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Han T, Xue M, Guan Y, Ju T, Shi K, Fu M, Jia L, Gao C, Xia Z. Serum IgE levels are a risk factor with prognosis of pediatric minimal change disease. Front Pediatr 2023; 11:1234655. [PMID: 37559950 PMCID: PMC10407802 DOI: 10.3389/fped.2023.1234655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Minimal change disease (MCD) is one of the most common primary glomerular disorders with high serum IgE levels. This study was aimed to investigate the clinical features of different serum IgE levels in pediatric MCD and evaluate the prognostic significance of serum IgE levels with regard to remission and relapse in pediatric cohort. METHODS This study enrolled 142 new-onset children diagnosed with biopsy-proven MCD from January 2010 to December 2021 at the Jinling Hospital in Nanjing, China. These cases were divided into three groups according to serum IgE levels. MCD patients' demographics, clinical parameters, and follow-up data were collected and analyzed. The primary and secondary outcomes were defined as the time to the first complete remission (CR) and the first relapse. RESULTS The results manifested that 85.2% (121/142) of MCD children had high serum IgE levels (IgE > 90.0 IU/ml). A total of 142 patients were divided into the normal-, low-, and high-IgE groups based on the normal reference value level (90.0 IU/ml) and median serum IgE level (597.5 IU/ml). The high-IgE group had a significantly lower cumulative rate of the first CR (log-rank, P = 0.032) and a higher rate of the first relapse (log-rank, P = 0.033) than the normal-IgE and low-IgE groups. Multivariate Cox analysis showed that IgE ≥597.5 IU/ml was independently associated with the delayed first CR [hazard ratio (HR) = 0.566, 95% confidence interval (CI) = 0.330-0.972, P = 0.039] and the early first relapse (HR = 2.767, 95% CI = 1.150-6.660, P = 0.023). CONCLUSIONS Serum IgE levels were an independent correlation factor for pediatric MCD-delayed remissions and early relapses.
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Affiliation(s)
- Tingting Han
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mei Xue
- Department of Pediatrics, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, China
| | - Yafei Guan
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Ju
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Kaili Shi
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Mengzhen Fu
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Lili Jia
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Chunlin Gao
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Zhengkun Xia
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Pediatrics, Jinling Hospital, Nanjing, China
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Chen DP, Helmuth ME, Smith AR, Canetta PA, Ayoub I, Mucha K, Kallash M, Kopp JB, Gbadegesin R, Gillespie BW, Greenbaum LA, Parekh RS, Hunley TE, Sperati CJ, Selewski DT, Kidd J, Chishti A, Reidy K, Mottl AK, Gipson DS, Srivastava T, Twombley KE. Age of Onset and Disease Course in Biopsy-Proven Minimal Change Disease: An Analysis From the Cure Glomerulonephropathy Network. Am J Kidney Dis 2023; 81:695-706.e1. [PMID: 36608921 PMCID: PMC10200745 DOI: 10.1053/j.ajkd.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/19/2022] [Indexed: 01/05/2023]
Abstract
RATIONALE & OBJECTIVE Adolescent- and adult-onset minimal change disease (MCD) may have a clinical course distinct from childhood-onset disease. We characterized the course of children and adults with MCD in the Cure Glomerulonephropathy Network (CureGN) and assessed predictors of rituximab response. STUDY DESIGN Prospective, multicenter, observational study. STUDY PARTICIPANTS CureGN participants with proven MCD on biopsy. EXPOSURE Age at disease onset, initiation of renin-angiotensin-aldosterone system (RAAS) blockade, and immunosuppression including rituximab during the study period. OUTCOME Relapse and remission, change in estimated glomerular filtration rate (eGFR), and kidney failure. ANALYTICAL APPROACH Remission and relapse probabilities were estimated using Kaplan-Meier curves and gap time recurrent event models. Linear regression models were used for the outcome of change in eGFR. Cox proportional hazards models were used to estimate the association between rituximab administration and remission. RESULTS The study included 304 childhood- (≤12 years old), 49 adolescent- (13-17 years old), and 201 adult- (≥18 years) onset participants with 2.7-3.2 years of follow-up after enrollment. Children had a longer time to biopsy (238 vs 23 and 36 days in adolescent- and adult-onset participants, respectively; P<0.001) and were more likely to have received therapy before biopsy. Children were more likely to be treated with immunosuppression but not RAAS blockade. The rate of relapse was higher in childhood- versus adult-onset participants (HR, 1.69 [95% CI, 1.29-2.21]). The probability of remission was also higher in childhood-onset disease (HR, 1.33 [95%CI, 1.02-1.72]). In all groups eGFR loss was minimal. Children were more likely to remit after rituximab than those with adolescent- or adult-onset disease (adjusted HR, 2.1; P=0.003). Across all groups, glucocorticoid sensitivity was associated with a greater likelihood of achieving complete remission after rituximab (adjusted HR, 2.62; P=0.002). LIMITATIONS CureGN was limited to biopsy-proven disease. Comparisons of childhood to nonchildhood cases of MCD may be subject to selection bias, given that childhood cases who undergo a biopsy may be limited to patients who are least responsive to initial therapy. CONCLUSIONS Among patients with MCD who underwent kidney biopsy, there were differences in the course (relapse and remission) of childhood-onset compared with adolescent- and adult-onset disease, as well as rituximab response. PLAIN-LANGUAGE SUMMARY Minimal change disease is a biopsy diagnosis for nephrotic syndrome. It is diagnosed in childhood, adolescence, or adulthood. Patients and clinicians often have questions about what to expect in the disease course and how to plan therapies. We analyzed a group of patients followed longitudinally as part of the Cure Glomerulonephropathy Network (CureGN) and describe the differences in disease (relapse and remission) based on the age of onset. We also analyzed rituximab response. We found that those with childhood-onset disease had a higher rate of relapse but also have a higher probability of reaching remission when compared with adolescent- or adult-onset disease. Children and all steroid-responsive patients are more likely to achieve remission after rituximab.
