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Zhang Q, Zhao Y, Luo Y, Guo S, Hou H, Han X, Zhou Y. Urinary exosomal miRNA-451a can be used as a potential noninvasive biomarker for diagnosis, reflecting tubulointerstitial damage and therapeutic response in IgA nephropathy. Ren Fail 2024; 46:2319326. [PMID: 38379319 PMCID: PMC10883088 DOI: 10.1080/0886022x.2024.2319326] [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: 09/27/2023] [Accepted: 02/09/2024] [Indexed: 02/22/2024] Open
Abstract
To investigate the potential clinical value of urinary exosomal (uE) miR-451a as a biomarker for IgAN, urinary exosomes were isolated from 40 patients with IgAN, 30 patients with primary renal diseases without IgA as disease controls (non-IgAN group) and 21 healthy controls (HCs). The expression of miR-451a within exosomes was examined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). uE miR-451a was significantly upregulated in patients with IgAN compared to non-IgAN and HCs. The uE miR-451a level was positively correlated with the change in eGFR and negatively correlated with serum creatinine, urinary macrophage migration inhibitory factor (MIF), interleukin-6 (IL-6) and tumor necrosis factor (TNF-α). A dual-luciferase reporter assay confirmed that MIF was a direct target of miR-451a. Receiver operating characteristic (ROC) curve analysis revealed that the expression of uE miR-451a showed potential diagnostic value for IgAN. Additionally, the uE miR-451a level could distinguish patients with IgAN with mild tubular atrophy/interstitial fibrosis from those with severe tubular atrophy/interstitial fibrosis. After a mean follow-up of 14.2 months, the levels of eGFR loss (ml/min/1.73 m2/year) were negatively correlated with baseline miR-451a. The levels of baseline miR-451a in the complete remission group were significantly higher than those in the non-complete remission group. uE miR-451a expression was significantly elevated in patients with IgA nephropathy and may serve as a potential biomarker for the diagnosis of IgAN and evaluation of tubulointerstitial damage, while the baseline levels of uE miR-451a may be predictors of therapeutic efficacy and disease progression.
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Affiliation(s)
- Qiong Zhang
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Yan Zhao
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Yankun Luo
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Songjia Guo
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Haizhu Hou
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Xiaoli Han
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Yun Zhou
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University, Fifth Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Genetic Engineering Center for Experimental Animal Models, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Shanxi Provincial People's Hospital, Taiyuan, China
- Department of Nephrology, Shanxi Province Integrated Traditional and Western Medicine Hospital, Taiyuan, China
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Selvaskandan H, Barratt J. Dynamic Individualized Risk Prediction in IgA Nephropathy: Entering the Era of Artificial Intelligence. Clin J Am Soc Nephrol 2024:01277230-990000000-00402. [PMID: 38863116 DOI: 10.2215/cjn.0000000000000500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
- Haresh Selvaskandan
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, United Kingdom and Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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Alladin A, Hahn D, Hodson EM, Ravani P, Pfister K, Quinn RR, Samuel SM. Immunosuppressive therapy for IgA nephropathy in children. Cochrane Database Syst Rev 2024; 6:CD015060. [PMID: 38864363 PMCID: PMC11167693 DOI: 10.1002/14651858.cd015060.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common cause of primary glomerulonephritis. It is a heterogeneous disease with different presentations and high morbidity. Thirty per cent of adults and 20% of children (followed into adulthood) will have a 50% decline in kidney function or develop kidney failure after 10 years. OBJECTIVES To determine the benefits and harms of immunosuppressive therapy for the treatment of IgAN in children. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 03 October 2023 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) investigating the treatment of IgAN in children with immunosuppressive therapies compared to placebo, no treatment, supportive care, standard therapy (Japanese protocol), other immunosuppressive therapies or non-immunosuppressive therapies. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias. Random effects meta-analyses were used to summarise estimates of treatment effects. Treatment effects were expressed as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and the mean difference (MD) and 95% CI for continuous outcomes. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs and the ROBIN-I tool for NRSIs. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). MAIN RESULTS This review included 13 studies with 686 participants. Ten RCTs included 334 children and 191 adults, and three NRSIs included 151 participants, all children. Most participants had mild kidney disease. The risk of bias was unclear for most of the domains relating to allocation concealment, blinding of participants, personnel, and outcome assessment. In children with IgAN, it is uncertain if corticosteroid (steroid) therapy, compared to placebo reduces proteinuria (1 study, 64 children and young adults: RR 0.47, 95% CI 0.13 to 1.72; low certainty evidence) or the decline in estimated glomerular filtration rate (eGFR) (1 study, 64 children and young adults: RR 0.47, 95% CI 0.09 to 2.39; low certainty evidence). It is uncertain if steroids reduce proteinuria compared to supportive care (2 studies, 61 children: RR 0.04, 95% CI -0.83 to 0.72; low certainty evidence). Adverse events associated with steroid therapy were not assessed due to heterogeneity in steroid protocols, including dose and duration, and lack of systematic assessment for adverse events in the included studies. Azathioprine, mycophenolate mofetil, mizoribine, or cyclophosphamide alone or in combination with steroid therapy had uncertain effects on improving proteinuria or preventing eGFR decline in children with IgAN. Fish oil, vitamin E and tonsillectomy had uncertain effects on improving proteinuria or preventing eGFR decline. Effects of other immunosuppressive therapies, secondary outcomes and adverse events were not assessed due to insufficient data. AUTHORS' CONCLUSIONS There is a lack of high-quality evidence to guide the management of IgAN in children. There is no evidence to indicate that steroids, other immunosuppressive therapies, or tonsillectomy, when added to optimal supportive care, prevent a decline in eGFR or proteinuria in children with IgAN. Available studies were few, with small numbers, low-quality evidence, high or uncertain risk of bias, did not systematically assess harms associated with treatment, or report net benefits or harms. Severe cases and atypical presentations of IgAN were not included in the reviewed studies, and our findings cannot be generalised to these situations.
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Affiliation(s)
- Areefa Alladin
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
- School of Medicine, University of Guyana, Georgetown, Guyana
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kenneth Pfister
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Susan M Samuel
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
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Kohan DE, Bedard P, Jenkinson C, Hendry B, Komers R. Mechanism of protective actions of sparsentan in the kidney: lessons from studies in models of chronic kidney disease. Clin Sci (Lond) 2024; 138:645-662. [PMID: 38808486 PMCID: PMC11139641 DOI: 10.1042/cs20240249] [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: 02/19/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/30/2024]
Abstract
Simultaneous inhibition of angiotensin II AT1 and endothelin ETA receptors has emerged as a promising approach for treatment of chronic progressive kidney disease. This therapeutic approach has been advanced by the introduction of sparsentan, the first dual AT1 and ETA receptor antagonist. Sparsentan is a single molecule with high affinity for both receptors. It is US Food and Drug Administration approved for immunoglobulin A nephropathy (IgAN) and is currently being developed as a treatment for rare kidney diseases, such as focal segmental glomerulosclerosis. Clinical studies have demonstrated the efficacy and safety of sparsentan in these conditions. In parallel with clinical development, studies have been conducted to elucidate the mechanisms of action of sparsentan and its position in the context of published evidence characterizing the nephroprotective effects of dual ETA and AT1 receptor inhibition. This review summarizes this evidence, documenting beneficial anti-inflammatory, antifibrotic, and hemodynamic actions of sparsentan in the kidney and protective actions in glomerular endothelial cells, mesangial cells, the tubulointerstitium, and podocytes, thus providing the rationale for the use of sparsentan as therapy for focal segmental glomerulosclerosis and IgAN and suggesting potential benefits in other renal diseases, such as Alport syndrome.
