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Wang X, Zhang J, Zou GM, Zheng XM, Li JY, Gao HM, Jiang SM, Li WG. Clinical characteristics of membranous nephropathy with spontaneous remission: An analysis of 24 patients. Med Clin (Barc) 2023; 160:421-427. [PMID: 36690554 DOI: 10.1016/j.medcli.2022.10.014] [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: 08/25/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 01/23/2023]
Abstract
PURPOSE To investigate the prognosis of patients with spontaneous remission (SR) of phospholipase A2 receptor (PLA2R)-associated membranous nephropathy (MN). PATIENTS AND METHODS Patients diagnosed with MN were recruited after examining their renal biopsy in the Renal Department of China-Japan Friendship Hospital between January 2015 and September 2021. Among them, 24 patients with SR were included in this study and follow-up. RESULTS Twenty-four patients diagnosed with SR of PLA2R-associated MN were recruited; 11 were male, and 13 were female, with a mean age of 49.5±14.5 years (range, 30-77 years). The initial 24-hour urinary total protein and serum albumin levels were 0.29±0.14g/d and 37.5±4.4g/L, respectively, and the initial serum creatinine was 65.0±15.8μmol/L. During the follow-up of 33.9±19.1 months (range, 6-73 months), 22 (91.7%) patients maintained remission; however, one patient had impaired renal function due to acute coronary syndrome and coronary angiography findings, and one patient experienced a repeated relapse caused by respiratory tract infection, at 50 and 70 months. A systematic review of the relevant literature was conducted, and records of patients with SR of PLA2R-associated MN were retrieved from 16 case reports or case series with a total of 97 cases. CONCLUSIONS Most patients with SR of MN had a promising long-term prognosis, with only a few cases of relapse.
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Affiliation(s)
- Xu Wang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jiao Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China; Beijing University of Chinese Medicine, Beijing 100029, China
| | - Gu-Ming Zou
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xu-Min Zheng
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jia-Yi Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Hong-Mei Gao
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shi-Min Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Wen-Ge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China.
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Sun IO, Bae YU, Lee H, Kim H, Jeon JS, Noh H, Choi JS, Doh KO, Kwon SH. Circulating miRNAs in extracellular vesicles related to treatment response in patients with idiopathic membranous nephropathy. J Transl Med 2022; 20:224. [PMID: 35568952 PMCID: PMC9107687 DOI: 10.1186/s12967-022-03430-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/05/2022] [Indexed: 12/29/2022] Open
Abstract
Background Extracellular vesicle (EV)-microRNAs (miRNAs) are potential biomarkers for various renal diseases. This study attempted to identify the circulating EV-miRNA signature not only for discriminating idiopathic membranous nephropathy (IMN) from idiopathic nephrotic syndrome (INS), but also to predict the treatment response of patients with IMN. Methods We prospectively enrolled 60 participants, including those with IMN (n = 19) and INS (n = 21) and healthy volunteers (HVs; n = 20) in this study. Using RNA sequencing, we assessed the serum EV-miRNA profiles of all participants. To identify the EV-miRNAs predictive of treatment response in IMN, we also analyzed EV-miRNAs among patients with IMN with and without clinical remission. Results The expression levels of 3 miRNAs differed between IMN patients, INS patients and HVs. In addition, compared to HVs, RNA sequencing revealed differential expression of 77 and 44 EV-miRNAs in patients with IMN without and with remission, respectively. We also identified statistically significant (|fold change ≥ 2, p < 0.05) differences in the expression levels of 23 miRNAs in IMN without remission. Biological pathway analysis of miRNAs in IMN without remission indicated that they are likely involved in various pathways, including renal fibrosis. Conclusion Our study identified EV-miRNAs associated with IMN as well as those associations with therapeutic response. Therefore, these circulating EV-miRNAs may be used as potential markers for the diagnosis and prediction of treatment response in patients with IMN. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03430-7.
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Affiliation(s)
- In O Sun
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Yun-Ui Bae
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Haekyung Lee
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Jin Seok Jeon
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Hyunjin Noh
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Jong-Soo Choi
- Department of Physiology, College of Medicine, Yeungnam University, Daegu, 42415, Republic of Korea
| | - Kyung-Oh Doh
- Department of Physiology, College of Medicine, Yeungnam University, Daegu, 42415, Republic of Korea.
| | - Soon Hyo Kwon
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea.
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Structural determinants of the dominant conformational epitopes of phospholipase A2 receptor in primary membranous nephropathy. J Biol Chem 2022; 298:101605. [PMID: 35065076 PMCID: PMC8867125 DOI: 10.1016/j.jbc.2022.101605] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/27/2022] Open
Abstract
Anti-phospholipase A2 receptor autoantibody (PLA2R-Ab) plays a critical role in the pathogenesis of primary membranous nephropathy (PMN), an autoimmune kidney disease characterized by immune deposits in the glomerular subepithelial spaces and proteinuria. However, the mechanism of how PLA2R-Abs interact with the conformational epitope(s) of PLA2R has remained elusive. PLA2R is a single transmembrane helix receptor containing ten extracellular domains that begin with a CysR domain followed by a FnII and eight CTLD domains. Here, we examined the interactions of PLA2R-Ab with the full PLA2R protein, N-terminal domain truncations, and C-terminal domain deletions under either denaturing or physiological conditions. Our data demonstrate that the PLA2R-Abs against the dominant epitope (the N-terminal CysR-CTLD1 triple domain) possess weak cross-reactivities to the C-terminal domains beyond CTLD1. Moreover, both the CysR and CTLD1 domains are required to form a conformational epitope for PLA2R-Ab interaction, with FnII serving as a linker domain. Upon close examination, we also observed that patients with newly diagnosed PMN carry two populations of PLA2R-Abs in sera that react to the denatured CysR-CTLD3 (the PLA2R-Ab1) and denatured CysR-CTLD1 (the PLA2R-Ab2) domain complexes on Western blots, respectively. Furthermore, the PLA2R-Ab1 appeared at an earlier time point than PLA2R-Ab2 in patients, whereas the increased levels of PLA2R-Ab2 coincided with the worsening of proteinuria. In summary, our data support that an integrated folding of the three PLA2R N-terminal domains, CysR, FnII, and CTLD1, is a prerequisite to forming the PLA2R conformational epitope and that the dominant epitope-reactive PLA2R-Ab2 plays a critical role in PMN clinical progression.
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4
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Spain RI, Andeen NK, Gibson PC, Samuels MH, Morris CD, Solomon AJ, Solomon R, Waslo C, Avasare RS. Lipoic acid supplementation associated with neural epidermal growth factor-like 1 (NELL1)-associated membranous nephropathy. Kidney Int 2021; 100:1208-1213. [PMID: 34662650 DOI: 10.1016/j.kint.2021.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/21/2021] [Accepted: 10/10/2021] [Indexed: 12/13/2022]
Abstract
Lipoic acid (alpha lipoic acid, thioctic acid) is a popular over-the-counter antioxidant and insulin-mimetic supplement under investigation in a variety of conditions including multiple sclerosis, diabetes, and schizophrenia. Unfortunately, high-grade proteinuria was an unexpected adverse event specific to the treatment arm of our clinical trial investigating lipoic acid supplementation in patients with multiple sclerosis. This observation led to detection of similar patients in our nephrology practice. Here, we describe four biopsy-proven cases of neural epidermal growth factor-like 1 (NELL1)-associated membranous nephropathy following lipoic acid supplementation and a fifth suspected case. Discontinuation of lipoic acid and supportive therapy resulted in remission.