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Affiliation(s)
- Dhruti P Chen
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina.
| | - Margaret E Helmuth
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Abigail R Smith
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, and Irving Medical Center, Columbia University, New York, and Montefiore Medical Center, Bronx, New York
| | - Isabelle Ayoub
- Division of Nephrology, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Krzysztof Mucha
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Mahmoud Kallash
- Division of Nephrology, Wexner Medical Center, The Ohio State University, Columbus, Ohio; Division of Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey B Kopp
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Baltimore, Maryland
| | - Rasheed Gbadegesin
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina
| | - Brenda W Gillespie
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Rulan S Parekh
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - David T Selewski
- Medical University of South Carolina, Charleston, South Carolina
| | - Jason Kidd
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Kimberly Reidy
- Division of Nephrology, Department of Medicine, and Irving Medical Center, Columbia University, New York, and Montefiore Medical Center, Bronx, New York
| | - Amy K Mottl
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina
| | - Debbie S Gipson
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
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Conte C, Antonelli G, Melica ME, Tarocchi M, Romagnani P, Peired AJ. Role of Sex Hormones in Prevalent Kidney Diseases. Int J Mol Sci 2023; 24:ijms24098244. [PMID: 37175947 PMCID: PMC10179191 DOI: 10.3390/ijms24098244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/29/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic kidney disease (CKD) is a constantly growing global health burden, with more than 840 million people affected worldwide. CKD presents sex disparities in the pathophysiology of the disease, as well as in the epidemiology, clinical manifestations, and disease progression. Overall, while CKD is more frequent in females, males have a higher risk to progress to end-stage kidney disease. In recent years, numerous studies have highlighted the role of sex hormones in the health and diseases of several organs, including the kidney. In this review, we present a clinical overview of the sex-differences in CKD and a selection of prominent kidney diseases causing CKD: lupus nephritis, diabetic kidney disease, IgA nephropathy, and autosomal dominant polycystic kidney disease. We report clinical and experimental findings on the role of sex hormones in the development of the disease and its progression to end-stage kidney disease.
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Affiliation(s)
- Carolina Conte
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Giulia Antonelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Maria Elena Melica
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
| | - Mirko Tarocchi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
| | - Paola Romagnani
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Anna Julie Peired
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
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Osterholt T, Todorova P, Kühne L, Ehren R, Weber LT, Grundmann F, Benzing T, Brinkkötter PT, Völker LA. Repetitive administration of rituximab can achieve and maintain clinical remission in patients with MCD or FSGS. Sci Rep 2023; 13:6980. [PMID: 37117201 PMCID: PMC10141841 DOI: 10.1038/s41598-023-32576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/29/2023] [Indexed: 04/30/2023] Open
Abstract
Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are glomerulopathies associated with nephrotic syndrome. Primary forms of these diseases are treated with various regimes of immunosuppression. Frequently relapsing or glucocorticoid-dependent courses remain challenging. Here, a B-cell-depleting strategy with rituximab represents a salvage option although data are sparse in the adult population. In particular, there is limited evidence on the efficacy of restoring remission after initial successful treatment with rituximab and whether patients benefit from an individualized, relapse-based approach. We identified 13 patients who received multiple therapies with rituximab from the FOrMe-registry (NCT03949972), a nationwide registry for MCD and FSGS in Germany, or from the University Hospital of Cologne. Disease status, changes in serum creatinine, proteinuria, and time to relapse were evaluated. Relapse-free survival was compared to the patients' previous therapy regimens. Through all treatment cycles, an improvement of disease activity was shown leading to a complete remission in 72% and partial remission in 26% after 3 ([Formula: see text]0.001) and 6 months ([Formula: see text]0.001). Relapse-free survival increased from 4.5 months (95%-CI 3-10 months) to 21 months (95%-CI 16-32 months) ([Formula: see text]0.001) compared to previous immunosuppression regimens with no loss in estimated glomerular filtration over time (p = 0.53). Compared to continuous B-cell depletion, an individualized relapse-based approach led to a reduced rituximab exposure and significant cost savings. Relapse-based administration of rituximab in patients with MCD/FSGS with an initial good clinical response did not result in a decreased efficacy at a median follow-up duration of 110 months. Thus, reinduction therapies may provide an alternative to continuous B-cell-depletion and reduce the long-term side effects of continuous immunosuppression.
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Affiliation(s)
- Thomas Osterholt
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Polina Todorova
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lucas Kühne
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Rasmus Ehren
- Faculty of Medicine, Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lutz Thorsten Weber
- Faculty of Medicine, Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Franziska Grundmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
| | - Paul Thomas Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany.
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany.
| | - Linus Alexander Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
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Ma L, Zhang Y, Zhang L, Shao C, Yu N. Development and validation of a simple-to-use nomogram for predicting minimal change disease based on quantification of color Doppler sonography data from a region of interest. Abdom Radiol (NY) 2023; 48:1020-1032. [PMID: 36627405 DOI: 10.1007/s00261-022-03780-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To establish a simple-to-use nomogram based on quantification of color Doppler sonography data from a region of interest (ROI) to diagnose minimal change disease (MCD) promptly and non-invasively, and to evaluate the prediction capability of the nomogram. METHODS We recruited 564 patients with pathology-proven renal disease who were admitted to our hospital from July 2020 to July 2021 (388 patients in the training dataset and 176 patients in the validation dataset), and their color Doppler sonography data were acquired from a ROI and underwent ipsilateral renal biopsy. The collected clinical features and ultrasonic features were imported into Rstuido and statistically significant features were selected by stepwise regression using the forward-backward method. Multivariate Logistic regression analysis was combined with clinical analysis to obtain the final modeling features. General and dynamic nomogram models were constructed with the selected features, depending on whether they were MCD or not. Bootstrapping and internal validation were used for internal and external validation of the nomogram, respectively. The performance of the nomogram was assessed by C-index, calibration curve, and receiver operating characteristic (ROC) curve. RESULTS Age and VI were independent factors in predicting MCD. The value of Age (Best cut-off value: 33.5 years) combined with VI (Best cut-off value: 40.50 points) in the diagnosis of MCD was significantly higher than that of single diagnosis (AUC 0.901, 95% CI 0.863-0.938). The C-index of the nomogram constructed with age and VI in the training and validation datasets was 0.915 [95% confidence interval (CI) 0.874-0.956 and 0.875 95% CI 0.783-0.967], respectively. Calibration curves were fitted well. The sensitivity, specificity, and accuracy were 76.1%, 95.6%, and 78.3%, respectively, in the training dataset, and 74.1%, 94.4%, and 76.1% in the validation dataset, respectively. CONCLUSION The nomogram constructed with age and VI showed a satisfactory degree of differentiation and accuracy, which is of great significance for early, non-invasively, and individually analysis of the risk of MCD.
