1
|
Sun Y, Li Z, Sun J, Zhang S, Wang R, Chen B. The efficacy and safety of rituximab with or without glucocorticoid in inducing remission of MCD with different clinical presentations in adults: a retrospective study. Clin Kidney J 2024; 17:sfae139. [PMID: 38854425 PMCID: PMC11161702 DOI: 10.1093/ckj/sfae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 06/11/2024] Open
Abstract
Background To investigate the efficacy and safety of rituximab (RTX) with or without glucocorticoid (GC) in inducing remission of minimal change disease (MCD) in adults. Methods Twenty-one adult MCD patients were included in the study. The patients were assigned to the following three groups according to their background before RTX treatment: an RTX single drug direct induction treatment group (Group A; n = 9), a short-term, low-dose GC combined with RTX induction treatment group (Group B; n = 4), and a short-term, adequate-dose GC-induced remission and RTX maintenance treatment group (Group C; n = 8). The primary endpoints were the time to induction of remission and the rate of clinical remission at 12 months. Results All patients achieved clinical remission, with 19 (90.48%) achieving complete remission (CR), and the median remission time was 4 (2.5, 12) weeks. Eight (88.89%) patients in Group A achieved CR, and the median remission time was 3 (2.25, 14) weeks. In Group B, three (75.00%) patients achieved CR, with a median remission time of 4 (4, 10) weeks. In Group C, eight (100.00%) patients achieved CR, and the median remission time was 3.5 (2, 4) weeks. Conclusions In MCD patients without acute kidney injury, adequate RTX alone or short-term combined treatment with low-dose GCs can effectively induce and maintain MCD remission. Adequate short-term GCs combined with RTX maintenance may be an effective alternative for MCD patients in context of acute kidney injury. There is a need to investigate different induction therapy regimens for the remission of MCD patients with different backgrounds.
Collapse
Affiliation(s)
- Yujiao Sun
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhuo Li
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Sun
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shasha Zhang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bing Chen
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| |
Collapse
|
2
|
Xu R, Hu H, Xu H, Li Z, Guo J, Cao T, Yu Y, Chen X, Xu Y, Wan Q. Initial rituximab monotherapy for adult indiopathic nephrotic syndrome with minimal change lesion pattern. Nephrol Dial Transplant 2024; 39:893-895. [PMID: 38218590 DOI: 10.1093/ndt/gfae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Indexed: 01/15/2024] Open
Affiliation(s)
- Ricong Xu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Haofei Hu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Hengchang Xu
- Department of Nephrology, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Zhijian Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianying Guo
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Tao Cao
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Yi Yu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Xiaojie Chen
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Yi Xu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Qijun Wan
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| |
Collapse
|
3
|
Maniar A, Gipson DS, Brady T, Srivastava T, Selewski DT, Greenbaum LA, Dell KM, Kaskel F, Massengill S, Tran C, Trachtman H, Lafayette R, Almaani S, Hingorani S, Wang CS, Reidy K, Cara-Fuentes G, Gbadegesin R, Myers K, Sethna CB. Growth in children with nephrotic syndrome: a post hoc analysis of the NEPTUNE study. Pediatr Nephrol 2024:10.1007/s00467-024-06375-9. [PMID: 38671228 DOI: 10.1007/s00467-024-06375-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Steroids, the mainstay of treatment for nephrotic syndrome in children, have multiple adverse effects including growth suppression. METHODS Anthropometric measurements in children < 18 years enrolled in the Nephrotic Syndrome Study Network (NEPTUNE) were collected. The longitudinal association of medication exposure and nephrotic syndrome characteristics with height z-score and growth velocity was determined using adjusted Generalized Estimating Equation regression and linear regression. RESULTS A total of 318 children (57.2% males) with a baseline age of 7.64 ± 5.04 years were analyzed. The cumulative steroid dose was 216.4 (IQR 61.5, 652.7) mg/kg (N = 233). Overall, height z-scores were not significantly different at the last follow-up compared to baseline (- 0.13 ± 1.21 vs. - 0.23 ± 1.71, p = 0.21). In models adjusted for age, sex, and eGFR, greater cumulative steroid exposure (β - 7.5 × 10-6, CI - 1.2 × 10-5, - 3 × 10-6, p = 0.001) and incident cases of NS (vs. prevalent) (β - 1.1, CI - 2.22, - 0.11, p = 0.03) were significantly associated with lower height z-scores over time. Rituximab exposure was associated with higher height z-scores (β 0.16, CI 0.04, 0.29, p = 0.01) over time. CONCLUSION Steroid dose was associated with lower height z-score, while rituximab use was associated with higher height z-score.
Collapse
Affiliation(s)
- Aesha Maniar
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Tammy Brady
- Division of Nephrology, Department of Pediatrics, Johns Hopkins, Baltimore, MD, USA
| | - Tarak Srivastava
- Division of Nephrology, Children's Mercy Hospital and University of Missouri at Kansas City, Kansas City, MO, USA
| | - David T Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Larry A Greenbaum
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Katherine M Dell
- Center for Pediatric Nephrology and Hypertension, Cleveland Clinic Children's, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Frederick Kaskel
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Susan Massengill
- Division of Nephrology, Department of Pediatrics, Levine Children's Hospital, Charlotte, NC, USA
| | - Cheryl Tran
- Division of Nephrology, Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Richard Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Salem Almaani
- Division of Nephrology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sangeeta Hingorani
- Division of Nephrology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Chia-Shi Wang
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kimberly Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Gabriel Cara-Fuentes
- Division of Nephrology, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Kevin Myers
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christine B Sethna
- Division of Pediatric Nephrology, Northwell, Cohen Children's Medical Center, 2000 Marcus Ave, Suite 300, New Hyde Park, Northwell, NY, 11042-1069, USA.
| |
Collapse
|
4
|
Koizumi M, Ishimoto T, Shimizu S, Sasaki S, Kurita N, Wada T. Japanese clinical practice patterns of rituximab treatment for minimal change disease in adults 2021: A web-based questionnaire survey of certified nephrologists. PLoS One 2024; 19:e0299053. [PMID: 38551948 PMCID: PMC10980199 DOI: 10.1371/journal.pone.0299053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/04/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND In Japan, rituximab (RTX) for adult-onset frequently relapsing (FR)/steroid-dependent (SD) minimal change disease (MCD) is not explicitly reimbursed by insurance, and its standard regimen has not been established. METHODS We conducted a cross-sectional web-based survey between November and December 2021. The participants were nephrologists certified by the Japanese Society of Nephrology and answered 7 items about RTX for adult MCD. Factors related to the experience of RTX administration at their facilities were estimated by generalized estimating equations. RESULTS Of 380 respondents, 181 (47.6%) reported the experience of RTX use for adult MCD at their current facilities. Those who worked at university hospitals (vs. non-university hospitals, proportion difference 13.7%) and at facilities with frequent kidney biopsies (vs. 0 cases/year, 19.2% for 1-40 cases/year; 37.9% for 41-80 cases/year; 51.9% for ≥ 81 cases/year) used RTX more frequently. Of 181 respondents, 28 (15.5%) answered that there was no insurance coverage for RTX treatment. Of 327 respondents who had the opportunity to treat MCD, which was a possible indication for RTX, 178 (54.4%) indicated withholding of RTX administration. The most common reason was the cost due to lack of insurance coverage (141, 79.2%). Regarding RTX regimens for FR/SD MCD, introduction treatment with a single body surface area-based dose of 375 mg/m2 and maintenance treatment with a 6-month interval were the most common. CONCLUSION This survey revealed the nephrologists' characteristics associated with RTX use, the barriers to RTX use, and the variation in the regimens for adult MCD in Japan.
Collapse
Affiliation(s)
- Masahiro Koizumi
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Kanagawa, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Aichi, Japan
| | - Sayaka Shimizu
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University, Kyoto, Japan
- Patient Driven Academic League (PeDAL), Tokyo, Japan
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Sho Sasaki
- Section of Education for Clinical Research, Kyoto University Hospital, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Noriaki Kurita
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
| | - Takehiko Wada
- Department of Nephrology, Toranomon Hospital, Tokyo, Japan
| |
Collapse
|
5
|
Jiang H, Shen Z, Zhuang J, Lu C, Qu Y, Xu C, Yang S, Tian X. Understanding the podocyte immune responses in proteinuric kidney diseases: from pathogenesis to therapy. Front Immunol 2024; 14:1335936. [PMID: 38288116 PMCID: PMC10822972 DOI: 10.3389/fimmu.2023.1335936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
The glomerular filtration barrier, comprising the inner layer of capillary fenestrated endothelial cells, outermost podocytes, and the glomerular basement membrane between them, plays a pivotal role in kidney function. Podocytes, terminally differentiated epithelial cells, are challenging to regenerate once injured. They are essential for maintaining the integrity of the glomerular filtration barrier. Damage to podocytes, resulting from intrinsic or extrinsic factors, leads to proteinuria in the early stages and eventually progresses to chronic kidney disease (CKD). Immune-mediated podocyte injury is a primary pathogenic mechanism in proteinuric glomerular diseases, including minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and lupus nephritis with podocyte involvement. An extensive body of evidence indicates that podocytes not only contribute significantly to the maintenance of the glomerular filtration barrier and serve as targets of immune responses but also exhibit immune cell-like characteristics, participating in both innate and adaptive immunity. They play a pivotal role in mediating glomerular injury and represent potential therapeutic targets for CKD. This review aims to systematically elucidate the mechanisms of podocyte immune injury in various podocyte lesions and provide an overview of recent advances in podocyte immunotherapy. It offers valuable insights for a deeper understanding of the role of podocytes in proteinuric glomerular diseases, and the identification of new therapeutic targets, and has significant implications for the future clinical diagnosis and treatment of podocyte-related disorders.
Collapse
Affiliation(s)
- Hong Jiang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Zhirang Shen
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Jing Zhuang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chen Lu
- Division of Nephrology, Department of Internal Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yue Qu
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chengren Xu
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Shufen Yang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xuefei Tian
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| |
Collapse
|
6
|
Tang B, Yang X. Clinical advances in immunotherapy for immune-mediated glomerular diseases. Clin Exp Med 2023; 23:4091-4105. [PMID: 37889398 PMCID: PMC10725396 DOI: 10.1007/s10238-023-01218-7] [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: 08/25/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Due to the suboptimal therapeutic efficacy and potential adverse effects associated with traditional immunosuppressive medications, there has been an increasing emphasis on the development and utilization of immunotherapies. This paper aims to provide clinicians with valuable insights for selecting appropriate therapeutic approaches and contribute to the development of novel immunotherapeutic drugs. MAIN BODY This paper categorizes the immunotherapeutic drugs that are used for the treatment of immune-mediated glomerular diseases into three groups: immunotherapies targeting antigen-presenting cells (anti-CD80), immunotherapies targeting T/B cells (anti-CD20, anti-CD22, BAFF and APRIL inhibitors, CD40-CD40L inhibitors, proteasome inhibitors, Syk inhibitors, and Btk inhibitors), and immunotherapies targeting the complement system (C5 inhibitors, C5a/C5aR inhibitors, C3 inhibitors, MASP2 inhibitors, factor B inhibitors, and factor D inhibitors). The article then provides a comprehensive overview of advances related to these immunotherapeutic drugs in clinical research. CONCLUSION Certain immunotherapeutic drugs, such as rituximab, belimumab, and eculizumab, have exhibited notable efficacy in treating specific immune-mediated glomerular diseases, thereby providing novel therapeutic approaches for patients. Nonetheless, the efficacy of numerous immunotherapeutic drugs remains to be substantiated.
Collapse
Affiliation(s)
- Bihui Tang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Xiao Yang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
| |
Collapse
|
7
|
Salfi G. A Unifying Theory for Idiopathic Nephrotic Syndrome Pathogenesis? JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 211:1441. [PMID: 37931212 DOI: 10.4049/jimmunol.2300590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Affiliation(s)
- Giuseppe Salfi
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| |
Collapse
|
8
|
Salfi G, Casiraghi F, Remuzzi G. Current understanding of the molecular mechanisms of circulating permeability factor in focal segmental glomerulosclerosis. Front Immunol 2023; 14:1247606. [PMID: 37795085 PMCID: PMC10546017 DOI: 10.3389/fimmu.2023.1247606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023] Open
Abstract
The pathogenetic mechanisms underlying the onset and the post-transplant recurrence of primary focal segmental glomerulosclerosis (FSGS) are complex and remain yet to be fully elucidated. However, a growing body of evidence emphasizes the pivotal role of the immune system in both initiating and perpetuating the disease. Extensive investigations, encompassing both experimental models and patient studies, have implicated T cells, B cells, and complement as crucial actors in the pathogenesis of primary FSGS, with various molecules being proposed as potential "circulating factors" contributing to the disease and its recurrence post kidney-transplantation. In this review, we critically assessed the existing literature to identify essential pathways for a comprehensive characterization of the pathogenesis of FSGS. Recent discoveries have shed further light on the intricate interplay between these mechanisms. We present an overview of the current understanding of the engagement of distinct molecules and immune cells in FSGS pathogenesis while highlighting critical knowledge gaps that require attention. A thorough characterization of these intricate immune mechanisms holds the potential to identify noninvasive biomarkers that can accurately identify patients at high risk of post-transplant recurrence. Such knowledge can pave the way for the development of targeted and personalized therapeutic approaches in the management of FSGS.