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Affiliation(s)
- Donald E. Kohan
- Division of Nephrology, University of Utah Health, Salt Lake City, UT, U.S.A
| | | | | | - Bruce Hendry
- Travere Therapeutics, Inc., San Diego, CA, U.S.A
| | - Radko Komers
- Travere Therapeutics, Inc., San Diego, CA, U.S.A
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Lafayette R, Barbour S, Israni R, Wei X, Eren N, Floege J, Jha V, Kim SG, Maes B, Phoon RKS, Singh H, Tesař V, Lin CJF, Barratt J. A phase 2b, randomized, double-blind, placebo-controlled, clinical trial of atacicept for treatment of IgA nephropathy. Kidney Int 2024; 105:1306-1315. [PMID: 38552841 DOI: 10.1016/j.kint.2024.03.012] [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: 10/11/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 04/17/2024]
Abstract
Atacicept is a first-in-class, dual anti-B-cell Activation Factor-A Proliferation-Inducing Ligand fusion protein in clinical evaluation for treatment of IgA nephropathy. To compare efficacy and safety of atacicept versus placebo in patients with IgAN, this randomized, double-blind, placebo-controlled phase 2b clinical trial ORIGIN enrolled 116 individuals with biopsy-proven IgA nephropathy. Participants were randomized to atacicept 150, 75, or 25 mg versus placebo once weekly for up to 36 weeks. Primary and key secondary endpoints were changes in urine protein creatinine ratio based on 24-hour urine collection at weeks 24 and 36, respectively, in the combined atacicept 150 mg and 75 mg group versus placebo. The primary endpoint was met at week 24 as the mean urine protein creatinine ratio was reduced from baseline by 31% in the combined atacicept group versus 8% with placebo, resulting in a significant 25% reduction with atacicept versus placebo. At week 36, the key secondary endpoint was met as the mean urine protein creatinine ratio reduced from baseline by 34% in the combined atacicept group versus a 2% increase with placebo, resulting in a significant 35% reduction with atacicept versus placebo. The reduction in proteinuria was accompanied by stabilization in endpoint eGFR with atacicept compared to a decline with placebo at week 36, resulting in significant between-group geometric mean difference of 11%, approximating an absolute difference of 5.7 mL/min/1.73m2. Endpoint galactose deficient IgA1 levels significantly decreased from baseline by 60% versus placebo. The safety profile of atacicept was like placebo. Thus, our results provide evidence to support a pivotal, phase 3 study of atacicept in IgA nephropathy.
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Affiliation(s)
- Richard Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Sean Barbour
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Rubeen Israni
- Clinical Development, Vera Therapeutics, Inc., Brisbane, California, USA
| | - Xuelian Wei
- Biostatistics, Vera Therapeutics, Inc., Brisbane, California, USA
| | - Necmi Eren
- Department of Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, Rheinisch Westfälische Technische Hochschule, Aachen University Hospital, Aachen, Germany
| | - Vivekanand Jha
- The George Institute for Global Health India, New Delhi, India; Faculty of Medicine, School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Sung Gyun Kim
- Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Richard K S Phoon
- Westmead Clinical School, The University of Sydney, Sydney, Australia
| | | | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Celia J F Lin
- Medical, Vera Therapeutics, Inc., Brisbane, California, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK.
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Haas M. Podocyte injury as a potential therapeutic target in IgA nephropathy: should pathology guide us? Kidney Int 2024; 105:1165-1167. [PMID: 38777401 DOI: 10.1016/j.kint.2024.03.021] [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: 03/11/2024] [Accepted: 03/19/2024] [Indexed: 05/25/2024]
Abstract
The Oxford histopathologic classification (MEST-C: scores for lesions indicating active glomerular inflammation, mesangial [M] and endocapillary [E] hypercellularity as well as cellular or fibrocellular crescents [C], and for segmental glomerulosclerosis [S] and interstitial fibrosis and/or tubular atrophy [T]) is useful in helping assess prognosis in patients with IgA nephropathy. Elements of this classification indicative of active glomerular inflammation, endocapillary hypercellularity and crescents, also have been found to be responsive to immunosuppressive therapy, potentially including newer agents specifically targeting mediators of such inflammation. In this issue of Kidney International, Bellur and coworkers identify histopathologic subtypes of segmental glomerulosclerosis in IgA nephropathy showing podocyte injury that also behave like active lesions, including showing improved outcomes with immunosuppression. This podocyte injury, identifiable only by kidney biopsy, may represent a potential therapeutic target in some patients with IgA nephropathy.