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Affiliation(s)
- Rebecca I Spain
- Neurology Division, Portland VA Medical Center, Portland, Oregon, USA.
| | - Nicole K Andeen
- Department of Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Pamela C Gibson
- Department of Pathology and Larboratory Medicine, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Mary H Samuels
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Cynthia D Morris
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrew J Solomon
- Department of Neurological Sciences, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Richard Solomon
- Division of Nephrology and Hypertension, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Carin Waslo
- Research Division, Portland VA Medical Center, Portland, Oregon, USA
| | - Rupali S Avasare
- Department of Medicine, Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA
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Meyer N, Cooper W, Kirwan P, Garsia R, Dunkley S, Gracey DM. Primary membranous glomerulonephritis with negative serum PLA2R in haemophilia A successfully managed with rituximab - case report and review of the literature. BMC Nephrol 2021; 22:268. [PMID: 34294065 PMCID: PMC8299630 DOI: 10.1186/s12882-021-02475-y] [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: 11/11/2020] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) cause a wide range of glomerular pathologies. In people with haemophilia, transfusion-associated infections with these viruses are common and definitive pathological diagnosis in this population is complicated by the difficulty of safely obtaining a renal biopsy. Membranous nephropathy (MN) is a common cause of adult onset nephrotic syndrome occurring in both primary and secondary forms. Primary MN is associated with podocyte autoantibodies, predominantly against phospholipase A2 receptor (PLA2R). Secondary disease is often associated with viral infection; however, infrequently with HIV or HCV. Distinguishing these entities from each other and other viral glomerular disease is vital as treatment strategies are disparate. CASE PRESENTATION We present the case of a 48-year-old man with moderate haemophilia A and well-controlled transfusion-associated HCV and HIV coinfection who presented with sudden onset nephrotic range proteinuria. Renal biopsy demonstrated grade two membranous nephropathy with associated negative serum PLA2R testing. Light and electron microscopic appearances were indeterminant of a primary or secondary cause. Given his extremely stable co-morbidities, treatment with rituximab and subsequent angiotensin receptor blockade was initiated for suspected primary MN and the patient had sustained resolution in proteinuria over the following 18 months. Subsequent testing demonstrated PLA2R positive glomerular immunohistochemistry despite multiple negative serum results. CONCLUSIONS Pursuing histological diagnosis is important in complex cases of MN as the treatment strategies between primary and secondary vary significantly. Serum PLA2R testing alone may be insufficient in the presence of multiple potential causes of secondary MN.
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Affiliation(s)
- Nicholas Meyer
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| | - Wendy Cooper
- Tissue Pathology and Diagnostic Oncology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Paul Kirwan
- Electron Microscopy Unit, Department of Anatomical Pathology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Roger Garsia
- Department of Immunology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Scott Dunkley
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - David M Gracey
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
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Su Z, Jin Y, Zhang Y, Guan Z, Li H, Chen X, Xie C, Zhang C, Liu X, Li P, Ye P, Zhang L, Kong Y, Luo W. The Diagnostic and Prognostic Potential of the B-Cell Repertoire in Membranous Nephropathy. Front Immunol 2021; 12:635326. [PMID: 34122405 PMCID: PMC8190383 DOI: 10.3389/fimmu.2021.635326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/07/2021] [Indexed: 11/13/2022] Open
Abstract
Membranous nephropathy (MN), an autoimmune glomerular disease, is one of the most common causes of nephrotic syndrome in adults. In current clinical practice, the diagnosis is dependent on renal tissue biopsy. A new method for diagnosis and prognosis surveillance is urgently needed for patients. In the present study, we recruited 66 MN patients before any treatment and 11 healthy control (HC) and analyzed multiple aspects of the immunoglobulin heavy chain (IGH) repertoire of these samples using high-throughput sequencing. We found that the abnormalities of CDR-H3 length, hydrophobicity, somatic hypermutation (SHM), and germ line index were progressively more prominent in patients with MN, and the frequency of IGHV3-66 in post-therapy patients was significantly lower than that in pre-therapy patients. Moreover, we found that the IGHV3-38 gene was significantly related to PLA2R, which is the most commonly used biomarker. The most important discovery was that several IGHV, IGHD transcripts, CDR-H3 length, and SHM rate in pre-therapy patients had the potential to predict the therapeutic effect. Our study further demonstrated that the IGH repertoire could be a potential biomarker for prognosis prediction of MN. The landscape of circulating B-lymphocyte repertoires sheds new light on the detection and surveillance of MN.
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Affiliation(s)
- Zuhui Su
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Yabin Jin
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Yu Zhang
- Nephrology Department, The First People's Hospital of Foshan, Foshan, China
| | - Zhanwen Guan
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Huishi Li
- Nephrology Department, The First People's Hospital of Foshan, Foshan, China
| | - Xiangping Chen
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Chao Xie
- Nephrology Department, The First People's Hospital of Foshan, Foshan, China
| | - Chuling Zhang
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Xiaofen Liu
- Nephrology Department, The First People's Hospital of Foshan, Foshan, China
| | - Peixian Li
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Peiyi Ye
- Nephrology Department, The First People's Hospital of Foshan, Foshan, China
| | - Lifang Zhang
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
| | - Yaozhong Kong
- Nephrology Department, The First People's Hospital of Foshan, Foshan, China
| | - Wei Luo
- Clinical Research Institute, The First People's Hospital of Foshan, Foshan, China
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7
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Rojas-Rivera JE, Ortiz Arduán A. Primary membranous nephropathy in the era of autoantibodies and biological therapies. Med Clin (Barc) 2021; 157:121-129. [PMID: 33832765 DOI: 10.1016/j.medcli.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022]
Abstract
Primary membranous nephropathy is an autoimmune kidney disease and the most common cause of nephrotic syndrome in adults. About 70%-80% of cases are caused by anti-PLA2R antibodies. Its association with anti-THSD7A antibodies and other autoantibodies has also been described. Recent pilot studies and clinical trials have shown that several biological agents targeting autoantibody-producing cells are effective in controlling the disease with an acceptable safety profile. In this narrative review, we update key concepts about the pathogenesis, autoantibody-based diagnosis, and kidney biopsy findings in primary membranous nephropathy. In addition, we propose a diagnostic and therapeutic algorithm, including guidance on monitoring the response to therapy. We compare the efficacy and safety of currently available treatments, including rituximab and new biological agents, and identify unmet clinical needs.
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Affiliation(s)
- Jorge Enrique Rojas-Rivera
- Unidad de Enfermedades Glomerulares y Autoinmunes; Servicio de Nefrología e Hipertensión, Hospital Universitario Fundación Jiménez Díaz, Madrid, España; Grupo Español de Estudio en Enfermedades Glomerulares (GLOSEN), España; Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, España.
| | - Alberto Ortiz Arduán
- Servicio de Nefrología e Hipertensión, Hospital Universitario Fundación Jiménez Díaz, Madrid, España; Grupo Español de Estudio en Enfermedades Glomerulares (GLOSEN), España; Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, España
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8
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Safar-Boueri L, Piya A, Beck LH, Ayalon R. Membranous nephropathy: diagnosis, treatment, and monitoring in the post-PLA2R era. Pediatr Nephrol 2021; 36:19-30. [PMID: 31811540 DOI: 10.1007/s00467-019-04425-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/11/2019] [Accepted: 11/15/2019] [Indexed: 01/10/2023]
Abstract
Membranous nephropathy (MN) is an immune complex-mediated cause of the nephrotic syndrome that can occur in all age groups, from infants to the very elderly. However, nephrotic syndrome in children is more frequently caused by conditions such as minimal change disease or focal segmental glomerulosclerosis, and much less commonly by MN. While systemic conditions such as lupus or infections such as hepatitis B may more commonly be associated as secondary causes with MN in the younger population, primary or "idiopathic" MN has generally been considered a disease of adults. Autoantibodies both to the M-type phospholipase A2 receptor (PLA2R) and to thrombospondin type-1 domain-containing 7A (THSD7A), initially described in adult MN, have now been identified in children and adolescents with MN and serve as a useful diagnostic and monitoring tool in this younger population as well. Whereas definitive therapy for secondary forms of MN should be targeted at the underlying cause, immunosuppressive therapy is often necessary for primary disease. Rituximab has been successfully used in the treatment of MN, and is likely effective in children with MN as well, although dosing in the pediatric population is not well established. This review highlights the new findings in adult and pediatric MN since last reviewed in this journal.
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Affiliation(s)
- Luisa Safar-Boueri
- Boston Medical Center and Boston University School of Medicine, Boston, MA, 02118, USA
| | - Albina Piya
- Boston Medical Center and Boston University School of Medicine, Boston, MA, 02118, USA
| | - Laurence H Beck
- Boston Medical Center and Boston University School of Medicine, Boston, MA, 02118, USA
| | - Rivka Ayalon
- Boston Medical Center and Boston University School of Medicine, Boston, MA, 02118, USA.
