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Yaung KN, Yeo JG, Kumar P, Wasser M, Chew M, Ravelli A, Law AHN, Arkachaisri T, Martini A, Pisetsky DS, Albani S. Artificial intelligence and high-dimensional technologies in the theragnosis of systemic lupus erythematosus. THE LANCET. RHEUMATOLOGY 2023; 5:e151-e165. [PMID: 38251610 DOI: 10.1016/s2665-9913(23)00010-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 02/22/2023]
Abstract
Systemic lupus erythematosus is a complex, systemic autoimmune disease characterised by immune dysregulation. Pathogenesis is multifactorial, contributing to clinical heterogeneity and posing challenges for diagnosis and treatment. Although strides in treatment options have been made in the past 15 years, with the US Food and Drug Administration approval of belimumab in 2011, there are still many patients who have inadequate responses to therapy. A better understanding of underlying disease mechanisms with a holistic and multiparametric approach is required to improve clinical assessment and treatment. This Review discusses the evolution of genomics, epigenomics, transcriptomics, and proteomics in the study of systemic lupus erythematosus and ways to amalgamate these silos of data with a systems-based approach while also discussing ways to strengthen the overall process. These mechanistic insights will facilitate the discovery of functionally relevant biomarkers to guide rational therapeutic selection to improve patient outcomes.
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Affiliation(s)
- Katherine Nay Yaung
- Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre, Singapore; Duke-NUS Medical School, Singapore.
| | - Joo Guan Yeo
- Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre, Singapore; Duke-NUS Medical School, Singapore; Rheumatology and Immunology Service, KK Women's and Children's Hospital, Singapore
| | - Pavanish Kumar
- Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Martin Wasser
- Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Marvin Chew
- Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università degli Studi di Genova, Genoa, Italy
| | - Annie Hui Nee Law
- Duke-NUS Medical School, Singapore; Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Thaschawee Arkachaisri
- Duke-NUS Medical School, Singapore; Rheumatology and Immunology Service, KK Women's and Children's Hospital, Singapore
| | | | - David S Pisetsky
- Department of Medicine and Department of Immunology, Duke University Medical Center, Durham, NC, USA; Medical Research Service, Veterans Administration Medical Center, Durham, NC, USA
| | - Salvatore Albani
- Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre, Singapore; Duke-NUS Medical School, Singapore; Rheumatology and Immunology Service, KK Women's and Children's Hospital, Singapore
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2
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Parikh SV, Malvar A, Song H, Shapiro J, Mejia-Vilet JM, Ayoub I, Almaani S, Madhavan S, Alberton V, Besso C, Lococo B, Satoskar A, Zhang J, Yu L, Fadda P, Eadon M, Birmingham D, Ganesan LP, Jarjour W, Rovin BH. Molecular profiling of kidney compartments from serial biopsies differentiate treatment responders from non-responders in lupus nephritis. Kidney Int 2022; 102:845-865. [PMID: 35788359 PMCID: PMC9613357 DOI: 10.1016/j.kint.2022.05.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
The immune pathways that define treatment response and non-response in lupus nephritis (LN) are unknown. To characterize these intra-kidney pathways, transcriptomic analysis was done on protocol kidney biopsies obtained at flare (initial biopsy (Bx1)) and after treatment (second biopsy (Bx2)) in 58 patients with LN. Glomeruli and tubulointerstitial compartments were isolated using laser microdissection. RNA was extracted and analyzed by nanostring technology with transcript expression from clinically complete responders, partial responders and non-responders compared at Bx1 and Bx2 and to the healthy controls. Top transcripts that differentiate clinically complete responders from non-responders were validated at the protein level by confocal microscopy and urine ELISA. At Bx1, cluster analysis determined that glomerular integrin, neutrophil, chemokines/cytokines and tubulointerstitial chemokines, T cell and leukocyte adhesion genes were able to differentiate non-responders from clinically complete responders. At Bx2, glomerular monocyte, extracellular matrix, and interferon, and tubulointerstitial interferon, complement, and T cell transcripts differentiated non-responders from clinically complete responders. Protein analysis identified several protein products of overexpressed glomerular and tubulointerstitial transcripts at LN flare, recapitulating top transcript findings. Urine complement component 5a and fibronectin-1 protein levels reflected complement and fibronectin expression at flare and after treatment. Thus, transcript analysis of serial LN kidney biopsies demonstrated how gene expression in the kidney changes with clinically successful and unsuccessful therapy. Hence, these insights into the molecular landscape of response and non-response may help align LN management with the pathogenesis of kidney injury.
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Affiliation(s)
- Samir V Parikh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Ana Malvar
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Huijuan Song
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John Shapiro
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Juan Manuel Mejia-Vilet
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico; Department of Pathology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Isabelle Ayoub
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salem Almaani
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sethu Madhavan
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Valeria Alberton
- Department of Pathology, Hospital Fernandez, Buenos Aires, Argentina
| | - Celeste Besso
- Department of Pathology, Hospital Fernandez, Buenos Aires, Argentina
| | - Bruno Lococo
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Anjali Satoskar
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jianying Zhang
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lianbo Yu
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paolo Fadda
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael Eadon
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Dan Birmingham
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Latha P Ganesan
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Wael Jarjour
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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3
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Histopathological prognostic factors in ANCA-associated glomerulonephritis. Autoimmun Rev 2022; 21:103139. [PMID: 35835443 DOI: 10.1016/j.autrev.2022.103139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are a group of multisystemic autoimmune diseases characterized by necrotizing inflammation of small vessels. Kidney involvement is frequent in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), and accounts for a significant proportion of the morbidity and mortality related to these diseases. Despite improvement in therapeutic management of ANCA-glomerulonephritis (ANCA-GN), end-stage kidney disease (ESKD) still occurs in up to 30% of affected patients within 5 years following diagnosis. Thus, identifying patients for whom aggressive immunosuppressive therapy will be more beneficial than deleterious is of great importance. Several clinical, biological and histological factors have been proposed as predictors of ESKD. The kidney biopsy is essential not only for the diagnosis, but also for evaluating renal prognosis. In this review, we discuss the prognostic value of renal lesions at the diagnosis of ANCA-GN by analyzing each compartment of the nephron. We also review existing ESKD risk classification in ANCA-GN and finally propose an example of a standardized pathology report that could be used in routine practice.