Collapse
Affiliation(s)
| | - Federica Casiraghi
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | | |
Collapse
|
9
|
Ji B, Liu J, Yin Y, Xu H, Shen Q, Yu J. Minnelide combined with anti-ANGPTL3-FLD monoclonal antibody completely protects mice with adriamycin nephropathy by promoting autophagy and inhibiting apoptosis. Cell Death Dis 2023; 14:601. [PMID: 37689694 PMCID: PMC10492865 DOI: 10.1038/s41419-023-06124-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
Minimal change disease (MCD) is the common type of nephrotic syndrome (NS) in children. Currently, there is an urgent need to explore new treatments because of the significant side effects of long-term use of glucocorticoids and immunosuppressive drugs and the failure to reduce proteinuria in some patients. Angiopoietin-like protein 3 (Angptl3) is an essential target of NS, and anti-ANGPTL3-FLD monoclonal antibody (mAb) significantly reduces proteinuria in mice with adriamycin nephropathy (AN). However, some proteinuria is persistent. Minnelide, a water-soluble prodrug of triptolide, has been used for the treatment of glomerular disease. Therefore, the present study aimed to investigate whether minnelide combined with mAb could further protect mice with AN and the underlying mechanisms. 8-week-old C57BL/6 female mice were injected with 25 mg/kg of Adriamycin (ADR) by tail vein to establish the AN model. A dose of 200 μg/kg of minnelide or 20 mg/kg of mAb was administered intraperitoneally for the treatment. In vitro, the podocytes were treated with 0.4 μg/mL of ADR for 24 h to induce podocyte injury, and pretreatment with 10 ng/mL of triptolide for 30 min or 100 ng/mL of mAb for 1 h before ADR exposure was used to treat. The results showed that minnelide combined with mAb almost completely ameliorates proteinuria and restores the ultrastructure of the podocytes in mice with AN. In addition, minnelide combined with mAb restores the distribution of Nephrin, Podocin, and CD2AP and reduces the level of inflammatory factors in mice with AN. Mechanistically, minnelide combined with mAb could further alleviate apoptosis and promote autophagy in mice with AN by inhibiting the mTOR signaling pathway. In vitro, triptolide combined with mAb increases the expression of Nephrin, Podocin, and CD2AP, alleviates apoptosis, and promotes autophagy. Overall, minnelide combined with mAb completely protects the mice with AN by promoting autophagy and inhibiting apoptosis.
Collapse
Affiliation(s)
- Baowei Ji
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Junchao Liu
- Department of Traditional Chinese Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Ye Yin
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China.
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Jian Yu
- Department of Traditional Chinese Medicine, Children's Hospital of Fudan University, Shanghai, China
| |
Collapse
|
10
|
Basu B, Erdmann S, Sander A, Mahapatra TKS, Meis J, Schaefer F. Long-Term Efficacy and Safety of Rituximab Versus Tacrolimus in Children With Steroid Dependent Nephrotic Syndrome. Kidney Int Rep 2023; 8:1575-1584. [PMID: 37547526 PMCID: PMC10403658 DOI: 10.1016/j.ekir.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction In the Rituximab for Relapse Prevention in Nephrotic Syndrome (RITURNS) trial, we demonstrated superior efficacy of single-course rituximab over maintenance tacrolimus in preventing relapses in children with steroid dependent nephrotic syndrome (SDNS) during a 1-year observation. Here we present the long-term outcomes of all 117 trial completers, who were followed up for another 2 years. Methods Relapsing patients in the rituximab arm received a second course of rituximab, either with (n = 44) or without mycophenolate mofetil (MMF) cotreatment (n = 15). In the tacrolimus arm, second line rituximab monotherapy was initiated after relapses (n = 32) or electively (n = 24). Results All 12-month relapse-free patients in the rituximab arm relapsed in the second postexposure year, resulting in similar median relapse-free survival times in the 2 trial arms (62 vs. 59 weeks). Second line rituximab in the tacrolimus arm was less effective than first-line therapy in patients switched to rituximab following a relapse (relapse-free survival 55 vs. 63 weeks, P < 0.01). B-cell counts 6 months post-rituximab predicted relapse risk both for first and second line therapy. MMF cotreatment yielded much improved 2-year relapse-free survival as compared to rituximab monotherapy (67% vs. 9%, P < 0.0001). Higher grade 2 adverse event rates were observed post-rituximab versus on tacrolimus (0.87 vs. 0.53 per year). Conclusion The superior therapeutic effect of rituximab in SDNS vanishes during the second year post-exposure. Rituximab appears to yield longer remission when applied as first line as compared to second line therapy. Maintenance MMF following rituximab induces long-term disease remission.
Collapse
Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Stella Erdmann
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | | | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
11
|
Beck LH, Ayoub I, Caster D, Choi MJ, Cobb J, Geetha D, Rheault MN, Wadhwani S, Yau T, Whittier WL. KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases. Am J Kidney Dis 2023; 82:121-175. [PMID: 37341661 DOI: 10.1053/j.ajkd.2023.02.003] [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: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 06/22/2023]
Abstract
The KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases represents the first update to this set of recommendations since the initial set of KDIGO guideline recommendations was published in 2012. The pace of growth in our molecular understanding of glomerular disease has quickened and a number of newer immunosuppressive and targeted therapies have been introduced since the original set of guideline recommendations, making such an update necessary. Despite these updates, many areas of controversy remain. In addition, further updates since the publication of KDIGO 2021 have occurred which this guideline does not encompass. With this commentary, the KDOQI work group has generated a chapter-by-chapter companion opinion article that provides commentary specific to the implementation of the KDIGO 2021 guideline in the United States.
Collapse
Affiliation(s)
- Laurence H Beck
- Division of Nephrology, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Isabelle Ayoub
- Department of Medicine, Division of Nephrology, Wexner Medical, The Ohio State University, Columbus, Ohio
| | - Dawn Caster
- Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky
| | | | - Jason Cobb
- Division of Renal Medicine, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Shikha Wadhwani
- Division of Nephrology and Hypertension, Northwestern University, Chicago, Illinois
| | - Timothy Yau
- Division of Nephrology, Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri
| | - William L Whittier
- Division of Nephrology, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
12
|
Roccatello D, Baffa A, Naretto C, Barreca A, Cravero R, Roscini E, Sciascia S, Fenoglio R. Focal segmental glomerular sclerosis can be effectively treated using an intensive B-cell depletion therapy. Clin Kidney J 2023; 16:1258-1264. [PMID: 37529640 PMCID: PMC10387391 DOI: 10.1093/ckj/sfac207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Indexed: 08/03/2023] Open
Abstract
Background Focal segmental glomerular sclerosis (FSGS) is a histologic lesion rather than a specific disease entity and represents a cluster of different conditions affecting both children and adults that includes primary, secondary and genetically mediated forms. These forms can be distinguished by electron microscopy and genetic assessment and show different responsiveness to steroids and immunosuppressants. Despite some promising effects of rituximab in nephrotic syndrome in children, the results in adults with FSGS are disappointing. Our group previously explored the effectiveness of rituximab in eight adult patients with unselected forms of FSGS and achieved a consistent reduction in proteinuria in one case. Following this experience, we developed an alternative therapeutic option intended to enhance the potential of rituximab with the support of other synergic drugs. We herein report the results of this therapeutic protocol (six administrations of rituximab plus two of intravenous cyclophosphamide plus glucocorticoids) in seven prospectively enrolled patients with extensive podocyte effacement and recurrent relapses or steroid dependence. Results Patients had a median baseline serum creatinine level of 2.2 mg/dl (range 1-4.7) that decreased to 1.1 mg/dl (range 0.9-2.2) and 1.1 mg/dl (range 0.75-2.21) after 3 and 6 months, respectively, and remained unchanged at 12 months. Three of five patients with renal failure turned to normal function while the other two patients maintained a stable impairment after 18 and 52 months. The median proteinuria decreased from 6.1 g/24 h to 3.5, 3.5 and 1.9 g/24 h at 3, 6 and 12 months, respectively. Specifically, five of seven patients had a partial response at 12 months and became non-nephrotic. One of them had a complete response at 18 months and was still in complete remission at the last follow-up visit at 36 months. Proteinuria persisted unchanged in two of seven patients with a genetic-related disease. No serious late adverse events were observed. Conclusions Our results show that intensive B-cell depletion therapy is able to reverse the nephrotic syndrome of steroid-dependent or frequently relapsing adult patients with putatively idiopathic FSGS (i.e. with extensive podocyte effacement).
Collapse
Affiliation(s)
| | - Alessandra Baffa
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnet and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, 10154 Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnet and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, 10154 Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | - Raffaella Cravero
- Unit of Nephrology and Dialysis, Ospedale degli Infermi, Biella, Italy
| | - Elisabetta Roscini
- Unit of Nephrology and Dialysis, Casale Monferrato and Novi Ligure Hospitals, Alessandria, Italy
| | | | | |
Collapse
|
13
|
Gomes R, Mosca S, Bastos-Gomes M, Correia-Costa L, Rocha L, Teixeira A, Costa T, Sameiro-Faria M, Matos P, Mota C. Rituximab therapy for childhood onset idiopathic nephrotic syndrome: experience of a Portuguese tertiary center. J Bras Nefrol 2023; 45:326-334. [PMID: 36259942 PMCID: PMC10697169 DOI: 10.1590/2175-8239-jbn-2022-0056en] [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: 03/31/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Rituximab (RTX) is a therapeutic option in pediatric difficult-to-treat idiopathic nephrotic syndrome (NS). We aimed to assess the efficacy and safety of RTX use in these patients. METHOD A retrospective study of all patients with idiopathic NS treated with RTX was conducted in a pediatric nephrology division of a tertiary hospital. Demographic, anthropometric, clinical and analytical data were collected prior to treatment and at 6, 12, and 24 months. RESULTS Sixteen patients were included (11 males), with a median (25th-75th percentile, P25-P75) age at diagnosis of 2 (2.0-2.8) years. Fifteen were steroid-sensitive and 1 was steroid-resistant and sensitive to cyclosporine. The median age at administration of RTX was 10 (6.3-14.0) years. Throughout a median follow-up time of 2.5 (1.0-3.0) years, 6 (37.5%) patients achieved partial remission and 7 (43.8%) had no relapses and were not taking any immunosuppressants at the 24-month follow-up visit. Regarding complications, 1 patient presented persistent hypogammaglobulinemia. Compared with the 12-month period before RTX, there was a decrease in the median number of relapses at 6 and 12 months [3 (3.0-4.0) vs 0 (0-0.8) and 0.50 (0-1.0), respectively; p = 0.001] and in the daily steroids dose (mg/kg/day) at 6, 12, and 24 months [0.29 (0.15-0.67)vs [0.10 (0.07-0.13); p = 0.001], [0.12 (0.05-0.22); p = 0.005] and [0.07(0.04-0.18); p = 0.021]], respectively. There was also a reduction in the median BMI z score at 24 months [2.11 (0.45-3.70) vs. 2.93 (2.01-3.98); p = 0.049]. CONCLUSION Our results confirm the efficacy and safety of RTX use in pediatric idiopathic NS and highlight its' potential cardiometabolic benefits.
Collapse
Affiliation(s)
- Rita Gomes
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Porto, Portugal
| | - Sara Mosca
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Porto, Portugal
| | - Mariana Bastos-Gomes
- Unidade Local de Saúde do Alto Minho, Serviço de Pediatria, EPE,
Viana do Castelo, Portugal
| | - Liane Correia-Costa
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Liliana Rocha
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Ana Teixeira
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Teresa Costa
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Maria Sameiro-Faria
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Paula Matos
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Conceição Mota
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| |
Collapse
|
14
|
Zhang L, Du M, Tu Y, Liang D, Wu X, Xie H. Clinicopathological features and long-term prognosis of glomerular diseases associated with mercury-containing cosmetics. J Nephrol 2023; 36:1401-1407. [PMID: 37060438 DOI: 10.1007/s40620-023-01606-y] [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: 09/24/2022] [Accepted: 02/15/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE The pathological types and long-term prognosis of glomerular diseases related to mercury exposure are unclear. This study retrospectively examined 41 cases of glomerulonephropathy caused by mercury-containing cosmetics. METHODOLOGY Forty-one subjects with glomerular diseases presumably caused by mercury-containing cosmetics were selected. Clinical features, kidney biopsy, treatment, and follow-up data were collected. RESULTS All patients were female with an average age of 39.4 ± 6.6 years at diagnosis. Median time of exposure to mercury-containing cosmetics was six months, and average urine mercury level was 66.80 ± 38.55ug/(g·Cr). Most patients presented with nephrotic syndrome. Renal histopathology showed membranous nephropathy in 22 patients (53.65%), minimal change disease in 13 patients (31.71%), IgA nephropathy with minimal change disease in 5 patients (12.20%), and focal segmental glomerulosclerosis in 1 patient. Median time of exposure to mercury was longer and the proportion of patients with autoantibodies (mainly antinuclear antibodies) was higher in patients with membranous nephropathy. Both blood phospholipase A2 receptor -Ab and kidney tissue phospholipase A2 receptor were negative. Thirty-six patients received glucocorticosteroids and/or immunosuppressants. Five patients were treated with an angiotensin receptor blocker, and nine patients were treated with chelation therapy. The median follow-up time was 40 months (range 27-94). All patients achieved complete remission, and the median time to complete remission was one month. They all successfully discontinued the drugs without relapsing; withdrawal time was 26 months. CONCLUSION Membranous nephropathy was the most common pathological type in mercury-induced glomerular disease. Patients were sensitive to glucocorticosteroids and immunosuppressants and achieved complete remission quickly. Contrary to primary glomerulonephritides, patients with mercury-induced glomerular diseases had no relapses after withdrawal of the mercury containing cosmetics.