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Affiliation(s)
- Leiyuan Ma
- Department of Abdominal Ultrasound, The Affiliated Hospital of Qingdao University, No.16, Jiangsu Road, Shinan District, Qingdao, 266003, China
| | - Yuhan Zhang
- University of Southern California, Los Angeles, USA
| | - Liang Zhang
- Department of Abdominal Ultrasound, The Affiliated Hospital of Qingdao University, No.16, Jiangsu Road, Shinan District, Qingdao, 266003, China
| | - Changjie Shao
- Department of Abdominal Ultrasound, The Affiliated Hospital of Qingdao University, No.16, Jiangsu Road, Shinan District, Qingdao, 266003, China
| | - Ning Yu
- Department of Abdominal Ultrasound, The Affiliated Hospital of Qingdao University, No.16, Jiangsu Road, Shinan District, Qingdao, 266003, China.
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Bai M, Zhang J, Su X, Yao X, Li H, Cheng J, Mao J, Li X, Chen J, Lin W. Serum IL-12p40: A novel biomarker for early prediction of minimal change disease relapse following glucocorticoids therapy. Front Med (Lausanne) 2022; 9:922193. [PMID: 36507530 PMCID: PMC9729255 DOI: 10.3389/fmed.2022.922193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022] Open
Abstract
Background Minimal change disease (MCD) has a high recurrence rate, but currently, no biomarker can predict its recurrence. To this end, this study aimed at identifying potential serum cytokines as valuable biomarkers for predicting the risk of MCD recurrence. Materials and methods Raybiotech 440 cytokine antibody microarray was used to detect the serum samples of eight relapsed, eight non-relapsed MCD patients after glucocorticoid treatment, and eight healthy controls. The differentially expressed cytokines were confirmed by enzyme-linked immunosorbent assay (ELISA) with serum samples from 29 non-relapsed and 35 relapsed MCD patients. The study used the receiver operating characteristic (ROC) curve analysis to investigate the sensitivity and specificity of a serum biomarker for predicting the MCD relapse. Results Serum IL-12p40 levels increased significantly in the relapsed group. The Area Under the ROC Curve (AUC) of IL-12p40 was 0.727 (95%CI: 0.597-0.856; P < 0.01). The RNA-sequencing analysis and qPCR assay performed on the IL-12 treated mouse podocytes and the control group showed increased expression of podocyte damage genes, such as connective tissue growth factor (CTGF), matrix metallopeptidase 9 (MMP9), secreted phosphoprotein 1 (SPP1), and cyclooxygenase-2 (COX-2) in the former group. Conclusion IL-12p40 may serve as a new biomarker for predicting the risk of MCD recurrence after glucocorticoid treatment, and it may be involved in the pathogenesis and recurrence of MCD.
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Affiliation(s)
- Mengqiu Bai
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Department of Nephrology, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Jinhua, Zhejiang, China,Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Zhang
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinwan Su
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Department of Nephrology, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Xi Yao
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Heng Li
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Cheng
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiayu Li
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Xiayu Li,
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Jianghua Chen,
| | - Weiqiang Lin
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Department of Nephrology, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Jinhua, Zhejiang, China,*Correspondence: Weiqiang Lin,
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7
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Li H, Wang L, Li X, Chen W, Zhang Y, Chen J. Serum IgE Levels Are Associated With the Prognosis of Minimal Change Disease. Front Immunol 2022; 13:840857. [PMID: 35371097 PMCID: PMC8968917 DOI: 10.3389/fimmu.2022.840857] [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: 12/21/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Previous reports showed that some patients with minimal change disease (MCD) had high serum immunoglobulin E (IgE) levels. This study aimed to explore the proportion of MCD patients with high serum IgE levels and evaluate the correlation between serum IgE levels and MCD remission and relapse. Methods This study enrolled 222 new-onset patients with renal biopsy-confirmed MCD from October 2012 to October 2019 at the First Affiliated Hospital of Zhejiang University in Hangzhou, China. Patients’ demographics and clinical parameters were analyzed. Results The results indicated that 70.3% of 222 MCD patients had high serum IgE levels (IgE > 100.0 IU/mL). Moreover, 134 patients were treated with glucocorticoids alone and divided into the low- and high-IgE groups, according to the median serum IgE level (523.5 IU/mL). The mean time to complete remission of the low- and high-IgE groups was 29.0 ± 2.2 and 45.7 ± 4.2 days, respectively (log-rank test; P = 0.002). The mean time to total remission was 19.1 ± 1.4 and 31.6 ± 3.2 days of the low- and high-IgE groups, respectively (log-rank test; P < 0.001). The mean time to first relapse in the low- and high-IgE groups was 701.2 ± 65.0 and 425.0 ± 52.6 days, respectively (log-rank test; P = 0.002). Serum IgE ≥ 523.5 IU/mL was an independent correlation factor affecting the patients’ remission and relapse. Conclusion Serum IgE level was an independent correlation factor for MCD remission and relapse. MCD patients with high serum IgE levels were prone to delayed remissions and early relapses.
