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Alladin A, Hahn D, Hodson EM, Ravani P, Pfister K, Quinn RR, Samuel SM. Immunosuppressive therapy for IgA nephropathy in children. Cochrane Database Syst Rev 2024; 6:CD015060. [PMID: 38864363 PMCID: PMC11167693 DOI: 10.1002/14651858.cd015060.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common cause of primary glomerulonephritis. It is a heterogeneous disease with different presentations and high morbidity. Thirty per cent of adults and 20% of children (followed into adulthood) will have a 50% decline in kidney function or develop kidney failure after 10 years. OBJECTIVES To determine the benefits and harms of immunosuppressive therapy for the treatment of IgAN in children. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 03 October 2023 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) investigating the treatment of IgAN in children with immunosuppressive therapies compared to placebo, no treatment, supportive care, standard therapy (Japanese protocol), other immunosuppressive therapies or non-immunosuppressive therapies. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias. Random effects meta-analyses were used to summarise estimates of treatment effects. Treatment effects were expressed as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and the mean difference (MD) and 95% CI for continuous outcomes. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs and the ROBIN-I tool for NRSIs. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). MAIN RESULTS This review included 13 studies with 686 participants. Ten RCTs included 334 children and 191 adults, and three NRSIs included 151 participants, all children. Most participants had mild kidney disease. The risk of bias was unclear for most of the domains relating to allocation concealment, blinding of participants, personnel, and outcome assessment. In children with IgAN, it is uncertain if corticosteroid (steroid) therapy, compared to placebo reduces proteinuria (1 study, 64 children and young adults: RR 0.47, 95% CI 0.13 to 1.72; low certainty evidence) or the decline in estimated glomerular filtration rate (eGFR) (1 study, 64 children and young adults: RR 0.47, 95% CI 0.09 to 2.39; low certainty evidence). It is uncertain if steroids reduce proteinuria compared to supportive care (2 studies, 61 children: RR 0.04, 95% CI -0.83 to 0.72; low certainty evidence). Adverse events associated with steroid therapy were not assessed due to heterogeneity in steroid protocols, including dose and duration, and lack of systematic assessment for adverse events in the included studies. Azathioprine, mycophenolate mofetil, mizoribine, or cyclophosphamide alone or in combination with steroid therapy had uncertain effects on improving proteinuria or preventing eGFR decline in children with IgAN. Fish oil, vitamin E and tonsillectomy had uncertain effects on improving proteinuria or preventing eGFR decline. Effects of other immunosuppressive therapies, secondary outcomes and adverse events were not assessed due to insufficient data. AUTHORS' CONCLUSIONS There is a lack of high-quality evidence to guide the management of IgAN in children. There is no evidence to indicate that steroids, other immunosuppressive therapies, or tonsillectomy, when added to optimal supportive care, prevent a decline in eGFR or proteinuria in children with IgAN. Available studies were few, with small numbers, low-quality evidence, high or uncertain risk of bias, did not systematically assess harms associated with treatment, or report net benefits or harms. Severe cases and atypical presentations of IgAN were not included in the reviewed studies, and our findings cannot be generalised to these situations.
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Affiliation(s)
- Areefa Alladin
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
- School of Medicine, University of Guyana, Georgetown, Guyana
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kenneth Pfister
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Susan M Samuel
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
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Barr B, Barbour S. New therapies for immunoglobulin A nephropathy: what's the standard of care in 2023? Curr Opin Nephrol Hypertens 2024; 33:311-317. [PMID: 38411173 DOI: 10.1097/mnh.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW As the most common primary glomerulonephritis, immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of kidney failure and mortality. Until recently, therapeutic options were limited. Fortunately, there have been numerous recent clinical trials demonstrating efficacy of new therapies in slowing chronic kidney disease (CKD) progression at varying stages of disease. RECENT FINDINGS The TESTING trial has provided high-quality evidence for slowing estimated glomerular filtration rate (eGFR) decline with a reduced-dose glucocorticoid regimen, while demonstrating an improved safety profile. Targeted-release budesonide represents a well tolerated therapy for reducing eGFR decline. Mycophenolate mofetil may reduce CKD progression in some populations, while hydroxychloroquine is efficacious in reducing proteinuria. Sodium-glucose cotransporter (SGLT2) inhibitors and sparsentan are effective therapies for CKD due to IgAN, but should not be used in lieu of disease-modifying immunosuppressive therapy. Many new therapies are approaching readiness for clinical use. SUMMARY Numerous therapeutic options now exist and include disease-modifying and nephroprotective drugs. Identifying the right treatment for the right patient is now the clinical challenge and, with new drugs on the horizon, represents the primary unmet research need in this rapidly-developing field.
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Affiliation(s)
- Bryce Barr
- Section of Nephrology, Department of Medicine, Max Rady College of Medicine, University of Manitoba
| | - Sean Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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Tunnicliffe DJ, Reid S, Craig JC, Samuels JA, Molony DA, Strippoli GF. Non-immunosuppressive treatment for IgA nephropathy. Cochrane Database Syst Rev 2024; 2:CD003962. [PMID: 38299639 PMCID: PMC10832348 DOI: 10.1002/14651858.cd003962.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non-immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long-term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non-immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. OBJECTIVES To assess the benefits and harms of non-immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non-immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of non-immunosuppressive agents in adults and children with biopsy-proven IgAN were included. DATA COLLECTION AND ANALYSIS Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random-effects meta-analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non-immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin-angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD - 0.71 g/24 h, 95% CI -1.04 to -0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD -1.16 g/24 h, 95% CI -1.52 to -0.81) and SCr (MD -9.37 µmol/L, 95% CI -71.95 to -6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. AUTHORS' CONCLUSIONS Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long-term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non-immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non-immunosuppressive treatments evaluated here.
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Affiliation(s)
| | - Sharon Reid
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Joshua A Samuels
- Division of Pediatric Nephrology and Hypertension, UT-Houston Health Science Center, Houston, TX, USA
| | - Donald A Molony
- Internal Medicine, UT-Houston Health Science Center, Houston, TX, USA
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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El Karoui K, Fervenza FC, De Vriese AS. Treatment of IgA Nephropathy: A Rapidly Evolving Field. J Am Soc Nephrol 2024; 35:103-116. [PMID: 37772889 PMCID: PMC10786616 DOI: 10.1681/asn.0000000000000242] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
The pivotal event in the pathophysiology of IgA nephropathy is the binding of circulating IgA-containing immune complexes to mesangial cells, with secondary glomerular and tubulointerstitial inflammation and fibrosis. The paramount difficulty in the management of IgA nephropathy is the heterogeneity in its clinical presentation and prognosis, requiring an individualized treatment approach. Goal-directed supportive care remains the bedrock of therapy for all patients, regardless of risk of progression. Sodium-glucose transporter 2 inhibitors and sparsentan should be integral to contemporary supportive care, particularly in patients with chronic kidney damage. Pending the development of reliable biomarkers, it remains a challenge to identify patients prone to progression due to active disease and most likely to derive a net benefit from immunosuppression. The use of clinical parameters, including the degree of proteinuria, the presence of persistent microscopic hematuria, and the rate of eGFR loss, combined with the mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, crescents score, is currently the best approach. Systemic glucocorticoids are indicated in high-risk patients, but the beneficial effects wane after withdrawal and come at the price of substantial treatment-associated toxicity. Therapies with direct effect on disease pathogenesis are increasingly becoming available. While targeted-release budesonide has garnered the most attention, anti-B-cell strategies and selective complement inhibition will most likely prove their added value. We propose a comprehensive approach that tackles the different targets in the pathophysiology of IgA nephropathy according to their relevance in the individual patient.