Collapse
Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Mengru Du
- Naijing Drum Tower Hospital, The Affiliated Hospital of Nanjing University School of Medicine, Nanjing, 210008, China
| | - Yuanmao Tu
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Dandan Liang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Xiaomei Wu
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Honglang Xie
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China.
| |
Collapse
|
15
|
Chen DP, Helmuth ME, Smith AR, Canetta PA, Ayoub I, Mucha K, Kallash M, Kopp JB, Gbadegesin R, Gillespie BW, Greenbaum LA, Parekh RS, Hunley TE, Sperati CJ, Selewski DT, Kidd J, Chishti A, Reidy K, Mottl AK, Gipson DS, Srivastava T, Twombley KE. Age of Onset and Disease Course in Biopsy-Proven Minimal Change Disease: An Analysis From the Cure Glomerulonephropathy Network. Am J Kidney Dis 2023; 81:695-706.e1. [PMID: 36608921 PMCID: PMC10200745 DOI: 10.1053/j.ajkd.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/19/2022] [Indexed: 01/05/2023]
Abstract
RATIONALE & OBJECTIVE Adolescent- and adult-onset minimal change disease (MCD) may have a clinical course distinct from childhood-onset disease. We characterized the course of children and adults with MCD in the Cure Glomerulonephropathy Network (CureGN) and assessed predictors of rituximab response. STUDY DESIGN Prospective, multicenter, observational study. STUDY PARTICIPANTS CureGN participants with proven MCD on biopsy. EXPOSURE Age at disease onset, initiation of renin-angiotensin-aldosterone system (RAAS) blockade, and immunosuppression including rituximab during the study period. OUTCOME Relapse and remission, change in estimated glomerular filtration rate (eGFR), and kidney failure. ANALYTICAL APPROACH Remission and relapse probabilities were estimated using Kaplan-Meier curves and gap time recurrent event models. Linear regression models were used for the outcome of change in eGFR. Cox proportional hazards models were used to estimate the association between rituximab administration and remission. RESULTS The study included 304 childhood- (≤12 years old), 49 adolescent- (13-17 years old), and 201 adult- (≥18 years) onset participants with 2.7-3.2 years of follow-up after enrollment. Children had a longer time to biopsy (238 vs 23 and 36 days in adolescent- and adult-onset participants, respectively; P<0.001) and were more likely to have received therapy before biopsy. Children were more likely to be treated with immunosuppression but not RAAS blockade. The rate of relapse was higher in childhood- versus adult-onset participants (HR, 1.69 [95% CI, 1.29-2.21]). The probability of remission was also higher in childhood-onset disease (HR, 1.33 [95%CI, 1.02-1.72]). In all groups eGFR loss was minimal. Children were more likely to remit after rituximab than those with adolescent- or adult-onset disease (adjusted HR, 2.1; P=0.003). Across all groups, glucocorticoid sensitivity was associated with a greater likelihood of achieving complete remission after rituximab (adjusted HR, 2.62; P=0.002). LIMITATIONS CureGN was limited to biopsy-proven disease. Comparisons of childhood to nonchildhood cases of MCD may be subject to selection bias, given that childhood cases who undergo a biopsy may be limited to patients who are least responsive to initial therapy. CONCLUSIONS Among patients with MCD who underwent kidney biopsy, there were differences in the course (relapse and remission) of childhood-onset compared with adolescent- and adult-onset disease, as well as rituximab response. PLAIN-LANGUAGE SUMMARY Minimal change disease is a biopsy diagnosis for nephrotic syndrome. It is diagnosed in childhood, adolescence, or adulthood. Patients and clinicians often have questions about what to expect in the disease course and how to plan therapies. We analyzed a group of patients followed longitudinally as part of the Cure Glomerulonephropathy Network (CureGN) and describe the differences in disease (relapse and remission) based on the age of onset. We also analyzed rituximab response. We found that those with childhood-onset disease had a higher rate of relapse but also have a higher probability of reaching remission when compared with adolescent- or adult-onset disease. Children and all steroid-responsive patients are more likely to achieve remission after rituximab.
Collapse
Affiliation(s)
- Dhruti P Chen
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina.
| | - Margaret E Helmuth
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Abigail R Smith
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, and Irving Medical Center, Columbia University, New York, and Montefiore Medical Center, Bronx, New York
| | - Isabelle Ayoub
- Division of Nephrology, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Krzysztof Mucha
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Mahmoud Kallash
- Division of Nephrology, Wexner Medical Center, The Ohio State University, Columbus, Ohio; Division of Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey B Kopp
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Baltimore, Maryland
| | - Rasheed Gbadegesin
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina
| | - Brenda W Gillespie
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | - Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Rulan S Parekh
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - David T Selewski
- Medical University of South Carolina, Charleston, South Carolina
| | - Jason Kidd
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Kimberly Reidy
- Division of Nephrology, Department of Medicine, and Irving Medical Center, Columbia University, New York, and Montefiore Medical Center, Bronx, New York
| | - Amy K Mottl
- University of North Carolina, Chapel Hill, and Duke Children's Hospital Medical Center, Durham, North Carolina
| | - Debbie S Gipson
- Arbor Research Collaborative for Health, and University of Michigan, Ann Arbor, Michigan
| | | | | |
Collapse
|
16
|
Wang L, Yu L, Wang Y, Guo Y, Zhai Z, Tang L. Rituximab treatment of adults with primary focal segmental glomerulosclerosis. Sci Rep 2023; 13:6740. [PMID: 37185370 PMCID: PMC10130152 DOI: 10.1038/s41598-023-33678-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Abstract
To evaluate the efficacy and safety of rituximab (RTX) in the treatment of primary focal segmental glomerulosclerosis (FSGS) in adults. The clinical data of patients with primary FSGS who received RTX treatment in the First Affiliated Hospital of Zhengzhou University were analyzed retrospectively. The selected patients received RTX twice or four times, with a single dose of 375 mg/m2, and the interval between two times of administration of RTX was 2-4 weeks. The treatment target is to achieve the clearance of B cells (peripheral blood B cell count < 5/μl). The primary outcome measures were remission and recurrence of renal disease, and the secondary outcome measures were adverse events and renal outcomes. A total of 14 FSGS patients were included, including 12 males, 9 with glucocorticoid-dependent or frequently relapsing nephrotic syndrome, and 3 with newly diagnosed nephrotic syndrome. After RTX treatment, 7 patients with glucocorticoid-dependent/recurrent nephrotic syndrome were completely relieved. At 6 months of follow-up, glucocorticoids were discontinued in all patients except 1 patient. The other 5 patients achieved partial remission (PR), of which 1 patient relapsed after PR, and 1 initial patient achieved complete remission. One patient progressed to end-stage renal disease (ESRD) after 4 months of follow-up. RTX in the treatment of adult glucocorticoid-dependent/relapsing FSGS can reduce the risk of recurrence and help to decline or discontinue the use of glucocorticoid and immunosuppressants.
Collapse
Affiliation(s)
- Liuwei Wang
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Lu Yu
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Yulin Wang
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Yanhong Guo
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Zihan Zhai
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, 450052, Henan, China
| | - Lin Tang
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, 450052, Henan, China.
| |
Collapse
|
17
|
Casiraghi F, Todeschini M, Podestà MA, Mister M, Ruggiero B, Trillini M, Carrara C, Diadei O, Villa A, Benigni A, Remuzzi G. Immunophenotypic Alterations in Adult Patients with Steroid-Dependent and Frequently Relapsing Nephrotic Syndrome. Int J Mol Sci 2023; 24:ijms24097687. [PMID: 37175393 PMCID: PMC10178237 DOI: 10.3390/ijms24097687] [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: 03/03/2023] [Revised: 03/29/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Immune dysregulation plays a key role in the pathogenesis of steroid-dependent/frequently relapsing nephrotic syndrome (SDNS/FRNS). However, in contrast with evidence from the pediatric series, no major B- or T-cell alterations have been described for adults. In these patients, treatment with rituximab allows safe discontinuation of steroids, but long-term efficacy is variable, and some patients experience NS relapses after B cell reconstitution. In this study, we aimed to determine disease-associated changes in the B and T cell phenotype of adult patients with SDND/FRNS after steroid-induced remission. We also investigated whether any of these changes in immune cell subsets could discriminate between patients who developed NS relapses after steroid-sparing treatment with rituximab from those who did not. Lymphocyte subsets in SDNS/FRNS patients (n = 18) were compared to those from patients with steroid-resistant NS (SRNS, n = 7) and healthy volunteers (HV, n = 15). Before rituximab, SDND/FRNS patients showed increased frequencies of total and memory B cells, mainly with a CD38-negative phenotype. Within the T-cell compartment, significantly lower levels of FOXP3+ regulatory T cells (Tregs) were found, mostly due to a reduction in CD45RO+ memory Tregs compared to both SRNS and HV. The levels of CD45RO+ Tregs were significantly lower at baseline in patients who relapsed after rituximab (n = 9) compared to patients who did not (n = 9). In conclusion, patients with SDND/FRNS displayed expansion of memory B cells and reduced memory Tregs. Treg levels at baseline may help identify patients who will achieve sustained remission following rituximab infusion from those who will experience NS relapses.
Collapse
Affiliation(s)
- Federica Casiraghi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Marta Todeschini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | | | - Marilena Mister
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Barbara Ruggiero
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Matias Trillini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Camillo Carrara
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Olimpia Diadei
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Alessandro Villa
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24126 Bergamo, Italy
| |
Collapse
|
18
|
Chan EYH, Yap DYH, Colucci M, Ma ALT, Parekh RS, Tullus K. Use of Rituximab in Childhood Idiopathic Nephrotic Syndrome. Clin J Am Soc Nephrol 2023; 18:533-548. [PMID: 36456193 PMCID: PMC10103321 DOI: 10.2215/cjn.08570722] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 12/04/2022]
Abstract
Rituximab is an established therapy in children with idiopathic nephrotic syndrome to sustain short- to medium-term disease remission and avoid steroid toxicities. Recent trials focus on its use as a first-line agent among those with milder disease severity. Rituximab is used in multidrug refractory nephrotic syndrome and post-transplant disease recurrence, although the evidence is much less substantial. Available data suggest that the treatment response to rituximab depends on various patient factors, dosing regimen, and the concomitant use of maintenance immunosuppression. After repeated treatments, patients are found to have an improving response overall with a longer relapse-free period. The drug effect, however, is not permanent, and 80% of patients eventually relapse and many will require an additional course of rituximab. This underpins the importance of understanding the long-term safety profile on repeated treatments. Although rituximab appears to be generally safe, there are concerns about long-term hypogammaglobulinemia, especially in young children. Reliable immunophenotyping and biomarkers are yet to be discovered to predict treatment success, risk of both rare and severe side effects, e.g. , persistent hypogammaglobulinemia, and guiding of redosing strategy. In this review, we highlight recent advances in the use of rituximab for childhood nephrotic syndrome and how the therapeutic landscape is evolving.
Collapse
Affiliation(s)
- Eugene Yu-hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatric and Adolescent Medicine, Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Desmond Yat-hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alison Lap-tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatric and Adolescent Medicine, Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Rulan S. Parekh
- Departments of Medicine and Pediatrics, Women's College Hospital, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| |
Collapse
|
19
|
Nagai K. Immunosuppressive Agent Options for Primary Nephrotic Syndrome: A Review of Network Meta-Analyses and Cost-Effectiveness Analysis. Medicina (B Aires) 2023; 59:medicina59030601. [PMID: 36984602 PMCID: PMC10054564 DOI: 10.3390/medicina59030601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Therapeutic options with immunosuppressive agents for glomerular diseases have widened with refinements to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines from 2012 to 2021. However, international guidelines do not necessarily match the reality in each country. Expensive therapies such as rituximab and calcineurin inhibitors are sometimes inaccessible to patients with refractory nephrotic syndrome due to cost or regulations. Under the Japanese medical insurance system, rituximab is accessible but still limited to steroid-dependent patients who developed idiopathic nephrotic syndrome in childhood. Based on international KDIGO guidelines and other national guidelines, possible applications of immunosuppressive agents for nephrotic syndrome are comprehensively examined in this review. While rituximab has become the mainstay of immunosuppressive therapy for nephrotic syndrome, clinical trials have indicated that options such as cyclophosphamide, calcineurin inhibitors, and mycophenolate mofetil would be preferable. Given the rising number of patients with nephrotic syndrome worldwide, KDIGO guidelines mention the need for further consideration of cost-effectiveness. If the new option of rituximab is to be the first choice in combination with steroids for nephrotic syndrome, its cost-effectiveness should also be verified. Among the few studies examining the cost-effectiveness of treatments for nephrotic syndrome, administration of rituximab to young adults has been shown to be cost-beneficial, at least in Japan. However, further large-scale studies involving multiple facilities are needed to verify such findings. Network meta-analyses have concluded that the efficacy of rituximab remains controversial and confirmation through high-quality studies of large cohorts is needed. To this end, the mechanisms of action underlying immunosuppressive agents, both old and new, need to be understood and experience must be accumulated to evaluate possible effects and side effects.
