation by FH-related proteins and form multimeric complexes with increased inhibitory activity. In addition to substantially inhibiting alternative and classic pathway activation, MFHR1 blocked hemolysis mediated by serum from a patient with aHUS expressing truncated FH. In FH-/- mice, MFHR1 administration augmented serum C3 levels, reduced abnormal glomerular C3 deposition, and ameliorated C3 glomerulopathy. Taking the unique design of MFHR1 into account, we suggest that the combination of proximal and terminal cascade inhibition together with the ability to form multimeric complexes explain the strong inhibitory capacity of MFHR1, which offers a novel basis for complement therapeutics.
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Affiliation(s)
- Stefan Michelfelder
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Friedericke Fischer
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Astrid Wäldin
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Kim V Hörle
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | | | - Ralf Reski
- Plant Biotechnology, Faculty of Biology, and.,Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany; and
| | | | - Peter F Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Friedrich Schiller University, Jena, Germany
| | - Christine Skerka
- Leibniz Institute for Natural Product Research and Infection Biology, Friedrich Schiller University, Jena, Germany
| | - Karsten Häffner
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine,
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22
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Falix FA, Oosterveld MJS, Florquin S, Groothoff JW, Bouts AHM. Diagnostic dilemmas in a girl with acute glomerulonephritis: Answers. Pediatr Nephrol 2018; 33:65-69. [PMID: 28280937 PMCID: PMC5700220 DOI: 10.1007/s00467-017-3626-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Farah A Falix
- Pediatric Nephrology Department of the Emma Children's Hospital, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands.
| | - Michiel J S Oosterveld
- Pediatric Nephrology Department of the Emma Children's Hospital, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
| | - Sandrine Florquin
- Pathology Department, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
| | - Jaap W Groothoff
- Pediatric Nephrology Department of the Emma Children's Hospital, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
| | - Antonia H M Bouts
- Pediatric Nephrology Department of the Emma Children's Hospital, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
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23
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Zhang Y, Meyer NC, Fervenza FC, Lau W, Keenan A, Cara-Fuentes G, Shao D, Akber A, Fremeaux-Bacchi V, Sethi S, Nester CM, Smith RJH. C4 Nephritic Factors in C3 Glomerulopathy: A Case Series. Am J Kidney Dis 2017; 70:834-843. [PMID: 28838767 DOI: 10.1053/j.ajkd.2017.07.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 07/03/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND C3 glomerulopathy (C3G) defines a group of rare complement-mediated kidney diseases with a shared underlying pathophysiology: dysregulation of complement in the fluid phase and glomerular microenvironment. Dysregulation can be driven by autoantibodies to C3 and C5 convertases. STUDY DESIGN Case series. SETTING & PARTICIPANTS 168 patients with C3G (dense deposit disease, 68; C3 glumerulonephritis, 100) selected from our C3G biobank. OUTCOMES Patient-purified immunoglobulin Gs were tested for C4 nephritic factors (C4NeFs). These autoantibodies recognize C4b2a, the C3 convertase of the classical pathway of complement. MEASUREMENTS C4NeFs were detected using a modified hemolytic assay. RESULTS C4NeFs were identified in 5 patients, 4 of whom had C3 glomerulonephritis. C4NeFs were associated with dysregulation of C3 and C5 convertases, and they appear to stabilize these convertases in a dose-dependent manner. C4NeFs also appear to protect C4b2a from decay mediated by soluble CR1 and C4 binding protein. The stabilizing activity of the autoantibodies was further demonstrated by using heat treatment to inactivate complement. C4NeFs were not detected in 150 patients with another complement-mediated kidney disease, atypical hemolytic uremic syndrome. They were also absent in 300 apparently healthy controls. LIMITATIONS In addition to C4NeFs, 2 patients had positive findings for other autoantibodies: one patient also had autoantibodies to factor H; the other patient also had autoantibodies to C3bBb (C3NeFs). CONCLUSIONS The finding of C4NeFs in a small percentage of patients with C3G highlights the challenge in identifying autoantibodies that drive complement dysregulation and underscores the complexity of the autoantibody repertoire that can be identified in these patients.