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Affiliation(s)
- Khalil El Karoui
- Department of Nephrology, Hôpital Tenon, Sorbonne Université, Paris, France
| | | | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
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Locatelli F, Del Vecchio L, Ponticelli C. Systemic and targeted steroids for the treatment of IgA nephropathy. Clin Kidney J 2023; 16:ii40-ii46. [PMID: 38053978 PMCID: PMC10695509 DOI: 10.1093/ckj/sfad224] [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: 05/15/2023] [Indexed: 12/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is a common glomerulonephritis partially correlated with mucosal immune system dysfunction. Progressive renal failure occurs in many patients, with about 30-50% of the patients with IgAN developing end-stage kidney disease (ESKD). Many treatments have been used for decades, despite uncertainty about their effectiveness and the ideal dose. Randomised controlled trials reported that systemic glucocorticoids can be an effective treatment for patients with persistent and significant proteinuria despite renin-angiotensin system inhibitors use possibly causing systemic side effects. The primary focus of IgAN management should be based on optimised supportive care, including renin-angiotensin system (RAS) blockade and now SGLT2 inhibitors. The novel targeted-release formulation (TRF) of budesonide has been tested to reduce the adverse events of systemic steroids by delivering the drug to the distal ileum. The local efficacy of TRF-budesonide may represent a novel and promising approach to treating IgAN. Two clinical trials showed that TRF-budesonide could significantly reduce proteinuria and haematuria and possibly preserve renal function while significantly reducing the side effects. However, the limited number of treated patients and the relatively short follow-up suggest caution before considering budesonide superior to the current six-months steroid pulses scheme. Long-term data on the efficacy and safety of TRF budesonide are awaited, together with the design of trials with a head-to-head comparison with systemic steroids before considering TRF-budesonide as the standard of care treatment for IgAN nephropathy.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’ Anna Hospital, ASST Lariana, Como, Italy
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Guo Y, Shi S, Zhou X, Liu L, Lv J, Zhu L, Wang S, Zhang H. The predictive value and response to immunosuppressive therapy of IgA nephropathy patients with crescents in a large retrospective Chinese cohort. Clin Kidney J 2023; 16:2417-2428. [PMID: 38046023 PMCID: PMC10689141 DOI: 10.1093/ckj/sfad134] [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: 09/14/2022] [Indexed: 12/05/2023] Open
Abstract
Background The prognostic value and response to immunosuppressive therapy (IST) of patients with crescents in the different backgrounds of pathological presentations in immunoglobulin A nephropathy (IgAN) is unclear. Methods A total of 1262 IgAN patients were enrolled. Crescents (C, 0/1/2), fibrinoid necrosis (FN, 0/1) and endocapillary hypercellularity (E, 0/1) were integrated into different degrees of glomerular activity (0-4 points): mild (0), moderate (1-2) and severe (≥3). The effect of IST on patients with different glomerular activity scores and chronic tubular and interstitial lesions (T, 0/1/2) were analysed using Cox regression analysis. The kidney outcome was defined as an estimated glomerular filtration rate decrease ≥30% or end-stage kidney disease. Results C2 was an independent risk factor for kidney outcomes {overall cohort: hazard ratio [HR] 1.85 [95% confidence interval (CI) 1.03-3.31], P = .040; T0 patients: HR 6.52 [95% CI 2.92-14.54], P < .001; reference to C0} in those without IST, while the HR decreased to 0.83 (95% CI 0.54-1.27; P = .396) in the overall cohort and 2.39 (95% CI 1.00-5.67; P = .049) in T0 patients with IST. For patients with severe glomerular activity, IST decreased the risk of kidney outcomes by 70% in the overall cohort [HR 0.30 (95% CI 0.12-0.74), P = .009; reference to those without IST] and 86% in T0 patients [HR 0.14 (95% CI 0.04-0.54), P = 0.005; reference to those without IST]. Conclusions IST could reduce the risk for kidney outcomes in IgAN patients with C2 and T0 lesions together, as well as in those with crescents and at least one other active lesion, including FN and E1 lesions.
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Affiliation(s)
- Yingman Guo
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
| | - Xujie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
| | - Lijun Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
| | - Li Zhu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
| | - Suxia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
- Electron Microscopy Laboratory, Peking University First Hospital, Peking, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China
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Zhang Y, Hu YT, Lv JC, Zhang H. Corticosteroids in the treatment of IgA nephropathy: lessons from the TESTING trial. Pediatr Nephrol 2023; 38:3211-3220. [PMID: 36881171 DOI: 10.1007/s00467-023-05919-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/22/2023] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
IgA nephropathy (IgAN), the most common form of primary glomerulonephritis, is mainly observed in young adults and children. Clinical and basic studies indicate the role of immunity in IgAN pathogenesis; however, corticosteroid therapy has been controversial in past decades. The TESTING study, initiated in 2012, is an international, multicenter, double-blinded, randomized, placebo-controlled trial that aimed to evaluate oral methylprednisolone's safety and long-term efficacy under conditions of optimized supportive treatment in patients with IgAN whose risk of progression is high. After a decade of effort, the successful completion of the TESTING study showed that a 6- to 9-month course of oral methylprednisolone is an effective regimen to protect kidney function in high-risk patients with IgAN, but also demonstrated safety concerns. Compared with the full-dose regimen, the reduced-dose regimen was reported to be beneficial, with successfully increased safety. Overall, the TESTING trial provided more data regarding the treatment dosage and safety of corticosteroids, a cost-effective therapy, in IgAN, which have important implications for pediatric patients with IgAN. With a deeper understanding of the disease pathogenesis of IgAN, ongoing studies of novel therapeutic regimens would help further optimize the benefit-risk ratio.
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Affiliation(s)
- Yuemiao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China
| | - Yi-Tong Hu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China
- Peking University Health Science Center, Xue Yuan Road 38, Beijing, 100191, People's Republic of China
| | - Ji-Cheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China.
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Caster DJ, Abner CW, Walker PD, Wang K, Heo J, Rava AR, Bunke M. Clinicopathological Characteristics of Adult IgA Nephropathy in the United States. Kidney Int Rep 2023; 8:1792-1800. [PMID: 37705898 PMCID: PMC10496075 DOI: 10.1016/j.ekir.2023.06.016] [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: 12/14/2022] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction IgA nephropathy (IgAN) is a progressive autoimmune kidney disease and a leading cause of glomerular disease that can result in kidney failure (KF). The median age at diagnosis is 35 to 37 years and approximately 50% of patients will progress to KF within 20 years. We aimed to enhance the understanding of renal histology and chronic kidney disease (CKD) stage at the time of IgAN diagnosis using a large real-world biopsy cohort. Methods This retrospective cohort study evaluated biopsy data and clinical characteristics from adult patients within the US who were diagnosed with IgAN between January 1, 2016 to May 31, 2020. Descriptive statistics were summarized and relationship(s) between each Oxford Classification (MEST-C) component score with 24-hour proteinuria or CKD stage were examined using regression analysis. Results A total of 4375 patients (mean age 47.7 years, 62.7% male) met eligibility criteria. Mild to moderate mesangial hypercellularity (47.3%), segmental sclerosis (65.0%), tubular atrophy ≥25% (57.4%), and crescents (18.5%) were identified; and 74.6% of patients were at CKD stage ≥3. Proteinuria ≥1 g/d was associated with higher MEST-C scores, and the odds of mesangial hypercellularity, segmental sclerosis, tubular atrophy, and crescents increased with CKD stage. Conclusion Most patients with IgAN in our US cohort were diagnosed at CKD stage ≥3 and had high MEST-C scores and proteinuria that are suggestive of significant disease burden at the time of kidney biopsy. Strategies are required to raise awareness and promote earlier detection of asymptomatic urinary abnormalities before extensive irreversible kidney damage has occurred.
