1
|
Hullekes F, Uffing A, Verhoeff R, Seeger H, von Moos S, Mansur J, Mastroianni-Kirsztajn G, Silva HT, Buxeda A, Pérez-Sáez MJ, Arias-Cabrales C, Collins AB, Swett C, Morená L, Loucaidou M, Kousios A, Malvezzi P, Bugnazet M, Russo LS, Muhsin SA, Agrawal N, Nissaisorakarn P, Patel H, Al Jurdi A, Akalin E, Neto ED, Agena F, Ventura C, Manfro RC, Bauer AC, Mazzali M, de Sousa MV, La Manna G, Bini C, Comai G, Reindl-Schwaighofer R, Berger S, Cravedi P, Riella LV. Recurrence of membranous nephropathy after kidney transplantation: A multicenter retrospective cohort study. Am J Transplant 2024; 24:1016-1026. [PMID: 38341027 DOI: 10.1016/j.ajt.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
Membranous nephropathy (MN) is a leading cause of kidney failure worldwide and frequently recurs after transplant. Available data originated from small retrospective cohort studies or registry analyses; therefore, uncertainties remain on risk factors for MN recurrence and response to therapy. Within the Post-Transplant Glomerular Disease Consortium, we conducted a retrospective multicenter cohort study examining the MN recurrence rate, risk factors, and response to treatment. This study screened 22,921 patients across 3 continents and included 194 patients who underwent a kidney transplant due to biopsy-proven MN. The cumulative incidence of MN recurrence was 31% at 10 years posttransplant. Patients with a faster progression toward end-stage kidney disease were at higher risk of developing recurrent MN (hazard ratio [HR], 0.55 per decade; 95% confidence interval [CI], 0.35-0.88). Moreover, elevated pretransplant levels of anti-phospholipase A2 receptor (PLA2R) antibodies were strongly associated with recurrence (HR, 18.58; 95% CI, 5.37-64.27). Patients receiving rituximab for MN recurrence had a higher likelihood of achieving remission than patients receiving renin-angiotensin-aldosterone system inhibition alone. In sum, MN recurs in one-third of patients posttransplant, and measurement of serum anti-PLA2R antibody levels shortly before transplant could aid in risk-stratifying patients for MN recurrence. Moreover, patients receiving rituximab had a higher rate of treatment response.
Collapse
Affiliation(s)
- Frank Hullekes
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Audrey Uffing
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rucháma Verhoeff
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Surgery, Erasmus Medical Center Transplant Institute, Erasmus University, Rotterdam, The Netherlands
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Seraina von Moos
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Juliana Mansur
- Division of Nephrology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Anna Buxeda
- Division of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | | | - A Bernard Collins
- Renal Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christie Swett
- Renal Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leela Morená
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Paolo Malvezzi
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Mathilde Bugnazet
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Luis Sanchez Russo
- Translational Transplant Research Center, Renal Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Saif A Muhsin
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Pitchaphon Nissaisorakarn
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Het Patel
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayman Al Jurdi
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Enver Akalin
- Einstein/Montefiore Transplant Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Elias David Neto
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Fabiana Agena
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Carlucci Ventura
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Roberto C Manfro
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Carla Bauer
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Marilda Mazzali
- Division of Nephrology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Stefan Berger
- Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paolo Cravedi
- Translational Transplant Research Center, Renal Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
2
|
Peritore L, Labbozzetta V, Maressa V, Casuscelli C, Conti G, Gembillo G, Santoro D. How to Choose the Right Treatment for Membranous Nephropathy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1997. [PMID: 38004046 PMCID: PMC10673286 DOI: 10.3390/medicina59111997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023]
Abstract
Membranous nephropathy is an autoimmune disease affecting the glomeruli and is one of the most common causes of nephrotic syndrome. In the absence of any therapy, 35% of patients develop end-stage renal disease. The discovery of autoantibodies such as phospholipase A2 receptor 1, antithrombospondin and neural epidermal growth factor-like 1 protein has greatly helped us to understand the pathogenesis and enable the diagnosis of this disease and to guide its treatment. Depending on the complications of nephrotic syndrome, patients with this disease receive supportive treatment with diuretics, ACE inhibitors or angiotensin-receptor blockers, lipid-lowering agents and anticoagulants. After assessing the risk of progression of end-stage renal disease, patients receive immunosuppressive therapy with various drugs such as cyclophosphamide, steroids, calcineurin inhibitors or rituximab. Since immunosuppressive drugs can cause life-threatening side effects and up to 30% of patients do not respond to therapy, new therapeutic approaches with drugs such as adrenocorticotropic hormone, belimumab, anti-plasma cell antibodies or complement-guided drugs are currently being tested. However, special attention needs to be paid to the choice of therapy in secondary forms or in specific clinical contexts such as membranous disease in children, pregnant women and patients undergoing kidney transplantation.
Collapse
Affiliation(s)
- Luigi Peritore
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Vincenzo Labbozzetta
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Veronica Maressa
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Giovanni Conti
- Pediatric Nephrology Unit, AOU Policlinic “G Martino”, University of Messina, 98125 Messina, Italy;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| |
Collapse
|
3
|
Buxeda A, Caravaca-Fontán F, Vigara LA, Pérez-Canga JL, Calatayud E, Coloma A, Mazuecos A, Rodrigo E, Sancho A, Melilli E, Praga M, Pérez-Sáez MJ, Pascual J. High exposure to tacrolimus is associated with spontaneous remission of recurrent membranous nephropathy after kidney transplantation. Clin Kidney J 2023; 16:1644-1655. [PMID: 37779857 PMCID: PMC10539211 DOI: 10.1093/ckj/sfad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction We aimed to characterize the incidence and clinical presentation of membranous nephropathy (MN) after kidney transplantation (KT), and to assess allograft outcomes according to proteinuria rates and immunosuppression management. Methods Multicenter retrospective cohort study including patients from six Spanish centers who received a KT between 1991-2019. Demographic, clinical, and histological data were collected from recipients with biopsy-proven MN as primary kidney disease (n = 71) or MN diagnosed de novo after KT (n = 4). Results Up to 25.4% of patients with biopsy-proven MN as primary kidney disease recurred after a median time of 18.1 months posttransplant, without a clear impact on graft survival. Proteinuria at 3-months post-KT was a predictor for MN recurrence (rMN, HR 4.28; P = 0.008). Patients who lost their grafts had higher proteinuria during follow-up [1.0 (0.5-2.5) vs 0.3 (0.1-0.5) g/24 h], but only eGFR after recurrence treatment predicted poorer graft survival (eGFR < 30 ml/min: RR = 6.8). We did not observe an association between maintenance immunosuppression and recurrence diagnosis. Spontaneous remission after rMN was associated with a higher exposure to tacrolimus before recurrence (trough concentration/dose ratio: 2.86 vs 1.18; P = 0.028). Up to 94.4% of KT recipients received one or several treatments after recurrence onset: 22.2% rituximab, 38.9% increased corticosteroid dose, and 66.7% ACEi/ARBs. Only 21 patients had proper antiPLA2R immunological monitoring. Conclusions One-fourth of patients with biopsy-proven MN as primary kidney disease recurred after KT, without a clear impact on graft survival. Spontaneous remission after rMN was associated with a higher exposure to tacrolimus before recurrence.
Collapse
Affiliation(s)
- Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | | | - Luis Alberto Vigara
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - José Luis Pérez-Canga
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla / IDIVAL, Santander, Spain
| | - Emma Calatayud
- Department of Nephrology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Ana Coloma
- Department of Nephrology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | | | - Emilio Rodrigo
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla / IDIVAL, Santander, Spain
| | - Asunción Sancho
- Department of Nephrology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Edoardo Melilli
- Department of Nephrology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Julio Pascual
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| |
Collapse
|
4
|
Dantas M, Silva LBB, Pontes BTM, dos Reis MA, de Lima PSN, Moysés M. Membranous nephropathy. J Bras Nefrol 2023; 45:229-243. [PMID: 37527529 PMCID: PMC10627124 DOI: 10.1590/2175-8239-jbn-2023-0046en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.
Collapse
Affiliation(s)
- Márcio Dantas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
| | | | | | - Marlene Antônia dos Reis
- Universidade Federal do Triângulo Mineiro, Patologia Geral, Centro
de Pesquisa em Rim, Uberaba, MG, Brazil
| | | | - Miguel Moysés
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
| |
Collapse
|
5
|
Perna A, Ruggiero B, Podestà MA, Perico L, Orisio S, Debiec H, Remuzzi G, Ruggenenti P. Sexual dimorphic response to rituximab treatment: A longitudinal observational study in a large cohort of patients with primary membranous nephropathy and persistent nephrotic syndrome. Front Pharmacol 2022; 13:958136. [PMID: 36120314 PMCID: PMC9479107 DOI: 10.3389/fphar.2022.958136] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
Rituximab is one of the first-line therapies for patients with membranous nephropathy (MN) at high risk of progression towards kidney failure. We investigated whether the response to Rituximab was affected by sex and anti-PLA2R antibody levels in 204 consecutive patients (148 males and 56 females) with biopsy-proven MN who were referred to the Nephrology Unit of the Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII from March 2001 to October 2016 and managed conservatively for at least 6 months. The primary outcome was a combined endpoint of complete (proteinuria <0.3 g/24 h) or partial (proteinuria <3.0 g/24 h and >50% reduction vs. baseline) remission. Patients gave written informed consent to Rituximab treatment. The study was internally funded. No pharmaceutical company was involved. Anti-PLA2R antibodies were detectable in 125 patients (61.3%). At multivariable analyses, female gender (p = 0.0198) and lower serum creatinine levels (p = 0.0108) emerged as independent predictors of better outcome (p = 0.0198). The predictive value of proteinuria (p = 0.054) and anti-PLA2R titer (p = 0.0766) was borderline significant. Over a median (IQR) of 24.8 (12.0–36.0) months, 40 females (71.4%) progressed to the combined endpoint compared with 73 males (49.3%). Anti-PLA2R titers at baseline [127.6 (35.7-310.8) vs. 110.1 (39.9–226.7) RU/ml] and after Rituximab treatment were similar between the sexes. However, the event rate was significantly higher in females than in males [HR (95%): 2.12 (1.44–3.12), p = 0.0001]. Forty-five of the 62 patients (72.3%) with anti-PLA2R titer below the median progressed to the combined endpoint versus 35 of the 63 (55.6%) with higher titer [HR (95%): 1.97 (1.26–3.07), p < 0.0029]. The highest probability of progressing to the combined endpoint was observed in females with anti-PLA2R antibody titer below the median (86.7%), followed by females with anti-PLA2R antibody titer above the median (83.3%), males with titer below the median (68.1%), and males with titer above the median (44.4%). This trend was statistically significant (p = 0.0023). Similar findings were observed for complete remission (proteinuria <0.3 g/24 h) and after analysis adjustments for baseline serum creatinine. Thus, despite similar immunological features, females were more resilient to renal injury following Rituximab therapy. These findings will hopefully open new avenues to identify the molecular pathways underlying sex-related nephroprotective effects.