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Affiliation(s)
- Yuzhou Zhang
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Nicole C Meyer
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA
| | | | - Winnie Lau
- Internal Medicine, Nephrology, Indian River Medical Center, Vero Beach, FL
| | - Adam Keenan
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA
| | | | - Dingwu Shao
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Aalia Akber
- Department of Nephrology, Kaiser Permanente, Oakland, CA
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Carla M Nester
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA; Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA; Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA.
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Abstract
The role of the complement factor H-related (FHR) proteins in homeostasis, pathogen defense, and autoimmune disease has recently attracted considerable interest. We highlight the exciting research that has contributed to our understanding of the FHR protein family. Unlike factor H, a potent negative regulator of complement C3 activation, the FHR proteins appear to promote C3 activation. These data have important implications for understanding complement-mediated diseases because, depending on the context, the balance between the actions of factor H and the FHR proteins determines the degree of complement activation.
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Affiliation(s)
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College, London, UK
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25
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A novel CFHR1-CFHR5 hybrid leads to a familial dominant C3 glomerulopathy. Kidney Int 2017; 92:876-887. [PMID: 28729035 DOI: 10.1016/j.kint.2017.04.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 04/14/2017] [Accepted: 04/28/2017] [Indexed: 11/23/2022]
Abstract
The intrinsic similarity shared between the members of the complement factor H family, which comprises complement factor H and five complement factor H-related (CFHR) genes, leads to various recombination events. In turn these events lead to deletions of some genes or abnormal proteins, which are found in patients with atypical hemolytic uremic syndrome or C3 glomerulopathies. Here we describe a novel genetic rearrangement generated from a heterozygous deletion spanning 146 Kbp involving multiple CFHR genes leading to a CFHR1-R5 hybrid protein. This deletion was found in four family members presenting with a familial dominant glomerulopathy histologically classified as an overlap of dense deposit disease and C3 glomerulonephritis. Affected patients exhibited permanently low C3 and factor B levels and high amounts of activation fragments sC5b9 and Bb, indicating a systemic alternative pathway dysregulation. The abnormal protein, characterized by Western blot and immunoprecipitation, was shown to circulate in association with CFHR1 and CFHR2, attributable to its two N-terminal dimerization motifs. The presence of this protein is associated with a perturbation of Factor H activity on the C3 convertase decay. Thus, our study highlights the role of CFHRs in the physiopathology of C3 glomerulopathies and stresses the importance of screening CFHRs in all familial C3 glomerulopathies. Such hybrids described till now were always associated with familial forms.
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26
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Medjeral-Thomas NR, Lomax-Browne HJ, Beckwith H, Willicombe M, McLean AG, Brookes P, Pusey CD, Falchi M, Cook HT, Pickering MC. Circulating complement factor H-related proteins 1 and 5 correlate with disease activity in IgA nephropathy. Kidney Int 2017; 92:942-952. [PMID: 28673452 PMCID: PMC5611987 DOI: 10.1016/j.kint.2017.03.043] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/23/2017] [Accepted: 03/30/2017] [Indexed: 12/21/2022]
Abstract
IgA nephropathy (IgAN) is a common cause of chronic kidney disease and end-stage renal failure, especially in young people. Due to a wide range of clinical outcomes and difficulty in predicting response to immunosuppression, we need to understand why and identify which patients with IgAN will develop progressive renal impairment. A deletion polymorphism affecting the genes encoding the complement factor H-related protein (FHR)-1 and FHR-3 is robustly associated with protection against IgAN. Some FHR proteins, including FHR-1 and FHR-5, antagonize the ability of complement factor H (fH), the major negative regulator of the complement alternative pathway, to inhibit complement activation on surfaces, a process termed fH deregulation. From a large cohort of patients, we demonstrated that plasma FHR-1 and the FHR-1/fH ratio were elevated in IgAN and associated with progressive disease. Plasma FHR-1 negatively correlated with eGFR but remained elevated in patients with IgAN with normal eGFR. Serum FHR5 was slightly elevated in IgAN but did not correlate with eGFR. Neither FHR5 levels nor the FHR-5/fH ratio was associated with progressive disease. However, higher serum FHR-5 levels were associated with a lack of response to immunosuppression, the presence of endocapillary hypercellularity, and histology scores of disease severity (the Oxford Classification MEST score). Thus, FHR-1 and FHR-5 have a role in IgAN disease progression.