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Trachtman H, Komers R, Inrig J. Sparsentan: the first and only non-immunosuppressive therapy for the reduction of proteinuria in IgA nephropathy. Expert Rev Clin Immunol 2024; 20:571-576. [PMID: 38362830 DOI: 10.1080/1744666x.2024.2319132] [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: 12/30/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION IgA nephropathy is one of the most common forms of glomerular disease. Patients with persistent proteinuria are at increased risk of progression to kidney failure. There is a significant need for safe and effective therapies to lower proteinuria in these patients. Sparsentan is a non-immunosuppressive agent that acts as a dual angiotensin and endothelin receptor antagonist. It lowers proteinuria in experimental models of glomerular disease and in affected patients. AREAS COVERED This review covers the immunological and non-immunological actions of sparsentan in glomerular disease. It reviews the clinical trials that evaluated the impact of the drug in pediatric and adult patients with IgA nephropathy. It places the use of sparsentan in an overall treatment paradigm for the full spectrum of patients with IgA nephropathy including nonspecific renoprotective agents such as inhibitors of the renin-angiotensin-aldosterone axis and SGLT2 transporter and immunosuppressive drugs. The review represents a search of the current literature about the effect of the drug on normal physiology and the pathogenesis of IgA nephropathy. EXPERT OPINION The safety, tolerability, and therapeutic efficacy of sparsentan have been demonstrated in long-term studies of patients with primary glomerular diseases extending over 5 years. The evidence in support of a beneficial treatment effect of sparsentan is stronger in IgAN than in FSGS. It is anticipated that sparsentan will supplant the use of ACEI or ARB as the first-line therapy to reduce proteinuria prior to the implementation of immunosuppressive agents in patients with IgA nephropathy. It may be combined with other renoprotective drugs like SGLT2 inhibitors. Practice guidelines are needed to promote safe and effective use of this new drug by nephrologists caring for patients with IgAN in all clinical settings.
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Affiliation(s)
- Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Jula Inrig
- Travere Therapeutics, Inc, San Diego, CA, USA
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Antonucci L, Fuiano L, Gargiulo A, Gianviti A, Onetti Muda A, Diomedi Camassei F, Vivarelli M, Emma F. Childhood-onset IgA nephropathy: is long-term recovery possible? Pediatr Nephrol 2024; 39:1837-1846. [PMID: 38225439 DOI: 10.1007/s00467-023-06259-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/24/2023] [Accepted: 12/13/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. While studies have primarily focused on identifying risk factors for disease progression, very few data exist on the likelihood of achieving complete recovery from the disease. METHODS We conducted a single-center retrospective study on all consecutive patients with biopsy-proven IgAN diagnosed between 1986 and 2018 in our pediatric center. Biopsies were classified according to the MEST-C Oxford classification score. "Complete clinical remission" was defined as the absence of proteinuria, hematuria, and hypertension in patients with normal kidney function who had been off therapy for more than 2 years. RESULTS Overall, 153 patients with age at onset of 10.6 ± 4 years were enrolled in the study. Of these, 41 achieved "complete clinical remission." The estimated probability of complete clinical remission at 10 years was 43% (95%CI 33-54). However, seven patients relapsed within 10 years. Multivariable analysis showed that higher age at onset (HR 0.89, 95%CI 0.80-0.98, p = 0.017) and segmental glomerulosclerosis lesions (HR 0.28, 95%CI 0.10-0.79, p = 0.017) decreased significantly the chances of achieving complete clinical remission. Immunosuppressive therapy was not significantly associated with clinical outcomes. CONCLUSIONS Approximately one-third of patients with pediatric-onset IgAN achieve prolonged remission, in particular, very young children at disease onset without sclerotic glomerular lesions. Longer term follow-up is needed to assess if these patients have achieved permanent remission.