Collapse
Affiliation(s)
- Annalisa Perna
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Barbara Ruggiero
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Manuel Alfredo Podestà
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Department of Health Sciences, Università Degli Studi di Milano, Milano, Italy
| | - Luca Perico
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Orisio
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Hanna Debiec
- Sorbonne Université and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche, Paris, France
| | - Giuseppe Remuzzi
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- *Correspondence: Giuseppe Remuzzi,
| | - Piero Ruggenenti
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| |
Collapse
|
6
|
Liu Q, Liu J, Lin B, Zhang Y, Ma M, Yang M, Qin X. Novel Biomarkers in Membranous Nephropathy. Front Immunol 2022; 13:845767. [PMID: 35529848 PMCID: PMC9074781 DOI: 10.3389/fimmu.2022.845767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/25/2022] [Indexed: 01/13/2023] Open
Abstract
Membranous nephropathy (MN) is the main cause of adult nephrotic syndrome (NS). The pathogenesis of MN is complex and involves subepithelial immune complex deposition. Approximately one-third of patients with MN develop end-stage renal disease (ESRD). Timely diagnosis and reasonable intervention are the keys to improving prognosis. In recent years, with the development of high-throughput technologies, such as mass spectrometry (MS), microarray, and sequencing technologies, the discovery of biomarkers for MN has become an important area of research. In this review, we summarize the significant progress in biomarker identification. For example, a variety of podocyte target antigens and their autoantibodies have been reported. Phospholipase A2 receptor (PLA2R) is the most well-established target antigen in MN. PLA2R and its autoantibodies have clinical significance, with both diagnostic and therapeutic value for MN. In addition, a variety of new biomarkers, including proteins, metabolites, noncoding RNAs (ncRNAs), and immune cells, have recently been found. These MN-related biomarkers have great significance in the diagnosis, progression, prognosis, and treatment response of MN.
Collapse
Affiliation(s)
- Qiuying Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- Department of Laboratory Medicine, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China
| | - Jianhua Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Baoxu Lin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yue Zhang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meichen Ma
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mei Yang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaosong Qin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Xiaosong Qin,
| |
Collapse
|
7
|
Zanoni F, Khairallah P, Kiryluk K, Batal I. Glomerular Diseases of the Kidney Allograft: Toward a Precision Medicine Approach. Semin Nephrol 2022; 42:29-43. [PMID: 35618394 PMCID: PMC9139085 DOI: 10.1016/j.semnephrol.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The continual development of potent immunosuppressive regimens has led to a decreased incidence of acute rejection and improvement of short-term kidney allograft survival. In contrast to acute rejection, glomerular diseases of the kidney allograft are being encountered more frequently and are emerging as leading causes of late kidney allograft failure. Although data on the pathogeneses of glomerular diseases in the kidney allograft are sparse, cumulative evidence suggests that post-transplant glomerular diseases may be the result of inherited predispositions and immunologic triggers. Although studying immunologic signals and performing genome-wide association studies are ideal approaches to tackle glomerular diseases in the kidney allograft, such studies are challenging because of the lack of adequately powered cohorts. In this review, we focus on the most commonly encountered recurrent and de novo glomerular diseases in the kidney allograft. We address the important advances made in understanding the immunopathology and genetic susceptibility of glomerular diseases in the native kidney and how to benefit from such knowledge to further our knowledge of post-transplant glomerular diseases. Defining genomic and immune predictors for glomerular diseases in the kidney allograft would support novel donor-recipient matching strategies and development of targeted therapies to ultimately improve long-term kidney allograft survival.
Collapse
Affiliation(s)
- Francesca Zanoni
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Krzysztof Kiryluk
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ibrahim Batal
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA,Corresponding Author: Ibrahim Batal MD, Department of Pathology and Cell Biology, Renal Division, Columbia University Irving Medical Center, 630 W 168th street, VC14-238, New York, NY 10032, Phone: 212-305-9669, Fax: 212-342-5380,
| |
Collapse
|
8
|
Uffing A, Hullekes F, Riella LV, Hogan JJ. Recurrent Glomerular Disease after Kidney Transplantation: Diagnostic and Management Dilemmas. Clin J Am Soc Nephrol 2021; 16:1730-1742. [PMID: 34686531 PMCID: PMC8729409 DOI: 10.2215/cjn.00280121] [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] [Indexed: 02/04/2023]
Abstract
Recurrent glomerular disease after kidney transplant remains an important cause of allograft failure. Many of the different entities post-transplant still suffer from incomplete knowledge on pathophysiology, and therefore lack targeted and effective therapies. In this review, we focus on specific clinical dilemmas encountered by physicians in managing recurrent glomerular disease by highlighting new insights into the understanding and treatment of post-transplant focal segmental glomerulosclerosis, membranous nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, amyloid light-chain (AL) amyloidosis, and IgA nephropathy.
Collapse
Affiliation(s)
- Audrey Uffing
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Hullekes
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J. Hogan
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
De Souza L, Prunster J, Chan D, Chakera A, Lim WH. Recurrent glomerulonephritis after kidney transplantation: a practical approach. Curr Opin Organ Transplant 2021; 26:360-380. [PMID: 34039882 DOI: 10.1097/mot.0000000000000887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review will provide a practical approach in the assessment of kidney failure patients with primary glomerulonephritides (GN) being considered for kidney transplantation, focusing on high-risk subtypes of immunoglobulin A nephropathy, focal segmental glomerulosclerosis, idiopathic membranous glomerulonephritis and membranoproliferative glomerulonephritis. RECENT FINDINGS Recurrent glomerulonephritis remains one of the most common causes of allograft loss in kidney transplant recipients. Although the epidemiology and clinical outcomes of glomerulonephritis recurrence occurring after kidney transplantation are relatively well-described, the natural course and optimal treatment strategies of recurrent disease in kidney allografts remain poorly defined. With a greater understanding of the pathophysiology and treatment responses of patients with glomerulonephritis affecting the native kidneys, these discoveries have laid the framework for the potential to improve the management of patients with high-risk glomerulonephritis subtypes being considered for kidney transplantation. SUMMARY Advances in the understanding of the underlying immunopathogenesis of primary GN has the potential to offer novel therapeutic options for kidney patients who develop recurrent disease after kidney transplantation. To test the efficacy of novel treatment options in adequately powered clinical trials requires a more detailed understanding of the clinical and histological characteristics of kidney transplant recipients with recurrent glomerulonephritis.
Collapse
Affiliation(s)
- Laura De Souza
- Department of Renal Medicine, Cairns Hospital, Cairns North, Queensland
| | - Janelle Prunster
- Department of Renal Medicine, Cairns Hospital, Cairns North, Queensland
| | - Doris Chan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| |
Collapse
|
10
|
Berchtold L, Letouzé E, Alexander MP, Canaud G, Logt AEVD, Hamilton P, Mousson C, Vuiblet V, Moyer AM, Guibert S, Mrázová P, Levi C, Dubois V, Cruzado JM, Torres A, Gandhi MJ, Yousfi N, Tesar V, Viklický O, Hourmant M, Moulin B, Rieu P, Choukroun G, Legendre C, Wetzels J, Brenchley P, Ballarín Castan JA, Debiec H, Ronco P. HLA-D and PLA2R1 risk alleles associate with recurrent primary membranous nephropathy in kidney transplant recipients. Kidney Int 2021; 99:671-685. [DOI: 10.1016/j.kint.2020.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/30/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022]
|
11
|
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 249] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
Collapse
|
12
|
Bobart SA, Alexander MP, Bentall A. Recurrent Glomerulonephritis in the Kidney Allograft. Indian J Nephrol 2020; 30:359-369. [PMID: 33840954 PMCID: PMC8023028 DOI: 10.4103/ijn.ijn_193_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/05/2019] [Accepted: 10/30/2019] [Indexed: 01/05/2023] Open
Abstract
Renal transplantation is the preferred form of renal replacement therapy in patients who develop end-stage kidney disease (ESKD). Among the diverse etiologies of ESKD, glomerulonephritis is the third most common cause, behind hypertensive and diabetic kidney disease. Although efforts to prolong graft survival have improved over time with the advent of novel immunosuppression, recurrent glomerulonephritis remains a major threat to renal allograft survival despite concomitant immunosuppression. As a result, clinical expertise, early diagnosis and intervention will help identify recurrent disease and facilitate prompt treatment, thus minimizing graft loss, resulting in improved outcomes. In this review, we highlight the clinicopathologcal characteristics of certain glomerular diseases that recur in the renal allograft.