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Guo Y, Wu X, Liu L, Zhang H, Yang L, Chen W. Efficacy of leflunomide combined with prednisone for the treatment of PLA2R-associated primary membranous nephropathy. Ren Fail 2020; 42:122-130. [PMID: 31957527 PMCID: PMC7006764 DOI: 10.1080/0886022x.2020.1713806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective To evaluate the clinical efficacy and safety of leflunomide (LEF) combined with prednisone for the treatment of PLA2R-associated primary membranous nephropathy (PMN) and changes in anti-PLA2R antibody titers after treatment. Methods Sixty patients with nephrotic syndrome, biopsy-proven MN and anti-PLA2R antibody positivity were included in this study conducted from December 2017 to February 2019. The patients were randomly divided into an experimental group (n = 30) and a control group (n = 30). The patients in the experimental group were treated with LEF combined with prednisone, whereas the patients in the control group were treated with cyclophosphamide (CTX) combined with prednisone. We assessed 24-h urinary protein and serum albumin levels, kidney function markers, blood lipid levels and anti-PLA2R antibody titers before and after treatment. Adverse reactions during treatment were recorded. Results After 16 weeks of treatment, there were 2 cases of complete remission and 6 cases of partial remission in the experimental group, with a total effective rate of 26.67%. In the control group, there were 4 cases of complete remission and 8 cases of partial remission, with a total effective rate of 40% (p > .05). After 24 weeks of treatment, the total effective rates of the experimental and control groups were 66.67% and 76.67%, respectively (p > .05). There were no significant differences in 24-h urinary protein, serum albumin, kidney function marker or blood lipid levels between the two groups after treatment (p > .05). However, there were fewer adverse reactions in the experimental group than in the control group (p < .05). After treatment, serum anti-PLA2R antibody titers were clearly decreased in patients with complete remission and partial remission (p < .05), but these levels remained relatively high in patients without remission (p > .05). Conclusion LEF combined with prednisone has a certain efficacy for the treatment of PLA2R-associated PMN and provokes few adverse reactions. A large-sample randomized double-blind controlled study with a long follow-up period is needed to verify the efficacy of LEF combined with prednisone.
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Affiliation(s)
- Yaling Guo
- Department of Nephrology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, People's Republic of China
| | - Xueping Wu
- Department of Nephrology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, People's Republic of China
| | - Lei Liu
- Department of Nephrology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, People's Republic of China
| | - Haifeng Zhang
- Department of Nephrology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, People's Republic of China
| | - Lijuan Yang
- Department of Nephrology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, People's Republic of China
| | - Weidong Chen
- Department of Nephrology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, People's Republic of China
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10
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Dhaouadi T, Abdellatif J, Trabelsi R, Gaied H, Chamkhi S, Sfar I, Goucha R, Ben Hamida F, Ben Abdallah T, Gorgi Y. PLA2R antibody, PLA2R rs4664308 polymorphism and PLA2R mRNA levels in Tunisian patients with primary membranous nephritis. PLoS One 2020; 15:e0240025. [PMID: 33002091 PMCID: PMC7529277 DOI: 10.1371/journal.pone.0240025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/17/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Primary membranous nephritis (PMN) is an autoimmune disease induced by the deposit of antibodies (Ab) to the phospholipase receptor A2 receptor (PLA2R) on podocytes. In this context, we aimed to assess the relationships between anti-PLA2R Ab, PLA2R rs4664308 SNP, PLA2R mRNA levels and PMN susceptibility and outcome. METHODS Sixty-eight PMN patients, 30 systemic lupus erythematosus (SLE) patients with secondary MN and 30 healthy control subjects served for anti-PLA2R Ab measurement by ELISA and PLA2R rs4664308 SNP genotyping by a commercial real-time PCR. Twenty patients with tubulo-interstitial nephritis (TIN) were used as controls for renal PLA2R mRNA quantification in PMN patients from kidney biopsies. PLA2R mRNA quantification was carried-out by real-time PCR after RNA extraction. RESULTS Forty-three (63.2%) PMN patients received initial therapy consisting of alternating monthly cycles of corticosteroids and cyclophosphamide. Twelve (17.6%) patients had resistant PMN to initial therapy and were consecutively treated by cyclosporine or tacrolimus. Anti-PLA2R Ab were positive in 54 (79.4%) PMN patients, while all SLE patients and controls were negative, p<0.0001. Moreover, anti-PLA2R Ab levels were significantly higher in PMN patients (134.85 [41.25-256.97] RU/ml) than in SLE patients (3.35 [2.3-4.35] RU/ml) and controls (2 [2-2.3]), p<0.0001. Consequently, a ROC curve showed for 100% specificity a sensitivity of 94.1% at a threshold of 2.6 RU/ml. Besides, Anti-PLA2R antibodies levels were significantly associated to non-remission; p = 0.002. The rs4664308*A wild-type allele was significantly more frequent in PMN patients (0.809) than in controls (0.633) and SLE patients (0.65); p = 0.008, OR [95% CI] = 2.44 [1.24-4.82] and p = 0.016, OR [95% CI] = 2.27 [1.15-4.5], respectively. Renal PLA2R mRNA levels were significantly higher in PMN patients (218.29 [66.05-486.07]) than in TIN patients (22.09 [13.62-43.34]), p<0.0001. Moreover, PLA2R mRNA levels were significantly higher in non-remission patients (fold-factor vs. partial remission = 2.46 and fold-factor vs. complete remission = 12.25); p = 1.56 10E-8. In addition, PLA2R mRNA and anti-PLA2R Ab levels were significantly correlated, Spearman Rho = 0.958, p<0.0001. CONCLUSION Anti-PLA2R Ab and renal PLA2R mRNA could be useful markers for PMN outcome predicting. The PLA2R rs6446308 SNP is associated with PMN susceptibility in Tunisians.
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Affiliation(s)
- Tarak Dhaouadi
- Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
- * E-mail:
| | - Jihen Abdellatif
- Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Raja Trabelsi
- Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Hanene Gaied
- Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Sameh Chamkhi
- Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Imen Sfar
- Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Rym Goucha
- Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Taieb Ben Abdallah
- Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
- Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
| | - Yousr Gorgi
- Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
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Feng Z, Liu W, Jiang HX, Dai H, Gao C, Dong Z, Gao Y, Liu F, Zhang Z, Zhao Q, Zhang L, Liu B. How Does Herbal Medicine Treat Idiopathic Membranous Nephropathy? Front Pharmacol 2020; 11:994. [PMID: 32719601 PMCID: PMC7350518 DOI: 10.3389/fphar.2020.00994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/19/2020] [Indexed: 02/06/2023] Open
Abstract
Idiopathic membranous nephropathy (IMN) has made increasing progress in mechanism and treatment research. Herbal medicine is gradually being accepted as an alternative therapy in treating IMN. However, the intervention mechanism of herbal medicine in the treatment of membranous nephropathy is still unclear. In this review, we summarize some achievements of herb medicine in treating IMN and discuss the research direction of herb in IMN. Finally, we propose the dilemma about the study on the treatment of IMN with herb medicine. We hope that this article can bring some thoughts for clinical and scientific researchers on the treatment of IMN with herb medicine.
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Affiliation(s)
- Zhendong Feng
- Department of Nephropathy, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Department of Nephropathy, Beijing Traditional Chinese Medicine Hospital Pinggu Hospital, Beijing, China
| | - Wenbin Liu
- Department of Nephropathy, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Han Xue Jiang
- Beijing University of Chinese Medicine, Beijing, China
| | - Haoran Dai
- Shunyi Branch, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Chang Gao
- Beijing University of Chinese Medicine, Beijing, China
| | | | - Yu Gao
- Department of Nephropathy, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Fei Liu
- Beijing University of Chinese Medicine, Beijing, China
| | - Zihan Zhang
- Beijing University of Chinese Medicine, Beijing, China
| | - Qihan Zhao
- Department of Nephropathy, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lei Zhang
- Department of Nephropathy, Beijing Traditional Chinese Medicine Hospital Pinggu Hospital, Beijing, China
| | - Baoli Liu
- Department of Nephropathy, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
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Abstract
PURPOSE OF REVIEW Continuous expansion of our knowledge in the pathogenesis of membranous nephropathy possible by the identification of antibodies recognized specific podocytes antigens results in unprecedent patient management strategy. RECENT FINDINGS Circulating anti-phospholipase A2 receptor (PLA2R) and anti-thrombospondin domain 7A (THSD7A) antibodies strongly relate with the modifications of podocytes biology leading to the new molecular diagnosis of membranous nephropathy. Immunization against THSD7A involves extra-renal mechanism. However, the pathway of anti-PLA2R immunization still remains unresolved. Experimental data highlight the crucial role of THSD7A in the attachment of podocytes to the glomerular basement membrane, rewarding the THSD7A pathogenicity, whereas the third of Koch's postulates is still not fulfilled for anti-PLA2R antibodies. The anti-PLA2R antibodies epitope spreading will possibly be even more specific marker improving the molecular classification of membranous nephropathy. Two immune epitopes have been identified in the N-terminal tail of THSD7A but without evidence of epitope spreading as for anti-PLA2R. SUMMARY In 2019, the Kidney Diseases: Improving Global Outcomes guidelines recognized anti-PLA2R antibodies (but not anti-THSD7A antibodies) as a valuable molecular risk factor for the pejorative evolution of kidney function and recommended their monitoring for the diagnosis and the assessment of membranous nephropathy immune activity. Screening for malignancy is particularly advised in THSD7A-mediated membranous nephropathy.