Collapse
Affiliation(s)
- Kei Nagai
- University of Tsukuba Hospital Hitachi Social Cooperation Education Research Center, Hitachi 317-0077, Ibaraki, Japan
| |
Collapse
|
20
|
Minnelide combined with Angptl3 knockout completely protects mice with adriamycin nephropathy via suppression of TGF-β1-Smad2 and p53 pathways. Int Immunopharmacol 2023; 115:109656. [PMID: 36608441 DOI: 10.1016/j.intimp.2022.109656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 01/05/2023]
Abstract
Minimal change disease (MCD) is the common type of nephrotic syndrome in children. There is an urgent need to explore new treatment methods as current treatments have many drawbacks and cause significant side effects. Our group found that Angiopoietin-like protein 3 (Angptl3) is closely related to renal disease and Angptl3 knockout significantly alleviated proteinuria in mice with adriamycin nephropathy (AN), however, some proteinuria was still present. Minnelide is a water-soluble prodrug of triptolide which has been used for the treatment of glomerular diseases. Therefore, this study aimed to investigate whether minnelide, combined with Angptl3 knockout, could completely protect mice with AN and its mechanism. AN was induced in B6;129S5 female mice by tail vein injection of 25 mg/kg of Adriamycin (ADR), and treatment with 200 ug/kg/d of minnelide. The results showed that minnelide combined with Angptl3 knockout completely reduced proteinuria and restored the foot processes in mice with AN. Moreover, in Angptl3 knockout mice with AN, minnelide restored the distribution of nephrin, podocin and cd2ap and reduced inflammatory factors (Tumor necrosis factor alpha (TNF-α), Interleukin-6 (IL-6) and Interleukin-1β (IL-1β)). Through RNA sequencing and related experiments, we found minnelide could ameliorate fibrosis and apoptosis by inhibiting TGF-β1-Smad2 and p53 pathways in Angptl3 knockout mice with AN, respectively. In Angptl3 knockout primary podocytes, triptolide alleviates ADR-induced decreases in nephrin, podocin and cd2ap, upregulation of Bax and downregulation of Bcl-2. Overall, our study shows that minnelide combined with Angptl3 knockout completely protects mice with AN by inhibiting the TGF-β1-smad2 and p53 pathways.
Collapse
|
21
|
Dong Z, Zhou J, Xu Z, Ni Z, He Y, Lin H, Jiang G, Sun X, Zhang L, Chen X. Efficacy and Safety of Mizoribine in comparison with Cyclophosphamide for Treatment of Refractory Nephrotic Syndrome: Protocol for a Multi-center, Controlled, Open-label, Randomized Controlled Trial (Preprint). JMIR Res Protoc 2023. [PMID: 36990111 DOI: 10.2196/46101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Nephrotic syndrome that is resistant to steroidal therapy is termed refractory nephrotic syndrome (RNS), a condition that is associated with an increased risk of end-stage renal disease (ESRD). Immunosuppressants are utilized to treat RNS, however prolonged may lead to significant adverse effects. Mizoribine (MZR) is a novel agent used in long-term immunosuppressive therapy that has few adverse effects, but data on its long-term use in patients with RNS are unavailable. OBJECTIVE We propose a trial to examine the efficacy and safety of MZR compared to cyclophosphamide (CYC) in Chinese adult patients with RNS. METHODS This is a multi-center, randomized, controlled interventional study with a screening phase (1 week) and a treatment phase (52 weeks). This study was reviewed and approved by the Medical Ethics Committees of all 34 medical centers. Patients with RNS consented to participation, and were enrolled and randomized into an MZR group or a CYC group (1:1 ratio), with each group receiving tapering doses of oral corticosteroids. Participants were assessed for adverse effects and collection of laboratory results at 8 visits during the treatment phase on week-4, week-8, week-12, week-16, week-20, week-32, week-44, and week-52 (exit visit). Participants were able to withdraw voluntarily and investigators were required to remove patients when there were safety concerns or deviations from protocol. RESULTS The study started in November 2014, and was completed in March 2019. A total of 239 participants from 34 hospitals in China were enrolled. Data analysis is completed. The results are waiting to be finalized by Center for Drug Evaluation. CONCLUSIONS The purpose of the current study is to evaluate the efficacy and safety of MZR in comparison with CYC for treatment of RNS in Chinese adult patients with glomerular diseases. It is the longest lasting and largest randomized controlled trial to examine MZR in Chinese patients. The results can help determine whether RNS should be considered as an additional indication for MZR treatment in China. CLINICALTRIAL ClinicalTrials.gov Register, NCT02257697. Registered 2014-10-01, https://clinicaltrials.gov/ct2/show/NCT02257697?term=MZR&rank=2.
Collapse
Affiliation(s)
- Zheyi Dong
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Jianhui Zhou
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Zhonggao Xu
- The First Hospital of Jilin University, Changchun, CN
| | - Zhaohui Ni
- Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, CN
| | - Yani He
- Daping Hospital, Army Medical University, Chongqing, CN
| | - Hongli Lin
- Key Laboratory of Kidney Disease, The Center for the Transformation Medicine of Kidney Disease, The First Affiliated Hospital of Dalian Medical University, Dalian, CN
| | - Gengru Jiang
- XinHua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, CN
| | - Xuefeng Sun
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Li Zhang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Fuxing Road No.28, Beijing, CN
| |
Collapse
|
22
|
Aslam A, Koirala A. Review of the Role of Rituximab in the Management of Adult Minimal Change Disease and Immune-Mediated Focal and Segmental Glomerulosclerosis. GLOMERULAR DISEASES 2023; 3:211-219. [PMID: 37901702 PMCID: PMC10601923 DOI: 10.1159/000533695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/14/2023] [Indexed: 10/31/2023]
Abstract
Background Minimal change disease and primary FSGS are podocytopathies but are also immune-mediated diseases. Rituximab acts via multiple mechanisms by tilting the balance between autoreactive B and T cells in favor of regulatory B and T cells. The consequences are decreased production of cytokines, chemokines, and permeability factors by these cells. In the past decade, we have seen the discovery of autoantibodies mediating nephrotic syndrome (anti-annexin A2 antibody, anti-UCHL1 antibody, and anti-nephrin antibody), and rituximab decreases their production. Rituximab also binds to podocyte SMPDL3b and has direct podocyte actions. Summary Rituximab's role in managing these primary podocytopathies has been discussed in this brief review. Rituximab has been used extensively in children and adults with frequently relapsing and steroid-dependent nephrotic syndrome. However, rituximab is not very promising in adult steroid-resistant nephrotic syndrome. Although ofatumumab would cause prolonged B-cell depletion and is fully humanized, it is unclear if it is superior to rituximab in preventing relapse of nephrotic syndrome. Key Messages Rituximab therapy can induce prolonged remission in adults with frequently relapsing and steroid-dependent nephrotic syndrome. However, no good data exist on using rituximab in steroid-resistant nephrotic syndrome.
Collapse
Affiliation(s)
- Ahsan Aslam
- Division of Nephrology and Hypertension, Assistant Professor of Clinical Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abbal Koirala
- Division of Nephrology, Clinical Assistant Professor of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
23
|
Xu Y, Huang Y, Zhang C, Sun L, Sun Z, Wang L, Zhang B, Yuan Y, Xing C, Mao H. Efficacy and safety of rituximab for primary nephrotic syndrome with acute kidney injury: A two-center prospective cohort study. Clin Immunol 2023; 246:109211. [PMID: 36563945 DOI: 10.1016/j.clim.2022.109211] [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: 10/07/2022] [Revised: 11/27/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
The purpose of this study was to investigate the efficacy and safety of a low-dose Rituximab (RTX) regimen driven by peripheral blood B lymphocyte count in the treatment of adult patients with nephrotic syndrome (NS) complicated with acute kidney disease (AKI). We conducted a prospective single-arm study to evaluate the effect of B cells-driven RTX regimen. Patients with NS (MCD, FSGS, MN, IgAN) complicated with AKI fulfilling the inclusion criteria were eligible for this study. Patients were followed up at intervals of 2 months. Student's t-test and Chi-squared test were used to analyze normally distributed continuous variables and non-normally distributed continuous variables, respectively. From August 2018 to January 2022, 23 patients met the inclusion criteria and agreed to participate in the study. 3, 9, and 11 patients were AKI stage 1, 2, and 3, respectively. From baseline to the latest follow-up, 20 patients had complete and partial recovery of renal function. Accompanied by depletion of B cells, significant reduction of urinary protein excretion, serum total cholesterol, and the number of relapses were observed during the 12 months after the first RTX infusion as compared with during the 12 months before RTX injection. The number of patients who maintained steroids and immunosuppressive medications also remarkably decreased. This study indicates that the targets-driven treatment of low-dose RTX can achieve a high remission rate and alleviate the loss of kidney function in treating NS with AKI. The long-term efficacy, side effects, and therapeutic economics of RTX are reasonable.
Collapse
Affiliation(s)
- Yili Xu
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yiqing Huang
- Department of Nephrology, Wuxi People's Hospital, Affiliated with Nanjing Medical University, Wuxi, China
| | - Chengning Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Lianqin Sun
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Zhuxing Sun
- Department of Nephrology, Wuxi People's Hospital, Affiliated with Nanjing Medical University, Wuxi, China
| | - Liang Wang
- Department of Nephrology, Wuxi People's Hospital, Affiliated with Nanjing Medical University, Wuxi, China
| | - Bo Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yanggang Yuan
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.
| | - Changying Xing
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.
| | - Huijuan Mao
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.
| |
Collapse
|
24
|
Shimizu A, Shirai I, Ogawa K, Miura A, Haruhara K, Oshiro K, Hamaguchi A, Yokote S, Okabe M, Ueda H, Tsuboi N, Ikeda M, Yokoo T. Persistent SARS-CoV-2 Infection in a Patient with Nephrotic Syndrome under Rituximab Therapy: Successful Treatment with a Combination of Remdesivir and Monoclonal Antibodies. Intern Med 2022; 61:3703-3708. [PMID: 36171121 PMCID: PMC9841105 DOI: 10.2169/internalmedicine.0241-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Rituximab is an effective treatment for frequently relapsing/steroid-dependent nephrotic syndrome, but there is concern about infections caused by humoral immunodeficiency. We herein report a case of prolonged (>7 weeks) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A 24-year-old man with minimal change disease treated with rituximab developed SARS-CoV-2 infection. The clinical response to remdesivir was soon transiently abolished. Treatment with casirivimab and imdevimab (REGEN-COV) monoclonal antibodies in combination with remdesivir resulted in complete clearance of the infection. The REGEN-COV antibody cocktail may improve the outcome of SARS-CoV-2 infection in patients with humoral immunodeficiency.
Collapse
Affiliation(s)
- Akihiro Shimizu
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Izumi Shirai
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Kyohei Ogawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Akane Miura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Kotaro Haruhara
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Kentaro Oshiro
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Akihiko Hamaguchi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Shinya Yokote
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Japan
| | - Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Daisan Hospital, Japan
| | - Hiroyuki Ueda
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Masato Ikeda
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| |
Collapse
|
25
|
Campbell RE, Thurman JM. The Immune System and Idiopathic Nephrotic Syndrome. Clin J Am Soc Nephrol 2022; 17:1823-1834. [PMID: 36198505 PMCID: PMC9718018 DOI: 10.2215/cjn.07180622] [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] [Indexed: 01/27/2023]
Abstract
Idiopathic nephrotic syndrome often responds to immunosuppressive treatment. Nevertheless, this syndrome-and the drugs used to treat it-remain important causes of patient morbidity. Idiopathic nephrotic syndrome is usually caused by minimal change disease or FSGS, diseases that primarily affect the podocytes. In spite of decades of research, the underlying causes of both diseases remain incompletely understood. There is, however, a large body of observational and experimental data linking the immune system with both minimal change disease and FSGS, including associations with systemic infections and hematologic malignancies. Perhaps most compellingly, many different immunomodulatory drugs are effective for treating idiopathic nephrotic syndrome, including biologic agents that have well-defined immune targets. In fact, the unexpected efficacy of targeted therapeutic agents has provided important new insights into the pathogenesis of these diseases. Given the large number of drugs that are available to deplete or block specific cells and molecules within the immune system, a better understanding of the immunologic causes of idiopathic nephrotic syndrome may lead to better diagnostic and therapeutic approaches.
Collapse
Affiliation(s)
- Ruth E. Campbell
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado
| | - Joshua M. Thurman
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
26
|
Zhang X, Jin Y, Li Q, Xie Y, Liu F, Huang G, Chen J, Fu H, Wang J, Shen H, Mao J. Successful Treatment of New-Onset Pediatric Nephrotic Syndrome With Rituximab as a First-Line Therapy. Kidney Int Rep 2022; 7:2750-2751. [PMID: 36506238 PMCID: PMC9727513 DOI: 10.1016/j.ekir.2022.10.016] [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: 08/21/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Xiaojing Zhang
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yanyan Jin
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiuyu Li
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yi Xie
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fei Liu
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guoping Huang
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Junyi Chen
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Haidong Fu
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jingjing Wang
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Huijun Shen
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China,Correspondence: Jianhua Mao, Department of Nephrology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, No. 3333, Binsheng Road, Binjiang District, Hangzhou 310052, Zhejiang, China.
| |
Collapse
|
27
|
Alzayer H, Sebastian KK, O’Shaughnessy MM. Rituximab Dosing in Glomerular Diseases: A Scoping Review. Can J Kidney Health Dis 2022; 9:20543581221129959. [PMID: 36275037 PMCID: PMC9583230 DOI: 10.1177/20543581221129959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose of Review Rituximab is increasingly prescribed for glomerular diseases. However, the recently published Kidney Disease Improving Global Outcomes (KDIGO) 2021 Clinical Practice Guideline for the Management of Glomerular Diseases lacks details on recommended dosing regimens for most individual glomerular diseases. We performed this scoping review summarizing the evidence for rituximab dosing in glomerular disease. Sources of Information PubMed database. Methods The PubMed search methodology was developed with a medical librarian and performed by the first, with review by a second, author. Randomized controlled trials (RCTs) and prospective cohort studies (PCSs) examining rituximab efficacy and/or safety in antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV), membranous nephropathy (MN), lupus nephritis (LN), or podocytopathies (minimal change disease or focal segmental glomerulosclerosis [FSGS]) were included. Fifty-three studies (14 RCTs and 39 PCSs) were included. Key Findings We identified 16 different rituximab dosing regimens studied as induction therapy for one or more of the 5 glomerular diseases of interest. The most frequently studied rituximab induction regimens were 1000 mg as 2 doses 2 weeks apart (17 studies, 32%) and 4 doses of 375 mg/m2/week (18 studies, 33.9%). Twenty-six studies (49%) examined rituximab as monotherapy or in conjunction with corticosteroids alone, while the remaining studies examined rituximab as part of combination immunosuppression. Adapting treatment to achieve B-cell depletion, with frequent evaluation of disease-specific biomarkers, might prove the optimal approach to achieving and maintaining remission. Rituximab might also enable steroid minimization or avoidance. Limitations Restriction of the search to a single database and to studies published in the English language, and with an accompanying abstract, could have led to selection bias. While the search was limited to prospective observational studies and RCTs, no formal assessment of study quality was performed.