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Prediction models of treatment response in lupus nephritis. Kidney Int 2022; 101:379-389. [PMID: 34871620 PMCID: PMC8792241 DOI: 10.1016/j.kint.2021.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 10/28/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023]
Abstract
In order to develop prediction models of one-year treatment response in lupus nephritis, an approach using machine learning to combine traditional clinical data and novel urine biomarkers was undertaken. Contemporary lupus nephritis biomarkers were identified through an unbiased PubMed search. Thirteen novel urine proteins contributed to the top 50% of ranked biomarkers and were selected for measurement at the time of lupus nephritis flare. These novel markers along with traditional clinical data were incorporated into a variety of machine learning algorithms to develop prediction models of one-year proteinuria and estimated glomerular filtration rate (eGFR). Models were trained on 246 individuals from four different sub-cohorts and validated on an independent cohort of 30 patients with lupus nephritis. Seven models were considered for each outcome. Three-quarters of these models demonstrated good predictive value with areas under the receiver operating characteristic curve over 0.7. Overall, prediction performance was the best for models of eGFR response to treatment. Furthermore, the best performing models contained both traditional clinical data and novel urine biomarkers, including cytokines, chemokines, and markers of kidney damage. Thus, our study provides further evidence that a machine learning approach can predict lupus nephritis outcomes at one year using a set of traditional and novel biomarkers. However, further validation of the utility of machine learning as a clinical decision aid to improve outcomes will be necessary before it can be routinely used in clinical practice to guide therapy.
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Mejia-Vilet JM, Malvar A, Arazi A, Rovin BH. The lupus nephritis management renaissance. Kidney Int 2021; 101:242-255. [PMID: 34619230 DOI: 10.1016/j.kint.2021.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022]
Abstract
Over the past year, and for the first time ever, the US Food and Drug Administration approved 2 drugs specifically for the treatment of lupus nephritis (LN). As the lupus community works toward understanding how to best use these new therapies, it is also an ideal time to begin to rethink the overall management strategy of LN. In addition to new drugs, this must include how to use kidney biopsies for management and not just diagnosis, how molecular technologies can be applied to interrogate biopsies and how such data can impact management, and how to incorporate LN biomarkers into management paradigms. Herein, we will review new developments in these areas of LN and put them into perspective for disease management now and in the future.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology, Instituto Nacional de Ciencas Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Ana Malvar
- Department of Nephrology, Hospital Fernandez, Buenos Aires, Argentina
| | - Arnon Arazi
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Brad H Rovin
- Department of Medicine and Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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6
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Obrișcă B, Sorohan B, Tuță L, Ismail G. Advances in Lupus Nephritis Pathogenesis: From Bench to Bedside. Int J Mol Sci 2021; 22:ijms22073766. [PMID: 33916456 PMCID: PMC8038540 DOI: 10.3390/ijms22073766] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 11/29/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is the prototype of autoimmune disorders caused by a loss of tolerance to endogenous nuclear antigens triggering an aberrant autoimmune response targeting various tissues. Lupus nephritis (LN), a major cause of morbidity and mortality in patients with SLE, affects up to 60% of patients. The recent insights into the genetic and molecular basis of SLE and LN paved the way for newer therapies to be developed for these patients. Apart from the traditional B-cell-centered view of this disease pathogenesis, acknowledging that multiple extrarenal and intrarenal pathways contribute to kidney-specific autoimmunity and injury may help refine the individual therapeutic and prognostic characterization of such patients. Accordingly, the formerly induction-maintenance treatment strategy was recently challenged with the exciting results obtained from the trials that evaluated add-on therapy with voclosporin, belimumab, or Obinutuzumab. The scope of this review is to provide an insight into the current knowledge of LN pathogenesis and future therapeutic strategies.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania; (B.O.); (B.S.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania; (B.O.); (B.S.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Liliana Tuță
- Department of Nephrology, “Ovidius” University, 900527 Constanta, Romania;
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania; (B.O.); (B.S.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
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Robin B, Dagobert J, Isnard P, Rabant M, Duong-Van-Huyen JP. [New technologies for renal pathology: Transcriptomics on paraffin-embedded fixed tissue]. Nephrol Ther 2021; 17S:S54-S59. [PMID: 33910699 DOI: 10.1016/j.nephro.2020.03.004] [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: 02/21/2020] [Accepted: 03/01/2020] [Indexed: 11/19/2022]
Abstract
The development of new high-throughput technologies in genomics and then in transcriptomics has modified clinical approach in nephrology. At the interface between high-throughput technologies (microarray, new generation sequencing «NGS») and few mRNA analysis (reverse transcriptase quantitative PCR [RT-qPCR]), the nCounter® of NanoString® offers a new and complementary approach. Capable of analyzing formalin-fixed paraffin-embedded samples, this technology is a credible candidate for implanting transcriptomics in clinical routine.
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Affiliation(s)
- Blaise Robin
- Paris Translational Research Center for Organ Transplantation, 56, rue Leblanc, 75015 Paris, France; Université de Paris, 56, rue Leblanc, 75015 Paris, France; Inserm U970, 56, rue Leblanc, 75015 Paris, France.