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Affiliation(s)
- Heng Li
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Lefeng Wang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Xiayu Li
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Wenqing Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Ying Zhang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
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Yamamoto R, Imai E, Maruyama S, Yokoyama H, Sugiyama H, Takeda A, Tsukamoto T, Uchida S, Tsuruya K, Shoji T, Hayashi H, Akai Y, Fukunaga M, Konta T, Nishio S, Goto S, Tamai H, Nagai K, Katafuchi R, Masutani K, Wada T, Nishino T, Shirasaki A, Sobajima H, Nitta K, Yamagata K, Kazama JJ, Hiromura K, Yasuda H, Mizutani M, Akahori T, Naruse T, Hiramatsu T, Morozumi K, Mimura T, Saka Y, Ishimura E, Hasegawa H, Ichikawa D, Shigematsu T, Sato H, Narita I, Isaka Y. Time to remission of proteinuria and incidence of relapse in patients with steroid-sensitive minimal change disease and focal segmental glomerulosclerosis: the Japan Nephrotic Syndrome Cohort Study. J Nephrol 2022; 35:1135-1144. [PMID: 35366214 DOI: 10.1007/s40620-022-01279-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Minimal change disease (MCD) is characterized by a nephrotic syndrome usually steroid-sensitive and a high incidence of relapse of proteinuria. Previous cohort studies have reported conflicting results regarding the association between the time to remission and incidence of relapse. METHODS This multicenter prospective cohort study included 102 adult patients with steroid-sensitive MCD or focal segmental glomerulosclerosis from a 5-year cohort study of primary nephrotic syndrome, the Japan Nephrotic Syndrome Cohort Study, who achieved remission of proteinuria within 2 months of immunosuppressive therapy (IST). The association between the time to remission of proteinuria after immunosuppressive therapy and incidence of relapse was assessed using Cox proportional hazards models adjusted for clinically relevant factors. RESULTS Remission was observed at 3-7, 8-14, 15-21, 22-28, and 30-56 days after initiation of immunosuppressive therapy in 17 (16.7%), 37 (36.3%), 21 (20.6%), 13 (12.7%), and 14 (13.7%) patients, respectively. During a median observation period of 2.3 years after the end of the 2nd month after initiation of immunosuppressive therapy, 46 (45.1%) patients relapsed. The time to remission was associated with the incidence of relapse in an inverse U-shaped pattern (multivariable-adjusted hazard ratios [95% confidence intervals] of the time to remission of 3-7, 8-14, 15-21, 22-28, 30-56 days: 1.00 [reference], 1.76 [0.56, 5.51], 6.06 [1.85, 19.80], 5.46 [1.44, 20.64], and 2.19 [0.52, 9.30], respectively). CONCLUSION The time to remission was identified as a significant predictor of relapse in steroid-sensitive patients.
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Affiliation(s)
- Ryohei Yamamoto
- Health and Counseling Center, Osaka University, 1-17 Machikaneyama-cho, Toyonaka, Osaka, 560-0043, Japan. .,Department of Nephrology, Osaka University Graduate School of Medicine, 2-2-D11 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Enyu Imai
- Nakayamadera Imai Clinic, 2-8-18 Nakayamadera, Takarazuka, Hyogo, 665-0861, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Hitoshi Sugiyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Asami Takeda
- Kidney Disease Center, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myokencho, Showa-ku, Nagoya, Aichi, 466-8650, Japan
| | - Tatsuo Tsukamoto
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ogimachi, Kita-ku, Osaka, Osaka, 530-8480, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Tatsuya Shoji
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, Osaka, 558-8558, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi, 470-1192, Japan
| | - Yasuhiro Akai
- First Department of Internal Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Megumu Fukunaga
- Division of Nephrology, Department of Internal Medicine, Toyonaka Municipal Hospital, 4-14-1 Shibaharacho, Toyonaka, Osaka, 560-8565, Japan
| | - Tsuneo Konta
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2 Iida-Nishi, Yamagata-shi, Yamagata, Yamagata, 990-9585, Japan
| | - Saori Nishio
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hirofumi Tamai
- Department of Nephrology, Anjo Kosei Hospital, 28 Higashihirokute, Anjocho, Anjo, Aichi, 446-8602, Japan
| | - Kojiro Nagai
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Ritsuko Katafuchi
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, 1-1-1 Chidori, Koga, Fukuoka, 811-3195, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, Fukuoka, 814-0180, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Arimasa Shirasaki
- Department of Nephrology, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, Aichi, 491-8558, Japan
| | - Hiroshi Sobajima
- Department of Diabetology and Nephrology, Ogaki Municipal Hospital, 4-86 Minaminokawacho, Ogaki, Gifu, 503-8502, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Junichiro J Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima-City, Fukushima, 960-1295, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Hideo Yasuda
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Makoto Mizutani
- Department of Nephrology, Handa City Hospital, 2-29 Toyocho, Handa, Aichi, 475-8599, Japan
| | - Toshiyuki Akahori
- Department of Nephrology, Chutoen General Medical Center, 1-1 Shobugaike, Kakegawa, Shizuoka, 436-8555, Japan
| | - Tomohiko Naruse
- Department of Nephrology, Kasugai Municipal Hospital, 1-1-1 Takakicho, Kasugai, Aichi, 486-8510, Japan
| | - Takeyuki Hiramatsu
- Department of Nephrology, Konan Kosei Hospital, 137 Omatsubara, Takayacho, Konan, Aichi, 483-8704, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, 35-28 Takebashicho, Nakamura-ku, Nagoya, Aichi, 453-8566, Japan
| | - Tetsushi Mimura
- Department of Nephrology, Gifu Prefectural Tajimi Hospital, 5-161 Maebatacho, Tajimi, Gifu, 507-8522, Japan
| | - Yosuke Saka
- Department of Nephrology, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi, Mie, 510-8567, Japan
| | - Eiji Ishimura
- Department of Nephrology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hajime Hasegawa
- Department of Nephrology and Hypertension, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-850, Japan
| | - Daisuke Ichikawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-000, Japan
| | - Takashi Shigematsu
- Department of Nephrology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-City, Wakayama, 641-8509, Japan
| | - Hiroshi Sato
- Department of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 757 Ichibancho, Asahimachi-dori, Chuo Ward, Niigata, Niigata, 951-8510, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2-D11 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Abstract
There is increasing understanding that a multifaceted interplay of sex-dependent genetic and immune dysregulation underpins the development of glomerular disorders. Regional and ethnic variations in glomerular disease incidence make delineating the effects of sex and gender on disease pathophysiology more complex, but there is a marked paucity of research in this area. This review article presents a summary of the current understanding of sex and gender in glomerular disease, highlighting the broader effects of sex and gender on autoimmunity, clinical presentations, and pathophysiology of individual glomerular diseases, as well as exploring sex, gender, and glomerular disease within a wider socioenvironmental context. It is important to specifically consider the effects of sex and gender when presenting and analyzing clinical and scientific studies on glomerular disease. Failure to do so risks promoting disparities within health care provision, neglecting opportunities to identify sex-specific biomarkers, and potentially hindering the development of sex-specific therapies.