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Chen X, Chen Y, Ding X, Zhou Y, Lv Y, Li D, Chen B, Chen T, Chen C. Baseline proteinuria level is associated with prognosis in idiopathic membranous nephropathy. Ren Fail 2019; 41:363-369. [PMID: 31057017 PMCID: PMC6508055 DOI: 10.1080/0886022x.2019.1605294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives: This study aimed to investigate the unique prognostic, clinical, and renal histopathological characteristics of patients with idiopathic membranous nephropathy (IMN) with different levels of proteinuria. Methods: This retrospective observational study included 190 IMN patients with low levels of proteinuria (low group), 193 IMN patients with medium levels of proteinuria (medium group), and 123 IMN patients with high levels of proteinuria (high group) treated between September 2006 and November 2015. Prognostic and baseline clinical and histopathological data were compared among the three groups. Poor prognostic events included the occurrence of a persistent 50% reduction in estimated glomerular filtration rate (eGFR), end-stage renal disease, or all-cause mortality. Results: The severity of clinical symptoms and laboratory indices, such as blood pressure; extent of edema and hematuria; levels of fibrinogen, immunoglobulin (Ig)-G, complement (C)-4, total protein, albumin (ALB), and serum creatinine (SCr); and eGFR increased with increasing proteinuria (all p< .001). Based on renal histopathology, the extent of segmental sclerosis and balloon adhesion and renal interstitial lesion stage also increased in severity with increasing proteinuria (all p< .001). The Kaplan–Meier analysis showed that compared with patients with low and medium levels of proteinuria, patients with high levels of proteinuria had significantly lower cumulative poor event-free renal survival rates (p= .0039). Conclusions: Baseline proteinuria level is indicative of prognosis in IMN patients; the greater the extent of proteinuria is, the worse the prognosis.
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Affiliation(s)
- Xinxin Chen
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Yu Chen
- b Department of Nephrology , Zhejiang Chinese Medical University Affiliated Wenzhou Hospital of Traditional Chinese Medicine , Wenzhou , China
| | - Xiaokai Ding
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Ying Zhou
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Yinqiu Lv
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Duo Li
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Bo Chen
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Tianxin Chen
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Chaosheng Chen
- a Department of Nephrology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
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Zhang Q, Liu X, Zhang Z, Wu M, Huang B, Zhang Y, Liu B, Qi Z, Shan W, Wang L, Hu Z, Sun Z. A comparison of clinical features between idiopathic membranous nephropathy patients with and without serum antibody against phospholipase A2 receptor. Medicine (Baltimore) 2019; 98:e17658. [PMID: 31702617 PMCID: PMC6855492 DOI: 10.1097/md.0000000000017658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with idiopathic membranous nephropathy (IMN) can be categorized into phospholipase A2 receptor (PLA2R)-associated and non-PLA2R-associated cases, according to serum PLA2R antibody status. The present study aimed to determine whether clinical features differed between these.A total of 89 patients with IMN were retrospectively recruited for the present study. Serum PLA2R-Ab levels were determined by time-resolved fluoroimmunoassay. Furthermore, the relationship between serum PLA2R antibody levels and their responses to immunosuppressants among patients with a complete follow-up period, which was defined as at least 1 year, was analyzed.Among these enrollees, 71 (80.0%) patients were positive for serum PLA2R antibody. Furthermore, patients with PLA2R-associated IMN had significantly higher age (with vs without, 54.31 ± 14.03 vs 46.67 ± 13.30 years old; P = .04), proteinuria (4.32 ± 1.84 vs 3.29 ± 1.90 g/d, P = .039), and serum albumin (25.33 ± 9.60 vs 31.38 ± 9.52 g/L, P = .019), but had lower serum immunoglobulin G (6.83 ± 2.89 vs 8.72 ± 2.95 g/L, P = .016) and erythrocyte sedimentation rate (47.31 ± 32.11 vs 26.33 ± 27.94, P = .013), when compared to IMN patients without PLA2R. Furthermore, IMN patients without PLA2R exhibited a better response to immunosuppressants, when compared to patients with PLA2R-associated IMN (without vs with, 66.7% vs 62.5% at 6 months and 100% vs 87.5% at 12 months), but the difference was not statistically significant.Patients with PLA2R-associated IMN had higher disease severity than IMN patients without PLA2R. Furthermore, PLA2R negative patients had a better response to immunosuppressive therapies than PLA2R-positive patients, but the difference was not statistically significant.
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Affiliation(s)
- Qiuhua Zhang
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Xiaobin Liu
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Zhijian Zhang
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Mian Wu
- Nanjing Medical University, Nanjing
| | - Biao Huang
- School of Life Science, Zhejiang, Sci-Tech University, Hangzhou
| | - Yi Zhang
- Jiangsu Institute of Nuclear Medicine, Wuxi, China
| | - Bin Liu
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Zhen Qi
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Weiwei Shan
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Liang Wang
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Zhigang Hu
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
| | - Zhuxing Sun
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi
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Prognostic value of phospholipase A2 receptor in primary membranous nephropathy: a systematic review and meta-analysis. Int Urol Nephrol 2019; 51:1581-1596. [PMID: 31140029 DOI: 10.1007/s11255-019-02147-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/10/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE We aimed to evaluate the prognostic value of serum anti-PLA2R and glomerular PLA2R deposit (gPLA2R) in predicting remission of proteinuria in Primary Membranous Nephropathy (PMN) patients. METHODS PUBMED, EMBASE, WEB OF SCIENCE, COCHRANE LIBRARY and CNKI were searched from 2008 January to December 2018. Heterogeneity was assessed by Cochran Q test and I2. Source of heterogeneity was explored by subgroup analysis and sensitivity analysis. RESULTS Totally 2345 patients from 29 cohort studies were eligible for inclusion. The results suggested that PMN patients with negative anti-PLA2R at the time of biopsy had a 1.31 times (95% CI 1.12-1.46, p < 0.05) higher possibility in achieving remission than those with positive anti-PLA2R. The clearance of anti-PLA2R at the end of immunosuppressive therapy showed an even greater chance of achieving remission (RR = 2.86, 95% CI 1.75-4.69, p < 0.05). The relative ratios for complete remission and spontaneous remission with negative anti-PLA2R were 1.65 (95% CI 1.46-1.87, p < 0.05) and 1.93, respectively (95% CI 1.53-2.45, p < 0.05), and heterogeneity percentages were I2 = 18% and 46%, respectively. The possibility for remission was significantly greater among PMN patients with negative gPLA2R (RR = 1.30, 95% CI 1.13-1.50, p < 0.05). Subgroup analyses revealed that retrospective design of study might be the potential source of heterogeneity. CONCLUSIONS Negative anti-PLA2R or gPLA2R might predict higher possibility of remission, and the presence of anti-PLA2R or gPLA2R might serve as a useful biomarker for clinical outcome and predicting response to immunosuppressive therapy in PMN.