| | - Jessy Dagobert
- Paris Translational Research Center for Organ Transplantation, 56, rue Leblanc, 75015 Paris, France; Université de Paris, 56, rue Leblanc, 75015 Paris, France; Inserm U970, 56, rue Leblanc, 75015 Paris, France
| | - Pierre Isnard
- Service d'anatomie pathologique, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Marion Rabant
- Service d'anatomie pathologique, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Jean-Paul Duong-Van-Huyen
- Paris Translational Research Center for Organ Transplantation, 56, rue Leblanc, 75015 Paris, France; Université de Paris, 56, rue Leblanc, 75015 Paris, France; Inserm U970, 56, rue Leblanc, 75015 Paris, France; Service d'anatomie pathologique, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
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8
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Parikh SV, Malvar A, Shapiro J, Turman JM, Song H, Alberton V, Lococo B, Mejia-Vilet JM, Madhavan S, Zhang J, Yu L, Satoskar AA, Birmingham D, Jarjour WN, Rovin BH, Ganesan LP. A Novel Inflammatory Dendritic Cell That Is Abundant and Contiguous to T Cells in the Kidneys of Patients With Lupus Nephritis. Front Immunol 2021; 12:621039. [PMID: 33659005 PMCID: PMC7919935 DOI: 10.3389/fimmu.2021.621039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/25/2021] [Indexed: 01/06/2023] Open
Abstract
The mechanisms that promote local inflammatory injury during lupus nephritis (LN) flare are largely unknown. Understanding the key immune cells that drive intrarenal inflammation will advance our knowledge of disease pathogenesis and inform the development of new therapeutics for LN management. In this study, we analyzed kidney biopsies from patients with proliferative LN and identified a novel inflammatory dendritic cell (infDC) population that is highly expressed in the LN kidney, but minimally present in healthy human kidneys. During an agnostic evaluation of immune transcript expression in the kidneys of patients with proliferative LN, the most abundantly overexpressed transcript from isolated glomeruli was FCER1G, which encodes the Fc receptor gamma chain (FcRγ). To identify the cell types expressing FcRγ that infiltrate the kidney in LN, studies were done on kidney biopsies from patients with active LN using confocal immunofluorescence (IF) microscopy. This showed that FcRγ is abundantly present in the periglomerular (PG) region of the kidney and to a lesser extent in the tubulointerstitium (TI). Further investigation of the surface markers of these cells showed that they were FcRγ+, MHC II+, CD11c+, CD163+, CD5-, DC-SIGN+, CD64+, CD14+, CD16+, SIRPα+, CD206-, CD68-, CD123-, CD3-, and CD11b-, suggesting the cells were infDCs. Quantification of the infDCs showed an average 10-fold higher level of infDCs in the LN kidney compared to the healthy kidneys. Importantly, IF identified CD3+ T cells to be adjacent to these infDCs in the PG space of the LN kidney, whereas both cell types are minimally present in the healthy kidney. Thus, we have identified a previously undescribed DC in lupus kidneys that may interact with intrarenal T cells and play a role in the pathogenesis of kidney injury during LN flare.
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Affiliation(s)
- Samir V. Parikh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ana Malvar
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - John Shapiro
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James M. Turman
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Huijuan Song
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Valeria Alberton
- Department of Pathology, Hospital Fernandez, Buenos Aires, Argentina
| | - Bruno Lococo
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Juan M. Mejia-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Sethu Madhavan
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jianying Zhang
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | - Lianbo Yu
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | - Anjali A. Satoskar
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dan Birmingham
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Wael N. Jarjour
- Division of Rheumatology and Immunology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Brad H. Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Latha P. Ganesan
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Division of Rheumatology and Immunology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Koopman JJE, Rennke HG, Leatherwood C, Speyer CB, D'Silva K, McMahon GM, Waikar SS, Costenbader KH. Renal deposits of complement factors as predictors of end-stage renal disease and death in patients with lupus nephritis. Rheumatology (Oxford) 2021; 59:3751-3758. [PMID: 32413140 PMCID: PMC7733722 DOI: 10.1093/rheumatology/keaa174] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/17/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Lupus nephritis (LN) increases the risks of end-stage renal disease (ESRD) and death, but these risks are difficult to estimate. Since complement factors play an essential role in the pathogenesis and are deposited in the kidneys as C1q and C3, we studied whether these deposits predict ESRD and death in patients with LN. METHODS We collected demographic, clinical and pathological data from 183 adult patients with LN classes II-V diagnosed with a first native kidney biopsy. Pathological data included the localization and intensity of immunofluorescence staining of C1q and C3. We obtained dates of incident ESRD and death from the United States Renal Data System and National Death Index, respectively, and evaluated survival curves and hazard ratios for ESRD and death as a composite outcome and as separate outcomes. RESULTS The presence and intensity of deposits of C1q and C3 in glomeruli, tubular walls and vascular walls differed between classes and were associated with known unfavourable prognostic factors, such as hypertension, hypoalbuminemia and hypocomplementemia. However, over a median follow-up of 7.5 years, their presence and intensity were associated with neither survival free of ESRD and death nor hazard ratios for ESRD and death. CONCLUSION Renal deposits of complement factors did not predict ESRD and death in patients with LN.
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Affiliation(s)
- Jacob J E Koopman
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Helmut G Rennke
- Renal Pathology Service, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Cianna Leatherwood
- Department of Rheumatology, Richmond Medical Center, Kaiser Permanente Medical Group, Richmond, CA, USA
| | - Cameron B Speyer
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin D'Silva
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gearoid M McMahon
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sushrut S Waikar
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karen H Costenbader
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Fujio K, Takeshima Y, Nakano M, Iwasaki Y. Review: transcriptome and trans-omics analysis of systemic lupus erythematosus. Inflamm Regen 2020; 40:11. [PMID: 32566045 PMCID: PMC7301441 DOI: 10.1186/s41232-020-00123-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE), which was recognized as a defined clinical entity more than 100 years ago, is an archetype for systemic autoimmune diseases. The 10-year survival of SLE patients has shown dramatic improvement during the last half-century. However, SLE patients receiving long-term prednisone therapy are at high risk of morbidity due to organ damage. Identification of key immune pathways is mandatory to develop a suitable therapy and to stratify patients based on their responses to therapy. Recently developed transcriptome and omic analyses have revealed a number of immune pathways associated with systemic autoimmunity. In addition to type I interferon, plasmablast and neutrophil signatures demonstrate associations with the SLE phenotype. Systematic investigations of these findings enable us to understand and stratify SLE according to the clinical and immunological features.