Collapse
Affiliation(s)
- Shane A. Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
13
|
Kidney transplantation for primary glomerulonephritis: Recurrence risk and graft outcomes with related versus unrelated donors. Transplant Rev (Orlando) 2020; 35:100584. [PMID: 33069562 DOI: 10.1016/j.trre.2020.100584] [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: 08/15/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 11/20/2022]
Abstract
Primary glomerulonephritis can recur after kidney transplantation and may jeopardize the survival of the renal allograft. The risks of living-related kidney transplantation remain controversial in this group of patients. Living related transplantation offers potentially better HLA matching, therefore improve the long-term graft survival. However, the concern for increased rates of recurrence of the primary glomerulonephritis in the transplanted kidney from living related donors complicates the selection of donors. With the recent dramatic rise in the use of paired kidney exchange, there is now often the option of having a living related donor donate through a paired exchange. This raises the question of whether patients with primary glomerulonephritis should receive living donor kidneys through paired kidney exchange programs to obtain the benefits of a living donor kidney transplant while also reducing the risk of recurrent glomerulonephritis. Our review of the literature suggests that although the recurrence of primary glomerulonephritis occurs more often when donation occurs from a living related donor as compared to an unrelated donor, the graft survival advantage of living related donation is generally maintained despite the recurrence. We suggest that despite the increased risk of recurrence, living related donation should not be avoided in patients with primary glomerulonephritis as the cause of their end-stage renal disease.
Collapse
|
14
|
Huang L, Dong QR, Zhao YJ, Hu GC. Rituximab for the management of idiopathic membranous nephropathy: a meta-analysis. Int Urol Nephrol 2020; 53:111-119. [PMID: 32944889 DOI: 10.1007/s11255-020-02633-5] [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: 05/26/2020] [Accepted: 08/31/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study was to evaluate the efficacy of rituximab therapy in the management of idiopathic membranous nephropathy (IMN). METHODS After literature search, data from eligible studies were used to perform random-effects meta-analyses to estimate remission rates and changes in proteinuria at the latest follow-up after rituximab therapy. The outcomes were used for metaregression to identify the factors affecting the efficacy of rituximab. RESULTS Twenty-one studies were included in the analysis (602 patients; age 50 years [95% CI 46.8, 53.3]; 30% females [95% CI 23, 31]). Follow-up duration was 20.3 months [95% CI 17.1, 23.5]. Remission rate (67% [95% CI 61, 73]) was higher in studies with below average baseline proteinuria (76% [95% CI 61, 88]) than in studies with above average baseline proteinuria (61% [95% CI 54, 68]). The complete and partial remission rates were 26% [95% CI 20, 33] and 37% [95% CI 31, 43], respectively. Rituximab therapy significantly reduced proteinuria (mean difference between final and baseline values: - 4.90 g/day [95% CI - 6.18, - 3.63]; p < 0.00001; % reduction: 62% [95% CI 57, 68]). The reduction in proteinuria was inversely associated with baseline serum albumin levels (p = 0.021) and the estimated glomerular filtration rate (p < 0.00001) and was positively associated with baseline proteinuria (p < 0.00001). The remission rate or decrease in proteinuria was not significantly related to the anti-PLA2R antibody status or previous immunosuppressant therapy. CONCLUSION Rituximab therapy in IMN patients can provide approximately 67% remission rate. The reduction in proteinuria was greater in patients who had higher baseline proteinuria.
Collapse
Affiliation(s)
- Lan Huang
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, 36 Nanyingzi St, Shuangqiao Qu, Chengde, 067000, Hebei, China
| | - Qiao-Rong Dong
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, 36 Nanyingzi St, Shuangqiao Qu, Chengde, 067000, Hebei, China
| | - Ya-Juan Zhao
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, 36 Nanyingzi St, Shuangqiao Qu, Chengde, 067000, Hebei, China
| | - Gui-Cai Hu
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, 36 Nanyingzi St, Shuangqiao Qu, Chengde, 067000, Hebei, China.
| |
Collapse
|
15
|
Batal I, Vasilescu ER, Dadhania DM, Adel AA, Husain SA, Avasare R, Serban G, Santoriello D, Khairallah P, Patel A, Moritz MJ, Latulippe E, Riopel J, Khallout K, Swanson SJ, Bomback AS, Mohan S, Ratner L, Radhakrishnan J, Cohen DJ, Appel GB, Stokes MB, Markowitz GS, Seshan SV, De Serres SA, Andeen N, Loupy A, Kiryluk K, D'Agati VD. Association of HLA Typing and Alloimmunity With Posttransplantation Membranous Nephropathy: A Multicenter Case Series. Am J Kidney Dis 2020; 76:374-383. [PMID: 32359820 PMCID: PMC7483441 DOI: 10.1053/j.ajkd.2020.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/07/2020] [Indexed: 12/20/2022]
Abstract
RATIONALE & OBJECTIVES Posttransplantation membranous nephropathy (MN) represents a rare complication of kidney transplantation that can be classified as recurrent or de novo. The clinical, pathologic, and immunogenetic characteristics of posttransplantation MN and the differences between de novo and recurrent MN are not well understood. STUDY DESIGN Multicenter case series. SETTING & PARTICIPANTS We included 77 patients from 5 North American and European medical centers with post-kidney transplantation MN (27 de novo and 50 recurrent). Patients with MN in the native kidney who received kidney allografts but did not develop recurrent MN were used as nonrecurrent controls (n = 43). To improve understanding of posttransplantation MN, we compared de novo MN with recurrent MN and then contrasted recurrent MN with nonrecurrent controls. FINDINGS Compared with recurrent MN, de novo MN was less likely to be classified as primary MN (OR, 0.04; P < 0.001) and had more concurrent antibody-mediated rejection (OR, 12.0; P < 0.001) and inferior allograft survival (HR for allograft failure, 3.2; P = 0.007). HLA-DQ2 and HLA-DR17 antigens were more common in recipients with recurrent MN compared with those with de novo MN; however, the frequency of these recipient antigens in recurrent MN was similar to that in nonrecurrent MN controls. Among the 93 kidney transplant recipients with native kidney failure attributed to MN, older recipient age (HR per each year older, 1.03; P = 0.02), recipient HLA-A3 antigen (HR, 2.5; P = 0.003), steroid-free immunosuppressive regimens (HR, 2.84; P < 0.001), and living related allograft (HR, 1.94; P = 0.03) were predictors of MN recurrence. LIMITATIONS Retrospective case series, limited sample size due to rarity of the disease, nonstandardized nature of data collection and biopsies. CONCLUSIONS De novo and recurrent MN likely represent separate diseases. De novo MN is associated with humoral alloimmunity and guarded outcome. Potential predisposing factors for recurrent MN include recipients who are older, recipient HLA-A3 antigen, steroid-free immunosuppressive regimen, and living related donor kidney.
Collapse
Affiliation(s)
- Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY.
| | - Elena-Rodica Vasilescu
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Darshana M Dadhania
- Department of Medicine, Nephrology, Weill Cornell Medical College, New York, NY
| | | | - S Ali Husain
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Rupali Avasare
- Department of Medicine, Nephrology, Oregon Health & Science University, Portland, OR
| | - Geo Serban
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Pascale Khairallah
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Ankita Patel
- Department of Medicine, Nephrology, Hackensack University Medical Center, Hackensack, NJ
| | - Michael J Moritz
- Department of Surgery, Lehigh Valley Health Network, Allentown, PA
| | - Eva Latulippe
- Department of Pathology, University Health Center of Quebec, Laval University, Québec, QC, Canada
| | - Julie Riopel
- Department of Pathology, University Health Center of Quebec, Laval University, Québec, QC, Canada
| | - Karim Khallout
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | | | - Andrew S Bomback
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Sumit Mohan
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Lloyd Ratner
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Jai Radhakrishnan
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - David J Cohen
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Gerald B Appel
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Michael B Stokes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Surya V Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Sacha A De Serres
- Renal Division, Department of Medicine, University Health Center of Quebec, Laval University, Québec, QC, Canada
| | - Nicole Andeen
- Department of Pathology, Oregon Health & Science University, Portland, OR
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - Krzysztof Kiryluk
- Department of Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
16
|
Lu W, Gong S, Li J, Luo H, Wang Y. Efficacy and safety of rituximab in the treatment of membranous nephropathy: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19804. [PMID: 32311997 PMCID: PMC7440335 DOI: 10.1097/md.0000000000019804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab (RTX) is considered to be a promising drug for curing membranous nephropathy. However, the efficacy and safety of RTX in treating membranous nephropathy remain uncertain. This meta-analysis aimed to investigate the efficacy and safety of RTX in patients with membranous nephropathy. METHODS A literature search was performed using Pubmed, Embase, OVID, and Cochrane Library and randomized controlled trials (RCTs) case-controls and cohort studies published till 30 July 2019 were assessed. The studies assessing the efficacy and safety of RTX in patients with membranous nephropathy were included. RESULTS Eight relevant trials involving 542 patients were included in the meta-analysis. It was found that RTX did not significantly improve serum albumin levels and e-GFR when compared with the control group (including cyclosporine and cyclophosphamide, chlorambucil, prednisone, non-immunosuppressive anti-proteinuria treatment), serum albumin levels (OR = 0.31, 95%CI-0.12-0.74, P = .15), e-GFR (OR = -1.49, 95%CI-17.14-14.17, P = .85). However, RTX did reduce the serum creatinine (OR = -0.01, 95%CI-0.36-0.34, P = .95) and urinary protein (OR = -2.39, 95%CI -7.30 -2.53, P = .34) levels. Also, in comparison to the control group, RTX did improve the total remission rate (OR = 1.63, 95%CI 0.48-5.54, P = .43), achieve a higher rate of complete remission (OR = 2.54, 95%CI 1.65-3.90, P < .01) and also reduced the amount of M-type phospholipase A2 receptor-Antibody depletion in patients (OR = 5.59, 95%CI 1.81-17.2, P = .003). RTX-related adverse events were mostly mild (most infusion-related reactions) in nature and serious adverse events were rare. CONCLUSION RTX proved to be efficient, well-tolerated and a safe drug in the treatment of membranous nephropathy. Most patients reach complete remission during the follow-up period, and relapse is rare. RTX may turn out to be promising in membranous nephropathy patients.