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Affiliation(s)
- Hannah Beckwith
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
| | - Liz Lightstone
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Steve McAdoo
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
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10
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Clinical Characteristics and Outcomes of Adults with Nephrotic Syndrome Due to Minimal Change Disease. J Clin Med 2021; 10:jcm10163632. [PMID: 34441929 PMCID: PMC8397036 DOI: 10.3390/jcm10163632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Minimal change disease (MCD) is considered a relatively benign glomerulopathy, as it rarely progresses to end-stage kidney disease. The aim of this study was to describe the characteristics and outcomes of adults with MCD and identify potential risk factors for relapse. PATIENTS & METHODS We retrospectively studied a cohort of adults with biopsy-proven MCD in terms of clinical features and treatment outcomes. Baseline characteristics and outcomes were recorded and predictors of relapse were analyzed using logistic regression multivariate analysis. RESULTS 59 patients with adult-onset primary MCD with nephrotic syndrome were included. Mean serum creatinine at diagnosis was 0.8 mg/dL (±2.5) and estimated GFR (eGFR) was 87 mL/min/1.73 m2 (±29.5). Mean serum albumin was 2.5 g/dL (±0.8) and 24 h proteinuria 6.8 g (±3.7). Microscopic hematuria was detected in 35 (58.5%) patients. 42 patients received prednisone alone, six patients received prednisone plus cyclophosphamide, five patients received prednisone plus cyclosporine, one patient received prednisone plus rituximab and five patients did not receive immunosuppression at all since they achieved spontaneous remission. During a mean follow up time of 34.7(22.1) months, 46.1% of patients experienced at least one episode of relapse. The mean age of patients who did not experience a relapse was significantly higher than that of patients who relapsed while relapsers had a significantly longer duration of 24 h proteinuria prior to biopsy compared to non-relapsers. Overall, 10% of patients experienced acute kidney injury while the mean eGFR at the end was 82 mL/min/1.73 m2 (±29.1) and one patient ended up in chronic dialysis. Overall, the proportion of non-relapsers, who experienced acute kidney injury (17%) was significantly higher than the one recorded among relapsers (0%). CONCLUSION In this series of patients, almost 46% of adult-onset nephrotic MCD patients experienced a relapse, although their renal progression was rare. Younger onset age was an independent risk factor for relapse in adult-onset MCD patients.
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11
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Kristensen T, Birn H, Ivarsen P. A randomised controlled unblinded multicentre non-inferiority trial with activated vitamin D and prednisolone treatment in patients with minimal change nephropathy (ADAPTinMCN). Trials 2021; 22:442. [PMID: 34247632 PMCID: PMC8273943 DOI: 10.1186/s13063-021-05393-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Minimal change nephropathy (MCN) is a common cause of nephrotic syndrome in both adults and children. International guidelines recommend treatment with prednisolone 1 mg/kg/day to adults. This dose is derived from an empirically established dose in children, although children generally attain remission faster and relapse more rapidly than adults. Prednisolone is associated with multiple and serious adverse events. Activated vitamin D has been shown to reduce albuminuria in other glomerular renal diseases with a minimum of adverse events. This study tests the hypothesis that a new treatment regimen in MCN combining reduced dose prednisolone and active vitamin D is as efficient in inducing remission and has fewer and less severe adverse events than standard prednisolone. Furthermore, we aim to establish models allowing for more personalized medicine based on assessment of the individual's prednisolone metabolism. METHODS A randomised controlled multicentre non-inferior unblinded trial including 96 adult, incident patients with biopsy-proven MCN, albuminuria > 3 g/day, and an estimated glomerular filtration rate (eGFR) > 30 ml/min from renal departments in Denmark. Patients are randomised to standard prednisolone (1 mg/kg/day) or reduced prednisolone (0.5 mg/kg/day) and alfacalcidol (0.5 μg/day). The primary outcome is the rate of remissions after 16 weeks and the time from diagnosis to remission. The study will include a saliva test to characterise prednisolone pharmacokinetics and compare them to genetic variations in specific liver enzymes responsible for prednisolone metabolism. DISCUSSION Reducing the prednisolone dose is expected to reduce the number of severe adverse events. This study will examine if reduced prednisolone dose with active vitamin D but without additional immunosuppression is feasible in the treatment of MCN and will reduce the number of adverse events. The findings can potentially change current guidelines for treatment of MCN in adults. Additional outcomes on inter-individual pharmacokinetic and metabolic variations may allow for a more personalised treatment strategy. TRIAL REGISTRATION EudraCT 2017-001206-16, ClinicalTrials.gov NCT03210688 . Registered on June 3, 2017.
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Affiliation(s)
- Tilde Kristensen
- Department of Internal Medicine, renal unit, Regional Hospital Viborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Henrik Birn
- Department of Nephrology, Aarhus University Hospital and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Per Ivarsen
- Department of Nephrology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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12
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Chin HJ, Chae DW, Kim YC, An WS, Ihm C, Jin DC, Kim SG, Kim YL, Kim YS, Kim YG, Koo HS, Lee JE, Lee KW, Oh J, Park JH, Jiang H, Lee H, Lee SK. Comparison of the Efficacy and Safety of Tacrolimus and Low-Dose Corticosteroid with High-Dose Corticosteroid for Minimal Change Nephrotic Syndrome in Adults. J Am Soc Nephrol 2021; 32:199-210. [PMID: 33168602 PMCID: PMC7894664 DOI: 10.1681/asn.2019050546] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/08/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Tacrolimus is used as a steroid-sparing immunosuppressant in adults with minimal change nephrotic syndrome. However, combined treatment with tacrolimus and low-dose steroid has not been compared with high-dose steroid for induction of clinical remission in a large-scale randomized study. METHODS In this 24-week open-label noninferiority study, we randomized 144 adults with minimal change nephrotic syndrome to receive 0.05 mg/kg twice-daily tacrolimus plus once-daily 0.5 mg/kg prednisolone, or once-daily 1 mg/kg prednisolone alone, for up to 8 weeks or until achieving complete remission. Two weeks after complete remission, we tapered the steroid to a maintenance dose of 5-7.5 mg/d in both groups until 24 weeks after study drug initiation. The primary end point was complete remission within 8 weeks (urine protein: creatinine ratio <0.2 g/g). Secondary end points included time until remission and relapse rates (proteinuria and urine protein: creatinine ratio >3.0 g/g) after complete remission to within 24 weeks of study drug initiation. RESULTS Complete remission within 8 weeks occurred in 53 of 67 patients (79.1%) receiving tacrolimus and low-dose steroid and 53 of 69 patients (76.8%) receiving high-dose steroid; this difference demonstrated noninferiority, with an upper confidence limit below the predefined threshold (20%) in both intent-to-treat (11.6%) and per-protocol (17.0%) analyses. Groups did not significantly differ in time until remission. Significantly fewer patients relapsed on maintenance tacrolimus (3-8 ng/ml) plus tapered steroid versus tapered steroid alone (5.7% versus 22.6%, respectively; P=0.01). There were no clinically relevant safety differences. CONCLUSIONS Combined tacrolimus and low-dose steroid was noninferior to high-dose steroid for complete remission induction in adults with minimal change nephrotic syndrome. Relapse rates were significantly lower with maintenance tacrolimus and steroid compared with steroid alone. No clinically-relevant differences in safety findings were observed.