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Affiliation(s)
| | | | - Hannah Beckwith
- Centre for Complement and Inflammation Research, Imperial College London, UK
| | - Michelle Willicombe
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Adam G McLean
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Brookes
- Histocompatibility & Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Imperial College London, UK
| | - Mario Falchi
- Department of Twin Research and Genetic Epidemiology, King's College London, UK
| | - H Terence Cook
- Centre for Complement and Inflammation Research, Imperial College London, UK
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College London, UK.
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27
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Kerr H, Wong E, Makou E, Yang Y, Marchbank K, Kavanagh D, Richards A, Herbert AP, Barlow PN. Disease-linked mutations in factor H reveal pivotal role of cofactor activity in self-surface-selective regulation of complement activation. J Biol Chem 2017. [PMID: 28637873 PMCID: PMC5555194 DOI: 10.1074/jbc.m117.795088] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Spontaneous activation enables the complement system to respond very rapidly to diverse threats. This activation is efficiently suppressed by complement factor H (CFH) on self-surfaces but not on foreign surfaces. The surface selectivity of CFH, a soluble protein containing 20 complement-control protein modules (CCPs 1-20), may be compromised by disease-linked mutations. However, which of the several functions of CFH drives this self-surface selectivity remains unknown. To address this, we expressed human CFH mutants in Pichia pastoris We found that recombinant I62-CFH (protective against age-related macular degeneration) and V62-CFH functioned equivalently, matching or outperforming plasma-derived CFH, whereas R53H-CFH, linked to atypical hemolytic uremic syndrome (aHUS), was defective in C3bBb decay-accelerating activity (DAA) and factor I cofactor activity (CA). The aHUS-linked CCP 19 mutant D1119G-CFH had virtually no CA on (self-like) sheep erythrocytes (ES) but retained DAA. The aHUS-linked CCP 20 mutant S1191L/V1197A-CFH (LA-CFH) had dramatically reduced CA on ES but was less compromised in DAA. D1119G-CFH and LA-CFH both performed poorly at preventing complement-mediated hemolysis of ES PspCN, a CFH-binding Streptococcus pneumoniae protein domain, binds CFH tightly and increases accessibility of CCPs 19 and 20. PspCN did not improve the DAA of any CFH variant on ES Conversely, PspCN boosted the CA, on ES, of I62-CFH, R53H-CFH, and LA-CFH and also enhanced hemolysis protection by I62-CFH and LA-CFH. We conclude that CCPs 19 and 20 are critical for efficient CA on self-surfaces but less important for DAA. Exposing CCPs 19 and 20 with PspCN and thus enhancing CA on self-surfaces may reverse deficiencies of some CFH variants.