Collapse
Affiliation(s)
- Husam Alzayer
- Department of Nephrology, Ministry of
Health, Arar, Saudi Arabia,Royal College of Surgeons in Ireland,
Dublin, Ireland,Husam Alzayer, Department of Nephrology,
Ministry of Health, Arar, Northern Boarders, 73241, Saudi Arabia.
;
| | - Kuruvilla K. Sebastian
- Department of Renal Medicine, Cork
University Hospital, Ireland,Department of Medicine, National
University of Ireland Galway, Ireland
| | | |
Collapse
|
28
|
Gomes R, Mosca S, Bastos-Gomes M, Correia-Costa L, Rocha L, Teixeira A, Costa T, Sameiro-Faria M, Matos P, Mota C. Terapia com Rituximabe para síndrome nefrótica idiopática de início na infância: experiência de um centro terciário português. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-0056pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Introdução: Rituximabe (RTX) é uma opção terapêutica na síndrome nefrótica (SN) idiopática pediátrica de difícil tratamento. Visamos avaliar eficácia e segurança do uso de RTX nestes pacientes. Método: Realizou-se estudo retrospectivo de todos os pacientes com SN idiopática tratados com RTX, em uma unidade de nefrologia pediátrica de um hospital terciário. Dados demográficos, antropométricos, clínicos e analíticos foram coletados antes do tratamento e aos 6, 12 e 24 meses. Resultados: Incluímos 16 pacientes (11 do sexo masculino), com idade mediana (percentil 25–75, P25–P75) de 2 (2,0–2,8) anos ao diagnóstico. Quinze eram sensíveis a esteroides, e 1 resistente a esteroides e sensível à ciclosporina.A idade mediana na administração do RTX foi 10 (6,3–14,0) anos. Durante um tempo mediano de acompanhamento de 2,5(1,0–3,0) anos, 6 (37,5%) pacientes alcançaram remissão parcial e 7 (43,8%) não tiveram recidivas e não estavam tomando imunossupressor no acompanhamento aos 24 meses. Quanto às complicações,1 paciente apresentou hipogamaglobulinemia persistente. Comparado ao período de12 meses anterior ao RTX, houve diminuição no número mediano de recidivas em 6 e 12 meses [3 (3,0–4,0) vs 0 (0–0,8) e 0,50 (0–1,0), respectivamente; p = 0,001] e na dose diária de esteroides (mg/kg/dia) aos 6, 12 e 24 meses [0,29 (0,15–0,67) >vs [0,10 (0,07–0,13); p = 0,001], [0,12 (0,05–0,22); p = 0,005] e [0,07 (0,04–0,18); p = 0,021], respectivamente. Houve também redução na mediana do escore z do IMC aos 24 meses [2,11 (0,45–3,70) vs 2,93 (2,01–3,98);p = 0,049]. Conclusões: Nossos resultados confirmam a eficácia e segurança do uso de RTX em SN idiopática pediátrica, destacando seus potenciais benefícios cardiometabólicos.
Collapse
Affiliation(s)
- Rita Gomes
- Centro Hospitalar Universitário do Porto, Portugal
| | - Sara Mosca
- Centro Hospitalar Universitário do Porto, Portugal
| | | | | | | | - Ana Teixeira
- Centro Hospitalar Universitário do Porto, Portugal
| | - Teresa Costa
- Centro Hospitalar Universitário do Porto, Portugal
| | | | - Paula Matos
- Centro Hospitalar Universitário do Porto, Portugal
| | | |
Collapse
|
29
|
Ambarsari CG, Saraswati M, Laudza GS. Rituximab, Mycophenolic Acid, and Calcineurin Inhibitors Achieve Long-Term Remission in Pediatric Focal Segmental Glomerulosclerosis with Steroid-Resistant and Frequently Relapsing Nephrotic Syndrome: A Report of Two Cases. Case Rep Nephrol Dial 2022; 12:167-177. [PMID: 36518356 PMCID: PMC9743143 DOI: 10.1159/000525776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/19/2022] [Indexed: 11/05/2022] Open
Abstract
Studies investigating the effect of rituximab in children with nephrotic syndrome (NS) due to focal segmental glomerulosclerosis (FSGS) have reported conflicting results, with some concluding that patients may require additional immunosuppressive therapy to achieve and/or maintain long-term remission. We report successful treatment of pediatric FSGS with rituximab infusions, followed by maintenance immunosuppression with mycophenolic acid (MPA) and a calcineurin inhibitor (CNI) in 1 patient with refractory steroid-resistant NS (SRNS), and one with frequently relapsing NS (FRNS). Case 1 is a patient with refractory SRNS due to FSGS. MPA and tacrolimus induced complete remission within 6 months following rituximab treatment. Remission was maintained for over 2 years, and the patient's kidney function and body height also returned to normal ranges within this time. Case 2 is a patient with FRNS due to FSGS, who was treated with rituximab followed by MPA and cyclosporine, which successfully prevented relapses for 18 months, that is, at the end point of the observation. Our case report demonstrates that rituximab and a combination of CNIs and MPA can be effective in achieving complete remission in pediatric refractory SRNS and sustaining remission in pediatric FSGS with FRNS and SRNS for several years. This treatment regimen has the advantage of eliminating the need for long-term high-dose steroid treatments, allowing 1 patient to achieve normal growth and recover from other adverse steroid effects.
Collapse
Affiliation(s)
- Cahyani Gita Ambarsari
- aDepartment of Child Health, Faculty of Medicine Universitas Indonesia − Cipto Mangunkusumo Hospital, Jakarta, Indonesia,bSchool of Medicine, University of Nottingham, Nottingham, UK,cPediatric Centre, Pondok Indah Bintaro Jaya Hospital, South Tangerang, Indonesia,*Cahyani Gita Ambarsari,
| | - Meilania Saraswati
- dDepartment of Pathology Anatomy, Faculty of Medicine Universitas Indonesia − Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Genta Syaifrin Laudza
- aDepartment of Child Health, Faculty of Medicine Universitas Indonesia − Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| |
Collapse
|
30
|
Jauhal A, Reich HN, Hladunewich M, Barua M, Hansen BE, Naimark D, Troyanov S, Cattran DC. Quantifying the benefits of remission duration in focal and segmental glomerulosclerosis. Nephrol Dial Transplant 2022; 38:950-960. [PMID: 35948275 PMCID: PMC10064837 DOI: 10.1093/ndt/gfac238] [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: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although the clinical benefit of obtaining a remission in proteinuria in nephrotic patients with focal and segmental glomerulosclerosis (FSGS) is recognized, the long-term value of maintaining it and the impact of relapses on outcome are not well described. METHODS We examined the impact of remissions and relapses on either a 50% decline in kidney function or ESKD (combined event) using time-dependent and landmark analyses in a retrospective study of all patients from the Toronto Glomerulonephritis Registry with biopsy-proven FSGS, established nephrotic-range proteinuria and at least one remission. RESULTS In the 203 FSGS individuals with a remission, 89 never relapsed and 114 experienced at least one relapse. The first recurrence was often followed by a repeating pattern of remission and relapse. The 10-year survival from a combined event was 15% higher in those with no relapse versus those with any relapse. This smaller than anticipated difference was related to the favorable outcome in individuals whose relapses quickly remitted. Relapsers who ultimately ended in remission (n = 46) versus in relapse (n = 68) experienced a 91% and 32% 7-year event survival (p<0.001). Using time-varying survival analyses that considered all periods of remission and relapse in every patient and adjusting for each period's initial eGFR, the state of relapse was associated with a 2.17 (95%CI,1.32-3.58, p = 0.002) greater risk of experiencing a combined event even in this FSGS remission cohort. CONCLUSIONS In FSGS, unless remissions are maintained and relapses avoided, long-term renal survival remains poor. Treatment strategies addressing remission duration remain poorly defined and should be an essential question in future trials.
Collapse
Affiliation(s)
- Arenn Jauhal
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Science Center, University of Toronto, Toronto, Ontario, Canada
| | - Moumita Barua
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - David Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Science Center, University of Toronto, Toronto, Ontario, Canada
| | - Stéphan Troyanov
- Division of Nephrology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Daniel C Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
31
|
Protective effects of rituximab on puromycin-induced apoptosis, loss of adhesion and cytoskeletal alterations in human podocytes. Sci Rep 2022; 12:12297. [PMID: 35853959 PMCID: PMC9296604 DOI: 10.1038/s41598-022-16333-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/08/2022] [Indexed: 11/08/2022] Open
Abstract
Podocytes are highly specialized cells playing a key role in the filtration function of the kidney. A damaged podocyte ultrastructure is associated with a reorganization of the actin cytoskeleton and accompanied with a loss of adhesion to the glomerular basement membrane leading to proteinuria in many forms of glomerular diseases, e.g. nephrotic syndrome. If the first-line therapy with glucocorticoids fails, alternative immunosuppressive agents are used, which are known to have the potential to stabilize the actin cytoskeleton. A new option for preventing relapses in steroid dependent nephrotic syndrome is the monoclonal antibody rituximab, which, in addition to its B-cell depleting effect, is assumed to have direct effects on podocytes. We here provide data on the non-immunological off-target effects of the immunosuppressant rituximab on podocyte structure and dynamics in an in vitro puromycin aminonucleoside model of podocyte injury. A conditionally immortalized human podocyte cell line was used. Differentiated podocytes were treated with puromycin aminonucleoside and rituximab. Our studies focussed on analyzing the structure of the actin cytoskeleton, cellular adhesion and apoptosis using immunofluorescence staining and protein biochemistry methods. Treatment with rituximab resulted in a stabilization of podocyte actin stress fibers in the puromycin aminonucleoside model, leading to an improvement in cell adhesion. A lower apoptosis rate was observed after parallel treatment with puromycin aminonucleoside and rituximab visualized by reduced nuclear fragmentation. Consistent with this data, Western-blot analyses demonstrated that rituximab directly affects the caspase pathways by inhibiting the activation of Caspases-8, -9 and -3, suggesting that rituximab may inhibit apoptosis. In conclusion, our results indicate an important role of the immunosuppressant rituximab in terms of stability and morphogenesis of podocytes, involving apoptosis pathways. This could help to improve therapeutical concepts for patients with proteinuria mediated by diseased podocytes.
Collapse
|
32
|
Ye Q, Lan B, Liu H, Persson PB, Lai EY, Mao J. A critical role of the podocyte cytoskeleton in the pathogenesis of glomerular proteinuria and autoimmune podocytopathies. Acta Physiol (Oxf) 2022; 235:e13850. [PMID: 35716094 DOI: 10.1111/apha.13850] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/23/2022] [Accepted: 06/13/2022] [Indexed: 01/19/2023]
Abstract
Selective glomerular filtration relies on the membrane separating the glomerular arterioles from the Bowman space. As a major component of the glomerular filtration barrier, podocytes form foot processes by the actin cytoskeleton, which dynamically adjusts in response to environmental changes to maintain filtration barrier integrity. The slit diaphragms bridge the filtration slits between neighboring foot processes and act as signaling hubs interacting with the actin cytoskeleton. Focal adhesions relay signals to regulate actin dynamics while allowing podocyte adherence to the basement membrane. Mutations in actin regulatory and signaling proteins may disrupt the actin cytoskeleton, resulting in foot process retraction, effacement, and proteinuria. Large-scale gene expression profiling platforms, transgenic animal models, and other in vivo gene delivery methods now enhance our understanding of the interactions among podocyte focal adhesions, slit diaphragms, and actin dynamics. In addition, our team found that at least 66% of idiopathic nephrotic syndrome (INS) children have podocyte autoantibodies, which was defined as a new disease subgroup-, autoimmune podocytopathies. This review outlines the pathophysiological mechanisms of podocyte cytoskeleton protein interactions in proteinuria and glomerular podocytopathy.
Collapse
Affiliation(s)
- Qing Ye
- Department of Clinical Laboratory, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Bing Lan
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Huihui Liu
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Pontus B Persson
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Translational Physiology, Berlin, Germany
| | - En Yin Lai
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Translational Physiology, Berlin, Germany.,Department of Physiology, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| |
Collapse
|
33
|
Tedesco M, Mescia F, Pisani I, Allinovi M, Casazza G, Del Vecchio L, Santostefano M, Cirillo L, Ferrario F, Esposito C, Esposito P, Santoro D, Lazzarin R, Rossi GM, Fiaccadori E, Ferrantelli A, Sinico RA, Cozzolino M, Gallieni M, Cirami L, Scolari F, Vaglio A, Alberici F. The Role of Rituximab in Primary Focal Segmental Glomerular Sclerosis of the Adult. Kidney Int Rep 2022; 7:1878-1886. [PMID: 35967114 PMCID: PMC9366368 DOI: 10.1016/j.ekir.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/08/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Primary focal segmental glomerular sclerosis (FSGS) is a rare, likely immune-mediated disease. Rituximab (RTX) may play a role in management, although data in adults are scanty. Methods We collected cases of RTX-treated primary FSGS within the Italian Society of Nephrology Immunopathology Working Group and explored response rate (24-hour proteinuria <3.5 g and <50% compared with baseline, stable estimated glomerular filtration rate). Results A total of 31 patients were followed for at least 12 months; further follow-up (median 17 months, interquartile range [IQR] 15–33.5) was available for 11. At first RTX administration, median creatinine and 24-hour proteinuria were 1.17 mg/dl (IQR 0.83–1.62) and 5.2 g (IQR 3.3–8.81), respectively. Response rate at 3, 6, and 12 months was 39%, 52%, and 42%, respectively. In the first 12 months, creatinine level remained stable whereas proteinuria and serum albumin level improved, with an increase in the proportion of patients tapering other immunosuppressants. There were 6 patients who were retreated with RTX within 12 months, either for proteinuria increase or refractory disease; only the 2 responders to the first RTX course experienced a further response. At univariate analysis, 6-month response was more frequent in steroid-dependent patients (odds ratio [OR] 7.7 [95% CI 1.16–52.17]) and those with proteinuria <5 g/24 h (OR 8.25 [1.45–46.86]). During long-term follow-up, 4 of 5 responders at 12 months maintained a sustained response, either without further immunosuppression (2 of 4) or with pre-emptive RTX (2 of 4); 1 relapsed and responded to RTX retreatment. Conclusion RTX may be an option in primary FSGS, especially in steroid-dependent patients, with 24-hour proteinuria <5 g and previously responders to RTX. Optimal long-term management for responders is unclear, with some patients experiencing sustained remission and others requiring RTX retreatment, either preemptive or after rising proteinuria.