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Affiliation(s)
- Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, South Korea
| | - ChunGyoo Ihm
- Department of Nephrology, Kyunghee University Medical Center, Seoul, South Korea
| | - Dong-Chan Jin
- Department of Internal Medicine, St Vincent Hospital, Suwon, South Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, South Korea
| | - Yoon-Goo Kim
- Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Seok Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, South Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kang Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon, South Korea
| | - Jieun Oh
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Konkuk University Medical Center, Seoul, South Korea
| | - Hongsi Jiang
- Medical Affairs Asia Oceania, Astellas Pharma Singapore Pte. Ltd., Singapore
| | - Hyuncheol Lee
- Clinical Research, Astellas Pharma Korea Inc., Seoul, South Korea
| | - Sang Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
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13
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Stefan G, Busuioc R, Stancu S, Hoinoiu M, Zugravu A, Petre N, Mircescu G. Adult-onset minimal change disease: the significance of histological chronic changes for clinical presentation and outcome. Clin Exp Nephrol 2020; 25:240-250. [PMID: 33090339 DOI: 10.1007/s10157-020-01985-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/08/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Data on pathologic features with prognostic utility in adults with minimal change disease (MCD) are limited. We assessed the relationship between histologic chronic changes and clinical presentation and outcomes. METHODS The consecutive records of 79 patients with MCD and minimum of 6 months follow-up were retrospectively reviewed. Kidney survival was the primary endpoint (doubling serum creatinine or dialysis initiation). Secondary endpoints were time to remission and relapse. Total chronicity score was the sum of glomerulosclerosis (0-3), interstitial fibrosis (0-3), tubular atrophy (0-3), and arteriolosclerosis (0/1). RESULTS The median renal chronicity score was 1; 77% had minimal (0-1), 18% mild (2-4), and 5% moderate (5-7) chronicity. Fifty percent had a null score; they were younger, had higher eGFR, similar proteinuria, better renal survival, and lower mortality. Mean kidney survival time was 5.7 (95% CI 5.2-6.2) years; 89% reached a form of remission at a median of 8 weeks; 31% relapsed at a mean of 26 months. Chronic changes severity predicted both relapses and kidney survival, each one-point increase in score raised with 27% the risk of relapse and with 31% the risk of dialysis initiation. Acute kidney injury (AKI) was present in 42% of the patients; they had more often mesangial proliferation, interstitial inflammation, tubular atrophy, arteriosclerosis, podocyte villous hypertrophy, and higher chronicity score. CONCLUSION Standardized grading of chronicity was a predictor of kidney survival and disease relapse and was related to AKI. Older patients with severe nephrotic syndrome and with increased chronicity score could represent a high-risk category.
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Affiliation(s)
- Gabriel Stefan
- Dr. Carol Davila Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.
| | - Ruxandra Busuioc
- Dr. Carol Davila Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania
| | - Simona Stancu
- Dr. Carol Davila Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Madalina Hoinoiu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Adrian Zugravu
- Dr. Carol Davila Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Nicoleta Petre
- Dr. Carol Davila Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Gabriel Mircescu
- Dr. Carol Davila Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
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14
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Nicholas PD, Garrahy I. Adult minimal change disease with acute kidney injury: a case report and literature review. J Community Hosp Intern Med Perspect 2020; 9:507-510. [PMID: 32002160 PMCID: PMC6968635 DOI: 10.1080/20009666.2019.1688125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 10/17/2019] [Indexed: 10/30/2022] Open
Abstract
Minimal Change Disease (MCD) is identified via renal biopsy as the etiology of nephrotic syndrome in a minority of adult cases; however, a significant proportion of these occurrences are accompanied by acute kidney injury (AKI). Risk factors for AKI in MCD include increased age, male sex, hypertension, and marked proteinuria and hypoalbuminemia. The etiology of AKI appears to be tubular injury as demonstrated with biomarkers, and although it is usually reversible with steroid therapy, resistance and relapses can occur and may require the use of second-line agents. We present a case of an adult patient with acute onset of biopsy-proven MCD and AKI demonstrating a partial response to corticosteroids and aggressive diuresis and later relapsing and requiring further immunosuppression with tacrolimus. Ultimately, further studies are required to determine the optimal treatment regimen for MCD to ensure remission and avoid relapse.