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Affiliation(s)
- Heather Kerr
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Edwin Wong
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Elisavet Makou
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Yi Yang
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Kevin Marchbank
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - David Kavanagh
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Anna Richards
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Andrew P Herbert
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
| | - Paul N Barlow
- From the Schools of Chemistry and Biological Sciences, Joseph Black Building, University of Edinburgh, David Brewster Road, Edinburgh EH9 3FJ, Scotland, United Kingdom
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28
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Rituximab for Treatment of Membranoproliferative Glomerulonephritis and C3 Glomerulopathies. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2180508. [PMID: 28573137 PMCID: PMC5440792 DOI: 10.1155/2017/2180508] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 01/18/2023]
Abstract
Membranoproliferative glomerulonephritis (MPGN) is a histological pattern of injury resulting from predominantly subendothelial and mesangial deposition of immunoglobulins or complement factors with subsequent inflammation and proliferation particularly of the glomerular basement membrane. Recent classification of MPGN is based on pathogenesis dividing MPGN into immunoglobulin-associated MPGN and complement-mediated C3 glomerulonephritis (C3GN) and dense deposit disease (DDD). Current guidelines suggest treatment with steroids, cytotoxic agents with or without plasmapheresis only for subjects with progressive disease, that is, nephrotic range proteinuria and decline of renal function. Rituximab, a chimeric B-cell depleting anti-CD20 antibody, has emerged in the last decade as a treatment option for patients with primary glomerular diseases such as minimal change disease, focal-segmental glomerulosclerosis, or idiopathic membranous nephropathy. However, data on the use of rituximab in MPGN, C3GN, and DDD are limited to case reports and retrospective case series. Patients with immunoglobulin-associated and idiopathic MPGN who were treated with rituximab showed partial and complete responses in the majorities of cases. However, rituximab was not effective in few cases of C3GN and DDD. Despite promising results in immunoglobulin-associated and idiopathic MPGN, current evidence on this treatment remains weak, and controlled and prospective data are urgently needed.
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29
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Mastellos DC, Reis ES, Ricklin D, Smith RJ, Lambris JD. Complement C3-Targeted Therapy: Replacing Long-Held Assertions with Evidence-Based Discovery. Trends Immunol 2017; 38:383-394. [PMID: 28416449 DOI: 10.1016/j.it.2017.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/17/2017] [Accepted: 03/16/2017] [Indexed: 02/06/2023]
Abstract
Complement dysregulation underlies several inflammatory disorders, and terminal complement inhibition has thus far afforded significant clinical gains. Nonetheless, emerging pathologies, fueled by complement imbalance and therapy-skewing genetic variance, underscore the need for more comprehensive, disease-tailored interventions. Modulation at the level of C3, a multifaceted orchestrator of the complement cascade, opens up prospects for broader therapeutic efficacy by targeting multiple pathogenic pathways modulated by C3-triggered proinflammatory crosstalk. Notably, C3 intervention is emerging as a viable therapeutic strategy for renal disorders with predominantly complement-driven etiology, such as C3 glomerulopathy (C3G). Using C3G as a paradigm, we argue that concerns about the feasibility of long-term C3 intervention need to be placed into perspective and weighed against actual therapeutic outcomes in prospective clinical trials.
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Affiliation(s)
- Dimitrios C Mastellos
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Biodiagnostic Sciences and Technologies, Institute of Nuclear and Radiological Sciences and Technology, Energy, and Safety (INRASTES), National Center for Scientific Research 'Demokritos', Aghia Paraskevi Attikis, 15310 Athens, Greece
| | - Edimara S Reis
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel Ricklin
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland
| | - Richard J Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - John D Lambris
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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30
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Tackling another MGRS-related kidney disease. Blood 2017; 129:1405-1406. [DOI: 10.1182/blood-2017-02-763508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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31
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Correia SO, Santos S, Malheiro J, Cabrita A, Martins LS, Santos J. Monoclonal gammopathy of renal significance: Diagnostic workup. World J Nephrol 2017; 6:72-78. [PMID: 28316940 PMCID: PMC5339639 DOI: 10.5527/wjn.v6.i2.72] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/08/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
The clinical spectrum of diseases associated with monoclonal gammopathies is wide and they are most commonly the consequence of renal deposition of monoclonal immunoglobulin or its components. The differential diagnosis is difficult and renal biopsy is essential. To distinguish many of these pathologies is necessary to use techniques that are not always available, even in tertiary central hospitals. This review will discuss the clinical presentation, pathologic features, treatment, prognosis and common diagnostic difficulties of these entities.