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Affiliation(s)
| | | | | | - Kaijun Wang
- Travere Therapeutics, Inc., San Diego, California, USA
| | | | | | - Martin Bunke
- Travere Therapeutics, Inc., San Diego, California, USA
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Zanoni F, Abinti M, Belingheri M, Castellano G. Present and Future of IgA Nephropathy and Membranous Nephropathy Immune Monitoring: Insights from Molecular Studies. Int J Mol Sci 2023; 24:13134. [PMID: 37685941 PMCID: PMC10487514 DOI: 10.3390/ijms241713134] [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: 07/05/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
IgA Nephropathy (IgAN) and Membranous Nephropathy (MN) are primary immune-mediated glomerular diseases with highly variable prognosis. Current guidelines recommend that greater immunologic activity and worse prognosis should guide towards the best treatment in an individualized approach. Nevertheless, proteinuria and glomerular filtration rate, the current gold standards for prognosis assessment and treatment guidance in primary glomerular diseases, may be altered with chronic damage and nephron scarring, conditions that are not related to immune activity. In recent years, thanks to the development of new molecular technologies, among them genome-wide genotyping, RNA sequencing techniques, and mass spectrometry, we have witnessed an outstanding improvement in understanding the pathogenesis of IgAN and MN. In addition, recent genome-wide association studies have suggested potential targets for immunomodulating agents, stressing the need for the identification of specific biomarkers of immune activity. In this work, we aim to review current evidence and recent progress, including the more recent use of omics techniques, in the identification of potential biomarkers for immune monitoring in IgAN and MN.
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Affiliation(s)
- Francesca Zanoni
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
| | - Matteo Abinti
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Mirco Belingheri
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
| | - Giuseppe Castellano
- Division of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.A.); (M.B.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
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Xu LL, Zhang D, Weng HY, Wang LZ, Chen RY, Chen G, Shi SF, Liu LJ, Zhong XH, Hong SD, Duan LX, Lv JC, Zhou XJ, Zhang H. Machine learning in predicting T-score in the Oxford classification system of IgA nephropathy. Front Immunol 2023; 14:1224631. [PMID: 37600788 PMCID: PMC10437057 DOI: 10.3389/fimmu.2023.1224631] [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: 05/18/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023] Open
Abstract
Background Immunoglobulin A nephropathy (IgAN) is one of the leading causes of end-stage kidney disease (ESKD). Many studies have shown the significance of pathological manifestations in predicting the outcome of patients with IgAN, especially T-score of Oxford classification. Evaluating prognosis may be hampered in patients without renal biopsy. Methods A baseline dataset of 690 patients with IgAN and an independent follow-up dataset of 1,168 patients were used as training and testing sets to develop the pathology T-score prediction (T pre) model based on the stacking algorithm, respectively. The 5-year ESKD prediction models using clinical variables (base model), clinical variables and real pathological T-score (base model plus T bio), and clinical variables and T pre (base model plus T pre) were developed separately in 1,168 patients with regular follow-up to evaluate whether T pre could assist in predicting ESKD. In addition, an external validation set consisting of 355 patients was used to evaluate the performance of the 5-year ESKD prediction model using T pre. Results The features selected by AUCRF for the T pre model included age, systolic arterial pressure, diastolic arterial pressure, proteinuria, eGFR, serum IgA, and uric acid. The AUC of the T pre was 0.82 (95% CI: 0.80-0.85) in an independent testing set. For the 5-year ESKD prediction model, the AUC of the base model was 0.86 (95% CI: 0.75-0.97). When the T bio was added to the base model, there was an increase in AUC [from 0.86 (95% CI: 0.75-0.97) to 0.92 (95% CI: 0.85-0.98); P = 0.03]. There was no difference in AUC between the base model plus T pre and the base model plus T bio [0.90 (95% CI: 0.82-0.99) vs. 0.92 (95% CI: 0.85-0.98), P = 0.52]. The AUC of the 5-year ESKD prediction model using T pre was 0.93 (95% CI: 0.87-0.99) in the external validation set. Conclusion A pathology T-score prediction (T pre) model using routine clinical characteristics was constructed, which could predict the pathological severity and assist clinicians to predict the prognosis of IgAN patients lacking kidney pathology scores.
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Affiliation(s)
- Lin-Lin Xu
- Renal Division, Peking University First Hospital, Kidney Genetics Center, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Di Zhang
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- WeGene, Shenzhen Zaozhidao Technology, Shenzhen, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Hao-Yi Weng
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- WeGene, Shenzhen Zaozhidao Technology, Shenzhen, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Li-Zhong Wang
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- WeGene, Shenzhen Zaozhidao Technology, Shenzhen, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Ruo-Yan Chen
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- WeGene, Shenzhen Zaozhidao Technology, Shenzhen, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Gang Chen
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- WeGene, Shenzhen Zaozhidao Technology, Shenzhen, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Kidney Genetics Center, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Kidney Genetics Center, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Xu-Hui Zhong
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Shen-Da Hong
- Institute of Medical Technology, Health Science Center of Peking University, Beijing, China
| | - Li-Xin Duan
- The Sichuan Provincial Key Laboratory for Human Disease Gene Study, Research Unit for Blindness Prevention of Chinese Academy of Medical Sciences (2019RU026), Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Kidney Genetics Center, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Xu-Jie Zhou
- Renal Division, Peking University First Hospital, Kidney Genetics Center, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Kidney Genetics Center, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
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11
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Howie AJ, Lalayiannis AD. Systematic Review of the Oxford Classification of IgA Nephropathy: Reproducibility and Prognostic Value. KIDNEY360 2023; 4:1103-1111. [PMID: 37357346 PMCID: PMC10476683 DOI: 10.34067/kid.0000000000000195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/06/2023] [Indexed: 06/27/2023]
Abstract
Key Points The Oxford classification of IgA nephropathy defined five features scored subjectively in renal biopsies, identified by the initials MESTC. Two large studies with independent observers showed reproducibility was moderate for T, moderate or poor for M and S, and poor for E and C. In multivariate analyses including clinical features, T was related to 58% of outcomes, with no correlation of MESTC with 24% of outcomes. Background The Oxford classification of IgA nephropathy defined five prognostic features scored subjectively in renal biopsies: mesangial cellularity (M), endocapillary hypercellularity (E), segmental sclerosis (S), interstitial fibrosis/tubular atrophy (T), and (fibro)cellular crescents (C). Pathological scoring systems should be reproducible and have prognostic value independently of clinical features. Reproducibility of the classification was not previously investigated in a systematic review, and the most recent systematic reviews of prognostic value were in 2017. Methods This systematic review followed PRISMA 2020 guidelines. MEDLINE, PUBMED, and EMBASE databases were searched using the terms “IgA nephropathy” and “Oxford.” Eligible papers applied the classification and mentioned statistical analysis of interobserver reproducibility and/or included multivariate analysis of outcomes related to individual Oxford scores and clinical features, including treatment with corticosteroids or other immunosuppressive drugs. Results There were 99 suitable papers before September 23, 2022. Of 12 papers that mentioned reproducibility, only six reported statistics for MEST/MESTC scoring. Four of these were small studies and/or had observers at the same institution. These were considered less representative of application of the classification than two large studies with independent observers, in which agreement was moderate for T, either moderate or poor for M and S, and poor for E and C. In 92 papers with 125 multivariate analyses of various outcomes, the commonest Oxford element associated with outcomes was T (73 of 125, 58%), with no correlation of any element with outcomes in 30 analyses (24%). Treatment with immunosuppression was often related to scores, particularly C and E, without consistent relations between Oxford scores and outcomes in immunosuppressed patients. Conclusions This systematic review showed limitations of the Oxford classification in practice, particularly the moderate or poor reproducibility of scores. T was the Oxford score most often related to clinical outcomes, but even this was not consistently reliable as a prognostic indicator.