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Affiliation(s)
- Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, 113-8655 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yusuke Takeshima
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, 113-8655 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Masahiro Nakano
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, 113-8655 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yukiko Iwasaki
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, 113-8655 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
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11
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Song J, Zhao L, Li Y. Comprehensive bioinformatics analysis of mRNA expression profiles and identification of a miRNA-mRNA network associated with lupus nephritis. Lupus 2020; 29:854-861. [PMID: 32437257 DOI: 10.1177/0961203320925155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Lupus nephritis (LN) is one of the serious complications of systemic lupus erythematosus. The aim of this study was to identify core genes and pathways involved in the pathogenesis of LN. METHODS We screened differentially expressed genes (DEGs) in LN patients using mRNA expression profile data from the Gene Expression Omnibus. The functional and pathway enrichment analysis of DEGs was performed utilizing the Database for annotation, Visualization and Integrated Discovery. Target genes with differentially expressed miRNAs (DEMIs) were predicted using the miRTarBase database, and the intersection between these target genes and DEGs was selected to be studied further. RESULTS In total, 107 common DEGs (CDEGs) were identified from the Tub_LN group and Glom_LN group, and 66 DEMIs were identified. Fifty-three hub genes and two significant modules were identified from the protein-protein interaction (PPI) network, and a miRNA-mRNA network was constructed. The CDEGs, module genes in the PPI network and genes intersecting with the CDEGs and target genes of DEMIs were all associated with the PI3K-Akt signalling pathway. CONCLUSION In summary, this study reveals some crucial genes and pathways potentially involving in the pathogenesis of LN. These findings provide a new insight for the research and treatment of LN.
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Affiliation(s)
- Jianbo Song
- Department of pharmacy, Shanxi Provincial People's Hospital of Shanxi Medical University, Taiyuan, PR China
| | - Liqin Zhao
- Department of Infectious Diseases, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, PR China
| | - Yuanping Li
- Department of pharmacy, Shanxi Provincial People's Hospital of Shanxi Medical University, Taiyuan, PR China
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Mejia-Vilet JM, Parikh SV, Song H, Fadda P, Shapiro JP, Ayoub I, Yu L, Zhang J, Uribe-Uribe N, Rovin BH. Immune gene expression in kidney biopsies of lupus nephritis patients at diagnosis and at renal flare. Nephrol Dial Transplant 2020; 34:1197-1206. [PMID: 29800348 DOI: 10.1093/ndt/gfy125] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Up to 50% of lupus nephritis (LN) patients experience renal flares after their initial episode of LN. These flares contribute to poor renal outcomes. We postulated that intrarenal immune gene expression is different in flares compared with de novo LN, and conducted these studies to test this hypothesis. METHODS Glomerular and tubulointerstitial immune gene expression was evaluated in 14 patients who had a kidney biopsy to diagnose LN and another biopsy at their first LN flare. Ten healthy living kidney donors were included as controls. RNA was extracted from laser microdissected formalin-fixed paraffin-embedded kidney biopsies. Gene expression was analyzed using the Nanostring nCounter® platform and validated by quantitative real-time polymerase chain reaction. Differentially expressed genes were analyzed by the Ingenuity Pathway Analysis and Panther Gene Ontology tools. RESULTS Over 110 genes were differentially expressed between LN and healthy control kidney biopsies. Although there was considerable molecular heterogeneity between LN biopsies at diagnosis and flare, for about half the LN patients gene expression from the first LN biopsy clustered with the repeated LN biopsy. However, in all patients, a set of eight interferon alpha-controlled genes had a significantly higher expression in the diagnostic biopsy compared with the flare biopsy. In contrast, nine tumor necrosis factor alpha-controlled genes had higher expression in flare biopsies. CONCLUSIONS There is significant heterogeneity in immune-gene expression of kidney tissue from LN patients. There are limited but important differences in gene expression between LN flares, which may influence treatment decisions.
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Affiliation(s)
- Juan M Mejia-Vilet
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA.,Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Samir V Parikh
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Huijuan Song
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Paolo Fadda
- Genomics Shared Resource (GSR)-Comprehensive Cancer Center (CCC)
| | - John P Shapiro
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Isabelle Ayoub
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Lianbo Yu
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jianying Zhang
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Norma Uribe-Uribe
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Brad H Rovin
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
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13
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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14
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Rao DA, Arazi A, Wofsy D, Diamond B. Design and application of single-cell RNA sequencing to study kidney immune cells in lupus nephritis. Nat Rev Nephrol 2019; 16:238-250. [PMID: 31853010 DOI: 10.1038/s41581-019-0232-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 11/09/2022]
Abstract
The immune mechanisms that cause tissue injury in lupus nephritis have been challenging to define. The advent of high-dimensional cellular analyses, such as single-cell RNA sequencing, has enabled detailed characterization of the cell populations present in small biopsy samples of kidney tissue. In parallel, the development of methods that cryopreserve kidney biopsy specimens in a manner that preserves intact, viable cells, has enabled the uniform analysis of tissue samples collected at multiple sites and across many geographic areas and demographic cohorts with high-dimensional platforms. The application of these methods to kidney biopsy samples from patients with lupus nephritis has begun to define the phenotypes of both infiltrating and resident immune cells, as well as parenchymal cells, present in nephritic kidneys. The detection of similar immune cell populations in urine suggests that it might be possible to non-invasively monitor immune activation in kidneys. Once applied to large patient cohorts, these high-dimensional studies might enable patient stratification according to patterns of immune cell activation in the kidney or identify disease features that can be used as surrogate measures of efficacy in clinical trials. Applied broadly across multiple inflammatory kidney diseases, these studies promise to enormously expand our understanding of renal inflammation in the next decade.
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Affiliation(s)
- Deepak A Rao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arnon Arazi
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David Wofsy
- Rheumatology Division and Russell/Engleman Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Betty Diamond
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.
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15
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Rethinking Lupus Nephritis Classification on a Molecular Level. J Clin Med 2019; 8:jcm8101524. [PMID: 31547518 PMCID: PMC6832959 DOI: 10.3390/jcm8101524] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 09/13/2019] [Accepted: 09/20/2019] [Indexed: 12/19/2022] Open
Abstract
The International Society of Nephrology/Renal Pathology Society (ISN/RPS) lupus nephritis (LN) classification is under reconsideration, given challenges with inter-rater reliability and resultant inconsistent relationship with treatment response. Integration of molecular classifiers into histologic evaluation can improve diagnostic precision and identify therapeutic targets. This study described the relationship between histological and molecular phenotypes and clinical responses in LN. Renal compartmental mRNA abundance was measured in 54 biopsy specimens from LN patients and correlated to ISN/RPS classification and individual histologic lesions. A subset of transcripts was also evaluated in sequential biopsies of a separate longitudinal cohort of 36 patients with paired samples obtained at the time of flare and at follow up. Unsupervised clustering based on mRNA abundance did not demonstrate a relationship with the (ISN/RPS) classification, nor did univariate statistical analysis. Exploratory analyses suggested a correlation with individual histologic lesions. Glomerular FN1 (fibronectin), SPP1 (secreted phosphoprotein 1), and LGALS3 (galectin 3) abundance correlated with disease activity and changed following treatment. Exploratory analyses suggested relationships between specific transcripts and individual histologic lesions, with the important representation of interferon-regulated genes. Our findings suggested that the current LN classification could be refined by the inclusion of molecular descriptors. Combining molecular and pathologic kidney biopsy phenotypes may hold promise to better classify disease and identify actionable treatment targets and merits further exploration in larger cohorts.