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Zhang D, Wu Y, Zhang C, Zhang W, Zou J, Jiang G. Compared staining of the phospholipase A2 receptor in the glomeruli of Chinese adults and children with idiopathic membranous nephropathy. Pathol Res Pract 2019; 215:952-956. [DOI: 10.1016/j.prp.2019.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 01/11/2019] [Accepted: 01/29/2019] [Indexed: 12/14/2022]
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Stahl RA, Reinhard L, Hoxha E. Characterization of autoantibodies in primary membranous nephropathy and their clinical significance. Expert Rev Clin Immunol 2018; 15:165-175. [PMID: 30433832 DOI: 10.1080/1744666x.2019.1548934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Membranous nephropathy (MN) is the most common cause of a nephrotic syndrome in Caucasian adults. The identification of target antigens in MN in the last decade has had a major impact on the clinical approach to these patients. Areas covered: Since the discoveries in animal models in the 1980s that circulating autoantibodies induce disease upon in situ binding to glomerular podocytes, many attempts have been undertaken to define the human antigens responsible for disease induction. Only in 2009 was Phospholipase A2 Receptor 1 described as the major antigen responsible for MN onset in about 70% of patients. Subsequently, in 2014, Thrombospondin Type-1 Domain-Containing 7A was identified as a second antigen, accounting for 2-3% of patients with MN. The knowledge of the role of these antibodies in MN has improved the diagnosis and management of patients and helped to better define the need for immunosuppressive treatment. Expert commentary: These discoveries over the last 10 years in the discipline of nephrology have clearly shown the improvements a better understanding of disease pathogenesis can bring for patient care.
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Affiliation(s)
- Rolf Ak Stahl
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Linda Reinhard
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Elion Hoxha
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Shang SL, Cai GY, Duan SW, Li P, Li QG, Chen XM. Retrospective analysis of tacrolimus combined with Tripterygium wilfordii polyglycoside for treating idiopathic membranous nephropathy. BMC Nephrol 2018; 19:182. [PMID: 30021637 PMCID: PMC6052665 DOI: 10.1186/s12882-018-0967-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/26/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is one of the most common adult nephrotic syndromes. Some patients with this disorder require immunosuppressive therapy. This retrospective case series was performed to assess the effects of tacrolimus (TAC) combined with Tripterygium wilfordii polyglycoside (TWG) in treating IMN. METHODS From January 2015 to August 2016, kidney-biopsy-proven IMN patients treated with TAC in the Chinese PLA General Hospital were screened. Data were retrieved from the patients' medical records. The first efficacy evaluation index was remission rate (complete remission and partial remission), and the secondary efficacy evaluation indices included relapse rate, proteinuria, serum albumin and estimated glomerular filtration rate (eGFR). Adverse events were also assessed. RESULTS The included patients' treatments were tacrolimus monotherapy (TAC group, n = 33), tacrolimus combined with methylprednisolone (MP) (TAC + MP group, n = 24) and tacrolimus combined with Tripterygium wilfordii polyglycoside (TAC + TWG group, n = 21). The remission rates of the TAC, TAC + MP, and TAC + TWG groups in the 10th month were 54.5, 62.5, and 85.7%, respectively (TAC + TWG group vs TAC group, P = 0.037, TAC + TWG group vs TAC + MP group, P = 0.125). Moreover, the complete remission rates of the TAC, TAC + MP, and TAC + TWG groups in the 10th month were 21.2, 20.8, and 57.1%, respectively (TAC + TWG group vs TAC group, P = 0.007, TAC + TWG group vs TAC + MP group, P = 0.012). Compared with the TAC group, the TAC + TWG group had a higher remission rate during these ten months (log-rank, P = 0.005). Compared with the TAC and TAC + MP groups, the TAC + TWG group had a higher complete remission rate (log-rank, P = 0.019 and log-rank, P = 0.005, respectively). CONCLUSION This retrospective study showed that TAC combined with TWG may be effective for treating IMN. Further randomized controlled trials (RCTs) are needed to assess the efficacy and safety of TAC combined with TWG.
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Affiliation(s)
- Shun-Lai Shang
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guang-Yan Cai
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Shu-Wei Duan
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ping Li
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Qing-Gang Li
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Xiang-Mei Chen
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Affiliation(s)
- Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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Liang Q, Li H, Xie X, Qu F, Li X, Chen J. The efficacy and safety of tacrolimus monotherapy in adult-onset nephrotic syndrome caused by idiopathic membranous nephropathy. Ren Fail 2018; 39:512-518. [PMID: 28562168 PMCID: PMC6014322 DOI: 10.1080/0886022x.2017.1325371] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: The purpose of the study is to evaluate the efficiency and safety of tacrolimus (TAC) monotherapy in the treatment of nephrotic idiopathic membranous nephropathy (IMN) compared with the protocol of cyclophosphamide (CTX) combined with corticosteroids. Methods: In total, 58 patients with nephrotic syndrome and biopsy-proven IMN were included in this study. 30 patients received TAC monotherapy with an initial dose of 0.05–0.1 mg/kg/day. 28 patients received transvenous CTX at a dose of 0.5–0.75 g/m2 once in every month initially for 6 months and once in every 2 or 3 months for the later period, and the regimen was combined with corticosteroids (prednisone 1 mg/kg/d). All patients were observed for the treatment effects, recurrence and side effects. Results: Twelve months after the initial treatment, a total of 24 (80%) patients in the TAC group and 23 (82.1%) patients in the CTX group achieved remission (either partial or complete remission). The survival curve of the probability of remission and complete remission were similar between the two groups (p > .05). Proteinuria (based on 24 h urinary protein excretion) was significantly decreased, and serum albumin was significantly increased after immunosuppressive treatment in both the groups. Estimated glomerular filtration rate (eGFR) was comparable between before and after treatment. The main adverse effects in TAC treatment were glucose intolerance, diabetes and abnormal aminotransferase. Conclusions: TAC monotherapy is an alternative therapeutic regimen for patients with nephrotic IMN. Its short-term efficiency and patient tolerance are both acceptable.
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Affiliation(s)
- Qian Liang
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Heng Li
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Xishao Xie
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Fangzhi Qu
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Xiayu Li
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Jianghua Chen
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
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Zhang XD, Cui Z, Zhao MH. The Genetic and Environmental Factors of Primary Membranous Nephropathy: An Overview from China. KIDNEY DISEASES 2018; 4:65-73. [PMID: 29998121 DOI: 10.1159/000487136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/18/2018] [Indexed: 01/10/2023]
Abstract
Background Primary membranous nephropathy (pMN) is the most common cause of nephrotic syndrome in adults. The discovery of the 2 autoantigens, M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A), has defined pMN as an autoimmune disease. A remarkable increase in the frequency of pMN in primary glomerular disease was witnessed in China. The genetic and environmental contributors to disease susceptibility have been investigated in these patients. Summary We reviewed recent publications in genetic and environmental studies of pMN, focusing mainly on those undertaken in China. Following a genome-wide association study, the gene-gene interaction between the 2 most significant risk factors, PLA2R1 and DQA1, was validated in Chinese patients with MN. Fine mapping on human leukocyte antigen (HLA) locus found that DRB1*1501 and DRB1*0301 were risk alleles. Three amino acid residues on positions 13 and 71 of HLA-DRβ1 chain may confer the susceptibility to pMN by presenting T-cell epitopes on PLA2R. Another study found that DRB3*0202 was the most likely culprit allele for the signal at DRB1*0301. One environmental risk factor for pMN has been identified as the long-term exposure to high levels of PM2.5 in Chinese patients with MN. Each 10 μg/m3 increase in PM2.5 concentration was associated with 14% higher odds for pMN in the regions with PM2.5 above 70 μg/m3. Key Message A gene-environment interaction is suspected as an underlying mechanism for the increasing trend of pMN in China.
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Affiliation(s)
- Xiao-Dan Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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Membranous Nephropathy and Anti-Podocytes Antibodies: Implications for the Diagnostic Workup and Disease Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6281054. [PMID: 29511687 PMCID: PMC5817285 DOI: 10.1155/2018/6281054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/31/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
The discovery of circulating antibodies specific for native podocyte antigens has transformed the diagnostic workup and greatly improved management of idiopathic membranous nephropathy (iMN). In addition, their identification has clearly characterized iMN as a largely autoimmune disorder. Anti-PLA2R1 antibodies are detected in approximately 70% to 80% and anti-THSD7A antibodies in only 2% of adult patients with iMN. The presence of anti-THSD7A antibodies is associated with increased risk of malignancy. The assessment of PLA2R1 and THSD7A antigen expression in glomerular immune deposits has a better sensitivity than measurement of the corresponding autoantibodies. Therefore, in the presence of circulating anti-podocytes autoantibodies and/or enhanced expression of PLA2R1 and THSD7A antigens MN should be considered as primary MN (pMN). Anti-PLA2R1 or anti-THSD7A autoantibodies have been proposed as biomarkers of autoimmune disease activity and their blood levels should be regularly monitored in pMN to evaluate disease activity and predict outcomes. We propose a revised clinical workup flow for patients with MN that recommends assessment of kidney biopsy for PLA2R1 and THSD7A antigen expression, screening for circulating anti-podocytes antibodies, and assessment for secondary causes, especially cancer, in patients with THSD7A antibodies. Persistence of anti-podocyte antibodies for 6 months or their increase in association with nephrotic proteinuria should lead to the introduction of immunosuppressive therapies. Recent data have reported the efficacy and safety of new specific therapies targeting B cells (anti-CD20 antibodies, inhibitors of proteasome) in pMN which should lead to an update of currently outdated treatment guidelines.