Collapse
Affiliation(s)
- Martina Tedesco
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Federica Mescia
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
- Correspondence: Federica Mescia, University of Brescia-ASST Spedali Civili, Piazzale Spedali Civili 1, 25125 Brescia, Italy.
| | - Isabella Pisani
- Nephrology Unit, Parma University Hospital, and Department of Medicine and Surgery, Parma University Medical School, Parma, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Marisa Santostefano
- Division of Nephrology, Dialysis and Hypertension, Policlinico S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luigi Cirillo
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Ferrario
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri SpA SB, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Pasquale Esposito
- Department of Internal Medicine, Nephrology, Dialysis and Transplantation Clinics, University of Genoa, Genoa, Italy
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberta Lazzarin
- Nephrology and Dialysis, Ospedale San Giacomo Apostolo, Castelfranco Veneto, Italy
| | - Giovanni Maria Rossi
- Nephrology Unit, Parma University Hospital, and Department of Medicine and Surgery, Parma University Medical School, Parma, Italy
| | - Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, and Department of Medicine and Surgery, Parma University Medical School, Parma, Italy
| | | | - Renato Alberto Sinico
- Department of Medicine and Surgery, University of Milano—Bicocca and Nephrology Unit, ASST-Monza, Monza, Italy
| | - Mario Cozzolino
- Department of Health Sciences, University of Milano, Milan, Italy
- Nephrology Unit and Immunology Clinic, ASST Santi Paolo e Carlo, Milan, Italy
| | - Maurizio Gallieni
- Department of Clinical and Biomedical Sciences “L. Sacco,” University of Milano, Milan, Italy
- ASST Fatebenefratelli-Sacco, Milan, Italy
| | | | - Lino Cirami
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio,” University of Firenze, Firenze, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Firenze, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| |
Collapse
|
34
|
Zhong E, Ghadiri S, Pai A, Marin JG, Barbour SJ. Rituximab for Adults With Multi-Drug Resistant Focal Segmental Glomerulosclerosis: A Case Series and Review of the Literature. Can J Kidney Health Dis 2022; 9:20543581221090010. [PMID: 35465258 PMCID: PMC9021507 DOI: 10.1177/20543581221090010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/13/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Adults with primary focal segmental glomerulosclerosis (FSGS) are frequently resistant to multiple immunosuppressive agents, which is associated with ongoing complications of nephrotic syndrome and a high risk of progression to end-stage renal disease (ESRD). Rituximab, a monoclonal antibody against the B cell CD20 antigen, has shown some preliminary evidence in treating nephrotic syndrome. Objectives: Describe the usage and the efficacy of rituximab for adults with FSGS in British Columbia (BC) (Canada) and perform a literature review of multi-immunosuppressive drug resistant FSGS in adult patients treated with rituximab to estimate the overall response rate. Design: Case series report and a literature review. Patients: For the case-series, all BC patients who received rituximab for a diagnosis of primary FSGS were included. The literature review included all cases of immunosuppressive-resistant FSGS patients treated with rituximab. We excluded transplant and pediatric patients in both groups. Methods: We describe all cases of adults with native-kidney FSGS resistant to conventional immunosuppressive medications from our provincial health database who were treated with rituximab from 2014 to 2018. A review of the existing literature was performed via PubMed, MEDLINE, and Embase using the following keywords: rituximab, focal segmental glomerulosclerosis, and FSGS up to August 2019. Results: We characterize four immunosuppressive-resistant FSGS patients who were treated with rituximab as part of our provincial program, all of whom showed a response to rituximab with a sustained remission. We found 29 specific cases in the literature of adults with native-kidney FSGS treated with rituximab after being resistant to other immunosuppressive medications, of whom 15 cases showed a response to rituximab. This has increased the total response rate from 15/29 (52%) to 19/33 (58%). Limitations: Literature on this topic is coming predominantly from case series. Prospective trials are needed to confirm efficacy, tolerability, and duration of remission. Conclusions: Due to the low number of currently reported cases and variable response rates, these four cases provide critical data to generate a more accurate understanding of the role of rituximab in adults with resistant FSGS. Adding these results to the confirmed literature cases of multiple-immunosuppressive-resistant FSGS patients treated with rituximab results in a total remission rate of 19/33 cases.
Collapse
Affiliation(s)
- Ellia Zhong
- The University of British Columbia, Vancouver, Canada
| | | | - Alexander Pai
- The University of British Columbia, Vancouver, Canada
| | - Judith G Marin
- The University of British Columbia, Vancouver, Canada.,BC Provincial Renal Agency, Vancouver, Canada
| | - Sean J Barbour
- BC Provincial Renal Agency, Vancouver, Canada.,Division of Nephrology, The University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| |
Collapse
|
35
|
Chan E, Yu E, Angeletti A, Arslan Z, Basu B, Boyer O, Chan CY, Colucci M, Dorval G, Dossier C, Drovandi S, Ghiggeri GM, Gipson D, Hamada R, Hogan J, Ishikura K, Kamei K, Kemper M, Ma ALT, Parekh R, Radhakrishnan S, Saini P, Shen Q, Sinha R, Subun C, Teo S, Vivarelli M, Webb H, Xu H, Yap HK, Tullus K. Long-term Efficacy and Safety of Repeated Rituximab to Maintain Remission in Idiopathic Childhood Nephrotic Syndrome: An International Study. J Am Soc Nephrol 2022; 33:1193-1207. [PMID: 35354600 PMCID: PMC9161790 DOI: 10.1681/asn.2021111472] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/14/2022] [Indexed: 11/03/2022] Open
Abstract
Background: Long-term outcomes following multiple rituximab courses among children with frequently-relapsing, steroid-dependent nephrotic syndrome (FRSDNS) are unknown. Methods: A retrospective cohort study at 16 pediatric nephrology centers from 10 countries in Asia, Europe, and North America included children with FRSDNS who received ≥2 rituximab courses. Primary outcomes were relapse-free survival and adverse events. Results: 346 children (age 9.8 years, IQR 6.6-13.5; 73% boys) received 1149 rituximab courses. 145, 83, 50, 28, 22, and 18 children received 2, 3, 4, 5, 6 and ≥7 courses, respectively. Median follow-up was 5.9 years (IQR, 4.3-7.7). Relapse-free survival differed by treatment courses (clustered log-rank test p<0.001). Compared to the first course (10.0 months, 95% CI, 9.0-10.7), relapse-free period and relapse risk progressively improved following subsequent courses (12.0-16.0 months; HRadj, 0.03-0.13; 95% CI, 0.01-0.18; ps<0.001). B-cell depletion duration remained similar with repeated treatments (6.1 months, 95% CI, 6.0-6.3). Adverse events were mostly mild, most commonly hypogammaglobulinemia (50.9%), infection (4.5%), and neutropenia (3.7%). Side effects did not increase with more treatment courses nor higher cumulative dose. Only 78 of the 353 episodes of hypogammaglobulinemia were clinically significant. Younger age at presentation (2.8 vs 3.3 years; p=0.05) and at first rituximab (8.0 y vs 10.0 years; p=0.01) and history of steroid resistance (28% vs 18%; p=0.01) were associated with significant hypogammaglobulinemia. All 53 infective episodes resolved, except one patient with hepatitis B infection and another with EBV infection. There were 42 episodes of neutropenia, associated with history of steroid resistance (30% vs 20%, p=0.04). Upon last follow-up, 332 children (96%) had normal kidney function. Conclusion: Children receiving repeated rituximab for FRSDNS experience an improving clinical response. Side effects appear acceptable but significant complications can occur. These findings support repeated rituximab use in FRSDNS.
Collapse
Affiliation(s)
- Eugene Chan
- E Chan, Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Ellen Yu
- E Yu, Clinical Research Center, Princess Margaret Hospital, Toronto, Canada
| | - Andrea Angeletti
- A Angeletti, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Zainab Arslan
- Z Arslan, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Biswanath Basu
- B Basu, Division of Pediatric Nephrology, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Olivia Boyer
- O Boyer, Néphrologie pédiatrique, centre de référence du syndrome néphrotique de l'enfant et de l'adulte, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Chang-Yien Chan
- C Chan, Department of Paediatrics, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Manuela Colucci
- M Colucci, Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillaume Dorval
- G Dorval, Néphrologie pédiatrique, centre de référence du syndrome néphrotique de l'enfant et de l'adulte, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Claire Dossier
- C Dossier, Department of Pediatric Nephrology, Centre de Référence Syndrome Néphrotique de l'Enfant et de l'Adulte (CMR SNI), Hopital Universitaire Robert-Debre, Paris, France
| | - Stefania Drovandi
- S Drovandi, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Gian Marco Ghiggeri
- G Ghiggeri, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Debbie Gipson
- D Gipson, Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, United States
| | - Riku Hamada
- R Hamada, Department of Nephrology and Rheumatology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Julien Hogan
- J Hogan, Department of Pediatric Nephrology, Centre de Référence Syndrome Néphrotique de l'Enfant et de l'Adulte (CMR SNI), Hospital Robert Debré, Amboise, France
| | - Kenji Ishikura
- K Ishikura, Department of Pediatrics, Kitasato University School of Medicine, Japan, Japan
| | - Koichi Kamei
- K Kamei, Division of Nephrology and Rheumatology, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Markus Kemper
- M Kemper, Department of Pediatrics, Asklepios Medical School GmbH, Hamburg, Germany
| | - Alison Lap-Tak Ma
- A Ma, Paediatric Nephrology Centre, Princess Margaret Hospital, Hong Kong, Hong Kong
| | - Rulan Parekh
- R Parekh, Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Canada
| | - Seetha Radhakrishnan
- S Radhakrishnan, Division of Pediatric Nephrology, Hospital For Sick Children, London, United Kingdom of Great Britain and Northern Ireland
| | - Priya Saini
- P Saini, Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Canada
| | - Qian Shen
- Q Shen, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Rajiv Sinha
- R Sinha, Pediatric Nephrology Unit, Institute of Child Health, Kolkata, India
| | - Chantida Subun
- C Subun, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Sharon Teo
- S Teo, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Marina Vivarelli
- M Vivarelli, Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Roma, Italy
| | - Hazel Webb
- H Webb, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Hong Xu
- H Xu, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hui Kim Yap
- H Yap, Department of Paediatrics, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Kjell Tullus
- K Tullus, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
36
|
Meeuwisse C, Morgan CJ, Samuel S, Alexander RT, Rodriguez-Lopez S. Rituximab Use for the Treatment of Childhood Nephrotic Syndrome by Canadian Pediatric Nephrologists: A National Survey. Can J Kidney Health Dis 2022; 9:20543581221079959. [PMID: 35300066 PMCID: PMC8922210 DOI: 10.1177/20543581221079959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background: There is known practice variation in the treatment of frequently relapsing, steroid-dependent, and steroid-resistant nephrotic syndrome in children. Rituximab is an emerging therapy for difficult-to-treat nephrotic syndrome; however, there are no clear treatment guidelines. We therefore hypothesized that a wide variety of approaches to this therapy exist. Objective: To evaluate when and how rituximab is used for the treatment of childhood nephrotic syndrome in Canada. Design and setting: An online survey was used. Participants: Canadian pediatric nephrologists. Methods: A cross-sectional survey was distributed across Canada through the Canadian Association of Pediatric Nephrologists (CAPN) to evaluate rituximab treatment practices. Results: Of a total of 20 responses, 19 (95%) use rituximab in the treatment of nephrotic syndrome, usually as a third or fourth agent. For the number of rituximab doses, the majority (68%) uses 2 doses each time they use it. Eighteen respondents (90%) measure B cells when using this medication, mostly monthly (50%) or every 3 months (39%). Respondents were administered additional doses of rituximab prophylactically (74%) or at first relapse (47%). Long-term drug safety and drug funding were identified as the main barriers to rituximab use. Limitations: This survey represents the practice styles of physicians in a single country, and there is a nonresponse bias of 63%. Also, associations were not calculated. Conclusions: Among Canadian pediatric nephrologists, rituximab use for nephrotic syndrome appears to be increasing, but significant practice variations remain, including approaches to B-cell monitoring. It is reserved mostly for second-line and third-line use due to cost, funding issues, and residual uncertainty regarding long-term safety. Understanding these critical areas of practice uncertainty is a first step to optimize treatment of nephrotic syndrome in children.