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16
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Ayoub I, Cassol C, Almaani S, Rovin B, Parikh SV. The Kidney Biopsy in Systemic Lupus Erythematosus: A View of the Past and a Vision of the Future. Adv Chronic Kidney Dis 2019; 26:360-368. [PMID: 31733720 DOI: 10.1053/j.ackd.2019.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/22/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022]
Abstract
The kidney biopsy advanced our understanding of kidney disease in systemic lupus erythematosus. It allowed for better recognition and classification of lupus nephritis (LN). Several LN classifications have been devised in an effort to inform treatment decision and predict prognosis, and these are being further updated. In this review, we will examine the role of diagnostic as well as repeat kidney biopsy in the management of LN, including the potential role of molecular interrogation as a step forward beyond conventional histology to guide the discovery of novel biomarkers and a precision medicine approach to the management of LN.
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17
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Wardowska A, Komorniczak M, Bułło-Piontecka B, Dȩbska-Ślizień MA, Pikuła M. Transcriptomic and Epigenetic Alterations in Dendritic Cells Correspond With Chronic Kidney Disease in Lupus Nephritis. Front Immunol 2019; 10:2026. [PMID: 31507612 PMCID: PMC6718474 DOI: 10.3389/fimmu.2019.02026] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/12/2019] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a serious autoimmune disease with variety of organ manifestations. The most dreadful one, affecting the majority of SLE patients, is kidney manifestation-lupus nephritis (LN). Dendritic cells (DC) are believed to be one of the culprits of immune dysregulation in LN. Flow cytometry analysis was applied to identify the frequency and activity of peripheral blood DCs subpopulations: myeloid and plasmacytoid, in LN patients. Magnetically isolated mDCs and pDCs were subjected to molecular analysis of genes expression, evaluation of global DNA methylation and histone H3 methylation. We observed distinctive features of DCs associated with the stages of nephritis in LN patients. Lower numbers of pDCs were observed in patients with severe LN, while increased co-stimulatory potential of mDCs was connected with the early, mild stage of this disease. IRF1 transcript upregulation was specific for mDCs from total LN patients, while exceptional amount of IRF1 mRNA was detected in mDCs from severe LN patients. DCs DNA hypermethylation seemed characteristic for severe LN, whereas a decrease in H3K4me3 and H3K27me3 marks was significant for the early stages of LN. These findings present dendritic cell alterations that may reflect renal involvement in SLE, laying foundations for new strategy of diagnosis and monitoring of LN patients, omitting invasive kidney biopsies.
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Affiliation(s)
- Anna Wardowska
- Laboratory of Tissue Engineering and Regenerative Medicine, Department of Embryology, Medical University of Gdansk, Gdansk, Poland.,Department of Clinical Immunology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Michał Komorniczak
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Barbara Bułło-Piontecka
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - M Alicja Dȩbska-Ślizień
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Michał Pikuła
- Laboratory of Tissue Engineering and Regenerative Medicine, Department of Embryology, Medical University of Gdansk, Gdansk, Poland.,Department of Clinical Immunology and Transplantology, Medical University of Gdansk, Gdansk, Poland
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18
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19
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Immune Profiling and Precision Medicine in Systemic Lupus Erythematosus. Cells 2019; 8:cells8020140. [PMID: 30744169 PMCID: PMC6406577 DOI: 10.3390/cells8020140] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/24/2019] [Accepted: 02/09/2019] [Indexed: 12/12/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder with a wide range of clinical symptoms. Enormous progress has been made in the immunological and genetic understanding of SLE. However, the biology of disease heterogeneity in SLE has remained largely unexplored. Human immune profiling studies, helped by recent technological advances especially in single-cell and “omics” analyses, are now shedding light on the cellular and molecular basis of clinical symptoms and disease flares in individual patients. Peripheral blood immunophenotyping analysis with flow cytometry or mass cytometry are identifying responsible cell subsets and markers characteristic of disease heterogeneity. Transcriptome analysis is discovering molecular networks responsible for disease activity, disease subtype and future relapse. In this review, we summarize recent advances in the immune profiling analysis of SLE patients and discuss how they will be used for future precision medicine.
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20
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Rovin BH, Almaani S, Malvar A. Reimagining the kidney biopsy in the era of diagnostic biomarkers of glomerular disease. Kidney Int 2019; 95:265-267. [DOI: 10.1016/j.kint.2018.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
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21
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Abstract
PURPOSE OF REVIEW Lupus nephritis is a frequent complication of systemic lupus erythematosus and is more common and severe in children. This is a disease of the immune system characterized by T cell, B cell, and complement activation, as well as immune complex formation and deposition. The introduction of steroids and later cyclophosphamide transformed lupus nephritis from a fatal to a treatable condition. However, the standard therapies currently used for treatment carry significant toxicity and chronic kidney disease still remains a far too frequent outcome. To address these issues, we will review current and emerging induction therapies in LN. RECENT FINDINGS Several clinical trials have been undertaken to test more effective and safer drugs, often targeting mechanistic disease pathways. At present, it is difficult to identify an induction regimen that is more effective and less toxic than the standard of care; however, we believe continuing efforts in drug development will bring breakthrough agents to clinics.