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Affiliation(s)
- Alexander J. Howie
- Department of Pathology, University College London, London, United Kingdom
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12
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Ghaddar M, Barratt J, Barbour SJ. An update on corticosteroid treatment for IgA nephropathy. Curr Opin Nephrol Hypertens 2023; 32:263-270. [PMID: 36866805 DOI: 10.1097/mnh.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW The use of corticosteroids to treat IgA nephropathy (IgAN) has been limited by many controversies related to uncertain benefit and safety concerns. Recent trials have tried to address these limitations. RECENT FINDINGS After being paused because of an excess of adverse events in the full-dose steroid arm, the TESTING trial compared a reduced dose of methylprednisolone to placebo in patients with IgAN after optimization of supportive therapy. Steroid treatment was associated with a significant reduction in the risk of a 40% decline in estimated glomerular filtration rate (eGFR), kidney failure and kidney death as well as a sustained decrease in proteinuria compared with placebo. Serious adverse events were more frequent with the full dose regimen but less common in the reduced dose regimen. A phase III trial evaluating a new formulation of targeted-release budesonide showed a significant reduction in short-term proteinuria and has resulted in accelerated FDA approval for use in the United States. In a subgroup analysis of DAPA-CKD trial, sodium-glucose transport protein 2 inhibitors reduced the risk of kidney function decline in patients who have completed or are not eligible for immunosuppression. SUMMARY Both reduced-dose corticosteroids and targeted-release budesonide are new therapeutic options that can be used in patients with high-risk disease. More novel-targeted therapies with a better safety profile are currently under investigations.
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Affiliation(s)
- Malak Ghaddar
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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13
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Kim D, Wong MG. Corticosteroid Therapy in Immunoglobulin A Nephropathy: A Friend or Foe? Kidney Blood Press Res 2023; 48:392-404. [PMID: 36972570 DOI: 10.1159/000530285] [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: 09/22/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The administration of corticosteroids in addition to supportive care to delay progressive immunoglobulin A nephropathy (IgAN), the most common primary glomerulonephritis worldwide, remains controversial. This is partly due to the paucity of well-designed randomized controlled trials and well-known corticosteroid-related side effects. As a result, clinical equipoise in corticosteroid therapy exists depending on geographical regions and the clinician's preference. SUMMARY Better understanding around the pathogenesis of IgAN has prompted several clinical trials exploring the effects of immunosuppressive agents including corticosteroids. Earlier studies of corticosteroids were limited by suboptimal study designs, inadequate implementation of standard of care, and inconsistent adverse event data collection. Two well-designed, adequately powered, multi-centre randomized controlled trials, the STOP-IgAN and TESTING studies, have reported contrasting kidney outcomes that have further fuelled the clinical conundrum regarding the efficacy of corticosteroids. Both studies independently reported greater adverse events with corticosteroids. A novel targeted release formulation of budesonide, which has been hypothesized to reduce the adverse events associated with systemic corticosteroids, has shown promising results in the Phase 3 NefigaRD trial. Studies of treatments targeting B cells and the complement cascade are currently underway, and early data appear encouraging. This review provides an overview of the current literature around the understanding of the pathomechanisms and benefits and harm of corticosteroid use in IgAN. KEY MESSAGES Recent evidence suggests the use of corticosteroids in a selected cohort of people with IgAN at high risk of disease progression can improve kidney outcomes but comes with an associated risk of treatment-related adverse events, particularly with higher doses. Management decisions should therefore follow an informed patient-clinician discussion.
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Affiliation(s)
- Dana Kim
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, New South Wales, Australia
- Concord Clinical School, University of Sydney, Concord, New South Wales, Australia
| | - Muh Geot Wong
- Concord Clinical School, University of Sydney, Concord, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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14
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Trimarchi H, Haas M, Coppo R. Crescents and IgA Nephropathy: A Delicate Marriage. J Clin Med 2022; 11:jcm11133569. [PMID: 35806856 PMCID: PMC9267724 DOI: 10.3390/jcm11133569] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/06/2022] [Accepted: 06/18/2022] [Indexed: 12/20/2022] Open
Abstract
IgA nephropathy (IgAN) is a progressive disease with great variability in the clinical course. Among the clinical and pathologic features contributing to variable outcomes, the presence of crescents has attracted particular interest as a distinct pathological feature associated with severity. Several uncontrolled observations have led to the general thought that the presence and extent of crescents was a prognostic indicator associated with poor outcomes. However, KDIGO 2021 guidelines concluded that either the presence or the relative number of crescents should not be used to determine the progression of IgAN nor should they suggest the choice of immunosuppression. Our aim is to report and discuss recent data on the debated issue of the value of active (cellular and fibrocellular) crescents in the pathogenesis and clinical progression of IgAN, their predictive value, and the impact of immunosuppression on renal function. We conclude that the value of crescents should not be disregarded, although this feature does not have an independent predictive value for progression in IgAN, particularly when considering immunosuppressed patients. An integrated overall evaluation of crescents with other active MEST scores, clinical data, and novel biomarkers must be considered in achieving a personalized therapeutic approach to IgAN patients.