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32
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Lioufas N, Finlay M, Barbour T. Durable remission of C3 glomerulonephritis with mycophenolate mofetil. Nephrology (Carlton) 2017; 22 Suppl 1:36-39. [PMID: 28176473 DOI: 10.1111/nep.12939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In C3 glomerulopathy, uncontrolled complement C3 activation via the alternative pathway results in glomerular C3 deposition and, in many cases, progressive renal failure. Despite advances in understanding of C3G pathogenesis over the last few years, there are no proven treatments. We describe a patient in whom C3 glomerulopathy was associated with renal impairment and elevated serum free kappa light chains. An initial response to corticosteroids was followed by relapse once steroids were weaned, prompting use of mycophenolate mofetil to maintain remission. We discuss some of the diagnostic and therapeutic issues surrounding C3G, including in the setting of monoclonal gammopathy.
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Affiliation(s)
- Nicole Lioufas
- Department of Nephrology, The Royal Melbourne Hospital, Victoria, Australia
| | - Moira Finlay
- Department of Anatomical Pathology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Thomas Barbour
- Department of Nephrology, The Royal Melbourne Hospital, Victoria, Australia
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33
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Goodship THJ, Cook HT, Fakhouri F, Fervenza FC, Frémeaux-Bacchi V, Kavanagh D, Nester CM, Noris M, Pickering MC, Rodríguez de Córdoba S, Roumenina LT, Sethi S, Smith RJH. Atypical hemolytic uremic syndrome and C3 glomerulopathy: conclusions from a "Kidney Disease: Improving Global Outcomes" (KDIGO) Controversies Conference. Kidney Int 2016; 91:539-551. [PMID: 27989322 DOI: 10.1016/j.kint.2016.10.005] [Citation(s) in RCA: 411] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/10/2016] [Accepted: 10/20/2016] [Indexed: 02/06/2023]
Abstract
In both atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy (C3G) complement plays a primary role in disease pathogenesis. Herein we report the outcome of a 2015 Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference where key issues in the management of these 2 diseases were considered by a global panel of experts. Areas addressed included renal pathology, clinical phenotype and assessment, genetic drivers of disease, acquired drivers of disease, and treatment strategies. In order to help guide clinicians who are caring for such patients, recommendations for best treatment strategies were discussed at length, providing the evidence base underpinning current treatment options. Knowledge gaps were identified and a prioritized research agenda was proposed to resolve outstanding controversial issues.
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Affiliation(s)
| | - H Terence Cook
- Centre for Complement and Inflammation Research, Department of Medicine, Imperial College Hammersmith Campus, London, UK
| | - Fadi Fakhouri
- INSERM, UMR-S 1064, and Department of Nephrology and Immunology, CHU de Nantes, Nantes, France
| | - Fernando C Fervenza
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David Kavanagh
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carla M Nester
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Marina Noris
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Department of Medicine, Imperial College Hammersmith Campus, London, UK
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Madrid, Spain; Centro de Investigación Biomédica en Enfermedades Raras, Madrid, Spain
| | - Lubka T Roumenina
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1138, Complément et Maladies, Centre de Recherche des Cordeliers, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (UPMC-Paris-6), Paris, France
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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34
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Abstract
C3 glomerulopathy (C3G) is a recently identified disease entity caused by dysregulation of the alternative complement pathway, and dense deposit disease (DDD) and C3 glomerulonephritis (C3GN) are its components. Because laboratory detection of complement dysregulation is still uncommon in practice, "dominant C3 deposition by two orders greater than that of immunoglobulins in the glomeruli by immunofluorescence", as stated in the consensus report, defines C3G. However, this morphological definition possibly includes the cases with glomerular diseases of different mechanisms such as post-infectious glomerulonephritis. In addition, the differential diagnosis between DDD and C3GN is often difficult because the distinction between these two diseases is based solely on electron microscopic features. Recent molecular and genetic advances provide information to characterize C3G. Some C3G cases are found with genetic abnormalities in complement regulatory factors, but majority of cases seem to be associated with acquired factors that dysregulate the alternative complement pathway. Because clinical courses and prognoses among glomerular diseases with dominant C3 deposition differ, further understanding the background mechanism, particularly complement dysregulation in C3G, is needed. This may resolve current dilemmas in practice and shed light on novel targeted therapies to remedy the dysregulated alternative complement pathway in C3G.