Collapse
|
17
|
Leon J, Pérez-Sáez MJ, Batal I, Beck LH, Rennke HG, Canaud G, Legendre C, Pascual J, Riella LV. Membranous Nephropathy Posttransplantation: An Update of the Pathophysiology and Management. Transplantation 2019; 103:1990-2002. [PMID: 31568231 DOI: 10.1097/tp.0000000000002758] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Membranous nephropathy (MN) is a common cause of nephrotic syndrome after transplantation and is associated with an increased risk of allograft loss. MN may occur either as a recurrent or as a de novo disease. As in native kidneys, the pathophysiology of the MN recurrence is in most cases associated with antiphospholipid A2 receptor antibodies. However, the posttransplant course has some distinct features when compared with primary MN, including a lower chance of spontaneous remission and a greater requirement for adjuvant immunosuppressive therapy to induce complete remission. Although the efficacy of rituximab in primary MN is now well established, no randomized studies have assessed its effectiveness in MN after transplant, and there are no specific recommendations for the management of these patients. This review aims to synthesize and update the pathophysiology of posttransplant MN, as well as to address unsolved issues specific to transplantation, including the prognostic value of antiphospholipid A2 receptor, the risk of living-related donation, the link between de novo MN and rejection, and different therapeutic strategies so far deployed in posttransplant MN. Lastly, we propose a management algorithm for patients with MN who are planning to receive a kidney transplant, including pretransplant considerations, posttransplant monitoring, and the clinical approach after the diagnosis of recurrence.
Collapse
Affiliation(s)
- Juliette Leon
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France
| | - María José Pérez-Sáez
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Ibrahim Batal
- Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Laurence H Beck
- Division of Nephrology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Guillaume Canaud
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France
| | - Christophe Legendre
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Leonardo V Riella
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
18
|
Long-term outcomes of patients with end-stage kidney disease due to membranous nephropathy: A cohort study using the Australia and New Zealand Dialysis and Transplant Registry. PLoS One 2019; 14:e0221531. [PMID: 31442267 PMCID: PMC6707602 DOI: 10.1371/journal.pone.0221531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/08/2019] [Indexed: 01/17/2023] Open
Abstract
Background Clinical outcomes of patients with end-stage kidney disease (ESKD) secondary to membranous nephropathy (MN) have not been well described. This study aimed to evaluate patient and/or allograft outcomes of dialysis or kidney transplantation in patients with ESKD secondary to MN. Material and methods All adult patients with ESKD commencing renal replacement therapy in Australia and New Zealand from January 1998 to December 2010 were extracted retrospectively from ANZDATA registry on 31st December 2013. Outcomes of MN were compared to other causes of ESKD. In a secondary analysis, outcomes of MN were compared to all patients with ESKD due to other forms of glomerulonephritis. Results Of 32,788 included patients, 417 (1.3%) had MN. Compared to other causes of ESKD, MN experienced lower mortality on dialysis (adjusted hazard ratio [aHR] 0.79, 95% CI 0.68–0.92, p = 0.002) and following kidney transplantation (aHR 0.57, 95% CI 0.33–0.97, p = 0.04), had a higher risk of death-censored kidney allograft failure (aHR 1.55, 95% CI: 1.00–2.41, p = 0.05) but comparable risk of overall kidney allograft failure (aHR 1.35, 95% CI 0.91–2.01, p = 0.13). Similar results were obtained using competing-risk regression analyses. MN patients were significantly more likely to receive a kidney transplant (aHR 1.38, 95% CI 1.16–1.63, p<0.001) and to experience primary kidney disease recurrence in the allograft (aHR 4.92, 95% CI 3.02–8.01, p<0.001). Compared to other forms of glomerulonephritis, MN experienced comparable dialysis and transplant patient survival, but higher rates of kidney transplantation, primary renal disease recurrence and death-censored allograft failure. Conclusion MN was associated with superior survival on dialysis and following kidney transplantation compared to patients with other causes of ESKD, and comparable patient survival compared to patients with other forms of glomerulonephritis. However, patients with MN exhibited a higher rate of death-censored allograft loss as a result of primary kidney disease recurrence.
Collapse
|
19
|
Lim WH, Shingde M, Wong G. Recurrent and de novo Glomerulonephritis After Kidney Transplantation. Front Immunol 2019; 10:1944. [PMID: 31475005 PMCID: PMC6702954 DOI: 10.3389/fimmu.2019.01944] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
The prevalence, pathogenesis, predictors, and natural course of patients with recurrent glomerulonephritis (GN) occurring after kidney transplantation remains incompletely understood, including whether there are differences in the outcomes and advances in the treatment options of specific GN subtypes, including those with de novo GN. Consequently, the treatment options and approaches to recurrent disease are largely extrapolated from the general population, with responses to these treatments in those with recurrent or de novo GN post-transplantation poorly described. Given a greater understanding of the pathogenesis of GN and the development of novel treatment options, it is conceivable that these advances will result in an improved structure in the future management of patients with recurrent or de novo GN. This review focuses on the incidence, genetics, characteristics, clinical course, and risk of allograft failure of patients with recurrent or de novo GN after kidney transplantation, ascertaining potential disparities between “high risk” disease subtypes of IgA nephropathy, idiopathic membranous glomerulonephritis, focal segmental glomerulosclerosis, and membranoproliferative glomerulonephritis. We will examine in detail the management of patients with high risk GN, including the pre-transplant assessment, post-transplant monitoring, and the available treatment options for disease recurrence. Given the relative paucity of data of patients with recurrent and de novo GN after kidney transplantation, a global effort in collecting comprehensive in-depth data of patients with recurrent and de novo GN as well as novel trial design to test the efficacy of specific treatment strategy in large scale multicenter randomized controlled trials are essential to address the knowledge deficiency in this disease.
Collapse
Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Meena Shingde
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| |
Collapse
|
20
|
Passerini P, Malvica S, Tripodi F, Cerutti R, Messa P. Membranous Nephropathy (MN) Recurrence After Renal Transplantation. Front Immunol 2019; 10:1326. [PMID: 31244861 PMCID: PMC6581671 DOI: 10.3389/fimmu.2019.01326] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/24/2019] [Indexed: 11/22/2022] Open
Abstract
Primary membranous nephropathy (MN) is a frequent cause of NS in adults. In native kidneys the disease may progress to ESRD in the long term, in some 40–50% of untreated patients. The identification of the pathogenic role of anti-podocyte autoantibodies and the development of new therapeutic options has achieved an amelioration in the prognosis of this disease. MN may also develop in renal allograft as a recurrent or a de novo disease. Since the de novo MN may have some different pathogenetic and morphologic features compared to recurrent MN, in the present paper we will deal only with the recurrent disease. The true incidence of the recurrent form is difficult to assess. This is mainly due to the variable graft biopsy policies in kidney transplantation, among the different transplant centers. Anti-phospholipase A2 receptor (PLA2R) autoantibodies are detected in 70–80% of patients. The knowledge of anti-PLA2R status before transplant is useful in predicting the risk of recurrence. In addition, the serial survey of the anti-PLA2R titers is important to assess the rate of disease progression and the response to treatment. Currently, there are no established guidelines for prevention and treatment of recurrent MN. Symptomatic therapy may help to reduce the signs and symptoms related to the nephrotic syndrome. Anecdotal cases of response to cyclical therapy with steroids and cyclophosphamide have been published. Promising results have been reported with rituximab in both prophylaxis and treatment of recurrence. However, these results are based on observational data, and prospective controlled trials are still missing.
Collapse
Affiliation(s)
- Patrizia Passerini
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Malvica
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Tripodi
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberta Cerutti
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
21
|
Ishiwatari A, Wakai S, Shirakawa H, Honda K. Recurrent Membranous Nephropathy After Kidney Transplantation Associated With Phospholipase A2 Receptor and Successfully Treated With Rituximab: A Case Report. Transplant Proc 2018; 50:2565-2568. [PMID: 30316399 DOI: 10.1016/j.transproceed.2018.03.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
Primary membranous nephropathy (MN) is an organ-specific autoimmune disease mainly caused by autoantibodies acting against the podocyte antigen M-type phospholipase A2 receptor 1 (PLA2R). Herein we present the clinical and histologic findings, including PLA2R staining, of early recurrent MN after kidney transplantation that was successfully treated with rituximab. A 60-year-old Japanese man had end-stage renal failure due to steroid-resistant primary MN and underwent ABO-incompatible living donor kidney transplantation. At 1 month after transplantation, a protocol biopsy revealed positive granular staining of IgG, C4d, and PLA2R on glomerular capillaries (GCs) without any abnormalities on light microscopy (LM). Although the patient had low-level proteinuria, recurrent MN was suspected based on the positive PLA2R staining; he was treated with an angiotensin receptor blocker and a single dose of 200 mg rituximab. However, proteinuria gradually increased to 877 mg/d. At 21 months after transplantation, a graft biopsy revealed spikes along the outer aspects of GC on LM, with stronger staining for PLA2R than that at 1 month after transplantation. A single dose of 500 mg rituximab was added, which effectively reduced proteinuria, and clinical remission continued until 3 years after transplantation. The latest graft biopsy showed reduced staining of PLA2R. The disease activity and therapeutic effect were well-reflected in the intensity of PLA2R staining. An approach intending an early diagnosis by protocol biopsy using PLA2R immunostaining is made and early treatment with rituximab will help reduce the risk of kidney graft loss due to recurrent primary MN.