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Affiliation(s)
- Hernán Trimarchi
- Nephrology Service, Hospital Britanico de Buenos Aires, Buenos Aires C1280 AEB, Argentina;
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Correspondence: ; Tel.: +1-310-248-6695; Fax: +1-310-423-5881
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, 10126 Turin, Italy;
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15
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Klinkhammer BM, Buchtler S, Djudjaj S, Bouteldja N, Palsson R, Edvardsson VO, Thorsteinsdottir M, Floege J, Mack M, Boor P. Current kidney function parameters overestimate kidney tissue repair in reversible experimental kidney disease. Kidney Int 2022; 102:307-320. [PMID: 35483527 DOI: 10.1016/j.kint.2022.02.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 11/24/2022]
Abstract
Although underlying mechanisms and the clinical course of kidney disease progression are well described, less is known about potential disease reversibility. Therefore, to analyze kidney recovery, we adapted a commonly used murine chronic kidney disease (CKD) model of 2,8- dihydroxyadenine (2,8-DHA) crystal-induced nephropathy to study disease recovery and efficacy of disease-modifying interventions. The recovery phase after CKD was characterized by improved kidney function after two weeks which remained stable thereafter. By contrast, even after eight weeks recovery, tubular injury and inflammation were only partially reduced and fibrosis persisted. Deep-learning-based histologic analysis of 8,604 glomeruli and 596,614 tubular cross sections revealed numerous tubules had undergone either prominent dilation or complete atrophy, leading to atubular glomeruli and irreversible nephron loss. We confirmed these findings in a second CKD model, reversible unilateral ureteral obstruction, in which a rapid improvement of glomerular filtration rate during recovery also did not reflect the permanent histologic kidney injury. In 2,8-DHA nephropathy, increased drinking volume was highly effective in disease prevention. However, in therapeutic approaches, high fluid intake was only effective in moderate but not severe CKD and established tissue injury was again poorly reflective of kidney function parameters. The injury was particularly localized in the medulla, which is often not analyzed. Thus, recovery after crystal- or obstruction-induced CKD is characterized by ongoing tissue injury, fibrosis, and nephron loss, but not reflected by standard measures of kidney function. Hence, our data might aid in designing kidney recovery studies and suggest the need for biomarkers specifically monitoring intra-kidney tissue injury.
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Affiliation(s)
| | - Simone Buchtler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Sonja Djudjaj
- Institute of Pathology, RWTH University Hospital Aachen, Aachen, Germany
| | - Nassim Bouteldja
- Institute of Pathology, RWTH University Hospital Aachen, Aachen, Germany
| | - Runolfur Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Vidar Orn Edvardsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Children´s Medical Center, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Jürgen Floege
- Division of Nephrology and Immunology, RWTH University Hospital Aachen, Aachen, Germany
| | - Matthias Mack
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Peter Boor
- Institute of Pathology, RWTH University Hospital Aachen, Aachen, Germany; Division of Nephrology and Immunology, RWTH University Hospital Aachen, Aachen, Germany; Department of Electron Microscopy, RWTH University Hospital Aachen, Aachen, Germany.
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16
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Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
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17
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Lim CC, Shashidhar B, Choo JCJ, Woo KT. Individualizing immunosuppressive therapy decision in Immunoglobulin A nephropathy and application in a Southeast Asian cohort. Clin Kidney J 2022; 15:1434-1436. [PMID: 35756748 PMCID: PMC9217654 DOI: 10.1093/ckj/sfac067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Cynthia C Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Jason C J Choo
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Keng Thye Woo
- Department of Renal Medicine, Singapore General Hospital, Singapore
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18
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Bhat MA, Sofi IS, Sheikh RY, Wani I. Incidence, demographic, biochemical, and clinicopathological profile of primary IgAN in a tertiary care center from Northern India. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00109-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Primary IgA nephropathy (IgAN) has variable distribution and clinicopathological spectrum throughout the world. We report the incidence, demographic, and clinicopathological profile of primary IgAN from a tertiary care center in Northern India.
Methods
This is a single-center, prospective, observational study conducted at Sheri- Kashmir Institute of Medical Sciences, J&K, India, from January 2015 to December 2018. The study was approved by the hospital ethical committee.
Results
A total of 106 patients were included in this study, accounting for 19% (106/558) of all native kidney biopsies done during the period from January 2015 till December 2018. Males and females accounted for 60.4% (64/106) and 39.6% (42/106), respectively, with a ratio of 1.5:1. The mean age was 31.37±11.60 years. Edema and hypertension were the most common presenting symptoms and signs, seen in 69 (65.1%) and 72 (67.9%) patients, respectively. The baseline 24-h urine protein excretion was 2.32 ±1.34 g, Nephrotic range proteinuria (≥3.5g/day) was seen in 23/106 (21.7%). Average serum creatinine was 1.6±0.80 mg/dl and estimated glomerular filtration rate using CKD-EPI was <60 ml/min/1.73 m2 in 48.1% of patients (51/106). In patients with < 1 g proteinuria, 36.8% had E1, 78.9% had S1, 36.8% had T1, and 42.1% had T2 lesions.
Conclusions
IgAN is common in North India and has a more severe histopathological presentation, characterized by extensive sclerosis and tubulointerstitial fibrosis. Renal dysfunction and nephrotic range proteinuria are common. Hypertension, low eGFR, and proteinuria correlate with the presence of segmental scarring, endocapillary hypercellularity, and IFTA. Screening of asymptomatic individuals might help in early diagnosis and long-term preservation of renal function.
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Troyanov S, Hladunewich MA, Reich HN. How Should Pathology Findings Influence Treatment in IgA Nephropathy? Kidney Int Rep 2022; 7:3-5. [PMID: 35005306 PMCID: PMC8720810 DOI: 10.1016/j.ekir.2021.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stéphan Troyanov
- Division of Nephrology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Michelle A. Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Science Center, University of Toronto, Toronto, Ontario, Canada
| | - Heather N. Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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20
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Jia Q, Ma F, Yang X, Li L, Liu C, Sun R, Li R, Sun S. Long-term outcomes of IgA nephropathy patients with less than 25% crescents and mild proteinuria. Clin Exp Nephrol 2021; 26:257-265. [PMID: 34724588 DOI: 10.1007/s10157-021-02154-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whether immunosuppressive therapy in IgA nephropathy (IgAN) patients with less than 25% crescents (C1) and mild proteinuria can improve the renal outcome is still unclear. METHODS We recruited 140 IgAN patients with C1 and proteinuria < 1 g/24 h who received supportive care (n = 52) or steroid-based immunosuppressive therapy (n = 88) in Xijing Hospital from July 2008 to December 2016. The primary outcome was the rate of renal function decline. RESULTS The median of proteinuria was 575.5 mg/24 h, the fraction of crescents was 7% (5%, 12%) and follow-up time was 69.1 months. The rate of renal function decline [0.5 (- 1.5, 3.2) vs - 0.7 (- 3.5, 0.5) ml/min per 1.73 m2 per year; P = 0.01] was slower in steroid-based immunosuppressive therapy group than supportive care group. Multivariate linear regression analyses showed steroid-based immunosuppressive therapy significantly slowed down the rate of renal function decline (β = - 0.220, 95% CI - 3.804 to - 0.449, P = 0.013) after adjusting age, sex, MAP, proteinuria, eGFR, M1, E1, S1, T1-2, the fraction of crescents and RASB. In the matched cohort, the rate of renal function decline was also slower in steroid-based immunosuppressive therapy group. The incidence of adverse events was similar between the two groups. CONCLUSION Steroid-based immunosuppressive therapy may slow down the rate of renal function decline of IgAN patients with C1 and proteinuria ≤ 1 g/24 h.
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Affiliation(s)
- Qing Jia
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China. .,Xi'an Jiao Tong University-Affiliated Honghui Hospital, Xi'an, 710054, Shaanxi, China.
| | - Xiaoxia Yang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Linlin Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Chunmei Liu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Ruiling Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Rong Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China.