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35
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Vernon KA, Ruseva MM, Cook HT, Botto M, Malik TH, Pickering MC. Partial Complement Factor H Deficiency Associates with C3 Glomerulopathy and Thrombotic Microangiopathy. J Am Soc Nephrol 2016; 27:1334-42. [PMID: 26374608 PMCID: PMC4849824 DOI: 10.1681/asn.2015030295] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/28/2015] [Indexed: 11/03/2022] Open
Abstract
The complement-mediated renal diseases C3 glomerulopathy (C3G) and atypical hemolytic uremic syndrome (aHUS) strongly associate with inherited and acquired abnormalities in the regulation of the complement alternative pathway (AP). The major negative regulator of the AP is the plasma protein complement factor H (FH). Abnormalities in FH result in uncontrolled activation of C3 through the AP and associate with susceptibility to both C3G and aHUS. Although previously developed FH-deficient animal models have provided important insights into the mechanisms underlying susceptibility to these unique phenotypes, these models do not entirely reproduce the clinical observations. FH is predominantly synthesized in the liver. We generated mice with hepatocyte-specific FH deficiency and showed that these animals have reduced plasma FH levels with secondary reduction in plasma C3. Unlike mice with complete FH deficiency, hepatocyte-specific FH-deficient animals developed neither plasma C5 depletion nor accumulation of C3 along the glomerular basement membrane. In contrast, subtotal FH deficiency associated with mesangial C3 accumulation consistent with C3G. Although there was no evidence of spontaneous thrombotic microangiopathy, the hepatocyte-specific FH-deficient animals developed severe C5-dependent thrombotic microangiopathy after induction of complement activation within the kidney by accelerated serum nephrotoxic nephritis. Taken together, our data indicate that subtotal FH deficiency can give rise to either spontaneous C3G or aHUS after a complement-activating trigger within the kidney and that the latter is C5 dependent.
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Affiliation(s)
- Katherine A Vernon
- Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom
| | - Marieta M Ruseva
- Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom
| | - H Terence Cook
- Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom
| | - Marina Botto
- Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom
| | - Talat H Malik
- Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom
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36
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Teoh CW, Riedl M, Licht C. The alternative pathway of complement and the thrombotic microangiopathies. Transfus Apher Sci 2016; 54:220-31. [PMID: 27160864 DOI: 10.1016/j.transci.2016.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thrombotic microangiopathies (TMA) are disorders defined by microangiopathic hemolytic anemia, non-immune thrombocytopenia and have multi-organ involvement including the kidneys, brain, gastrointestinal, respiratory tract and skin. Emerging evidence points to the central role of complement dysregulation in leading to microvascular endothelial injury which is crucial for the development of TMAs. This key insight has led to the development of complement-targeted therapy. Eculizumab is an anti-C5 monoclonal antibody, which has revolutionized the treatment of atypical hemolytic uremic syndrome. Several other anti-complement therapeutic agents are currently in development, offering a potential armamentarium of therapies available to treat complement-mediated TMAs. The development of sensitive, reliable and easy to perform assays to monitor complement activity and therapeutic efficacy will be key to devising an individualized treatment regime with the potential of safely weaning or discontinuing treatment in the appropriate clinical setting.