Collapse
Affiliation(s)
- A Ishiwatari
- Department of Nephrology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Tokyo, Japan.
| | - S Wakai
- Department of Nephrology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Tokyo, Japan
| | - H Shirakawa
- Department of Urology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Tokyo, Japan
| | - K Honda
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| |
Collapse
|
22
|
Abstract
Rituximab is a chimeric anti-CD20 monoclonal protein used in various clinical scenarios in kidney transplant recipients. However, its evidence-based use there remains limited due to lack of controlled studies, limited sample size, short follow-up and poorly defined endpoints. Rituximab is indicated for CD20+ posttransplant lymphoproliferative disorder. It may be beneficial for treating recurrent membranous nephropathy and recurrent allograft antineutrophilic cytoplasmic antibody vasculitis and possibly for recurrent focal segmental glomerulosclerosis. Rituximab, in combination with IVIg/plasmapheresis, appears to decrease antibody level and increase the odds of transplantation in sensitized recipients. The role of Rituximab in ABOi transplant remains unclear, as similar outcomes are achieved without its use. Rituximab is not efficacious in antibody-mediated rejection/chronic antibody-mediated rejection. Strict randomized control trials are necessary to elucidate its true role in these settings.
Collapse
|
23
|
Clinical Presentation, Outcomes, and Treatment of Membranous Nephropathy after Transplantation. Int J Nephrol 2018; 2018:3720591. [PMID: 30112208 PMCID: PMC6077578 DOI: 10.1155/2018/3720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 05/20/2018] [Accepted: 06/12/2018] [Indexed: 11/17/2022] Open
Abstract
There are scarce data about clinical presentation and outcomes of posttransplant membranous nephropathy (MN), and few reports include a large number of patients. This was a retrospective cohort including adult patients with posttransplant MN transplanted between 1983 and 2015 in a single center (n=41). Only patients with histological diagnosis of MN in kidney grafts were included. Clinical and laboratory presentation, histological findings, treatment, and outcomes were detailed. Patients were predominantly male (58.5%), with a mean age of 49.4 ± 13.2 years; 15 were considered as recurrent primary MN; 3 were class V lupus nephritis; 14 were considered as de novo cases, 7 secondary and 7 primary MN; and 9 cases were considered primary but it was not possible to distinguish between de novo MN and recurrence. Main clinical presentations were proteinuria (75.6%) and graft dysfunction (34.1%). Most patients with primary recurrent and de novo primary MN were submitted to changes in maintenance immunosuppressive regimen, but no standard strategy was identified; 31 patients presented partial or complete remission, and glomerulopathy appeared not to impact graft and patient survival.
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW With improving short-term kidney transplant outcomes, recurrent glomerular disease is being increasingly recognized as an important cause of chronic allograft failure. Further understanding of the risks and pathogenesis of recurrent glomerular disease enable informed transplant decisions, along with the development of preventive and treatment strategies. RECENT FINDINGS Multiple observational studies have highlighted differences in rates and outcomes for various recurrent glomerular diseases, although these rates have not markedly improved over the last decade. Emerging evidence supports use of rituximab to treat recurrent primary membranous nephropathy and possibly focal segmental glomerulosclerosis (FSGS), whereas eculizumab is effective in glomerular diseases associated with complement dysregulation [C3 glomerulopathy (C3G) and atypical hemolytic uremic syndrome (aHUS)]. SUMMARY Despite the potential for recurrence in the allograft, transplant remains the optimal therapy for patients with advanced chronic kidney disease (CKD) secondary to primary glomerular disease. Biomarkers and therapeutic options necessitate accurate pretransplant diagnoses with opportunities for improved surveillance and treatment of recurrent glomerular disease posttransplant.
Collapse
|
25
|
Kofman T, Oniszczuk J, Lang P, Grimbert P, Audard V. [Current insights about recurrence of glomerular diseases after renal transplantation]. Nephrol Ther 2018; 14:179-188. [PMID: 29706414 DOI: 10.1016/j.nephro.2018.03.001] [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] [Indexed: 01/27/2023]
Abstract
Recurrence of glomerular disease after renal transplantation is a frequent cause of graft loss. Incidence, risk factors and outcome of recurrence are widely due to the underlying glomerular disease. Graft biopsy analysis is required to confirm the definitive diagnosis of recurrence and to start an appropriate therapy that, in some cases, remains challenging to prevent graft failure. Increased use of protocol biopsy and recent advances in our understanding of the pathogenesis of some glomerular diseases with the identification of some relevant biomarkers provide a unique opportunity to initiate kidney-protective therapy at early stages of recurrence on the graft. This review summarizes our current knowledge on the management of many recurrent primary and secondary glomerulonephritis after kidney transplantation.
Collapse
Affiliation(s)
- Tomek Kofman
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Julie Oniszczuk
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Philippe Lang
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Philippe Grimbert
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Vincent Audard
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
| |
Collapse
|
26
|
Abbas F, El Kossi M, Jin JK, Sharma A, Halawa A. De novo glomerular diseases after renal transplantation: How is it different from recurrent glomerular diseases? World J Transplant 2017; 7:285-300. [PMID: 29312858 PMCID: PMC5743866 DOI: 10.5500/wjt.v7.i6.285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/31/2017] [Accepted: 11/10/2017] [Indexed: 02/05/2023] Open
Abstract
The glomerular diseases after renal transplantation can occur de novo, i.e., with no relation to the native kidney disease, or more frequently occur as a recurrence of the original disease in the native kidney. There may not be any difference in clinical features and histological pattern between de novo glomerular disease and recurrence of original glomerular disease. However, structural alterations in transplanted kidney add to dilemma in diagnosis. These changes in architecture of histopathology can happen due to: (1) exposure to the immunosuppression specifically the calcineurin inhibitors (CNI); (2) in vascular and tubulointerstitial alterations as a result of antibody mediated or cell-mediated immunological onslaught; (3) post-transplant viral infections; (4) ischemia-reperfusion injury; and (5) hyperfiltration injury. The pathogenesis of the de novo glomerular diseases differs with each type. Stimulation of B-cell clones with subsequent production of the monoclonal IgG, particularly IgG3 subtype that has higher affinity to the negatively charged glomerular tissue, is suggested to be included in PGNMID pathogenesis. De novo membranous nephropathy can be seen after exposure to the cryptogenic podocyte antigens. The role of the toxic effects of CNI including tissue fibrosis and the hemodynamic alterations may be involved in the de novo FSGS pathophysiology. The well-known deleterious effects of HCV infection and its relation to MPGN disease are frequently reported. The new concepts have emerged that demonstrate the role of dysregulation of alternative complement pathway in evolution of MPGN that led to classifying into two subgroups, immune complex mediated MPGN and complement-mediated MPGN. The latter comprises of the dense deposit disease and the C3 GN disease. De novo C3 disease is rather rare. Prognosis of de novo diseases varies with each type and their management continues to be empirical to a large extent.
Collapse
Affiliation(s)
- Fedaey Abbas
- Department of Nephrology, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Kim Jin
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
| |
Collapse
|
27
|
Abbas F, El Kossi M, Jin JK, Sharma A, Halawa A. Recurrence of primary glomerulonephritis: Review of the current evidence. World J Transplant 2017; 7:301-316. [PMID: 29312859 PMCID: PMC5743867 DOI: 10.5500/wjt.v7.i6.301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/24/2017] [Accepted: 11/22/2017] [Indexed: 02/05/2023] Open
Abstract
In view of the availability of new immunosuppression strategies, the recurrence of allograft glomerulonephritis (GN) are reported to be increasing with time post transplantation. Recent advances in understanding the pathogenesis of the GN recurrent disease provided a better chance to develop new strategies to deal with the GN recurrence. Recurrent GN diseases manifest with a variable course, stubborn behavior, and poor response to therapy. Some types of GN lead to rapid decline of kidney function resulting in a frustrating return to maintenance dialysis. This subgroup of aggressive diseases actually requires intensive efforts to ascertain their pathogenesis so that strategy could be implemented for better allograft survival. Epidemiology of native glomerulonephritis as the cause of end-stage renal failure and subsequent recurrence of individual glomerulonephritis after renal transplantation was evaluated using data from various registries, and pathogenesis of individual glomerulonephritis is discussed. The following review is aimed to define current protocols of the recurrent primary glomerulonephritis therapy.
Collapse
Affiliation(s)
- Fedaey Abbas
- Department of Nephrology, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Kim Jin
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
| |
Collapse
|
28
|
Xipell M, Rodas LM, Villarreal J, Molina A, Reinoso-Moreno J, Blasco M, Poch E, Diekmann F, Campistol JM, Quintana LF. The utility of phospholipase A2 receptor autoantibody in membranous nephropathy after kidney transplantation. Clin Kidney J 2017; 11:422-428. [PMID: 29988247 PMCID: PMC6007417 DOI: 10.1093/ckj/sfx128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/28/2017] [Indexed: 01/31/2023] Open
Abstract
Membranous nephropathy (MN) is estimated to cause end-stage renal disease in ∼ 5% of patients, in whom renal transplantation is the therapy of choice. Among patients receiving a transplant for MN, the disease will recur in the graft in 30–50%; among these, graft loss will occur in 50% within 10 years. Several studies have suggested that phospholipase A2 receptor autoantibody (aPLA2R) levels before transplantation might be useful in predicting recurrence, and their titration after transplantation is clinically relevant to assess the risk of recurrence and progression, to guide treatment indications and to monitor treatment response. In this review we describe the evolving role of aPLA2R as a biomarker in primary MN and its current usefulness in predicting recurrence of this autoimmune podocytopathy after renal transplantation.