Collapse
Affiliation(s)
- Cory Meeuwisse
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Catherine J. Morgan
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Susan Samuel
- Section of Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, AB, Canada
| | - R Todd Alexander
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sara Rodriguez-Lopez
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| |
Collapse
|
37
|
Doi K, Kimura H, Matsunaga YT, Fujii T, Nangaku M. Glomerulus-on-a-Chip: Current Insights and Future Potential Towards Recapitulating Selectively Permeable Filtration Systems. Int J Nephrol Renovasc Dis 2022; 15:85-101. [PMID: 35299832 PMCID: PMC8922329 DOI: 10.2147/ijnrd.s344725] [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: 10/16/2021] [Accepted: 02/14/2022] [Indexed: 01/27/2023] Open
Affiliation(s)
- Kotaro Doi
- Institute of Industrial Science, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Kimura
- Department of Mechanical Engineering, School of Engineering, Tokai University, Kanagawa, Japan
| | | | | | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
- Correspondence: Masaomi Nangaku, Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan, Tel/Fax +81358009736, Email
| |
Collapse
|
38
|
Zotta F, Vivarelli M, Emma F. Update on the treatment of steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:303-314. [PMID: 33665752 DOI: 10.1007/s00467-021-04983-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
Steroid-sensitive nephrotic syndrome (SSNS) is a rare condition that develops primarily in preadolescent children after the age of 1 year. Since the 1950s, oral corticosteroids have been the mainstay of treatment of all children presenting with nephrotic syndrome, with most patients responding within 4 weeks to an oral course of prednisone (PDN). However, corticosteroids have important side effects and 60-80 % of patients relapse, developing frequently relapsing or steroid-dependent forms. For these reasons, many patients require second-line steroid-sparing immunosuppressive medications that have considerably improved relapse-free survival, while avoiding many PDN-related toxicities. Since most patients will eventually heal from their disease with a normal kidney function, the morbidity of SSNS is primarily related to side effects of drugs that are used to maintain prolonged remission. Therefore, treatment is essentially based on balancing the use of different drugs to achieve permanent remission with the lowest cumulative number of side effects. Treatment choice is based on the severity of SSNS, on patient age, and on drug tolerability. This review provides an update of currently available therapeutic strategies for SSNS.
Collapse
Affiliation(s)
- Federica Zotta
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| |
Collapse
|
39
|
Purohit S, Piani F, Ordoñez FA, de Lucas-Collantes C, Bauer C, Cara-Fuentes G. Molecular Mechanisms of Proteinuria in Minimal Change Disease. Front Med (Lausanne) 2022; 8:761600. [PMID: 35004732 PMCID: PMC8733331 DOI: 10.3389/fmed.2021.761600] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Minimal change disease (MCD) is the most common type of idiopathic nephrotic syndrome in childhood and represents about 15% cases in adults. It is characterized by massive proteinuria, edema, hypoalbuminemia, and podocyte foot process effacement on electron microscopy. Clinical and experimental studies have shown an association between MCD and immune dysregulation. Given the lack of inflammatory changes or immunocomplex deposits in the kidney tissue, MCD has been traditionally thought to be mediated by an unknown circulating factor(s), probably released by T cells that directly target podocytes leading to podocyte ultrastructural changes and proteinuria. Not surprisingly, research efforts have focused on the role of T cells and podocytes in the disease process. Nevertheless, the pathogenesis of the disease remains a mystery. More recently, B cells have been postulated as an important player in the disease either by activating T cells or by releasing circulating autoantibodies against podocyte targets. There are also few reports of endothelial injury in MCD, but whether glomerular endothelial cells play a role in the disease remains unexplored. Genome-wide association studies are providing insights into the genetic susceptibility to develop the disease and found a link between MCD and certain human haplotype antigen variants. Altogether, these findings emphasize the complex interplay between the immune system, glomerular cells, and the genome, raising the possibility of distinct underlying triggers and/or mechanisms of proteinuria among patients with MCD. The heterogeneity of the disease and the lack of good animal models of MCD remain major obstacles in the understanding of MCD. In this study, we will review the most relevant candidate mediators and mechanisms of proteinuria involved in MCD and the current models of MCD-like injury.
Collapse
Affiliation(s)
- Shrey Purohit
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Pediatrics, Section of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| | - Federica Piani
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Medicine and Surgery Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Flor A Ordoñez
- Division of Pediatric Nephrology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Colin Bauer
- Department of Pediatrics, Section of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| | - Gabriel Cara-Fuentes
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Pediatrics, Section of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| |
Collapse
|
40
|
Hladunewich MA, Cattran D, Sethi SM, Hayek SS, Li J, Wei C, Mullin SI, Reich HN, Reiser J, Fervenza FC. Efficacy of Rituximab in Treatment-Resistant Focal Segmental Glomerulosclerosis With Elevated Soluble Urokinase-Type Plasminogen Activator Receptor and Activation of Podocyte β3 Integrin. Kidney Int Rep 2022; 7:68-77. [PMID: 35005315 PMCID: PMC8720804 DOI: 10.1016/j.ekir.2021.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Severe, nonresponsive, primary focal segmental glomerular sclerosis (FSGS) can progress to end-stage kidney disease (ESKD) in <5 years. Soluble urokinase-type plasminogen activator receptor (suPAR) may contribute to podocyte effacement by activating podocyte β3 integrin. It has been reported as a potential permeability factor and biomarker for primary FSGS. Rituximab was found to have efficacy in case reports and small series. Whether rituximab is efficacious in patients with treatment-resistant FSGS in the context of high suPAR levels and evidence of podocyte B3 integrin activation remains unknown. Methods In this nonblinded, open-label pilot study, the safety and efficacy of rituximab were evaluated in treatment-resistant adult patients with primary FSGS and a suPAR level > 3500 pg/ml with evidence of β3 integrin activation. Rituximab (1 g) was given on days 1 and 15. The primary outcome was proteinuria at 12 months. Results Only 13 of 38 screened patients qualified for the study, of whom 9 consented to participate. The baseline proteinuria and glomerular filtration rate (GFR) levels were 7.70 ± 4.61 g/d and 67 ± 38 ml/min, respectively. A transient response at 6 months was noted in 2 patients without a parallel change in suPAR level. At 12 months, there was no statistically significant improvement in proteinuria level with all participants remaining nephrotic (7.27 ± 7.30 g/d). GFR level marginally declined to 60 ± 38 ml/min with one patient progressing to ESKD. There were 2 serious infections, an infusion-related reaction and leucopenia attributed to rituximab. Conclusion Rituximab was ineffective when administered to adult patients with treatment-resistant primary FSGS with a high suPAR and evidence of podocyte activation.
Collapse
Affiliation(s)
- Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dan Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sanjeev M Sethi
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Minnesota, USA
| | - Jing Li
- Division of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Changli Wei
- Division of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sarah I Mullin
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jochen Reiser
- Division of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Fernando C Fervenza
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
41
|
Del Vecchio L, Allinovi M, Rocco P, Brando B. Rituximab Therapy for Adults with Nephrotic Syndromes: Standard Schedules or B Cell-Targeted Therapy? J Clin Med 2021; 10:5847. [PMID: 34945143 PMCID: PMC8709396 DOI: 10.3390/jcm10245847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022] Open
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody. It acts mainly through complement-dependent cytotoxicity on B cells expressing the CD20 marker. In this review, we analyse the efficacy and possible pitfalls of rituximab to treat nephrotic syndromes by taking into account pharmacological considerations and CD19 marker testing utility. Despite the fact that the drug has been in use for years, efficacy and treatment schedules in adults with nephrotic syndrome are still a matter of debate. Clinical trials have proven the efficacy and safety of rituximab in idiopathic membranous nephropathy. Data from observational studies also showed the efficacy of rituximab in minimal change disease and focal segmental glomerulosclerosis. Rituximab use is now widely recommended by new Kidney Disease Improved Outcome (KDIGO) guidelines in membranous nephropathy and in frequent-relapsing, steroid-dependent minimal change disease or focal segmental glomerulosclerosis. However, rituximab response has a large interindividual variability. One reason could be that rituximab is lost in the urine at a higher extent in patients with nonselective nephrotic proteinuria, exposing patients to different rituximab plasma levels. Moreover, the association between CD19+ levels and clinical response or relapses is not always present, making the use of this marker in clinical practice complex. High resolution flow cytometry has increased the capability of detecting residual CD19+ B cells. Moreover, it can identify specific B-cell subsets (including IgG-switched memory B cells), which can repopulate at different rates. Its wider use could become a useful tool for better understanding reasons of rituximab failure or avoiding unnecessary retreatments.
Collapse
Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Paolo Rocco
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo, 71-20133 Milan, Italy;
| | - Bruno Brando
- Haematology Laboratory and Transfusion Centre, Legnano General Hospital (Milan), 20025 Milan, Italy;
| |
Collapse
|
42
|
Duarte I, Oliveira J, Outerelo C, Godinho I, Pereira M, Fernandes P, Jorge S, Gameiro J. Rituximab in glomerular diseases: a case series and narrative review. J Bras Nefrol 2021; 44:187-195. [PMID: 34874051 PMCID: PMC9269185 DOI: 10.1590/2175-8239-jbn-2021-0120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/27/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The use of Rituximab (RTX) in glomerular diseases (GD) has increased in the past years, although it is still only used in a small fraction of patients. METHODS A single center retrospective study of adult patients with membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), lupus nephritis (LN), and vasculitis treated with RTX as first or second-line therapy was conducted at our center from 2010 to 2020. RESULTS We identified 19 patients; 36.8% had MN and 25.0% each had FSGS, LN, and vasculitis. RTX was first-line therapy in 26.3% of patients and in 73.7% it was second-line therapy. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had complete remission (CR), 2 patients (28.6%) had partial remission (PR), and 3 patients (42.9%) had no response (NR). In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response, and 1 patient had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response, and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Infusion reactions were present in 2 patients (10.5%) and one patient had multiple infectious complications. CONCLUSIONS The efficacy of RTX in treating different types of immune-mediated GD has been demonstrated with different response rates, but an overall safe profile. In our case series, the results are also encouraging. Longitudinal studies are needed to better understand the effect of RTX in GD.
Collapse
Affiliation(s)
- Inês Duarte
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - João Oliveira
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Cristina Outerelo
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Iolanda Godinho
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Marta Pereira
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Paulo Fernandes
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Sofia Jorge
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Joana Gameiro
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| |
Collapse
|
43
|
Caravaca-Fontán F, Fernandez-Juarez GM, Floege J, Goumenos D, Kronbichler A, Turkmen K, van Kooten C, Frangou E, Stevens KI, Segelmark M, Tesar V, Anders HJ, Bruchfeld A. The management of membranous nephropathy - an update. Nephrol Dial Transplant 2021; 37:1033-1042. [PMID: 34748001 DOI: 10.1093/ndt/gfab316] [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: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
In the last decades several important advances have taken place in the understanding of the pathogenesis underlying membranous nephropathy, which have sparked renewed interest in its management. Four landmark trials in membranous nephropathy, and a fifth clinical trial-which was a pilot study-, have been published in the last years. The results from some of these trials have had a significant impact in the recommendations included in the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) Guideline for the Management of Glomerular Diseases, which represent a significant step forward compared to the previous guideline in several aspects such as diagnosis, disease monitoring and treatment strategies. However, considering the rapidly evolving advances in the knowledge of membranous nephropathy and the recent publication of the STARMEN and RI-CYCLO trials, several recommendations contained in the guideline warrant updates. This manuscript provides a perspective of the Immunonephrology Working Group of the European Renal Association (ERA) regarding the management of membranous nephropathy in native kidneys of adult patients.
Collapse
Affiliation(s)
| | | | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Dimitrios Goumenos
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | | | - Kultigin Turkmen
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Cees van Kooten
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleni Frangou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus. Medical School, University of Cyprus, Nicosia, Cyprus
| | - Kate I Stevens
- Department of Nephrology and Transplantation, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences Lund, Lund University and Skane University Hospital, Lund, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Hans-Joachim Anders
- Department of Internal Medicine IV, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
44
|
Fribourg M, Cioni M, Ghiggeri G, Cantarelli C, Leventhal JS, Budge K, Bin S, Riella LV, Colucci M, Vivarelli M, Angeletti A, Perin L, Cravedi P. CyTOF-Enabled Analysis Identifies Class-Switched B Cells as the Main Lymphocyte Subset Associated With Disease Relapse in Children With Idiopathic Nephrotic Syndrome. Front Immunol 2021; 12:726428. [PMID: 34621271 PMCID: PMC8490633 DOI: 10.3389/fimmu.2021.726428] [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: 06/16/2021] [Accepted: 09/01/2021] [Indexed: 01/21/2023] Open
Abstract
B cell depleting therapies permit immunosuppressive drug withdrawal and maintain remission in patients with frequently relapsing nephrotic syndrome (FRNS) or steroid–dependent nephrotic syndrome (SDNS), but lack of biomarkers for treatment failure. Post-depletion immune cell reconstitution may identify relapsing patients, but previous characterizations suffered from methodological limitations of flow cytometry. Time-of-flight mass cytometry (CyTOF) is a comprehensive analytic modality that simultaneously quantifies over 40 cellular markers. Herein, we report CyTOF-enabled immune cell comparisons over a 12-month period from 30 children with SDNS receiving B cell depleting therapy who either relapsed (n = 17) or remained stable (n = 13). Anti-CD20 treatment depleted all B cells subsets and CD20 depleting agent choice (rituximab vs ofatumumab) did not affect B cell subset recovery. Despite equal total numbers of B cells, 5 subsets of B cells were significantly higher in relapsing individuals; all identified subsets of B cells were class-switched. T cell subsets (including T follicular helper cells and regulatory T cells) and other major immune compartments were largely unaffected by B cell depletion, and similar between relapsing and stable children. In conclusion, CyTOF analysis of immune cells from anti-CD20 antibody treated patients identifies class-switched B cells as the main subset whose expansion associates with disease relapse. Our findings set the basis for future studies exploring how identified subsets can be used to monitor treatment response and improve our understanding of the pathogenesis of the disease.