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Affiliation(s)
- Isabelle Ayoub
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Jessica Nelson
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Division of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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22
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Suso JP, Posso-Osorio I, Jiménez CA, Naranjo-Escobar J, Ospina FE, Sánchez A, Cañas CA, Tobón GJ. Profile of BAFF and its receptors' expression in lupus nephritis is associated with pathological classes. Lupus 2017; 27:708-715. [PMID: 29087261 DOI: 10.1177/0961203317739132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background/Objective B-cell activating factor (BAFF) plays an important role in the pathogenesis of systemic lupus erythematosus. However, the role of BAFF in lupus nephritis (LN) is not understood. Our aim was to evaluate the expression of BAFF and its three receptors in renal biopsy samples from patients with LN and investigate a relationship with pathological class. Methods We conducted a prospective descriptive study (2011-2014) on 52 kidney biopsy samples from patients with LN. Immunohistochemistry for BAFF, its receptors (transmembrane activator and calcium modulator and cyclophilin ligand interaction (TACI), protein maturation of B cells (BCMA), and BAFF-receptor (BAFF-R)), and CD20 expression was performed. Samples were scored according to the percentage of cells with positive expression. Results In class II LN, BAFF-R and TACI were not expressed, whereas BCMA and BAFF were lowly expressed in the interstitial inflammatory infiltrates. Proliferative class III/IV had elevated BAFF expression in the glomeruli, and TACI was expressed in interstitial inflammatory infiltrates and the glomeruli. Interestingly, the class IV cases with vasculopathy ( n = 4) had endothelial BAFF expression, which was not visible in thrombotic microangiopathy ( n = 4). Class V was characterized by low BAFF expression in interstitial inflammatory infiltrates and by BAFF, TACI, and BCMA expression in the glomeruli. BAFF expression was associated with inflammatory scores and CD20 positive infiltrates, mainly in class IV. Conclusions Expression patterns of BAFF and its receptors differ according to LN class. Our study provides evidence that BAFF could be used as a routine marker in LN biopsies and to determine which patients will benefit from anti-BAFF therapy.
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Affiliation(s)
- J P Suso
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), Rheumatology Unit, 67597 Fundación Valle del Lili , and Universidad ICESI, School of Medicine, Cali, Colombia.,2 Clinical Investigation Institute, 67597 Fundación Valle del Lili , Cali, Colombia
| | - I Posso-Osorio
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), Rheumatology Unit, 67597 Fundación Valle del Lili , and Universidad ICESI, School of Medicine, Cali, Colombia.,2 Clinical Investigation Institute, 67597 Fundación Valle del Lili , Cali, Colombia
| | - C A Jiménez
- 3 Pathology Unit, 67597 Fundación Valle del Lili , Cali, Colombia
| | - J Naranjo-Escobar
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), Rheumatology Unit, 67597 Fundación Valle del Lili , and Universidad ICESI, School of Medicine, Cali, Colombia.,2 Clinical Investigation Institute, 67597 Fundación Valle del Lili , Cali, Colombia
| | - F E Ospina
- 2 Clinical Investigation Institute, 67597 Fundación Valle del Lili , Cali, Colombia
| | - A Sánchez
- 3 Pathology Unit, 67597 Fundación Valle del Lili , Cali, Colombia
| | - C A Cañas
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), Rheumatology Unit, 67597 Fundación Valle del Lili , and Universidad ICESI, School of Medicine, Cali, Colombia
| | - G J Tobón
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), Rheumatology Unit, 67597 Fundación Valle del Lili , and Universidad ICESI, School of Medicine, Cali, Colombia.,4 Laboratory of Immunology, 67597 Fundación Valle del Lili , Cali, Colombia
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23
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Liu J, Berthier CC, Kahlenberg JM. Enhanced Inflammasome Activity in Systemic Lupus Erythematosus Is Mediated via Type I Interferon-Induced Up-Regulation of Interferon Regulatory Factor 1. Arthritis Rheumatol 2017; 69:1840-1849. [PMID: 28564495 DOI: 10.1002/art.40166] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 05/25/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The inflammasome complex is a driver of organ damage in patients with systemic lupus erythematosus (SLE). Although type I interferons (IFNs) are well established as mediators of SLE pathogenesis, their role in inflammasome activation in SLE has not been assessed. The aim of this study was to examine type I IFNs as regulators of the inflammasome. METHODS SLE patients fulfilled ≥4 American College of Rheumatology criteria and were recruited from the University of Michigan Lupus Cohort. Primary monocytes were isolated from SLE patients or healthy controls by negative selection, treated with inflammasome activators in the presence or absence of IFNα, and IL-1β secretion was measured by enzyme-linked immunosorbent assay. Expression levels of IFN and inflammasome-related molecules were assessed by real-time polymerase chain reaction and Western blotting. IFN regulatory factor 1 (IRF-1) expression was specifically down-regulated by small interfering RNA (siRNA) transfection and a chemical inhibitor. RESULTS Monocytes from patients with SLE exhibited increased expression and enhanced activation of the inflammasome by ATP when compared with control monocytes. Expression of inflammasome and IFN-regulated genes was significantly correlated in monocytes from SLE patients but not in control monocytes. Inflammasome activity was increased after prolonged exposure to IFNα. Reduction of IRF-1 expression via siRNA blocked caspase 1 up-regulation after treatment with IFNα. Importantly, hyperactivity of the inflammasome in the monocytes of SLE patients was significantly reduced after knockdown or inhibition of IRF-1. CONCLUSION Prolonged type I IFN exposure, as seen in SLE patients, primes monocytes for robust inflammasome activation in an IRF-1-dependent manner. IRF-1 inhibition may serve as a novel target for treatment of SLE-associated inflammation and organ damage.
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24
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Schwarting A, Relle M, Meineck M, Föhr B, Triantafyllias K, Weinmann A, Roth W, Weinmann-Menke J. Renal tubular epithelial cell-derived BAFF expression mediates kidney damage and correlates with activity of proliferative lupus nephritis in mouse and men. Lupus 2017; 27:243-256. [PMID: 28659046 DOI: 10.1177/0961203317717083] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
B-cell activating factor of the tumour necrosis factor family (BAFF) is a cytokine, mainly produced by hematopoietic cells (e.g. monocytes/macrophages, dendritic cells), indispensable for B-cell maturation. The BLISS studies have demonstrated that blocking BAFF by the human monoclonal antibody belimumab is a valuable therapeutic approach in patients with clinically and serologically active systemic lupus erythematosus (SLE). However, the defined sources of BAFF, which contributes to SLE, are still unclear. Recent findings show that BAFF expression is not restricted to myeloid cells. Since lupus nephritis is the main cause of morbidity and mortality for SLE patients, the aim of this study was to investigate whether renal tubular epithelial cells (TEC) are an important source of BAFF and thus may contribute to the pathogenesis and progression of SLE. We found BAFF expression both in cultured murine and human TEC. These results could be verified with in situ data from the kidney. Moreover, BAFF expression in the kidneys of lupus-prone MRL- Faslpr mice correlated with disease activity, and BAFF expression on TEC in biopsies of patients with diffuse proliferative lupus nephritis showed a correlation with the histopathological activity index. In vitro functional assays revealed an autocrine loop of BAFF with its binding receptors on TEC, resulting in a strong induction of colony stimulating factor-1. Finally, we identified divergent effects of BAFF on TEC depending on the surrounding milieu ('inflammatory versus non-inflammatory'). Taken together, our findings indicate that renal-derived BAFF may play an important role in the pathophysiology of the systemic autoimmune disease SLE.