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Affiliation(s)
- Luca Antonucci
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
- PhD Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | - Laura Fuiano
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Antonio Gargiulo
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Alessandra Gianviti
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Andrea Onetti Muda
- Division of Pathology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | | | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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Toal M, Fergie R, Quinn M, Hill C, O'Neill C, Maxwell AP. Protocol for a systematic review of the application of the kidney failure risk equation and Oxford classification in estimating prognosis in IgA nephropathy. Syst Rev 2024; 13:122. [PMID: 38704598 PMCID: PMC11070080 DOI: 10.1186/s13643-024-02543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND IgA nephropathy (IgAN) is a common cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD). Outcomes are highly variable and predicting risk of disease progression at an individual level is challenging. Accurate risk stratification is important to identify individuals most likely to benefit from treatment. The Kidney Failure Risk Equation (KFRE) has been extensively validated in CKD populations and predicts the risk of ESRD at 2 and 5 years using non-invasive tests; however, its predictive performance in IgAN is unknown. The Oxford classification (OC) describes pathological features demonstrated on renal biopsy that are associated with adverse clinical outcomes that may also inform prognosis. The objective of this systematic review is to compare the KFRE with the OC in determining prognosis in IgAN. METHODS A systematic review will be conducted and reported in line with PRISMA guidelines (PRISMA-P checklist attached as Additional file 1). Inclusion criteria will be cohort studies that apply the KFRE or OC to determine the risk of CKD progression or ESRD in individuals with IgAN. Multiple databases will be searched in duplicate to identify relevant studies, which will be screened first by title, then by abstract and then by full-text analysis. Results will be collated for comparison. Risk of bias and confidence assessments will be conducted independently by two reviewers, with a third reviewer available if required. DISCUSSION Identifying individuals at the highest risk of progression to ESRD is challenging in IgAN, due to the heterogeneity of clinical outcomes. Risk prediction tools have been developed to guide clinicians; however, it is imperative that these aids are accurate and reproducible. The OC is based on observations made by specialist renal pathologists and may be open to observer bias, therefore the utility of prediction models incorporating this classification may be diminished, particularly as in the future novel biomarkers may be incorporated into clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022364569.
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Affiliation(s)
- Michael Toal
- Centre for Public Health, Queen's University of Belfast, Belfast, BT12 6AB, Northern Ireland.
- Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, BT9 7BA, Belfast, Northern Ireland.
| | - Ruth Fergie
- Centre for Public Health, Queen's University of Belfast, Belfast, BT12 6AB, Northern Ireland
- Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, BT9 7BA, Belfast, Northern Ireland
| | - Michael Quinn
- Centre for Public Health, Queen's University of Belfast, Belfast, BT12 6AB, Northern Ireland
| | - Christopher Hill
- Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, BT9 7BA, Belfast, Northern Ireland
| | - Ciaran O'Neill
- Centre for Public Health, Queen's University of Belfast, Belfast, BT12 6AB, Northern Ireland
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University of Belfast, Belfast, BT12 6AB, Northern Ireland
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Barr B, Barbour S. New therapies for immunoglobulin A nephropathy: what's the standard of care in 2023? Curr Opin Nephrol Hypertens 2024; 33:311-317. [PMID: 38411173 DOI: 10.1097/mnh.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW As the most common primary glomerulonephritis, immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of kidney failure and mortality. Until recently, therapeutic options were limited. Fortunately, there have been numerous recent clinical trials demonstrating efficacy of new therapies in slowing chronic kidney disease (CKD) progression at varying stages of disease. RECENT FINDINGS The TESTING trial has provided high-quality evidence for slowing estimated glomerular filtration rate (eGFR) decline with a reduced-dose glucocorticoid regimen, while demonstrating an improved safety profile. Targeted-release budesonide represents a well tolerated therapy for reducing eGFR decline. Mycophenolate mofetil may reduce CKD progression in some populations, while hydroxychloroquine is efficacious in reducing proteinuria. Sodium-glucose cotransporter (SGLT2) inhibitors and sparsentan are effective therapies for CKD due to IgAN, but should not be used in lieu of disease-modifying immunosuppressive therapy. Many new therapies are approaching readiness for clinical use. SUMMARY Numerous therapeutic options now exist and include disease-modifying and nephroprotective drugs. Identifying the right treatment for the right patient is now the clinical challenge and, with new drugs on the horizon, represents the primary unmet research need in this rapidly-developing field.