Collapse
Affiliation(s)
- Miguel Fribourg
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Michela Cioni
- Nephrology, Dialysis and Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - GianMarco Ghiggeri
- Nephrology, Dialysis and Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - Chiara Cantarelli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Dipartimento di Medicina e Chirurgia Università di Parma, Unitá Operativa (UO) Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Jeremy S Leventhal
- Division of Nephrology, White Plains Hospital, White Plains, NY, United States
| | - Kelly Budge
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sofia Bin
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Leonardo V Riella
- Center for Transplantation Sciences, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marina Vivarelli
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Andrea Angeletti
- Nephrology, Dialysis and Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - Laura Perin
- Gabriel Organization for All Renal Research (GOFARR) Laboratory, Children's Hospital Los Angeles, Division of Urology, Saban Research Institute, University of Southern California, Los Angeles, CA, United States
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
45
|
Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 657] [Impact Index Per Article: 219.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
|
46
|
El Ouafi Z, Mugnier C, Jeannet R, Danthu C, Duval M, Belle Mbou V, Touré F. Efficacy of rituximab in thymoma associated minimal change disease: case report. BMC Nephrol 2021; 22:303. [PMID: 34493204 PMCID: PMC8425126 DOI: 10.1186/s12882-021-02479-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 11/21/2022] Open
Abstract
Background Thymomas have been associated with a broad spectrum of autoimmune diseases. Minimal change disease (MCD) is the most frequent pathological lesion reported. Pathophysiological mechanisms involved in secondary MCD, and linking MCD to thymoma are not yet fully explained, although the hypothesis of T cell dysfunction has been suggested. The fundamental therapeutic principles are steroids and surgical treatment of thymoma, but failures and relapses often require immunosuppressant combinations. Case presentation A 62-year-old female was admitted in our unit for a nephrotic syndrome associated with a thymoma. The diagnosis of thymoma associated MCD was confirmed by kidney biopsy. After surgical resection of the thymoma and steroid therapy, no remission was observed. Immunosuppressive therapy was then intensified with introduction of rituximab. Here, we report a steroid-resistant nephrotic syndrome secondary to MCD associated thymoma, which achieved complete remission after rituximab therapy. To the best of our knowledge, this is the first report of the use and efficacy of rituximab therapy in this pathology. Conclusions Our case report suggests that primary and secondary MCD may share similar pathophysiological mechanisms. It does not allow us to draw any conclusions about the mechanism of action of rituximab, but we believe this report argues for the safety and efficacy of rituximab use in thymoma-associated MCD, and therefore constitutes a rationale for future studies.
Collapse
Affiliation(s)
| | | | - Robin Jeannet
- CHU Limoges, Division of Immunology, Limoges, France.,CNRS 7276 - Inserm U1262, CRIBL, University of Limoges, Limoges, France
| | | | - Marion Duval
- CHU Limoges, Division of Nephrology, Limoges, France
| | | | - Fatouma Touré
- CHU Limoges, Division of Nephrology, Limoges, France. .,CNRS 7276 - Inserm U1262, CRIBL, University of Limoges, Limoges, France.
| |
Collapse
|
47
|
Lanaret C, Anglicheau D, Audard V, Büchler M, Caillard S, Couzi L, Malvezzi P, Mesnard L, Bertrand D, Martinez F, Pernin V, Ducloux D, Poulain C, Thierry A, Del Bello A, Rerolle JP, Greze C, Uro-Coste C, Aniort J, Lambert C, Bouvier N, Schvartz B, Maillard N, Sayegh J, Oniszczuk J, Morin MP, Legendre C, Kamar N, Heng AE, Garrouste C. Rituximab for recurrence of primary focal segmental glomerulosclerosis after kidney transplantation: Results of a nationwide study. Am J Transplant 2021; 21:3021-3033. [PMID: 33512779 DOI: 10.1111/ajt.16504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 01/25/2023]
Abstract
Rituximab (RTX) therapy for primary focal segmental glomerulosclerosis recurrence after kidney transplantation (KT) has been extensively debated. We aimed to assess the benefit of adding RTX to plasmapheresis (PP), corticosteroids, and calcineurin inhibitors (standard of care, SOC). We identified 148 adult patients who received KT in 12/2004-12/2018 at 21 French centers: 109 received SOC (Group 1, G1), and 39 received immediate RTX along with SOC (Group 2, G2). In G1, RTX was introduced after 28 days of SOC in the event of failure (G1a, n = 19) or PP withdrawal (G1b, n = 12). Complete remission (CR) was achieved in 46.6% of patients, and partial remission (PR) was achieved in 33.1%. The 10-year graft survival rates were 64.7% and 17.9% in responders and nonresponders, respectively. Propensity score analysis showed no difference in CR+PR rates between G1 (82.6%) and G2 (71.8%) (p = .08). Following the addition of RTX (G1a), 26.3% of patients had CR, and 31.6% had PR. The incidence of severe infections was similar between patients treated with and without RTX. In multivariable analysis, infection episodes were associated with hypogammaglobulinemia <5 g/L. RTX could be used in cases of SOC failure or remission for early discontinuation of PP without increasing the risk of infection.
Collapse
Affiliation(s)
- Camille Lanaret
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Dany Anglicheau
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie et Transplantation, Hôpital Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
| | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris (AP-HP, Service de Néphrologie et Transplantation Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Hôpitaux Universitaires Henri-Mondor, Univ Paris Est Créteil, INSERM, IMRB, Créteil, France
| | - Mathias Büchler
- Service de Néphrologie et Immunologie Clinique, CHRU de Tours, Tours, France
| | - Sophie Caillard
- Service de Néphrologie, University Hospital, Strasbourg, France
| | - Lionel Couzi
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Laurent Mesnard
- Assistance Publique des Hôpitaux de Paris, Hôpital Universitaire Tenon, Urgences Néphrologiques et Transplantation Rénale, Université de Paris, Paris, France
| | | | - Franck Martinez
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie et Transplantation, Hôpital Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
| | - Vincent Pernin
- Service de Néphrologie, Dialyse et Transplantation, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Didier Ducloux
- Service de Néphrologie, Dialyse et Transplantation, CHU Besançon, Besançon, France
| | - Coralie Poulain
- Service de Néphrologie-Médecine Interne-Dialyse-Transplantation, CHU d'Amiens, Amiens, France
| | - Antoine Thierry
- Service de Néphrologie-Hémodialyse-Transplantation Rénale, CHU de Poitiers, Poitiers, France
| | - Arnaud Del Bello
- Département de Néphrologie et Transplantation d'Organes, CHU Toulouse, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Jean P Rerolle
- Service de Néphrologie, Dialyse et Transplantation, CHU Limoges, Limoges, France
| | - Clarisse Greze
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie, Hôpital Universitaire Bichat-Claude-Bernard, Université de Paris, Paris, France
| | - Charlotte Uro-Coste
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Julien Aniort
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Céline Lambert
- Unité de Biostatistiques (DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nicolas Bouvier
- Service de Néphrologie et Transplantation, CHU Caen, Caen, France
| | | | - Nicolas Maillard
- Service de Néphrologie et Transplantation, CHU Saint-Etienne, Saint-Etienne, France
| | - Johnny Sayegh
- Service de Néphrologie-Dialyse-Transplantation, CHU Angers, Angers, France
| | - Julie Oniszczuk
- Assistance Publique des Hôpitaux de Paris (AP-HP, Service de Néphrologie et Transplantation Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Hôpitaux Universitaires Henri-Mondor, Univ Paris Est Créteil, INSERM, IMRB, Créteil, France
| | | | - Christophe Legendre
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie et Transplantation, Hôpital Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
| | - Nassim Kamar
- Département de Néphrologie et Transplantation d'Organes, CHU Toulouse, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Anne E Heng
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| |
Collapse
|
48
|
Chan CY, Teo S, Lu L, Chan YH, Lau PYW, Than M, Jordan SC, Lam KP, Ng KH, Yap HK. Low regulatory T-cells: A distinct immunological subgroup in minimal change nephrotic syndrome with early relapse following rituximab therapy. Transl Res 2021; 235:48-61. [PMID: 33812063 DOI: 10.1016/j.trsl.2021.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
Rituximab is an important second line therapy in difficult nephrotic syndrome (NS), especially given toxicity of long-term glucocorticoid or calcineurin inhibitor (CNI) use. However, clinical response to rituximab is heterogenous. We hypothesized that this was underpinned by immunological differences amongst patients with NS. We recruited a cohort of 18 subjects with glucocorticoid-dependent or glucocorticoid-resistant childhood-onset minimal change NS who received rituximab either due to CNI nephrotoxicity, or due to persistent glucocorticoid toxicity with inadequate response to cyclophosphamide or CNIs. Immunological subsets, T-cell activation assays and plasma cytokines were measured at baseline and 6-months post-rituximab. Time to relapse was bifurcated: 56% relapsed within one year ("early relapse"), while the other 44% entered remission mainly lasting ≥3 years ("sustained remission"). At baseline, early relapse compared to sustained remission group had lower regulatory T-cells (Tregs) [2.94 (2.25, 3.33)% vs 6.48 (5.08, 7.24)%, P<0.001], PMA-stimulated IL-2 [0.03 (0, 1.85)% vs 4.78 (0.90, 9.18)%, P=0.014] and IFNγ [2.22 (0.18, 6.89)% vs 9.47 (2.72, 17.0)%, P=0.035] levels. Lower baseline Treg strongly predicted early relapse (ROC-AUC 0.99, 95% CI 0.97-1.00, P<0.001). There were no differences in baseline plasma cytokine levels. Following rituximab, there was significant downregulation of Th2 cytokines in sustained remission group (P=0.038). In particular, IL-13 showed a significant decrease in sustained remission group [-0.56 (-0.64, -0.35)pg/ml, P=0.007)], but not in the early relapse group. In conclusion, early relapse following rituximab is associated with baseline reductions in Treg and T-cell hyporesponsiveness, which suggest chronic T-cell activation and may be useful predictive biomarkers. Sustained remission, on the other hand, is associated with downregulation of Th2 cytokines following rituximab.
Collapse
Affiliation(s)
- Chang-Yien Chan
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Sharon Teo
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Liangjian Lu
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Yiong-Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Perry Yew-Weng Lau
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Mya Than
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | | | - Kong-Peng Lam
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Bioprocessing Technology Institute, Agency for Science, Technology and Research (A*STAR), Singapore; Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore; Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kar-Hui Ng
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Hui-Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore.
| |
Collapse
|
49
|
Clinical Characteristics and Outcomes of Adults with Nephrotic Syndrome Due to Minimal Change Disease. J Clin Med 2021; 10:jcm10163632. [PMID: 34441929 PMCID: PMC8397036 DOI: 10.3390/jcm10163632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Minimal change disease (MCD) is considered a relatively benign glomerulopathy, as it rarely progresses to end-stage kidney disease. The aim of this study was to describe the characteristics and outcomes of adults with MCD and identify potential risk factors for relapse. PATIENTS & METHODS We retrospectively studied a cohort of adults with biopsy-proven MCD in terms of clinical features and treatment outcomes. Baseline characteristics and outcomes were recorded and predictors of relapse were analyzed using logistic regression multivariate analysis. RESULTS 59 patients with adult-onset primary MCD with nephrotic syndrome were included. Mean serum creatinine at diagnosis was 0.8 mg/dL (±2.5) and estimated GFR (eGFR) was 87 mL/min/1.73 m2 (±29.5). Mean serum albumin was 2.5 g/dL (±0.8) and 24 h proteinuria 6.8 g (±3.7). Microscopic hematuria was detected in 35 (58.5%) patients. 42 patients received prednisone alone, six patients received prednisone plus cyclophosphamide, five patients received prednisone plus cyclosporine, one patient received prednisone plus rituximab and five patients did not receive immunosuppression at all since they achieved spontaneous remission. During a mean follow up time of 34.7(22.1) months, 46.1% of patients experienced at least one episode of relapse. The mean age of patients who did not experience a relapse was significantly higher than that of patients who relapsed while relapsers had a significantly longer duration of 24 h proteinuria prior to biopsy compared to non-relapsers. Overall, 10% of patients experienced acute kidney injury while the mean eGFR at the end was 82 mL/min/1.73 m2 (±29.1) and one patient ended up in chronic dialysis. Overall, the proportion of non-relapsers, who experienced acute kidney injury (17%) was significantly higher than the one recorded among relapsers (0%). CONCLUSION In this series of patients, almost 46% of adult-onset nephrotic MCD patients experienced a relapse, although their renal progression was rare. Younger onset age was an independent risk factor for relapse in adult-onset MCD patients.
Collapse
|
50
|
Koirala A, Jefferson JA. Steroid Minimization in Adults with Minimal Change Disease. GLOMERULAR DISEASES 2021; 1:237-249. [PMID: 36751385 PMCID: PMC9677715 DOI: 10.1159/000517626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/30/2021] [Indexed: 11/19/2022]
Abstract
Background Minimal change disease (MCD) causes approximately 10% of nephrotic syndrome in adults. While glucocorticoids (GCs) effectively induce remission in MCD, the disease has a high relapse rate (50-75%), and repeated exposure to GCs is often required. The adverse effects of GCs are well recognized and commonly encountered with the high doses and recurrent courses used in MCD. Summary In this review, we will discuss the standard therapy of MCD in adults and then describe new therapeutic options in induction therapy and treatment of relapses in MCD, minimizing the exposure to GCs. Key Messages Steroid minimization strategies may decrease adverse effects in the treatment of MCD.
Collapse
|