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Affiliation(s)
- P Daniel Nicholas
- Department of Internal Medicine, Reading Hospital and Medical Center, Tower Health, West Reading, PA, USA
| | - Ian Garrahy
- Department of Internal Medicine, Reading Hospital and Medical Center, Tower Health, West Reading, PA, USA
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15
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Zhang Q, Zhang M, Sun C, Wang H, Tang T, Xia Y, Shao Q, Liu J, Jiang C. Soluble Vascular Cell Adhesion Molecule-1 Is Associated With Disease Activity in Adult-Onset Minimal Change Disease. Am J Med Sci 2019; 357:311-315. [PMID: 30904046 DOI: 10.1016/j.amjms.2019.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cell adhesion molecules have been documented to be elevated in numerous immune inflammatory diseases. Minimal change disease (MCD) is an immune disorder. This study aimed to evaluate whether levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble E-selectin (sE-selectin) reflect disease activity in adult-onset MCD. METHODS A sandwich enzyme-linked immunosorbent assay was used to measure the soluble adhesion molecules in 40 patients with nephrotic-range proteinuria and biopsy-proven MCD, obtained at the time of diagnosis and during remission. Thirty-five age- and sex-matched healthy volunteers served as controls. RESULTS Patients with MCD during the active stage showed significantly higher levels of sVCAM-1 and sE-selectin when compared to controls. Moreover, sVCAM-1 had significantly positive correlations with both urine protein and serum cholesterol, and was negatively associated with serum albumin. Multiple analyses showed that serum albumin was an independent predictor of sVCAM-1. The correlations between sE-selectin and other clinical parameters were not statistically significant. At follow-up, these markers systematically decreased as the disease went into remission, but the increase in sVCAM-1 persisted even in patients obtaining complete remission for 6 months. CONCLUSIONS Patients with active MCD had increased levels of sVCAM-1 and sE-selectin. The correlation between sVCAM-1 and proteinuria, serum albumin and cholesterol and its decline during remission indicate that sVCAM-1 is associated with disease activity.
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Affiliation(s)
- Qingyan Zhang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Miao Zhang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Cheng Sun
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hengjin Wang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tianfeng Tang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yangyang Xia
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qiuyuan Shao
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing Liu
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chunming Jiang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
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Rémy P, Audard V, Natella PA, Pelle G, Dussol B, Leray-Moragues H, Vigneau C, Bouachi K, Dantal J, Vrigneaud L, Karras A, Pourcine F, Gatault P, Grimbert P, Ait Sahlia N, Moktefi A, Daugas E, Rigothier C, Bastuji-Garin S, Sahali D, Aldigier JC, Bataille P, Canaud B, Chauveau D, Combe C, Choukroun G, Cornec-Legall E, Dahan K, Delahousse M, Desvaux D, Deteix P, Durrbach A, Esnault V, Essig M, Fievet P, Frouget T, Guerrot D, Godin M, Gontiers-Picard A, Gosselin M, Hanrotel-Saliou C, Heng AE, Huart A, Humbert A, Kofman T, Hummel A, Lang P, Laville M, Lemeur Y, Malvezzi P, Matignon M, Mesbah R, Moulin B, Muller S, Olagne J, Pardon A, Provot F, Queffeulou G, Plaisier E, Raimbourg Q, Rieu P, Stehlé T, Vanhille P. An open-label randomized controlled trial of low-dose corticosteroid plus enteric-coated mycophenolate sodium versus standard corticosteroid treatment for minimal change nephrotic syndrome in adults (MSN Study). Kidney Int 2018; 94:1217-1226. [DOI: 10.1016/j.kint.2018.07.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 06/25/2018] [Accepted: 07/05/2018] [Indexed: 12/15/2022]
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Idiopathic Nephrotic Syndrome: Characteristics and Identification of Prognostic Factors. J Clin Med 2018; 7:jcm7090265. [PMID: 30205613 PMCID: PMC6162818 DOI: 10.3390/jcm7090265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/03/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022] Open
Abstract
There are various histopathological forms of idiopathic nephrotic syndrome, including minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). Whereas some relapse predictor factors have been identified in renal transplantation, the clinical future of idiopathic nephrotic syndrome in the native kidney remains uncertain. We designed a multicentric retrospective descriptive cohort study including all patients aged 15 years and over whose renal biopsy confirmed MCD or FSGS between January 2007 and December 2014. We studied 165 patients with idiopathic nephrotic syndrome; 97 with MCD and 68 with FSGS. In the MCD cohort, 91.7% of patients were treated with corticosteroids for a median total duration of 13 months. During 45 months of follow-up, 92.8% of patients achieved remission and 45.5% experienced relapse. In this cohort, 5% of patients experienced terminal kidney disease. With respect to FSGS patients, 51.5% were treated with corticosteroids for a median total duration of 15 months. During 66 months of follow-up, 73.5% of patients achieved remission and 20% experienced relapse. In this cohort, 26.5% of patients experienced terminal kidney disease. No statistical association was observed between clinical and biological initial presentation and relapse occurrence. This study describes the characteristics of a cohort of patients with the nephrotic idiopathic syndromes of MCD and FSGS from the time of renal biopsy and throughout follow-up.
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Fenton A, Smith SW, Hewins P. Adult minimal-change disease: observational data from a UK centre on patient characteristics, therapies, and outcomes. BMC Nephrol 2018; 19:207. [PMID: 30115013 PMCID: PMC6097194 DOI: 10.1186/s12882-018-0999-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background Minimal change disease (MCD) is a common cause of the nephrotic syndrome in adults with limited evidence on its treatment and prognosis. We examined the presenting characteristics, treatments, and outcomes of adult patients with MCD in our centre. Methods This was an observational cohort study using retrospectively-collected data. All patients who had a renal biopsy reported as MCD between 1996 and 2012 were included, and data were collected at baseline and during follow-up. Statistical analysis included Cox-regression analysis to examine which factors were associated with risk of relapse. Results Seventy-eight patients were included, and had a median age of 36 years, and were 60% male and 73% white. Median follow-up time was 72 months. 37% were in AKI at presentation, which was significantly associated with a lower serum albumin and older age. Although 10% were steroid-resistant, 98% achieved remission at a median time of 5 weeks. 61% relapsed, at a median time of 11 months, and patients had a median number of 2 relapses during follow-up. A higher eGFR was associated with an increased risk of relapse (hazard ratio 1.18 [1.03–1.36] per 10 mL/min increase in eGFR), and females were significantly more likely than males to have an early relapse. Nearly half of the cohort required an additional immunosuppressive agent on top of glucocorticoids, the most commonly used being calcineurin inhibitors. Five patients subsequently developed FSGS: these patients had a lower baseline creatinine, a higher serum albumin, a longer time to remission, and were more likely to be steroid-resistant. Follow-up renal function was generally preserved, but follow-up creatinine was higher in those who had presented with AKI, and in those who had been commenced on a RAS inhibitor after biopsy. Infection requiring admission, diabetes mellitus and venous thromboembolism developed in 14%, 12%, and 12% of patients respectively. Conclusions Nearly all adults with MCD achieve remission, but relapses and disease- and therapy-related complications are common. In our cohort, eGFR and gender were associated with risk of relapse, and these previously undescribed associations could be explored further in future work.