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Affiliation(s)
- Bryce Barr
- Section of Nephrology, Department of Medicine, Max Rady College of Medicine, University of Manitoba
| | - Sean Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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Haas M. IgA vasculitis nephritis: insights from kidney biopsies. Curr Opin Nephrol Hypertens 2024; 33:298-303. [PMID: 38411035 DOI: 10.1097/mnh.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW To present findings indicating the value of kidney biopsy in assessing prognosis and guiding clinical approach to patients with IgA vasculitis nephritis (IgAVN), including a recent international study examining the value of the Oxford (MEST-C) classification. RECENT FINDINGS Historically, kidney biopsies with IgAVN are scored using the International Society for Kidney Diseases in Children (ISKDC) classification. However, this classification has limited prognostic value, and most biopsies fall into just two of the six ISKDC grades. There are few studies examining the clinical value of the Oxford classification, which is well documented to be predictive of kidney outcomes in IgA nephropathy, in IgAVN. However, a recent study of 361 biopsied patients with IgAVN showed that endocapillary hypercellularity (Oxford E1) predicted a subclass of patients showing initial improvement in kidney function with immunosuppressive treatment, followed by a later decline. SUMMARY Kidney outcome in patients with biopsied IgAVN treated with immunosuppression is determined by clinical factors and endocapillary hypercellularity. The latter is not part of the ISKDC classification and supports including MEST-C scores in biopsy reports of IgAVN. Even patients showing a good initial response to immunosuppression require long-term follow-up due to risk of subsequent kidney function decline.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Del Vecchio L, Allinovi M, Comolli S, Peiti S, Rimoldi C, Locatelli F. Drugs in Development to Treat IgA Nephropathy. Drugs 2024; 84:503-525. [PMID: 38777962 DOI: 10.1007/s40265-024-02036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
IgA nephropathy is a common glomerulonephritis consequent to the autoimmune response to aberrant glycosylated immunoglobulin (Ig) A antibodies. Although it has historically been considered a benign disease, it has since become clear that a substantial percentage of patients reach end-stage kidney failure over the years. Several therapeutic attempts have been proposed, with systemic steroids being the most prevalent, albeit burdened by possible serious adverse events. Thanks to the more in-depth knowledge of the pathogenesis of IgA nephropathy, new treatment targets have been identified and new drugs developed. In this narrative review, we summarise the molecules under clinical development for the treatment of IgA nephropathy. As a search strategy, we used PubMed, Google, ClinicalTrials.gov and abstracts from recent international congresses. TRF budesonide and sparsentan are the two molecules at a more advanced stage, just entering the market. Other promising agents are undergoing phase III clinical development. These include anti-APRIL and anti-BLyS/BAFF antibodies and some complement inhibitors. Other new possible strategies include spleen tyrosine kinase inhibitors, anti-CD40 ligands and anti-CD38 antibodies. In an era increasingly characterised by 'personalised medicine' and 'precision therapy' approaches and considering that the potential therapeutic armamentarium for IgA nephropathy will be very broad in the near future, the identification of biomarkers capable of helping the nephrologist to select the right drug for the right patient should be the focus of future studies.
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Affiliation(s)
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Stefania Comolli
- Department of Nephrology and Dialysis, ASST Sette Laghi, Varese, Italy
| | - Silvia Peiti
- Department of Nephrology and Dialysis, ASST Lariana, Como, Italy
| | | | - Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, ASST Lecco, Lecco, Italy
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13
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Davies E, Chetwynd A, McDowell G, Rao A, Oni L. The current use of proteomics and metabolomics in glomerulonephritis: a systematic literature review. J Nephrol 2024:10.1007/s40620-024-01923-w. [PMID: 38689160 DOI: 10.1007/s40620-024-01923-w] [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: 10/22/2023] [Accepted: 02/24/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Glomerulonephritis inherently leads to the development of chronic kidney disease. It is the second most common diagnosis in patients requiring renal replacement therapy in the United Kingdom. Metabolomics and proteomics can characterise, identify and quantify an individual's protein and metabolite make-up. These techniques have been optimised and can be performed on samples including kidney tissue, blood and urine. Utilising omic techniques in nephrology can uncover disease pathophysiology and transform the diagnostics and treatment options for glomerulonephritis. OBJECTIVES To evaluate the utility of metabolomics and proteomics using mass spectrometry and nuclear magnetic resonance in glomerulonephritis. METHODS The systematic review was registered on PROSPERO (CRD42023442092). Standard and extensive Cochrane search methods were used. The latest search date was March 2023. Participants were of any age with a histological diagnosis of glomerulonephritis. Descriptive analysis was performed, and data presented in tabular form. An area under the curve or p-value was presented for potential biomarkers discovered. RESULTS Twenty-seven studies were included (metabolomics (n = 9)), and (proteomics (n = 18)) with 1818 participants. The samples analysed were urine (n = 19) blood (n = 4) and biopsy (n = 6). The typical outcome themes were potential biomarkers, disease phenotype, risk of progression and treatment response. CONCLUSION This review shows the potential of metabolomic and proteomic analysis to discover new disease biomarkers that may influence diagnostics and disease management. Further larger-scale research is required to establish the validity of the study outcomes, including the several proposed biomarkers.