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21
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Glassock RJ. IgA Nephropathy: "The Times They Are a-Changin". GLOMERULAR DISEASES 2021; 2:4-14. [PMID: 36751269 PMCID: PMC9677731 DOI: 10.1159/000515199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/08/2021] [Indexed: 11/19/2022]
Abstract
Background Primary IgA Nephropathy (IgA N) is a very common and often progressive glomerular disease. At present, the diagnosis of IgA N is totally dependent on kidney biopsy, but the prospect for a future diagnosis by means of a "liquid" biopsy is promising. A great deal is now understood regarding its diverse clinical and pathological features as well as its epidemiology, genetics, prognosis, and pathogenesis. Treatment approaches are now on increasingly solid evidence-based grounds, but many uncertainties continue to be devil the field. Better means of categorization of patients into a hierarchy of progression risk at the time of diagnosis will undoubtedly refine and personalize treatment decisions. Summary The panorama of treatment strategies is undergoing a rapid transformation, largely due to an increase in large randomized clinical trials testing available agents and novel therapeutic classes. It is anticipated that the combination of better prognostic tools and new strategies for treatment of IgA N will alter the landscape of therapeutic algorithms for patients with IgA N. Key Messages This review seeks to describe some of the evolutionary changes in the approach to treatment of IgA N, to place them in the context of current management, and to identify knowledge gaps that need to be addressed.
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Alexander S, Varughese S, Franklin R, Roy S, Rebekah G, David VG, Mohapatra A, Valson AT, Jacob S, Koshy PM, Rajan G, Daha MR, Feehally J, Barratt J, John GT. Epidemiology, baseline characteristics and risk of progression in the first South-Asian prospective longitudinal observational IgA nephropathy cohort. Kidney Int Rep 2021; 6:414-428. [PMID: 33615067 PMCID: PMC7879115 DOI: 10.1016/j.ekir.2020.11.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Glomerular Research And Clinical Experiments-IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South Asian IgAN cohort with protocolized follow-up and extensive biosample collection. Here we report the baseline clinical, biochemical, and histopathologic characteristics of GRACE IgANI and calculate baseline risk of progression for the cohort. METHODS 201 incident adults with kidney biopsy-proven primary IgAN were recruited into GRACE-IgANI between March 2015 and September 2017. As of April 30, 2020, the cohort had completed a median follow-up of 30 months (interquartile range [IQR] 16-39). RESULTS The commonest clinical presentation in GRACE IgANI was hypertension, with or without proteinuria, and nephrotic-range proteinuria was present in 34%, despite <10 months of lead time to kidney biopsy. The GRACE-IgANI kidney biopsy data demonstrated a disproportionate absence of active glomerular lesions and overrepresentation of segmental sclerosing lesions and tubulointerstitial fibrosis at presentation, often coexistent with relatively well-preserved estimated glomerular filtration rate (eGFR) and low levels of proteinuria, especially in males. Baseline risk of progression was calculated for each evaluable patient using 2 different risk prediction tools. The median 5-year absolute risk of end-stage kidney disease (ESKD) was 19.8% (IQR 2.7-57.4) and median 5-year risk of progression to the combined endpoint of 50% decline in eGFR or ESKD was 35.5% using the 2 tools. CONCLUSIONS The predicted risk of progression in this cohort was considerable. Over the next 5 years, we will dissect the pathogenic pathways that underlie this severe South Asian IgAN phenotype.
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Affiliation(s)
| | | | | | - Sanjeet Roy
- Department of General Pathology, Christian Medical College, Vellore, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore, India
| | | | - Anjali Mohapatra
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Anna T. Valson
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Shibu Jacob
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | - Gautham Rajan
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | - John Feehally
- University of Leicester College of Medicine Biological Sciences and Psychology, UK
| | - Jonathan Barratt
- University of Leicester College of Medicine Biological Sciences and Psychology, UK
| | - George T. John
- Department of Nephrology, Christian Medical College, Vellore, India
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Han S, Yao T, Lu Y, Chen M, Xu Y, Wang Y. Efficacy and Safety of Immunosuppressive Monotherapy Agents for IgA Nephropathy: A Network Meta-Analysis. Front Pharmacol 2021; 11:539545. [PMID: 33551793 PMCID: PMC7862876 DOI: 10.3389/fphar.2020.539545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/26/2020] [Indexed: 01/10/2023] Open
Abstract
Background: The efficacy and safety of immunosuppressive monotherapy agents were evaluated for immunoglobulin A nephropathy (IgAN) using a network meta-analysis approach. Methods: Randomized controlled trials (RCTs) published prior to October 1, 2019, using immunosuppressive agents for treating IgAN, were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science databases. Relative risks (RRs) or standard mean differences with 95% confidence intervals (CIs) were estimated using the random-effects model. The primary outcomes were clinical remission, end-stage renal disease (ESRD), and serious adverse events (SAEs). The secondary outcomes were urinary protein excretion and serum creatinine. Results: Twenty-five RCTs with 2,005 participants were deemed eligible. Six medications were evaluated: corticosteroids, mycophenolate mofetil (MMF), tacrolimus (TAC), cyclosporine, leflunomide, and hydroxychloroquine (HCQ). Steroids (RR 1.50, 95% CI 1.17-1.93), MMF (RR 2.05, 95% CI 1.15-3.65), TAC (RR 3.67, 95% CI 1.06-12.63), and HCQ (RR 3.25, 95% CI 1.05-10.09) significantly improved clinical remission rates compared to supportive care alone. Only steroids reduced the risk of ESRD (RR 0.35, 95% CI 0.12-0.98); however, there were significantly more SAEs than in the control group (RR 2.90, 95% CI 1.37-6.13). No significantly different effects in serum creatinine levels were found among the therapies. MMF showed no significant improvement in remission when excluding studies with a follow-up of fewer than 2 years in the sensitivity analysis (RR 1.41, 95% CI 0.40-4.92). The effect of TAC in the decrease of proteinuria was reversed after discontinuing medication for 3 months; the long-term effects of HCQ could not be evaluated due to the short follow-up duration. Conclusion: Corticosteroids might induce remission and increase renal survival in IgAN; however, adverse reactions should be taken into consideration. MMF, TAC, and HCQ might improve the remission of proteinuria when treating IgAN, but showed no superiority compared to steroids, and the long-term effects require further study.
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Affiliation(s)
| | | | | | | | | | - Yi Wang
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Zhang Y, Guo L, Wang Z, Wang J, Er L, Barbour SJ, Trimarchi H, Lv J, Zhang H. External Validation of International Risk-Prediction Models of IgA Nephropathy in an Asian-Caucasian Cohort. Kidney Int Rep 2020; 5:1753-1763. [PMID: 33102968 PMCID: PMC7572322 DOI: 10.1016/j.ekir.2020.07.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Two prediction models for IgA nephropathy (IgAN) using clinical variables and the Oxford MEST scores were developed and validated in 2 multiethnic cohorts. Additional external validation is required. Methods Biopsy-proven Chinese and Argentinian patients with IgAN were included. The primary outcome was defined as a 50% decline in estimated glomerular filtration rate (eGFR) or end-stage renal disease. C-statistics and stratified analyses were used for model discrimination, coefficient of determination (R2D) for model fit, and calibration plots for model calibration. Baseline survival function was also evaluated. Results A total of 1275 patients were enrolled, with a mean age of 34 (interquartile range: 27–42) years, 50% of whom (638 of 1275) were men. Use of renin-angiotensin system blockers was higher than in previously reported cohorts, whereas other variables were comparable. The C-statistic of the models was 0.81, and R2D was higher than reported. Survival curves in the subgroups (<16th, ∼16th to <50th, ∼50th to <84th, and ≥84th percentiles of linear predictor) were well separated. Most of the predictor variables, including hazard ratio, predicted 5-year risk, and eGFR decline slope, were worse with risk increasing. The baseline survival function was comparable in our cohort and the reported cohorts. The calibration was acceptable for the full model without race. However, the risk probability over 3 years was overestimated in the full model with race included. Conclusion The prediction models showed good performance on personalized risk assessment, which may be used as drug-specific, precision-medicine approaches to treatment decisionmaking.