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Affiliation(s)
- Anthony Fenton
- Department of Renal Medicine, Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Stuart W Smith
- Department of Renal Medicine, Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Hewins
- Department of Renal Medicine, Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Li T, Shi Y, Sun W, Wang H, Wang Q, Jiang Y. Increased PD-1 +CD154 + Tfh cells are possibly the most important functional subset of PD-1 + T follicular helper cells in adult patients with minimal change disease. Mol Immunol 2017; 94:98-106. [PMID: 29288900 DOI: 10.1016/j.molimm.2017.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/11/2022]
Abstract
T follicular helper (Tfh) cells, especially programmed cell death protein 1 (PD-1)+ Tfh cells, exert important functions in the normal immune response. The purpose of this study was to determine the frequency of different subsets of PD-1+ Tfh cells and their functional effects in adult patients with minimal change disease (MCD). The frequencies of circulating PD-1+, PD-1+CD154+, and PD-1+interleukin (IL)-21+ Tfh cells, and CD38+CD19+ and CD38+CD19+CD40+ B cells, as well as serum IL-2, IL-4, IL-17A, IL-6, IL-21, and interferon (IFN)-γ were significantly increased in the MCD patients compared with the healthy controls (HCs) (P < 0.05). However, no significant difference was found in PD-1+BCL-6+ or PD-1+ICOS+ Tfh cells. Furthermore, the percentages of PD-1+ Tfh and PD-1+CD154+ Tfh cells were negatively correlated with the estimated glomerular filtration rate (eGFR), but positively correlated with the 24-h urinary protein concentration and serum IL-21 level. The percentages of PD-1+ Tfh and PD-1+CD154+ Tfh cells were positively correlated with the percentages of CD38+ plasma cells and active CD38+CD40+ plasma cells, respectively. After an 8-12-week treatment with prednisolone, the percentages of PD-1+, PD-1+CD154+, and PD-1+IL-21+ Tfh cells as well as the serum level of IL-21 were significantly reduced; in contrast, the serum levels of IL-4 and IL-10 were increased (P < 0.05). We conclude that increased PD-1+CD154+ Tfh cells are possibly the most important functional subset of PD-1+ Tfh cells and may contribute towards the pathogenesis of MCD.
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Affiliation(s)
- Tao Li
- Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Yunpeng Shi
- Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Weixia Sun
- Department of Nephrology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Haifeng Wang
- Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Quan Wang
- Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Yanfang Jiang
- Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, 130021, China; Key Laboratory of Zoonoses Research, Ministry of Education, The First Hospital of Jilin University, Changchun, 130021, China; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Yangzhou 225009, China.
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Maas RJ, Deegens JK, Beukhof JR, Reichert LJ, Ten Dam MA, Beutler JJ, van den Wall Bake AWL, Rensma PL, Konings CJ, Geerse DA, Feith GW, Van Kuijk WH, Wetzels JF. The Clinical Course of Minimal Change Nephrotic Syndrome With Onset in Adulthood or Late Adolescence: A Case Series. Am J Kidney Dis 2017; 69:637-646. [PMID: 28089478 DOI: 10.1053/j.ajkd.2016.10.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 10/24/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Few studies have examined the treatment and outcome of adult-onset minimal change nephrotic syndrome (MCNS). We retrospectively studied 125 patients who had MCNS with onset in either adulthood or late adolescence. Presenting characteristics, duration of initial treatment and response to treatment, relapse patterns, complications, and long-term outcome were studied. STUDY DESIGN Case series. SETTING & PARTICIPANTS Patients with new-onset nephrotic syndrome 16 years or older and a histologic diagnosis of MCNS in 1985 to 2011 were identified from pathology records of 10 participating centers. OUTCOMES Partial and complete remission, treatment resistance, relapse, complications, renal survival. RESULTS Corticosteroids were given as initial treatment in 105 (84%) patients. After 16 weeks of corticosteroid treatment, 92 (88%) of these patients had reached remission. Median time to remission was 4 (IQR, 2-7) weeks. 7 (6%) patients initially received cyclophosphamide with or without corticosteroids, and all attained remission after a median of 4 (IQR, 3-11) weeks. 13 (10%) patients reached remission without immunosuppressive treatment. One or more relapses were observed in 57 (54%) patients who received initial corticosteroid treatment. Second-line cyclophosphamide resulted in stable remission in 57% of patients with relapsing MCNS. Acute kidney injury was observed in 50 (40%) patients. Recovery of kidney function occurred almost without exception. Arterial or venous thrombosis occurred in 11 (9%) patients. At the last follow-up, 113 (90%) patients were in remission and had preserved kidney function. 3 patients with steroid-resistant MCNS progressed to end-stage renal disease, which was associated with focal segmental glomerulosclerosis lesions on repeat biopsy. LIMITATIONS Retrospective design, variable treatment protocols. CONCLUSIONS The large majority of patients who had MCNS with onset in adulthood or late adolescence were treated with corticosteroids and reached remission, but many had relapses. Cyclophosphamide resulted in stable remission in many patients with relapses. Significant morbidity was observed due to acute kidney injury and other complications. Progression to end-stage renal disease occurred in a few patients and was explained by focal segmental glomerulosclerosis.
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Affiliation(s)
- Rutger J Maas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Jeroen K Deegens
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johan R Beukhof
- Department of Nephrology, Isala Klinieken, Zwolle, the Netherlands
| | | | - Marc A Ten Dam
- Department of Nephrology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Jaap J Beutler
- Department of Nephrology, Jeroen Bosch Ziekenhuis, 's Hertogenbosch, the Netherlands
| | | | - Pieter L Rensma
- Department of Nephrology, St. Elisabeth Ziekenhuis, Tilburg, the Netherlands
| | | | - Daniel A Geerse
- Department of Nephrology, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Geert W Feith
- Department of Nephrology, Gelderse Vallei, Ede, the Netherlands
| | - Willi H Van Kuijk
- Department of Nephrology, Viecuri Medisch Centrum, Venlo, the Netherlands
| | - Jack F Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
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