Collapse
Affiliation(s)
- Marc Xipell
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Lida M Rodas
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Jesús Villarreal
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Alicia Molina
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Johanna Reinoso-Moreno
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Jose M Campistol
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| |
Collapse
|
29
|
Abstract
In patients with membranous nephropathy, alkylating agents (cyclophosphamide or chlorambucil) alone or in combination with steroids achieve remission of nephrotic syndrome more effectively than conservative treatment or steroids alone, but can cause myelotoxicity, infections, and cancer. Calcineurin inhibitors can improve proteinuria, but are nephrotoxic. Most patients relapse after treatment withdrawal and can become treatment dependent, which increases the risk of nephrotoxicity. The discovery of nephritogenic autoantibodies against podocyte M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain- containing protein 7A (THSD7A) antigens provides a clear pathophysiological rationale for interventions that specifically target B-cell lineages to prevent antibody production and subepithelial deposition. The anti-CD20 monoclonal antibody rituximab is safe and achieves remission of proteinuria in approximately two-thirds of patients with membranous nephropathy. In those with PLA2R-related disease, remission can be predicted by anti-PLA2R antibody depletion and relapse by antibody re-emergence into the circulation. Thus, integrated evaluation of serology and proteinuria could guide identification of affected patients and treatment with individually tailored protocols. Nonspecific and toxic immunosuppressive regimens will fall out of use. B-cell modulation by rituximab and second-generation anti-CD20 antibodies (or plasma cell-targeted therapy in anti-CD20 resistant forms of disease) will lead to a novel therapeutic paradigm for patients with membranous nephropathy.
Collapse
|
30
|
Katsuma A, Yamakawa T, Nakada Y, Yamamoto I, Yokoo T. Histopathological findings in transplanted kidneys. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0089-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
|
31
|
Cosio FG, Cattran DC. Recent advances in our understanding of recurrent primary glomerulonephritis after kidney transplantation. Kidney Int 2016; 91:304-314. [PMID: 27837947 DOI: 10.1016/j.kint.2016.08.030] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 02/06/2023]
Abstract
Recurrent glomerulonephritis (GN) is an important cause of kidney allograft failure, particularly in younger recipients. Approximately 15% of death-censored graft failures are due to recurrent GN, but this incidence is likely an underestimation of the magnitude of the problem. Overall, 18% to 22% of kidney allografts are lost due to GN, either recurrent or presumed de novo. The impact of recurrent GN on allograft survival was recognized from the earliest times in kidney transplantation. However, progress in this area has been slow, and our understanding of GN recurrence remains limited, in large part due to incomplete understanding of the pathogenesis of these diseases. This review focuses on recent advances in our general understanding of the pathophysiology of primary GN, the risk of recurrence in the allograft, and the consequences for kidney graft survival. We focus specifically on the most common forms of primary GN, including focal segmental glomerulosclerosis, membranous nephropathy, membranoproliferative glomerulonephritis, and IgA nephropathy. New understanding of the pathogenesis of these diseases has had direct clinical implications for transplantation, allowing better identification of candidates at high risk of recurrence and earlier diagnoses, and it is expected to lead to significance improvements in the therapy and perhaps even prevention of GN recurrence. More than ever, it is essential to fully characterize GN before transplantation as this information will direct our management posttransplantation. Further, the relative rarity of recurrent GN dictates the need for multicenter studies in order to evaluate, test, and validate recent advances and therapies.
Collapse
Affiliation(s)
- Fernando G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, William von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic, Rochester, Minnesota, USA.
| | - Daniel C Cattran
- Department of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
32
|
Filippone EJ, Farber JL. Membranous nephropathy in the kidney allograft. Clin Transplant 2016; 30:1394-1402. [DOI: 10.1111/ctr.12847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 01/29/2023]
Affiliation(s)
- Edward J. Filippone
- Division of Nephrology; Department of Medicine; Sydney Kimmel Medical College at Thomas Jefferson University; Philadelphia PA USA
| | - John L. Farber
- Department of Pathology; Sydney Kimmel Medical College at Thomas Jefferson University; Philadelphia PA USA
| |
Collapse
|
33
|
Wen J, Xie K, Zhang M, Chen J, Zhang J, Cheng D, Li X, Ji S, Liu Z. HLA-DR, and not PLA2R, is expressed on the podocytes in kidney allografts in de novo membranous nephropathy. Medicine (Baltimore) 2016; 95:e4809. [PMID: 27631233 PMCID: PMC5402576 DOI: 10.1097/md.0000000000004809] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Idiopathic membranous nephropathy (IMN) is known to be associated with antibodies acting on the M-type phospholipase A2 receptor (PLA2R) of the podocyte. However, the mechanism underlying de novo membranous nephropathy (dn MN) posttransplantation remains unclear. In this study, we aimed to elucidate the mechanism underlying dn MN.We selected 8 cases with dn MN and compared them to 20 IMN cases. Fifteen cases of stable grafts were selected as controls.Several differences between the dn MN group and the IMN group were detected. IgG4 showed negligible positive staining in patients with dn MN, while it was predominant in the IMN group (1/8 vs 20/20, P < 0.001). Serum anti-PLA2R antibodies and anti-PLA2R antibodies of the podocyte were very few in the dn MN patients; however, these antibodies were detected in most of the IMN patients (serum anti-PLA2R antibodies: 1/8 vs 16/20, P = 0.002, anti-PLA2R antibodies of the podocyte: 0/8 vs 17/20, P < 0.001). The dn MN patients also showed higher ratio of interstitial inflammation, peritubular capillaritis, and peritubular capillary C4d deposition. Importantly, human leukocyte antigens (HLA)-DR expression was detected on the podocytes in most of the dn MN patients, but none of the IMN patients and stable graft patients showed HLA-DR expression.These data suggested that the PLA2R pathway, which is known to play a role in IMN, was not involved in the mechanism underlying dn MN. On the contrary, dn MN might be associated with the alloimmune response directed against the podocyte.
Collapse
Affiliation(s)
- Jiqiu Wen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, P. R. China
- Correspondence: Jiqiu Wen, National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, P. R. China (e-mail: )
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
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.
Collapse
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.
| |
Collapse
|
35
|
Ding Y, Francis J, Kalish J, Deshpande A, Quillen K. Recurrent focal segmental glomerulosclerosis apparently resistant to plasmapheresis improves after surgical repair of arteriovenous fistula aneurysms. Clin Kidney J 2016; 9:408-10. [PMID: 27274825 PMCID: PMC4886907 DOI: 10.1093/ckj/sfw011] [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: 09/30/2015] [Accepted: 02/02/2016] [Indexed: 11/21/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a leading cause of end-stage renal disease and has a high recurrence rate after kidney transplantation, attributed to a circulating permeability factor. Plasmapheresis is the treatment of choice after recurrence to remove the circulating factor. We present a case of recurrent FSGS 6 years after transplantation. It is instructive because proteinuria did not respond to intensive plasmapheresis—combined with rituximab—until the possibility of ineffective apheresis secondary to multiple aneurysms in the arteriovenous fistula (AVF) was considered. Proteinuria improved soon after alternative access for plasmapheresis was secured and AVF aneurysms were surgically repaired.
Collapse
Affiliation(s)
- Yanli Ding
- Department of Pathology and Laboratory Medicine , Boston Medical Center , Boston, MA 02118 , USA
| | - Jean Francis
- Department of Medicine , Boston Medical Center , Boston, MA , USA
| | - Jeffrey Kalish
- Department of Surgery , Boston Medical Center , Boston, MA , USA
| | - Anita Deshpande
- Department of Pathology and Laboratory Medicine , Boston Medical Center , Boston, MA 02118 , USA
| | - Karen Quillen
- Department of Pathology and Laboratory Medicine , Boston Medical Center , Boston, MA 02118 , USA
| |
Collapse
|
36
|
Gupta G, Fattah H, Ayalon R, Kidd J, Gehr T, Quintana LF, Kimball P, Sadruddin S, Massey HD, Kumar D, King AL, Beck LH. Pre-transplant phospholipase A2 receptor autoantibody concentration is associated with clinically significant recurrence of membranous nephropathy post-kidney transplantation. Clin Transplant 2016; 30:461-9. [PMID: 26854647 DOI: 10.1111/ctr.12711] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2016] [Indexed: 02/05/2023]
Abstract
Previous studies that have assessed the association of pre-transplant antiphospholipase A2 receptor autoantibody (PLA2R-Ab) concentration with a recurrence of membranous nephropathy (rMN) post-kidney transplant have yielded variable results. We tested 16 consecutive transplant patients with a history of iMN for pre-transplant PLA2R-Ab. Enzyme-linked immunosorbent assay titers (Euroimmun, NJ, USA) >14 RU/mL were considered positive. A receiver operating characteristic (ROC) analysis was performed after combining data from Quintana et al. (n = 21; Transplantation February 2015) to determine a PLA2R-Ab concentration which could predict rMN. Six of 16 (37%) patients had biopsy-proven rMN at a median of 3.2 yr post-transplant. Of these, five of six (83%) had a positive PLA2R-Ab pre-transplant with a median of 82 RU/mL (range = 31-1500). The only patient who had rMN with negative PLA2R-Ab was later diagnosed with B-cell lymphoma. One hundred percent (n = 10) of patients with no evidence of rMN (median follow-up = five yr) had negative pre-transplant PLA2R-Ab. In a combined ROC analysis (n = 37), a pre-transplant PLA2R-Ab > 29 RU/mL predicted rMN with a sensitivity of 85% and a specificity of 92%. Pre-transplant PLA2R-Ab could be a useful tool for the prediction of rMN. Patients with rMN in the absence of PLA2R-Ab should be screened for occult malignancy and/or alternate antigens.