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Affiliation(s)
- Yuemiao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing China; Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment of Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Guo
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing China; Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment of Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Zi Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing China; Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment of Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing China; Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment of Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Lee Er
- BC Renal, Vancouver, British Columbia, Canada
| | - Sean J. Barbour
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hernan Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Argentina
- Hernan Trimarchi, Nephrology Service, Hospital Británico de Buenos Aires, Perdriel 74 (1280), Buenos Aires, Argentina.
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing China; Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment of Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Correspondence: Jicheng Lv, Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing China; Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment of Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Validation of the revised Oxford classification for IgA nephropathy considering treatment with corticosteroids/immunosuppressors. Sci Rep 2020; 10:11151. [PMID: 32636449 PMCID: PMC7341848 DOI: 10.1038/s41598-020-68087-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/18/2020] [Indexed: 11/18/2022] Open
Abstract
The Oxford classification for IgA nephropathy (IgAN) was updated in 2017. We have validated the revised Oxford classification considering treatment with corticosteroids/immunosuppressors. In this retrospective analysis, 871 IgAN patients were enrolled. Patients were divided into two groups, those treated with or without corticosteroids/immunosuppressors. The 20-year renal prognosis up to end-stage renal disease was assessed using the Oxford classification. In all patients, the renal survival rate was 87.5% at 10 years and 72.6% at 20 years. The T score alone was significantly related to renal prognosis in the Kaplan–Meier analysis and multivariate Cox regression analysis. In the non-treatment group (n = 445), E, S, T, and C scores were significantly related to renal survival rates, however, in the treatment group (n = 426), T score alone was significantly related to renal prognosis on Kaplan–Meier analysis, indicating that corticosteroids/immunosuppressors improved renal prognosis in E1, S1, and C1. In patients with E1, S1, or C1, the treatment group showed significantly better renal prognosis than the non-treatment group in univariate and multivariate analysis. The Oxford classification and T score were used to determine renal prognosis in IgAN patients. Corticosteroids/immunosuppressors improved renal prognosis, especially E1, S1, and C1 scores.
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Lim CC, Baikunje S, Choo JCJ, Tan PH, Foo M, Woo KT. Clinical course of Immunoglobulin A nephropathy with crescents in a multi-ethnic Southeast Asian cohort. Nephrology (Carlton) 2020; 25:708-713. [PMID: 32400945 DOI: 10.1111/nep.13723] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/20/2020] [Accepted: 04/25/2020] [Indexed: 01/28/2023]
Abstract
AIM Clinical presentation and course of Immunoglobulin A nephropathy vary by ethnicity and geography and significance of extracapillary proliferation or crescents (IgAN-C) in Southeast Asia is not well described. We aimed to describe the clinical course of IgAN-C in Singapore. METHODS Retrospective cohort study of adult biopsy-proven IgAN diagnosed between February 2011 and October 2016 in 2 hospital-based nephrology units. Outcome was chronic kidney disease (CKD) progression, defined as reduction in eGFR ≥50% or end stage renal failure (ESRF). RESULTS One hundred and forty-five patients were studied. Among individuals with IgAN-C (n = 44, 30%), 38 patients had cellular or fibrocellular crescents in 1 to 25% of the glomeruli and 6 had crescents in >25%. Median eGFR was 54 (33, 83) mL/min/1.73 m2 . Compared to IgAN without crescents, IgAN-C had greater proteinuria (median 2.9 [1.4, 5.4] g/g vs 1.9 [1.1, 3.6] g/g, P = .03) and more had endocapillary hypercellularity (96% vs 39%, P < .001). IgAN-C were also more likely to receive immunosuppressants (66% vs 43%, P = .01) such as prednisolone (63% vs 38%, P = .006) and cyclophosphamide (12% vs 2%, P = .03). Median follow up was 27 (12, 46) months. IgAN-C were more likely to achieve proteinuria reduction ≥50% at 6 months (66% vs 44%, P = .03). CKD progression within 12 months was not different among those with and without crescents (13% vs 10% respectively, P = .73). However, immunosuppressant treatment of IgAN-C was associated with reduced ESRF (0 vs 20%, P = .03). CONCLUSION Immunosuppressants may attenuate the risk of ESRF in IgAN-C.
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Affiliation(s)
- Cynthia C Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Shashidhar Baikunje
- Department of General Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Jason C J Choo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Puay H Tan
- Division of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Marjorie Foo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Keng T Woo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Rauen T, Wied S, Fitzner C, Eitner F, Sommerer C, Zeier M, Otte B, Panzer U, Budde K, Benck U, Mertens PR, Kuhlmann U, Witzke O, Gross O, Vielhauer V, Mann JFE, Hilgers RD, Floege J. After ten years of follow-up, no difference between supportive care plus immunosuppression and supportive care alone in IgA nephropathy. Kidney Int 2020; 98:1044-1052. [PMID: 32450154 DOI: 10.1016/j.kint.2020.04.046] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/03/2020] [Accepted: 04/16/2020] [Indexed: 12/22/2022]
Abstract
The randomized, controlled STOP-IgAN trial in patients with IgA nephropathy (IgAN) and substantial proteinuria showed no benefit of immunosuppression added on top of supportive care on renal function over three years. As a follow-up we evaluated renal outcomes in patients over a follow-up of up to ten years in terms of serum creatinine, proteinuria, end-stage kidney disease (ESKD), and death. The adapted primary endpoint was the time to first occurrence of a composite of death, ESKD, or a decline of over 40% in the estimated glomerular filtration rate (eGFR) compared to baseline at randomization into STOP-IgAN. Data were analyzed by Cox-regression models. Follow-up data were available for 149 participants, representing 92% of the patients originally randomized. Median follow-up was 7.4 years (inter quartile range 5.7 to 8.3 years). The primary endpoint was reached in 36 of 72 patients randomized to supportive care and 35 of 77 patients randomized to additional immunosuppression (hazard ratio 1.20; 95% confidence interval 0.75 to 1.92). ESKD occurred in 17 of the patients with supportive care and in 20 of the patients with additional immunosuppression. Additionally, the rates of eGFR loss over 40% and annual eGFR loss did not differ between groups. Two patients died with supportive care and three with additional immunosuppression. Thus, within the limitations of a retrospective study, over a follow-up of up to ten years, and using an adapted primary endpoint, we failed to detect differences in key clinical outcomes in IgAN patients randomized to receive added immunosuppression on top of supportive care versus supportive care alone.