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Affiliation(s)
- Elin Davies
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Nephrology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
| | - Andrew Chetwynd
- Centre for Proteome Research, Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Garry McDowell
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Clinical Directorate, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Research Laboratory, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Anirudh Rao
- Department of Nephrology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Clinical Directorate, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Nephrology, Alder Hey Children's, NHS Foundation Trust Hospital, Eaton Road, Liverpool, UK
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14
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Obrișcă B, Mocanu V, Jurubiță R, Vrabie A, Berechet A, Lujinschi Ș, Sorohan B, Andronesi A, Achim C, Lupușoru G, Micu G, Caceaune N, Gherghiceanu M, Ismail G. Histological reappraisal of IgA nephropathy: the role of glomerular pattern of injury and mesangial complement deposition. BMC Nephrol 2024; 25:145. [PMID: 38658875 PMCID: PMC11040743 DOI: 10.1186/s12882-024-03577-z] [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: 01/19/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND There is a clear need to refine the histological assessment in IgA Nephropathy (IgAN). We sought to investigate the clinical significance of the light microscopy (LM) pattern of glomerular injury and of the intensity of mesangial C3 staining in IgAN. METHODS We conducted a retrospective, observational study that included all patients with biopsy-proven primary IgAN that had at least 12 months of follow-up. The LM pattern of glomerular injury was reevaluated based on a modified HAAS classification. Mesangial C3 deposition by immunofluorescence (IF) staining was scored semi-quantitatively. The study primary composite endpoint was defined as doubling of serum creatinine or ESRD (dialysis, renal transplant or eGFR < 15 ml/min). The secondary study endpoint was eGFR decline per year. RESULTS This cohort included 214 patients with IgAN (mean age, 41.4 ± 12.6 years), with a mean eGFR and median 24-h proteinuria of 55.2 ± 31.5 ml/min/1.73m2 and 1.5 g/day (IQR:0.8-3.25), respectively. The most frequent LM pattern was the mesangioproliferative (37.4%), followed by the sclerotic (22.5%) and proliferative/necrotizing patterns (21.4%). Regarding the IF findings, mild-moderate and intense mesangial C3 staining was present in 30.6% and 61.1% of patients, respectively. Those with sclerosing and crescentic patterns had the worst renal survival (5-year renal survival of 48.8% and 42.9%) and the highest rate of eGFR change/year (-2.32 ml/min/y and - 2.16 ml/min/y, respectively) compared to those with other glomerular patterns of injury. In addition, those with intense C3 staining reached the composite endpoint more frequently compared to those without intense C3 staining (35.5% vs. 21.4%, p = 0.04). After multivariate adjustment, patients with crescentic and sclerosing patterns had a 3.6-fold and 2.1-fold higher risk for the composite endpoint compared to those with mesangioproliferative pattern, while an intense mesangial C3 deposition being also associated with a worse renal outcome (HR, 3.33; 95%CI, 1.21-9.2). CONCLUSIONS We have shown that the LM pattern of glomerular injury and the intensity of mesangial C3 deposition might stratify more accurately the renal outcome in patients with IgAN.
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Affiliation(s)
- Bogdan Obrișcă
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.