Collapse
Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Hasan Fattah
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Rivka Ayalon
- Division of Nephrology, Boston University School of Medicine, Boston, MA, USA
| | - Jason Kidd
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Todd Gehr
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Luis F Quintana
- Servicio de Nefrología y Trasplante Renal, Hospital Clinic, Barcelona, Spain
| | - Pamela Kimball
- Division of Transplant Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Salima Sadruddin
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - H Davis Massey
- Department of Pathology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Laurence H Beck
- Division of Nephrology, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
37
|
Intravitreal Antivascular Endothelial Growth Factor Therapy May Induce Proteinuria and Antibody Mediated Injury in Renal Allografts. Transplantation 2016; 99:2382-6. [PMID: 25905984 DOI: 10.1097/tp.0000000000000750] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Systemic adverse effects of intravenous antivascular endothelial growth factor (VEGF) therapy include: hypertension, proteinuria, renal failure, and thrombotic microangiopathy. Intravitreal therapy with these agents is generally believed to be safe. METHODS We report 2 cases of renal transplant recipients who developed significant allograft dysfunction after the initiation of intravitreal anti-VEGF therapy. RESULTS The first case is a 67-year-old man with polycystic kidney disease and recipient of a zero-antigen mismatch kidney allograft which developed worsening proteinuria over the first year after transplantation. At 4 months, a biopsy showed only minimal fibrosis and atrophy. At 1 year, an allograft biopsy showed phospholipase A 2 receptor-negative membranous nephropathy. The second patient was a 52-year-old man with tuberous sclerosis who was a recipient of a living related kidney allograft with diminished but stable graft function 16 years from transplantation. After the initiation of intravitreal anti-VEGF therapy, there was an escalating degree of proteinuria. Renal biopsy revealed acute and chronic antibody-mediated rejection with glomerular thrombi and transplant glomerulopathy. CONCLUSIONS These cases, although do not prove causality, point to the need for careful follow-up of renal transplant recipients undergoing intravitreal therapy with anti-VEGF agents. These locally administered agents may play a role in the development of proteinuria and modulate antibody-mediated phenomena. We recommend that in renal transplant recipients undergoing therapy with intravitreal anti-VEGF agents, proteinuria be checked monthly, and there should be a low threshold for performing a biopsy to evaluate for allograft injury.
Collapse
|
38
|
Cosio FG, El Ters M, Cornell LD, Schinstock CA, Stegall MD. Changing Kidney Allograft Histology Early Posttransplant: Prognostic Implications of 1-Year Protocol Biopsies. Am J Transplant 2016; 16:194-203. [PMID: 26274817 DOI: 10.1111/ajt.13423] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/26/2015] [Accepted: 06/11/2015] [Indexed: 01/25/2023]
Abstract
Allograft histology 1 year posttransplant is an independent correlate to long-term death-censored graft survival. We assessed prognostic implications of changes in histology first 2 years posttransplant in 938 first kidney recipients, transplanted 1999-2010, followed for 93.4 ± 37.7 months. Compared to implantation biopsies, histology changed posttransplant showing at 1 year that 72.6% of grafts had minor abnormalities (favorable histology), 20.2% unfavorable histology, and 7.2% glomerulonephritis. Compared to favorable, graft survival was reduced in recipients with unfavorable histology (hazards ratio [HR] = 4.79 [3.27-7.00], p < 0.0001) or glomerulonephritis (HR = 5.91 [3.17-11.0], p < 0.0001). Compared to unfavorable, in grafts with favorable histology, failure was most commonly due to death (42% vs. 70%, p < 0.0001) and less commonly due to alloimmune causes (27% vs. 10%, p < 0.0001). In 80% of cases, favorable histology persisted at 2 years. However, de novo 2-year unfavorable histology (15.3%) or glomerulonephritis (4.7%) related to reduced survival. The proportion of favorable grafts increased during this period (odds ratio = 0.920 [0.871-0.972], p = 0.003, per year) related to fewer DGF, rejections, polyoma-associated nephropathy (PVAN), and better function. Graft survival also improved (HR = 0.718 [0.550-0.937], p = 0.015) related to better histology and function. Evolution of graft histologic early posttransplant relate to long-term survival. Avoiding risk factors associated with unfavorable histology relates to improved histology and graft survival.
Collapse
Affiliation(s)
- F G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN.,William von Liebig Center for Transplant and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - M El Ters
- Division of Nephrology and Hypertension, University of Kansas, Lawrence, KS
| | - L D Cornell
- William von Liebig Center for Transplant and Clinical Regeneration, Mayo Clinic, Rochester, MN.,Department of Pathology, Mayo Clinic, Rochester, MN
| | - C A Schinstock
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN.,William von Liebig Center for Transplant and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - M D Stegall
- William von Liebig Center for Transplant and Clinical Regeneration, Mayo Clinic, Rochester, MN.,Department of Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
39
|
Recurrent Membranous Nephropathy After Kidney Transplantation: Treatment and Long-Term Implications. Transplantation 2015; 100:2710-2716. [PMID: 26720301 DOI: 10.1097/tp.0000000000001056] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Membranous nephropathy (MN) can recur in kidney allografts leading to graft dysfunction and failure. The aims of these analyses were to assess MN recurrence, clinical and histologic progression, and response to anti-CD20 therapy. METHODS Included were 63 kidney allograft recipients with biopsy proven primary MN followed up for 77.0 (39-113) months (median, interquartile range). Disease recurrence was diagnosed by biopsy (protocol or clinical), and follow-up was monitored by laboratory parameters and protocol biopsies. RESULTS Thirty of 63 patients (48%) had histologic recurrence often during the first year. In 53% of the cases, recurrence was diagnosed by protocol biopsy. Recurrence risk was higher in patients with higher proteinuria pretransplant [hazard ratio = 1.869 (95% confidence interval, 1.164-3.001) per gram, P = 0.010] and those with anti-phospholipase A2 receptor antibodies [hazard ratio = 3.761 (1.635-8.652), P = 0.002]. Thirteen patients with recurrence had no clinical progression, and in 2, MN resolved histologically. Seventeen of 63 patients (27%) had progressive proteinuria and were treated with anti-CD20 antibodies, resulting in complete response in 9 (53%), partial response in 5 (29%), and no response in 3 (18%). Posttreatment biopsies were obtained in 15 patients and showed histologic resolution in 6 (40%). Disease recurrence did not correlate with graft survival. However, 5 of 11 (45.4%) graft losses were due to recurrent MN. Death-censored graft survival in MN did not differ from that of 273 control recipients with autosomal dominant polycystic kidney disease. CONCLUSIONS Membranous nephropathy recurs in 48% of cases threatening the allograft. Treatment of early but progressive recurrence with anti-CD20 antibodies is quite effective achieving clinical remission and histologic resolution of MN.
Collapse
|
40
|
Antiphospholipase A2 Receptor Antibody Levels Predict the Risk of Posttransplantation Recurrence of Membranous Nephropathy. Transplantation 2015; 99:1709-14. [DOI: 10.1097/tp.0000000000000630] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
41
|
Kattah A, Ayalon R, Beck LH, Sandor DG, Cosio FG, Gandhi MJ, Sethi S, Lorenz EC, Salant DJ, Fervenza FC. Anti-phospholipase A₂ receptor antibodies in recurrent membranous nephropathy. Am J Transplant 2015; 15:1349-59. [PMID: 25766759 PMCID: PMC4472303 DOI: 10.1111/ajt.13133] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 11/06/2014] [Accepted: 11/20/2014] [Indexed: 01/25/2023]
Abstract
About 70% of patients with primary membranous nephropathy (MN) have circulating anti-phospholipase A2 receptor (PLA2R) antibodies that correlate with disease activity, but their predictive value in post-transplant (Tx) recurrent MN is uncertain. We evaluated 26 patients, 18 with recurrent MN and 8 without recurrence, with serial post-Tx serum samples and renal biopsies to determine if patients with pre-Tx anti-PLA2R are at increased risk of recurrence as compared to seronegative patients and to determine if post-Tx changes in anti-PLA2R correspond to the clinical course. In the recurrent group, 10/17 patients had anti-PLA2R at the time of Tx versus 2/7 patients in the nonrecurrent group. The positive predictive value of pre-Tx anti-PLA2R for recurrence was 83%, while the negative predictive value was 42%. Persistence or reappearance of post-Tx anti-PLA2R was associated with increasing proteinuria and resistant disease in 6/18 cases; little or no proteinuria occurred in cases with pre-Tx anti-PLA2R and biopsy evidence of recurrence in which the antibodies resolved with standard immunosuppression. Some cases with positive pre-Tx anti-PLA2R were seronegative at the time of recurrence. In conclusion, patients with positive pre-Tx anti-PLA2R should be monitored closely for recurrent MN. Persistence or reappearance of antibody post-Tx may indicate a more resistant disease.
Collapse
Affiliation(s)
- Andrea Kattah
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rivka Ayalon
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston, MA
| | - Laurence H. Beck
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston, MA
| | - Dana G. Sandor
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston, MA
| | - Fernando G. Cosio
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | | | - David J. Salant
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston, MA
| | | |
Collapse
|
42
|
Abstract
Primary disease recurrence after renal transplantation is mainly diagnosed by examination of biopsy samples, but can also be associated with clinical symptoms. In some patients, recurrence can lead to graft loss (7-8% of all graft losses). Primary disease recurrence is generally associated with a high risk of graft loss in patients with focal segmental glomerulosclerosis, membranous proliferative glomerulonephritis, primary hyperoxaluria or atypical haemolytic uraemic syndrome. By contrast, disease recurrence is associated with a limited risk of graft loss in patients with IgA nephropathy, renal involvement associated with Henoch-Schönlein purpura, antineutrophil cytoplasmic antibody-associated glomerulonephritis or lupus nephritis. The presence of systemic diseases that affect the kidneys, such as sickle cell anaemia and diabetes mellitus, also increases the risk of delayed graft loss. This Review provides an overview of the epidemiology, pathophysiology and management of primary disease recurrence in paediatric renal graft recipients, and describes the overall effect on graft survival of each of the primary diseases listed above. With appropriate management, few paediatric patients should be excluded from renal transplantation programmes because of an increased risk of recurrence.