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Affiliation(s)
- A Schwarting
- 1 Department of Internal Medicine I, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Germany.,2 Acura Rheumatology Center Rhineland Palatinate, Bad Kreuznach, Germany
| | - M Relle
- 1 Department of Internal Medicine I, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - M Meineck
- 1 Department of Internal Medicine I, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - B Föhr
- 1 Department of Internal Medicine I, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - K Triantafyllias
- 2 Acura Rheumatology Center Rhineland Palatinate, Bad Kreuznach, Germany
| | - A Weinmann
- 1 Department of Internal Medicine I, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Germany.,3 Clinical Registry Unit, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - W Roth
- 4 Tissue Bank and Institute of Pathology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - J Weinmann-Menke
- 1 Department of Internal Medicine I, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
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25
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Abstract
SLE is a chronic inflammatory disease that affects the kidneys in about 50% of patients. Lupus nephritis is a major risk factor for overall morbidity and mortality in SLE, and despite potent anti-inflammatory and immunosuppressive therapies still ends in CKD or ESRD for too many patients. This review highlights recent updates in our understanding of disease epidemiology, genetics, pathogenesis, and treatment in an effort to establish a framework for lupus nephritis management that is patient-specific and oriented toward maintaining long-term kidney function in patients with lupus.
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Affiliation(s)
- Salem Almaani
- Department of Internal Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio
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26
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Tesar V, Hruskova Z. Understanding Histolopathologic Characteristics to Predict Renal Outcomes in Lupus Nephritis. Clin J Am Soc Nephrol 2017; 12:711-712. [PMID: 28473316 PMCID: PMC5477205 DOI: 10.2215/cjn.03490317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
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27
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Parikh SV, Malvar A, Song H, Alberton V, Lococo B, Vance J, Zhang J, Yu L, Birmingham D, Rovin BH. Molecular imaging of the kidney in lupus nephritis to characterize response to treatment. Transl Res 2017; 182:1-13. [PMID: 27842222 PMCID: PMC5362303 DOI: 10.1016/j.trsl.2016.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/20/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022]
Abstract
The consequences of treatment for the kidney at the molecular level have not been explored in human lupus nephritis (LN). In this investigation, changes in intrarenal transcript expression were measured and correlated with response in a LN cohort that underwent serial kidney biopsies. The intrarenal transcript expression of 19 patients with proliferative LN (Class III or IV) was measured at diagnostic biopsy (Bx1) and after induction therapy was completed (Bx2) using Nanostring technology. Patients were segregated by clinical response into complete responders (n = 5, CR) or nonresponders (n = 4, NR). Transcript expression for each biopsy was compared with normal controls (n = 4), and the change in expression was compared in each responder group and between groups. Compared with controls, the CR group had 21 and 28, whereas NR had 45 and 103 differentially-expressed transcripts at Bx1 and Bx2, respectively. The profiles of these differentially-expressed genes indicated that the type I and II interferon, alternative complement and T cell signaling pathways discriminated CR from NR. Comparing the change in transcript expression from Bx1 to Bx2 revealed a 5-gene signature that differentiated NR from CR and included increased IL1RAP and FCAR in NR and increased NCAM1 in CR. In summary, molecular imaging of serial kidney biopsies from LN patients shows several immune and inflammatory pathways that are dysregulated in the kidneys during active disease that may serve as therapeutic targets to improve clinical response. This approach to LN biomarker development may facilitate personalized medicine in LN and improve long-term kidney outcomes.
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Affiliation(s)
- Samir V Parikh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ana Malvar
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Huijuan Song
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Valeria Alberton
- Department of Pathology, Hospital Fernandez, Buenos Aires, Argentina
| | - Bruno Lococo
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Jay Vance
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jianying Zhang
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lianbo Yu
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Dan Birmingham
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Birmingham DJ, Merchant M, Waikar SS, Nagaraja H, Klein JB, Rovin BH. Biomarkers of lupus nephritis histology and flare: deciphering the relevant amidst the noise. Nephrol Dial Transplant 2017; 32:i71-i79. [PMID: 28391335 PMCID: PMC5837441 DOI: 10.1093/ndt/gfw300] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/11/2016] [Indexed: 12/12/2022] Open
Abstract
Biomarker development in lupus nephritis (LN) has traditionally relied on comparing the characteristics of candidate markers to clinical findings in patients and controls from cross-sectional cohorts. In this work, two additional strategies for LN biomarker development that are gaining ground will be discussed. One approach compares analytes directly to kidney histology. The second strategy utilizes longitudinal measurements of biomarker levels at regular intervals as patients move from disease quiescence to disease flare. These approaches have begun to empower biomarkers as diagnostic and prognostic tools in LN and have revealed novel and sometimes unexpected roles for these biomarkers in the pathogenesis and prediction of LN disease activity.