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Affiliation(s)
- Thomas Rauen
- Division of Nephrology and Clinical Immunology, RWTH Aachen University, Aachen, Germany
| | - Stephanie Wied
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Christina Fitzner
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Frank Eitner
- Division of Nephrology and Clinical Immunology, RWTH Aachen University, Aachen, Germany; Bayer AG, Kidney Diseases Research, Wuppertal, Germany
| | - Claudia Sommerer
- Department of Nephrology and Renal Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology and Renal Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Britta Otte
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - Ulf Panzer
- Division of Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Urs Benck
- Department of Medicine V, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Peter R Mertens
- Department of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Uwe Kuhlmann
- Medical Clinic III, Central Hospital Bremen, Bremen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gross
- Clinic for Nephrology and Rheumatology, University Medical Center Goettingen, Goettingen, Germany
| | - Volker Vielhauer
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Johannes F E Mann
- KfH Kidney Center Munich-Schwabing and Department of Medicine IV, University of Erlangen, Erlangen, Germany
| | | | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University, Aachen, Germany.
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Natale P, Palmer SC, Ruospo M, Saglimbene VM, Craig JC, Vecchio M, Samuels JA, Molony DA, Schena FP, Strippoli GFM. Immunosuppressive agents for treating IgA nephropathy. Cochrane Database Syst Rev 2020; 3:CD003965. [PMID: 32162319 PMCID: PMC7066485 DOI: 10.1002/14651858.cd003965.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND IgA nephropathy is the most common glomerulonephritis world-wide. IgA nephropathy causes end-stage kidney disease (ESKD) in 15% to 20% of affected patients within 10 years and in 30% to 40% of patients within 20 years from the onset of disease. This is an update of a Cochrane review first published in 2003 and updated in 2015. OBJECTIVES To determine the benefits and harms of immunosuppression strategies for the treatment of IgA nephropathy. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 9 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of treatment for IgA nephropathy in adults and children and that compared immunosuppressive agents with placebo, no treatment, or other immunosuppressive or non-immunosuppressive agents. DATA COLLECTION AND ANALYSIS Two authors independently assessed study risk of bias and extracted data. Estimates of treatment effect were summarised using random effects meta-analysis. Treatment effects were expressed as relative risk (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Risks of bias were assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE methodology. MAIN RESULTS Fifty-eight studies involving 3933 randomised participants were included. Six studies involving children were eligible. Disease characteristics (kidney function and level of proteinuria) were heterogeneous across studies. Studies evaluating steroid therapy generally included patients with protein excretion of 1 g/day or more. Risk of bias within the included studies was generally high or unclear for many of the assessed methodological domains. In patients with IgA nephropathy and proteinuria > 1 g/day, steroid therapy given for generally two to four months with a tapering course probably prevents the progression to ESKD compared to placebo or standard care (8 studies; 741 participants: RR 0.39, 95% CI 0.23 to 0.65; moderate certainty evidence). Steroid therapy may induce complete remission (4 studies, 305 participants: RR 1.76, 95% CI 1.03 to 3.01; low certainty evidence), prevent doubling of serum creatinine (SCr) (7 studies, 404 participants: RR 0.43, 95% CI 0.29 to 0.65; low certainty evidence), and may lower urinary protein excretion (10 studies, 705 participants: MD -0.58 g/24 h, 95% CI -0.84 to -0.33;low certainty evidence). Steroid therapy had uncertain effects on glomerular filtration rate (GFR), death, infection and malignancy. The risk of adverse events with steroid therapy was uncertain due to heterogeneity in the type of steroid treatment used and the rarity of events. Cytotoxic agents (azathioprine (AZA) or cyclophosphamide (CPA) alone or with concomitant steroid therapy had uncertain effects on ESKD (7 studies, 463 participants: RR 0.63, 95% CI 0.33 to 1.20; low certainty evidence), complete remission (5 studies; 381 participants: RR 1.47, 95% CI 0.94 to 2.30; very low certainty evidence), GFR (any measure), and protein excretion. Doubling of serum creatinine was not reported. Mycophenolate mofetil (MMF) had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, infection, and malignancy. Death was not reported. Calcineurin inhibitors compared with placebo or standard care had uncertain effects on complete remission, SCr, GFR, protein excretion, infection, and malignancy. ESKD and death were not reported. Mizoribine administered with renin-angiotensin system inhibitor treatment had uncertain effects on progression to ESKD, complete remission, GFR, protein excretion, infection, and malignancy. Death and SCr were not reported. Leflunomide followed by a tapering course with oral prednisone compared to prednisone had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, and infection. Death and malignancy were not reported. Effects of other immunosuppressive regimens (including steroid plus non-immunosuppressive agents or mTOR inhibitors) were inconclusive primarily due to insufficient data from the individual studies in low or very low certainty evidence. The effects of treatments on death, malignancy, reduction in GFR at least of 25% and adverse events were very uncertain. Subgroup analyses to determine the impact of specific patient characteristics such as ethnicity or disease severity on treatment effectiveness were not possible. AUTHORS' CONCLUSIONS In moderate certainty evidence, corticosteroid therapy probably prevents decline in GFR or doubling of SCr in adults and children with IgA nephropathy and proteinuria. Evidence for treatment effects of immunosuppressive agents on death, infection, and malignancy is generally sparse or low-quality. Steroid therapy has uncertain adverse effects due to a paucity of studies. Available studies are few, small, have high risk of bias and generally do not systematically identify treatment-related harms. Subgroup analyses to identify specific patient characteristics that might predict better response to therapy were not possible due to a lack of studies. There is no evidence that other immunosuppressive agents including CPA, AZA, or MMF improve clinical outcomes in IgA nephropathy.
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Affiliation(s)
- Patrizia Natale
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Marinella Ruospo
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Valeria M Saglimbene
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Joshua A Samuels
- UT‐Houston Health Science CenterDivision of Pediatric Nephrology and Hypertension6431 Fannin Street, MSB 3‐121HoustonTXUSA77030
| | - Donald A Molony
- UT‐Houston Health Science CenterInternal MedicineDivision of Renal Diseases and Hypertension64312 Fannin StHoustonTXUSA77030
| | | | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Obrișcă B, Sinescu I, Ismail G, Mircescu G. Has The Time Arrived to Refine The Indications of Immunosuppressive Therapy and Prognosis in IgA Nephropathy? J Clin Med 2019; 8:E1584. [PMID: 31581654 PMCID: PMC6833025 DOI: 10.3390/jcm8101584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most frequent glomerular disease worldwide and a leading cause of end-stage renal disease. Particularly challenging to the clinician is the early identification of patients at high risk of progression, an estimation of the decline in renal function, and the selection of only those that would benefit from additional immunosuppressive therapies. Nevertheless, the pathway to a better prognostication and to the development of targeted therapies in IgAN has been paved by recent understanding of the genetic and molecular basis of this disease. Merging the data from the Oxford Classification validation studies and prospective treatment studies has suggested that a disease-stratifying algorithm would be appropriate for disease management, although it awaits validation in a prospective setting. The emergence of potential noninvasive biomarkers may assist traditional markers (proteinuria, hematuria) in monitoring disease activity and treatment response. The recent landmark trials of IgAN treatment (STOP-IgAN and TESTING trials) have suggested that the risks associated with immunosuppressive therapy outweigh the benefits, which may shift the treatment paradigm of this disease. While awaiting the approval of the first therapies for IgAN, more targeted and less toxic immunotherapies are warranted. Accordingly, the targeting of complement activation, the modulation of mucosal immunity, the antagonism of B-cell activating factors, and proteasomal inhibition are currently being evaluated in pilot studies for IgAN treatment.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Ioanel Sinescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Gabriel Mircescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Department of Nephrology, “Dr. Carol Davila” Teaching Hospital of Nephrology, 010731 Bucharest, Romania
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