Collapse
|
43
|
Spinner ML, Bowman LJ, Horwedel TA, Delos Santos RB, Klein CL, Brennan DC. Single-dose rituximab for recurrent glomerulonephritis post-renal transplant. Am J Nephrol 2015; 41:37-47. [PMID: 25634230 DOI: 10.1159/000371587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Post-renal transplant recurrent glomerulonephritis (GN) contributes to allograft loss. Rituximab treatment has been used in a multidose strategy with variable efficacy and toxicity. We investigated a novel single-dose approach. METHODS A single center, retrospective, cohort study was conducted between January 1998 and April 2012 among renal allograft recipients with recurrent GN treated with rituximab (cases) or without (controls). The primary outcome was complete response (CR, urine protein/creatinine ratio (UP/C) <0.3). Secondary outcomes included partial response (PR >50% reduction in UP/C), response relapse, treatment-response by GN type, acute rejection incidence, time to graft loss, and infection incidence. RESULTS The median dose of rituximab was 200 mg per patient. Of 20 rituximab cases and 13 controls, CR was achieved in eight (40%) versus four (31%), respectively (p = 0.72). Three subjects in each group achieved PR (p = 0.66). Response relapse was similar between the two groups (p = 0.47). Significantly more subjects with recurrent membranous nephropathy (MN) achieved CR with rituximab treatment (p = 0.029). Acute rejection was lower in the rituximab group versus controls (n = 0 vs. 4; p = 0.046). The mean time to graft loss was much later in the rituximab group (35 months, (95% CI 33-37)) versus controls (29 months, (95% CI 24-35)) at 36 months (p = 0.04). There was no infection increase in rituximab-treated subjects (p = 0.16). CONCLUSION Single-dose rituximab for treatment of recurrent GN was associated with less subsequent rejection and longer time to graft loss without increased infection, but was no more effective than regimens not using rituximab at 36-months except those with recurrent membranous GN.
Collapse
Affiliation(s)
- Michael L Spinner
- Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, Saint Louis, Mo., USA
| | | | | | | | | | | |
Collapse
|
44
|
Broecker V, Mengel M. The significance of histological diagnosis in renal allograft biopsies in 2014. Transpl Int 2014; 28:136-43. [PMID: 25205033 DOI: 10.1111/tri.12446] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/26/2014] [Accepted: 09/01/2014] [Indexed: 01/20/2023]
Abstract
In 2014, the renal allograft biopsy still represents the best available diagnostic 'gold' standard to assess reasons for allograft dysfunction. However, it is well recognized that histological lesion observed in the biopsy is of limited diagnostic specificity and that the Banff classification as the international diagnostic standard represents mere expert consensus. Here, we review the role of the renal allograft biopsy in different clinical and diagnostic settings. To increase diagnostic accuracy and to compensate for lack of specificity, the interpretation of biopsy pathology needs to be within the clinical context, primarily defined by time post-transplantation and patient-specific risk profile. With this in mind, similar histopathological patterns will lead to different conclusions with regard to diagnosis, disease grading and staging and thus to patient-specific clinical decision-making. Consensus generation for such integrated diagnostic approach, preferably including new molecular tools, represents the next challenge to the transplant community on its way to precision medicine in transplantation.
Collapse
Affiliation(s)
- Verena Broecker
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | |
Collapse
|
45
|
Brenchley PE, Poulton K, Morton M, Picton ML. The genetic contribution to recurrent autoimmune nephritis. Transplant Rev (Orlando) 2014; 28:140-4. [DOI: 10.1016/j.trre.2014.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
|
46
|
Abstract
As recently as 2002, most cases of primary membranous nephropathy (MN), a relatively common cause of nephrotic syndrome in adults, were considered idiopathic. We now recognize that MN is an organ-specific autoimmune disease in which circulating autoantibodies bind to an intrinsic antigen on glomerular podocytes and form deposits of immune complexes in situ in the glomerular capillary walls. Here we define the clinical and pathological features of MN and describe the experimental models that enabled the discovery of the major target antigen, the M-type phospholipase A2 receptor 1 (PLA2R). We review the pathophysiology of experimental MN and compare and contrast it with the human disease. We discuss the diagnostic value of serological testing for anti-PLA2R and tissue staining for the redistributed antigen, and their utility for differentiating between primary and secondary MN, and between recurrent MN after kidney transplant and de novo MN. We end with consideration of how knowledge of the antigen might direct future therapeutic strategies.
Collapse
|
47
|
Schlumberger W, Hornig N, Lange S, Probst C, Komorowski L, Fechner K, Dähnrich C, Stöcker W. Differential diagnosis of membranous nephropathy with autoantibodies to phospholipase A2 receptor 1. Autoimmun Rev 2014; 13:108-13. [DOI: 10.1016/j.autrev.2013.09.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 09/15/2013] [Indexed: 11/30/2022]
|
48
|
Marinaki S, Skalioti C, Boletis JN. B cell depletion: rituximab in glomerular disease and transplantation. NEPHRON EXTRA 2013; 3:125-30. [PMID: 24550930 PMCID: PMC3919423 DOI: 10.1159/000356050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
B cells play a central role in the pathogenesis of many autoimmune diseases. Selective targeting can be achieved with the use of the monoclonal antibody rituximab. In addition to being a drug for non-Hodgkin's lymphoma, rituximab is also an FDA-approved treatment for refractory rheumatoid arthritis and, since recently, ANCA vasculitis. It has shown efficacy in many autoimmune diseases. This review will discuss current evidence and the rationale of the use of rituximab in glomerular diseases, including randomized controlled trials. The focus will be on the use of rituximab in idiopathic membranous nephropathy, systemic lupus erythematosus and ANCA-associated vasculitis. The emerging role of rituximab in renal transplantation, where it seems to be important for the desensitization protocols for highly sensitized patients as well as for the preconditioning of ABO-incompatible recipients and the treatment of antibody-mediated rejection, will also be addressed.
Collapse
Affiliation(s)
- S Marinaki
- Department of Nephrology and Renal Transplant Unit, General Hospital 'Laiko', Athens, Greece
| | - C Skalioti
- Department of Nephrology and Renal Transplant Unit, General Hospital 'Laiko', Athens, Greece
| | - J N Boletis
- Department of Nephrology and Renal Transplant Unit, General Hospital 'Laiko', Athens, Greece
| |
Collapse
|
49
|
Marinaki S, Lionaki S, Boletis JN. Glomerular disease recurrence in the renal allograft: a hurdle but not a barrier for successful kidney transplantation. Transplant Proc 2013; 45:3-9. [PMID: 23375268 DOI: 10.1016/j.transproceed.2012.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Almost all forms of primary as well as secondary glomerulonephritides may recur after renal transplantation. Recurrence of the original disease is now the third most common cause of late allograft loss. Nevertheless, in most cases it is difficult to assess the true impact of primary disease recurrence in the allograft; histological recurrence with mild features does not necessarily implicate clinically severe disease. Moreover it is often difficult to distinguish recurrent from de novo disease as in membranous glomerulopathy. Because recurrence occurs late, histological lesions of recurrent glomerulonephritis may be unmasked by chronic damage from other causes such as chronic rejection. Beside the difficulties to interpret renal histology due to the variety of allograft lesions, there are no well-established options to prevent clinically severe disease recurrence nor the therapeutic approaches to the problem. The purpose of this review was mainly to underline that almost all primary and secondary glomerulonephritides represent a contraindication to transplantation. For the majority of patients with end-stage renal disease due to glomerulonephritis, transplantation still represents the treatment of choice.
Collapse
Affiliation(s)
- S Marinaki
- Nephrology Department and Renal Transplant Unit, Laiko Hospital, Athens, Greece.
| | | | | |
Collapse
|
50
|
Sprangers B, Kuypers DR. Recurrence of glomerulonephritis after renal transplantation. Transplant Rev (Orlando) 2013; 27:126-34. [PMID: 23954034 DOI: 10.1016/j.trre.2013.07.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 07/09/2013] [Accepted: 07/09/2013] [Indexed: 02/07/2023]
Abstract
Recurrence of glomerulonephritis following renal transplantation is considered an important cause of allograft failure. The incidence of recurrence of glomerulonephritis varies widely depending on the definition of recurrence (pathologic recurrence or clinicopathologic recurrence) and the original glomerular disease. Moreover the impact of recurrence of glomerular disease on allograft outcome varies widely between different forms of glomerulonephritis. Whereas IgA nephritis recurs in up to one third of transplanted patients, this is not associated with adverse effects on graft survival. In contrast, recurrent focal segmental glomerulosclerosis and membranoproliferative glomerulopathy have an unfavorable prognosis. Overall, long-term graft survival in patients transplanted for glomerulonephritis is comparable to survival in patients with other causes of ESRD. In recent years, several mechanisms for recurrent disease after transplantation (e.g. PLA2R antibodies in membranous nephropathy and suPAR in FSGS) have been identified, and these findings have helped to elucidate the pathogenesis of glomerular diseases. Although renal transplantation is the treatment of choice for end-stage renal disease as a consequence of glomerulonephritis, further studies are required to develop optimal strategies to prevent, diagnose and treat recurrent glomerular diseases.
Collapse
Affiliation(s)
- Ben Sprangers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | |
Collapse
|