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Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Magdalena Riedl
- Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
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37
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Muff-Luett M, Nester CM. The Genetics of Ultra-Rare Renal Disease. J Pediatr Genet 2016; 5:33-42. [PMID: 27617140 DOI: 10.1055/s-0036-1572515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/02/2015] [Indexed: 12/14/2022]
Abstract
The complement-mediated renal diseases are a group of ultra-rare renal diseases that disproportionately affect children and young adults and frequently lead to irreversible renal failure. Genetic mutations in alternate pathway of complement genes are pathomechanistically involved in a significant number of these unique diseases. Here, we review our current understanding of the role of genetics in the primary complement-mediated renal diseases affecting children, with a focus on atypical hemolytic uremic syndrome and C3 glomerulopathy. Also, included is a brief discussion of the related diseases whose relationship to complement abnormality has been suspected but not yet confirmed. Advances in genetics have transformed both treatment and outcomes in these historically difficult to treat, highly morbid diseases.
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Affiliation(s)
- Melissa Muff-Luett
- Division of Pediatric Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Carla M Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States; Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, United States
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Angioi A, Fervenza FC, Sethi S, Zhang Y, Smith RJ, Murray D, Van Praet J, Pani A, De Vriese AS. Diagnosis of complement alternative pathway disorders. Kidney Int 2016; 89:278-88. [DOI: 10.1016/j.kint.2015.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 08/13/2015] [Accepted: 08/19/2015] [Indexed: 02/06/2023]
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Bu F, Borsa NG, Jones MB, Takanami E, Nishimura C, Hauer JJ, Azaiez H, Black-Ziegelbein EA, Meyer NC, Kolbe DL, Li Y, Frees K, Schnieders MJ, Thomas C, Nester C, Smith RJH. High-Throughput Genetic Testing for Thrombotic Microangiopathies and C3 Glomerulopathies. J Am Soc Nephrol 2015; 27:1245-53. [PMID: 26283675 DOI: 10.1681/asn.2015040385] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/01/2015] [Indexed: 11/03/2022] Open
Abstract
The thrombotic microangiopathies (TMAs) and C3 glomerulopathies (C3Gs) include a spectrum of rare diseases such as atypical hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, C3GN, and dense deposit disease, which share phenotypic similarities and underlying genetic commonalities. Variants in several genes contribute to the pathogenesis of these diseases, and identification of these variants may inform the diagnosis and treatment of affected patients. We have developed and validated a comprehensive genetic panel that screens all exons of all genes implicated in TMA and C3G. The closely integrated pipeline implemented includes targeted genomic enrichment, massively parallel sequencing, bioinformatic analysis, and a multidisciplinary conference to analyze identified variants in the context of each patient's specific phenotype. Herein, we present our 1-year experience with this panel, during which time we studied 193 patients. We identified 17 novel and 74 rare variants, which we classified as pathogenic (11), likely pathogenic (12), and of uncertain significance (68). Compared with controls, patients with C3G had a higher frequency of rare and novel variants in C3 convertase (C3 and CFB) and complement regulator (CFH, CFI, CFHR5, and CD46) genes (P<0.05). In contrast, patients with TMA had an increase in rare and novel variants only in complement regulator genes (P<0.01), a distinction consistent with differing sites of complement dysregulation in these two diseases. In summary, we were able to provide a positive genetic diagnosis in 43% and 41% of patients carrying the clinical diagnosis of C3G and TMA, respectively.