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Comparison of prognostic, clinical, and renal histopathological characteristics of overlapping idiopathic membranous nephropathy and IgA nephropathy versus idiopathic membranous nephropathy. Sci Rep 2017; 7:11468. [PMID: 28904360 PMCID: PMC5597578 DOI: 10.1038/s41598-017-11838-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/31/2017] [Indexed: 11/08/2022] Open
Abstract
Overlapping idiopathic membranous nephropathy (IMN) and immunoglobulin A nephropathy (IgAN) is rare. This study aims to investigate the unique prognostic, clinical, and renal histopathological characteristics of IMN+IgAN. This retrospective observational study included 73 consecutive cases of IMN+IgAN and 425 cases of IMN treated between September 2006 and November 2015. Prognostic and baseline clinical and histopathological data were compared between the two patient groups. Poor prognostic events included a permanent 50% reduction in eGFR, end-stage renal disease, and all-cause mortality. Renal histopathology demonstrated that the patients with IMN+IgAN presented with significantly increased mesangial cell proliferation and matrix expansion, increased inflammatory cell infiltration, and higher proportions of arteriole hyalinosis and lesions than the patients with IMN (all P < 0.05). Kaplan–Meier analysis showed that the patients with IMN+IgAN had significantly higher cumulative incidence rates of partial or complete remission (PR or CR, P = 0.0085). Multivariate Cox model analysis revealed that old age at biopsy and high baseline serum creatinine and uric acid levels were significantly associated with poor prognosis (all P < 0.05), and increased IgA expression correlated significantly with PR or CR (P < 0.05). The present study found that overlapping IMN and IgAN presents with unique renal histopathology and appears not to cause a poorer prognosis than IMN.
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Angioi A, Lepori N, López AC, Sethi S, Fervenza FC, Pani A. Treatment of primary membranous nephropathy: where are we now? J Nephrol 2017; 31:489-502. [PMID: 28875476 DOI: 10.1007/s40620-017-0427-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/26/2017] [Indexed: 02/02/2023]
Abstract
In the last 10 years, basic science and clinical research have made important contributions to the understanding and management of primary membranous nephropathy (MN). The identification of antibodies directed against the M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A protein have added a new perspective on diagnosis, monitoring the immunological activity, predicting prognosis and guiding therapy in patients with primary MN. Mounting evidence suggests that quantification and follow-up of antiPLA2R Abs levels can help in assessing prognosis and evaluate the response to treatment. The kidney disease improving global outcomes guidelines published in 2012 have not been updated. New data on the use of rituximab suggest it should be considered as a potential initial therapy in the treatment of patients with primary MN.
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Affiliation(s)
- Andrea Angioi
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy
| | - Nicola Lepori
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy
| | - Ana Coloma López
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, USA
| | - Sanjeev Sethi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Antonello Pani
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy.
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Xu NX, Xie QH, Sun ZX, Wang J, Li Y, Wang L, Liu SJ, Xue J, Hao CM. Renal Phospholipase A2 Receptor and the Clinical Features of Idiopathic Membranous Nephropathy. Chin Med J (Engl) 2017; 130:892-898. [PMID: 28397717 PMCID: PMC5407034 DOI: 10.4103/0366-6999.204096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: According to the renal phospholipase A2 receptor (PLA2R) immunohistochemistry, idiopathic membranous nephropathy (iMN) could be categorized into PLA2R-associated and non-PLA2R-associated iMN. This study aimed to examine whether the non-PLA2R-associated iMN had any difference in clinical features compared with PLA2R-associated iMN. Methods: A total of 231 adult patients diagnosed as iMN were recruited to this retrospective study. Renal PLA2R expression was examined by immunofluorescence. Among these patients, 186 (80.5%) with complete baseline clinical data were used for further study. Urinary protein excretion, serum albumin, and creatinine were analyzed. For those patients with follow-up longer than 1 year, the relationship between PLA2R and response to immunosuppressants were analyzed. The t-test was used for parametric analysis and the Mann-Whitney U-test was used for nonparametric analysis. Categorical variables were described as frequencies or percentages, and the data were analyzed with Pearson's Chi-square test or Fisher's exact test. Results: Of the 231 iMN patients, 189 showed renal detectable PLA2R expression (81.8%). The baseline serum creatinine, serum albumin, and urine protein excretion were not significantly different between PLA2R-associated (n = 145) and non-PLA2R-associated iMN patients (n = 41). However, about 1/3 of the non-PLA2R-associated iMN had abnormal serological tests, significantly more common than PLA2R-associated iMN (31.7% vs. 8.3%, P = 0.000). The non-PLA2R-associated iMN had lower C4 levels compared with PLA2R-associated iMN (P = 0.004). The non-PLA2R-associated iMN patients also showed a better response to immunosuppressants (complete remission [CR] 42.9%; partial remission [PR] 14.3%) compared with PLA2R-associated iMN (CR 3.2%; PR 48.4%, P = 0.004) at the 3rd month. Conclusions: There were no significant differences in serum creatinine, albumin, and urine protein excretion between PLA2R-associated and non-PLA2R-associated iMN, while the non-PLA2R-associated iMN patients showed more abnormal serological tests. The non-PLA2R-associated iMN seemed to respond more quickly to the immunosuppressive therapy compared with PLA2R-associated iMN.
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Affiliation(s)
- Ning-Xin Xu
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qiong-Hong Xie
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhu-Xing Sun
- Department of Nephrology, Wuxi People's Hospital, Wuxi, Jiangsu 214023, China
| | - Jia Wang
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yan Li
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Liang Wang
- Department of Nephrology, Wuxi People's Hospital, Wuxi, Jiangsu 214023, China
| | - Shao-Jun Liu
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chuan-Ming Hao
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
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Tomas NM, Meyer-Schwesinger C, von Spiegel H, Kotb AM, Zahner G, Hoxha E, Helmchen U, Endlich N, Koch-Nolte F, Stahl RAK. A Heterologous Model of Thrombospondin Type 1 Domain-Containing 7A-Associated Membranous Nephropathy. J Am Soc Nephrol 2017; 28:3262-3277. [PMID: 28814510 DOI: 10.1681/asn.2017010030] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/25/2017] [Indexed: 11/03/2022] Open
Abstract
Thrombospondin type 1 domain-containing 7A (THSD7A) is a target for autoimmunity in patients with membranous nephropathy (MN). Circulating autoantibodies from patients with THSD7A-associated MN have been demonstrated to cause MN in mice. However, THSD7A-associated MN is a rare disease, preventing the use of patient antibodies for larger experimental procedures. Therefore, we generated antibodies against the human and mouse orthologs of THSD7A in rabbits by coimmunization with the respective cDNAs. Injection of these anti-THSD7A antibodies into mice induced a severe nephrotic syndrome with proteinuria, weight gain, and hyperlipidemia. Immunofluorescence analyses revealed granular antigen-antibody complexes in a subepithelial location along the glomerular filtration barrier 14 days after antibody injection, and immunohistochemistry for rabbit IgG and THSD7A as well as ultrastructural analyses showed the typical characteristics of human MN. Mice injected with purified IgG from rabbit serum that was taken before immunization failed to develop any of these changes. Notably, MN developed in the absence of detectable complement activation, and disease was strain dependent. In vitro, anti-THSD7A antibodies caused cytoskeletal rearrangement and activation of focal adhesion signaling. Knockdown of the THSD7A ortholog, thsd7aa, in zebrafish larvae resulted in altered podocyte differentiation and impaired glomerular filtration barrier function, with development of pericardial edema, suggesting an important role of THSD7A in glomerular filtration barrier integrity. In summary, our study introduces a heterologous mouse model that allows further investigation of the molecular events that underlie MN.