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Affiliation(s)
- Daniel J Birmingham
- Division of Nephrology, Ohio State University Wexner Medical Center, 395 West 12th Avenue, Ground Floor, Columbus, OH 43210, USA
| | - Michael Merchant
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Haikady Nagaraja
- Ohio State University College of Public Health, Columbus, OH, USA
| | - Jon B Klein
- University of Louisville School of Medicine, Louisville, KY, USA
| | - Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, 395 West 12th Avenue, Ground Floor, Columbus, OH 43210, USA
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29
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Tsai F, Perlman H, Cuda CM. The contribution of the programmed cell death machinery in innate immune cells to lupus nephritis. Clin Immunol 2016; 185:74-85. [PMID: 27780774 DOI: 10.1016/j.clim.2016.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/15/2016] [Accepted: 10/20/2016] [Indexed: 12/24/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic multi-factorial autoimmune disease initiated by genetic and environmental factors, which in combination trigger disease onset in susceptible individuals. Damage to the kidney as a consequence of lupus nephritis (LN) is one of the most prevalent and severe outcomes, as LN affects up to 60% of SLE patients and accounts for much of SLE-associated morbidity and mortality. As remarkable strides have been made in unlocking new inflammatory mechanisms associated with signaling molecules of programmed cell death pathways, this review explores the available evidence implicating the action of these pathways specifically within dendritic cells and macrophages in the control of kidney disease. Although advancements into the underlying mechanisms responsible for inducing cell death inflammatory pathways have been made, there still exist areas of unmet need. By understanding the molecular mechanisms by which dendritic cells and macrophages contribute to LN pathogenesis, we can improve their viability as potential therapeutic targets to promote remission.
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Affiliation(s)
- FuNien Tsai
- Northwestern University, Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, 240 East Huron Street, Room M300, Chicago, IL 60611, USA.
| | - Harris Perlman
- Northwestern University, Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, 240 East Huron Street, Room M300, Chicago, IL 60611, USA.
| | - Carla M Cuda
- Northwestern University, Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, 240 East Huron Street, Room M300, Chicago, IL 60611, USA.
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30
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Abstract
The introduction of corticosteroids and later, cyclophosphamide dramatically improved survival in patients with proliferative lupus nephritis, and combined administration of these agents became the standard-of-care treatment for this disease. However, treatment failures were still common and the rate of progression to ESRD remained unacceptably high. Additionally, treatment was associated with significant morbidity. Therefore, as patient survival improved, the goals for advancing lupus nephritis treatment shifted to identifying therapies that could improve long-term renal outcomes and minimize treatment-related toxicity. Unfortunately, progress has been slow and the current approaches to the management of lupus nephritis continue to rely on high-dose corticosteroids plus a broad-spectrum immunosuppressive agent. Over the past decade, an improved understanding of lupus nephritis pathogenesis fueled several clinical trials of novel drugs, but none have been found to be superior to the combination of a cytotoxic agent and corticosteroids. Despite these trial failures, efforts to translate mechanistic advances into new treatment approaches continue. In this review, we discuss current therapeutic strategies for lupus nephritis, briefly review recent advances in understanding the pathogenesis of this disease, and describe emerging approaches developed on the basis of these advances that promise to improve upon the standard-of-care lupus nephritis treatments.
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Affiliation(s)
- Samir V Parikh
- Division of Nephrology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brad H Rovin
- Division of Nephrology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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31
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Abstract
Since its incorporation into clinical practice in the 1950s, the percutaneous kidney biopsy has played an important role in advancing our understanding of lupus nephritis (LN). The biopsy findings have been used to classify and subgroup LN in order to obtain an accurate diagnosis and also to inform treatment decisions and predict prognosis. Several classifications schemes have been applied clinically however despite this evolution in histopathologic classification, our ability to predict treatment response and determine prognosis remains limited. In this review we will examine the evolving role of the kidney biopsy in the management of LN, including the potentially larger role the biopsy could play in the future.
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Affiliation(s)
- Samir V Parikh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anthony Alvarado
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ana Malvar
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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32
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Larosa M, Iaccarino L, Gatto M, Punzi L, Doria A. Advances in the diagnosis and classification of systemic lupus erythematosus. Expert Rev Clin Immunol 2016; 12:1309-1320. [PMID: 27362864 DOI: 10.1080/1744666x.2016.1206470] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is the prototype of systemic autoimmune diseases. Patients with SLE display a wide spectrum of clinical and serological findings that can mislead and delay the diagnosis. Diagnostic criteria have not been developed yet, whereas several sets of classification criteria are available; however, none of them has 100% sensitivity and 100% specificity, i.e. the hallmark of diagnostic criteria. Nevertheless, classification criteria are often misused as diagnostic criteria, which may affect earliness of diagnosis and lead to more misdiagnosed cases. Areas covered: In this review, we compare old and new classification criteria, discussing their application and pinpointing their limitations in the management of patients. Moreover, we will focus on current and novel biomarkers for SLE diagnosis, highlighting their predictive value and applicability in clinical practice. Expert commentary: SLE diagnosis still represents a challenge, remaining largely based on a clinical judgment. Besides SLE diagnosis, even its classification is still challenging to date. Indeed, although classification of SLE seems to be achieved more frequently with the 2012 SLICC criteria than with the previous 1997 ACR criteria, this last-updated 2012 set might be improved. Notably, diagnostic and classification criteria should be applied to any subject in the world, and consequently they should include immunological variables validated in different populations, which is still an unmet need.
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Affiliation(s)
- Maddalena Larosa
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Luca Iaccarino
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Mariele Gatto
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Leonardo Punzi
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Andrea Doria
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
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Hurdles to the introduction of new therapies for immune-mediated kidney diseases. Nat Rev Nephrol 2016; 12:205-16. [PMID: 26804020 DOI: 10.1038/nrneph.2015.206] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Innovative immunotherapies continue to markedly benefit many disciplines in clinical medicine but disappointingly, these benefits have not translated to the treatment of kidney diseases despite encouraging findings from preclinical models of kidney dysfunction. This lack of progress in nephrology might relate to the unique biology of the kidney. More likely, this lack of progress relates to conceptual hurdles in the application of newer therapies to renal disease. In this Review we discuss seven hurdles that must be addressed in order to appropriately assess and introduce immunologic therapies for immune-mediated kidney disease: the use of appropriate criteria to define disease categories; issues relating to the heterogeneity of kidney diseases and how this heterogeneity affects approaches to treatment; issues related to the rarity of most kidney diseases; the paucity of good animal models of human kidney disease; issues relating to trial design; problems with current approaches to the identification and use of appropriate and feasible study end points; and a lack of adequate biomarkers of intrarenal inflammation and parenchymal injury. We suggest that overcoming these hurdles, in addition to searching for better therapeutic targets, will be necessary to progress the treatment of immune-mediated kidney disease into a new age of drug therapy.
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