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Affiliation(s)
- Fengxiao Bu
- Interdisciplinary PhD Program in Genetics, Molecular Otolaryngology and Renal Research Laboratories
| | | | | | - Erika Takanami
- Molecular Otolaryngology and Renal Research Laboratories
| | - Carla Nishimura
- Molecular Otolaryngology and Renal Research Laboratories, Iowa Institute of Human Genetics
| | | | - Hela Azaiez
- Molecular Otolaryngology and Renal Research Laboratories
| | | | - Nicole C Meyer
- Molecular Otolaryngology and Renal Research Laboratories
| | | | - Yingyue Li
- Molecular Otolaryngology and Renal Research Laboratories
| | - Kathy Frees
- Molecular Otolaryngology and Renal Research Laboratories
| | | | - Christie Thomas
- Molecular Otolaryngology and Renal Research Laboratories, Division of Nephrology, Department of Internal Medicine and Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Carla Nester
- Molecular Otolaryngology and Renal Research Laboratories, Division of Nephrology, Department of Internal Medicine and Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Iowa Institute of Human Genetics, Division of Nephrology, Department of Internal Medicine and Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Nichols EM, Barbour TD, Pappworth IY, Wong EKS, Palmer JM, Sheerin NS, Pickering MC, Marchbank KJ. An extended mini-complement factor H molecule ameliorates experimental C3 glomerulopathy. Kidney Int 2015. [PMID: 26221753 PMCID: PMC4650264 DOI: 10.1038/ki.2015.233] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abnormal regulation of the complement alternative pathway is associated with C3 glomerulopathy. Complement factor H is the main plasma regulator of the alternative pathway and consists of 20 short consensus repeat (SCR) domains. Although recombinant full-length factor H represents a logical treatment for C3 glomerulopathy, its production has proved challenging. We and others have designed recombinant mini-factor H proteins in which ‘non-essential' SCR domains have been removed. Here, we report the in vitro and in vivo effects of a mini-complement factor H protein, FH1–5^18–20, using the unique factor H–deficient (Cfh−/−) mouse model of C3 glomerulopathy. FH1–5^18–20 is comprised of the key complement regulatory domains (SCRs 1–5) linked to the surface recognition domains (SCRs 18–20). Intraperitoneal injection of FH1–5^18–20 in Cfh−/− mice reduced abnormal glomerular C3 deposition, similar to full-length factor H. Systemic effects on plasma alternative pathway control were comparatively modest, in association with a short half-life. Thus, FH1–5^18–20 is a potential therapeutic agent for C3 glomerulopathy and other renal conditions with alternative pathway-mediated tissue injury.
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Affiliation(s)
- Eva-Maria Nichols
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas D Barbour
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | - Isabel Y Pappworth
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Edwin K S Wong
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy M Palmer
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | - Kevin J Marchbank
- Institutes of Cellular and Genetic Medicine, School of Medicine, Newcastle University, Newcastle upon Tyne, UK
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Abstract
C3 glomerulonephritis is a clinicopathologic entity defined by the presence of isolated or dominant deposits of C3 on immunofluorescence. To explore the effect of immunosuppression on C3 glomerulonephritis, we studied a series of 60 patients in whom a complete registry of treatments was available over a median follow-up of 47 months. Twenty patients had not received immunosuppressive treatments. In the remaining 40 patients, 22 had been treated with corticosteroids plus mycophenolate mofetil while 18 were treated with other immunosuppressive regimens (corticosteroids alone or corticosteroids plus cyclophosphamide). The number of patients developing end-stage renal disease was significantly lower among treated compared with untreated patients (3 vs. 7 patients, respectively). No patient in the corticosteroids plus mycophenolate mofetil group doubled serum creatinine nor developed end-stage renal disease, as compared with 7 (significant) and 3 (not significant), respectively, in patients treated with other immunosuppressive regimens. Renal survival (100, 80, and 72% at 5 years) and the number of patients achieving clinical remission (86, 50, and 25%) were significantly higher in patients treated with corticosteroids plus mycophenolate mofetil as compared with patients treated with other immunosuppressive regimens and untreated patients, respectively. Thus, immunosuppressive treatments, particularly corticosteroids plus mycophenolate mofetil, can be beneficial in C3 glomerulonephritis.
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