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Affiliation(s)
| | | | | | - Ahmed M Kotb
- Institute of Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany; and.,Department of Anatomy and Histology, Faculty of Veterinary Medicine, Assiut University, Assiut, Egypt
| | | | | | | | - Nicole Endlich
- Institute of Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany; and
| | - Friedrich Koch-Nolte
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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28
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Gupta S, Connolly J, Pepper RJ, Walsh SB, Yaqoob MM, Kleta R, Ashman N. Membranous nephropathy: a retrospective observational study of membranous nephropathy in north east and central London. BMC Nephrol 2017. [PMID: 28637442 PMCID: PMC5480139 DOI: 10.1186/s12882-017-0615-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. MN is a clinically heterogeneous disease and it is difficult to accurately predict outcomes (including end stage renal failure) at presentation and whom to treat with potentially toxic therapies. We aimed to identify factors predicting outcome in MN in our cohort from two large tertiary London units by undertaking a retrospective data analysis of 148 biopsy-proven MN patients from North East and Central London between 1995 and 2015. Methods Review of clinical and biochemistry databases. Results Surprisingly, patients that reached end stage renal failure (ESRF) had a less severe nephrosis compared to those that did not develop ESRF; serum albumin 33 g/L (3.3 g/dL) versus 24 g/L (2.4 g/dL), p = 0.002 and urinary protein creatinine ratio (uPCR) 550 mg/mmol (5500 mg/g) versus 902 mg/mmol (9020 mg/g), p = 0.0124. The correlation with ESRF was strongest with the presenting creatinine; 215 μmol/L (2.43 mg/dL) compared to 81 μmol/L (0.92 mg/dL), p < 0.0001. Patients presenting with creatinine of >120 μmol/L (1.36 mg/dL; corresponding to an eGFR of ≤60 ml/min in non-Black males) had an increased rate of ESRF and a faster decline. Other traditional risk factors for progression were not significantly associated with ESRF. Black patients presented with higher serum creatinine but no statistically significant difference in the estimated glomerular filtration rate, a higher rate of progression to ESRF and had a poorer response to treatment. Conclusions This ethnically diverse cohort does not demonstrate the traditional risk profile associated with development of ESRF. Thus, careful consideration of therapeutic options is crucial, as current risk modelling cannot accurately predict the risk of ESRF. Further studies are required to elucidate the role of antibodies and risk genes.
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Affiliation(s)
- Sanjana Gupta
- UCL Centre for Nephrology, 1st Floor, Room 1.7007, Rowland Hill Street, London, NW3 2PF, UK.,Renal Unit, Barts Health NHS Trust, Whitechapel, London, E1 1BB, UK
| | - John Connolly
- UCL Centre for Nephrology, 1st Floor, Room 1.7007, Rowland Hill Street, London, NW3 2PF, UK
| | - Ruth J Pepper
- UCL Centre for Nephrology, 1st Floor, Room 1.7007, Rowland Hill Street, London, NW3 2PF, UK
| | - Stephen B Walsh
- UCL Centre for Nephrology, 1st Floor, Room 1.7007, Rowland Hill Street, London, NW3 2PF, UK
| | - Magdi M Yaqoob
- Renal Unit, Barts Health NHS Trust, Whitechapel, London, E1 1BB, UK
| | - Robert Kleta
- UCL Centre for Nephrology, 1st Floor, Room 1.7007, Rowland Hill Street, London, NW3 2PF, UK.
| | - Neil Ashman
- Renal Unit, Barts Health NHS Trust, Whitechapel, London, E1 1BB, UK
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29
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Dahan K. [Membranous nephropathy: New insights in therapeutic approach]. Nephrol Ther 2017; 13 Suppl 1:S83-S87. [PMID: 28577748 DOI: 10.1016/j.nephro.2017.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/17/2022]
Abstract
Membranous nephropathy is one of the leading causes of nephrotic syndrome in adults, evolving to 30 % end-stage renal disease after 10 years, in the absence of specific treatment. In 2009, the M-type phospholipase A2 receptor (PLA2R), a podocyte membrane glycoprotein, was identified as the first autoantigen involved in more than 70 % of primitive membranous nephropathy. Many studies have reported that high titers of PLA2R antibodies are correlated with a lower risk of spontaneous or immunosuppressant-induced remission, a higher risk of nephrotic syndrome and of progression to end-stage renal disease. Treatment is still challenging and controversial because of potential toxicity and lack of a reliable prognosis marker. In the past, the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines recommended immunosuppressive therapies as steroids and alkylating agents or cyclosporine in patients with persistent nephrotic syndrome or impaired renal function. Recent studies and one multicentric randomised controlled trial brought clear evidence to support the use of rituximab in these patients: rituximab regimen induces immunological and clinical remission in patients with membranous nephropathy, with a high safety profile. However, they have provided important data on the impact of PLA2R antibodies assessment as a prognostic biomarker in patients with membranous nephropathy. The next step will be the integration of this biomarker in KDIGO guidelines and the recommendation of rituximab as a first line immunosuppressive therapy in patient with persistent nephrotic syndrome due to membranous nephropathy.
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Affiliation(s)
- Karine Dahan
- Service de néphrologie et dialyses, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
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30
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Hoxha E, von Haxthausen F, Wiech T, Stahl RAK. Membranous nephropathy-one morphologic pattern with different diseases. Pflugers Arch 2017; 469:989-996. [PMID: 28555350 DOI: 10.1007/s00424-017-2000-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/14/2017] [Accepted: 05/16/2017] [Indexed: 01/05/2023]
Abstract
Since the discovery of the phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type-1 domain-containing 7A (THSD7A) as endogenous antigens involved in the development of membranous nephropathy (MN) in over 80% of adult patients, substantial progress in the diagnosis, prognosis, and therapy of MN has been made. In most cases of patients with MN, it is now possible to specifically define the responsible pathogenic mechanisms of disease and make a diagnosis even without a renal biopsy. Moreover, the presence of antibodies in the blood and the detection of the antigens in renal biopsies allow the definite diagnosis without the morphologic uncertainties, which now still apply for only about 20% of all renal biopsies showing MN. The discovery that the expression of THSD7A in malignant tumors might serve as the site of primary antigen recognition for the immune system to start MN might lead to a better understanding of not only tumor-associated MN, which accounts for up to 10% of all patients with MN, but also of the pathomechanisms relevant for MN development in general.
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Affiliation(s)
- Elion Hoxha
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,SFB 1192, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | | | - Thorsten Wiech
- SFB 1192, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Sektion Nephropathologie, Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf A K Stahl
- SFB 1192, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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31
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Expression, prognosis and functional role of Thsd7a in esophageal squamous cell carcinoma of Kazakh patients, Xinjiang. Oncotarget 2017; 8:60539-60557. [PMID: 28947992 PMCID: PMC5601160 DOI: 10.18632/oncotarget.16966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/01/2017] [Indexed: 12/12/2022] Open
Abstract
Thsd7a (Thrombospondin type 1 domain containing 7a) is a critical transmembrane protein. Studies have indicated that Thsd7a was associated with cytoskeletal organization, cell migration and filopodia formation. However, the involvement of Thsd7a remains elusive in human Esophageal Squamous Cell Carcinoma (ESCC). Consequently, immunohistochemistry and reverse transcription-polymerase chain reaction were utilized to study the correlation between the expression of Thsd7a and clinical-pathological characteristics. The influence of Thsd7a on apoptosis, cell proliferating activity, cell cycle, migratory and invasive capacity was determined in Eca 109 and EC 9706 cell lines in vitro. And the influence on proliferating activity was testified using naked mice model in vivo. In addition, the potential molecular mechanism was tested by microarray. It was discovered that there is a certain correlation between Thsd7a and the Kazakh ESCC. By knocking out Thsd7a, the invasion, migration and proliferation could be decreased. And it could also arrest the cell cycle at G1 phase and increase the apoptosis rate. It was further verified that Thsd7a had obvious effect on proliferation in naked mice with xenograft of Eca109 cells. Finally, it was uncovered by microarray analysis that a variety of tumor genes and pathways related to Thsd7a. Together, it was demonstrated that Thsd7a might have a certain degree of carcinogenesis in ESCC.
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32
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De Vriese AS, Glassock RJ, Nath KA, Sethi S, Fervenza FC. A Proposal for a Serology-Based Approach to Membranous Nephropathy. J Am Soc Nephrol 2017; 28:421-430. [PMID: 27777266 PMCID: PMC5280030 DOI: 10.1681/asn.2016070776] [Citation(s) in RCA: 218] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Primary membranous nephropathy (MN) is an autoimmune disease mainly caused by autoantibodies against the recently discovered podocyte antigens: the M-type phospholipase A2 receptor 1 (PLA2R) and thrombospondin type 1 domain-containing 7A (THSD7A). Assays for quantitative assessment of anti-PLA2R antibodies are commercially available, but a semiquantitative test to detect anti-THSD7A antibodies has been only recently developed. The presence or absence of anti-PLA2R and anti-THSD7A antibodies adds important information to clinical and immunopathologic data in discriminating between primary and secondary MN. Levels of anti-PLA2R antibodies and possibly, anti-THSD7A antibodies tightly correlate with disease activity. Low baseline and decreasing anti-PLA2R antibody levels strongly predict spontaneous remission, thus favoring conservative therapy. Conversely, high baseline or increasing anti-PLA2R antibody levels associate with nephrotic syndrome and progressive loss of kidney function, thereby encouraging prompt initiation of immunosuppressive therapy. Serum anti-PLA2R antibody profiles reliably predict response to therapy, and levels at completion of therapy may forecast long-term outcome. Re-emergence of or increase in antibody titers precedes a clinical relapse. Persistence or reappearance of anti-PLA2R antibodies after kidney transplant predicts development of recurrent disease. We propose that an individualized serology-based approach to MN, used to complement and refine the traditional proteinuria-driven approach, will improve the outcome in this disease.
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Affiliation(s)
- An S De Vriese
- Division of Nephrology, AZ Sint-Jan Brugge-Oostende, Brugge, Belgium;
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, California; and
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Francis JM, Beck LH, Salant DJ. Membranous Nephropathy: A Journey From Bench to Bedside. Am J Kidney Dis 2016; 68:138-47. [PMID: 27085376 PMCID: PMC4921260 DOI: 10.1053/j.ajkd.2016.01.030] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/31/2016] [Indexed: 12/28/2022]
Abstract
Lessons from an animal model that faithfully resembles human membranous nephropathy (MN) have informed our understanding of the pathogenesis of this organ-specific autoimmune disease and common cause of nephrotic syndrome. After it was established that the subepithelial immune deposits that characterize experimental MN form in situ when circulating antibodies bind to an intrinsic podocyte antigen, it was merely a matter of time before the human antigen was identified. The M-type phospholipase A2 receptor 1 (PLA2R) represents the major target antigen in primary MN, and thrombospondin type 1 domain-containing 7A (THSD7A) was more recently identified as a minor antigen. Serologic tests for anti-PLA2R and kidney biopsy specimen staining for PLA2R show >90% specificity and 70% to 80% sensitivity for the diagnosis of primary MN in most populations. The assays distinguish most cases of primary MN from MN associated with other systemic diseases, and sequential anti-PLA2R titers are useful to monitor treatment response. A positive pretransplantation test result for anti-PLA2R is also helpful for predicting the risk for posttransplantation recurrence. Identification of target epitopes within PLA2R and the genetic association of primary MN with class II major histocompatibility and PLA2R1 variants are 2 additional examples of our evolving understanding of this disease.
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Affiliation(s)
- Jean M Francis
- Department of Medicine, Boston University Medical Center, Boston, MA
| | - Laurence H Beck
- Department of Medicine, Boston University Medical Center, Boston, MA
| | - David J Salant
- Department of Medicine, Boston University Medical Center, Boston, MA.
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Hihara K, Iyoda M, Tachibana S, Iseri K, Saito T, Yamamoto Y, Suzuki T, Wada Y, Matsumoto K, Shibata T. Anti-Phospholipase A2 Receptor (PLA2R) Antibody and Glomerular PLA2R Expression in Japanese Patients with Membranous Nephropathy. PLoS One 2016; 11:e0158154. [PMID: 27355365 PMCID: PMC4927164 DOI: 10.1371/journal.pone.0158154] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 06/10/2016] [Indexed: 12/03/2022] Open
Abstract
The phospholipase A2 receptor (PLA2R) is the major target antigen (Ag) in idiopathic membranous nephropathy (IMN). Recently, several types of immunoassay systems for anti-PLA2R antibody (Ab) have been developed. However, the correlation of serum anti-PLA2R Abs and glomerular expression of PLA2R Ag, and their association with clinicopathological characteristics have yet to be proven in Japanese patients. We examined serum anti-PLA2R Abs by both ELISA and cell-based indirect immunofluorescence assay (CIIFA), and glomerular PLA2R expression by immunofluorescence (IF) in 59 biopsy-proven MN patients including IMN (n = 38) and secondary MN (SMN) (n = 21). In this study, anti-PLA2R Abs were present in 50% of IMN patients, but was absent in SMN patients. The concordance rate between ELISA and CIIFA was 100%. Serum IgG levels were significantly lower in anti-PLA2R Ab-positive patients. Serum albumin levels correlated inversely with serum anti-PLA2R Ab titers. The prevalence and intensity of glomerular staining for IgG4 by IF were significantly higher in anti-PLA2R Ab-positive patients than in -negative patients. Glomerular PLA2 Ag expression evaluated by IF was positive in 52.6% of IMN patients, but was absent in SMN patients. The concordance rate between the prevalence of glomerular PLA2R Ag expression and anti-PLA2R Ab was 84.2%. The prevalence of anti-PLA2R Abs measured by ELISA/CIIFA was equivalent to previous Japanese studies evaluated using Western blotting. These analyses showed an excellent specificity for the diagnosis of IMN, and anti-PLA2R positivity was associated with some clinicopathological features, especially glomerular IgG4-dominant deposition.
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Affiliation(s)
- Kei Hihara
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masayuki Iyoda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Shohei Tachibana
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Ken Iseri
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomohiro Saito
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yasutaka Yamamoto
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Taihei Suzuki
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yukihiro Wada
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kei Matsumoto
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takanori Shibata
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Abstract
Most glomerulonephritides, even the more common types, are rare diseases. They are nevertheless important since they frequently affect young people, often cannot be cured, and can lead to chronic kidney disease, including end-stage renal failure, with associated morbidity and cost. For example, in young adults, IgA nephropathy is the most common cause of end-stage renal disease. In this Seminar, we summarise existing knowledge of clinical signs, pathogenesis, prognosis, and treatment of glomerulonephritides, with a particular focus on data published between 2008 and 2015, and the most common European glomerulonephritis types, namely IgA nephropathy, membranous glomerulonephritis, minimal change disease, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, and the rare complement-associated glomerulonephritides such as dense deposit disease and C3 glomerulonephritis.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule Aachen, Aachen, Germany.
| | - Kerstin Amann
- Department of Nephropathology, Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
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36
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Murtas C, Ghiggeri GM. Membranous glomerulonephritis: histological and serological features to differentiate cancer-related and non-related forms. J Nephrol 2016; 29:469-78. [PMID: 26810113 DOI: 10.1007/s40620-016-0268-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022]
Abstract
Membranous nephropathy is a frequent cause of nephrotic syndrome in adults. In most patients, it appears as a primary renal disease but in about 20 % of cases membranous nephropathy is associated with systemic conditions such as systemic lupus erythematosus, infections or cancer, or with drug exposure. Reliable differentiation between primary and secondary membranous nephropathy has important implications for the patient, because of different therapeutic approaches between the different forms. The recent in vivo definition of glomerular targets of autoimmunity in idiopathic membranous nephropathy represented a real breakthrough and nowadays more than one podocyte antigen is considered in some way implicated in the pathogenesis of human membranous nephropathy. Specific antibodies against all these components have been detected in serum of patients and could become biomarkers of membranous nephropathy and/or of disease activity. In this brief review, we discuss the usefulness of newly described autoantibodies in the differential diagnosis of secondary membranous nephropathy. Histological clues for recognizing the two pathological entities are also analysed with regard to the available scientific evidence on this issue. Our evaluation shows that more research is needed to identify the best approach to reach a correct diagnosis of primary or secondary membranous nephropathy.
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Affiliation(s)
- Corrado Murtas
- Division of Nephrology and Dialysis, Ospedale San Martino, ASL 5, via Rockefeller, 09170, Oristano, Italy.
| | - Gian Marco Ghiggeri
- Division of Nephrology Dialysis and Transplantation, Istituto Giannina Gaslini, Genoa, Italy
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