| | - Valentin Mocanu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Roxana Jurubiță
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandra Vrabie
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Berechet
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Ștefan Lujinschi
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Bogdan Sorohan
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Andronesi
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Camelia Achim
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriela Lupușoru
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Georgia Micu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicu Caceaune
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Mihaela Gherghiceanu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Gener Ismail
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
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15
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Guo X, Tie X, Zhang Y, Dai Y, Yao S, Qiao X, Wang L, Su X. Management and Clinical Outcomes of Membranous Nephropathy, IgA Nephropathy, and Minimal Change Disease Two Years Post-Kidney Biopsy. Kidney Blood Press Res 2024; 49:345-354. [PMID: 38615671 DOI: 10.1159/000538851] [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: 12/13/2023] [Accepted: 04/08/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION This study evaluated the phenotypic and pathology characteristics of patients undergoing kidney biopsy at a single center, while also determining the frequency and factors associated with clinical outcomes. METHODS The incidence and distribution of biopsy-proven kidney diseases in 2000-2019 were surveyed. Consecutive individuals diagnosed with membranous nephropathy (MN), immunoglobulin A nephropathy (IgAN), and minimal change disease (MCD) between August 2015 and December 2019 were enrolled in the prospective 2-year follow-up study. Outcomes included remission of proteinuria and kidney disease progression events. Multivariable-adjusted Cox proportional hazards model was applied. RESULTS 4,550 kidney biopsies were performed in 2000-2019, showing a noticeable increase in the proportion of MN. 426 patients were enrolled in the follow-up cohort. 346 (81.2%) achieved remission of proteinuria, 39 (9.2%) suffered kidney disease progression and 51.3% of them were diagnosed with IgAN. Kidney pathological diagnosis (MN vs. MCD: hazard ratio [HR], 0.42; 95% confidence interval [95% CI], 0.31-0.57; IgAN vs. MCD: 0.58; 0.39-0.85), levels of 24-h urine protein at biopsy (1.04; 1.00-1.08) and presence of nodular mesangial sclerosis (0.70; 0.49-0.99) were significantly correlated with remission of proteinuria after adjusting for baseline variables. 24-h urine protein levels at biopsy (1.14; 1.04-1.25) and the presence of crescents (2.30; 1.06-4.95) were the independent risk factors for kidney disease progression events after adjusting for baseline variables. CONCLUSION The increasing frequency of MN has been affirmed over the past 2 decades. The therapeutic status, clinical outcomes, and factors influencing these outcomes were presented in this single-center study for the three primary glomerular diseases.
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Affiliation(s)
- Xiaojiao Guo
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Xuan Tie
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Yuyu Zhang
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Yemei Dai
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Shulei Yao
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Xi Qiao
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Lihua Wang
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
| | - Xiaole Su
- Department of Nephrology, Shanxi Medical University Second Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
- Institute of Nephrology, Shanxi Medical University, Taiyuan, China
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16
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Selvaskandan H, Barratt J. Charting new frontiers in IgA nephropathy: a paradigm shift toward precision medicine and early intervention? Kidney Int 2024; 105:659-661. [PMID: 38519229 DOI: 10.1016/j.kint.2024.01.023] [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: 01/09/2024] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 03/24/2024]
Abstract
Advancements in glomerular transcriptomics offer a promising avenue toward precision medicine in IgA nephropathy. Traditional prognostic biomarkers, including proteinuria, blood pressure, and histomorphometry, fall short at capturing the complexity of IgA nephropathy and can only crudely guide therapeutic decisions. This issue needs to be addressed urgently as pathway-specific treatments become available. Glomerular transcriptomics, although technically challenging, offers an opportunity to refine prognostic precision and identify therapeutic targets, even when apparent risk of disease progression is low.
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Affiliation(s)
- Haresh Selvaskandan
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK; Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jonathan Barratt
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK; Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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17
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Oni L, Smith R, Salama AD, Barratt J, Trachtman H, Saleem M. Bridging the 13-Year Evidence Gap: A Time for Age-Inclusive Research. J Am Soc Nephrol 2024; 35:502-504. [PMID: 38221654 PMCID: PMC11000737 DOI: 10.1681/asn.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 01/16/2024] Open
Affiliation(s)
- Louise Oni
- Department of Women's and Children's Health, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Nephrology, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Rona Smith
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Alan D. Salama
- University College London Centre for Kidney and Bladder Health, Royal Free Hospital, London, United Kingdom
| | - Jonathan Barratt
- John Walls Renal Unit, University Hospitals of Leicester, Leicester, United Kingdom
| | - Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Moin Saleem
- Bristol Renal, Department of Translational Health Sciences, University of Bristol, Bristol, United Kingdom
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18
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Li J, Dong Y, Chen F, Yang H, Chen P, Li H, Shi S, Zhou X, Zhu L, Zhang Y, Liu L, Xie X, Yu F, Jin J, Lv J, Zhang H. Heterozygous mutations in factor H aggravate pathological damage in a stable IgA deposition model induced by Lactobacillus casei cell wall extract. Front Immunol 2024; 15:1368322. [PMID: 38558821 PMCID: PMC10978756 DOI: 10.3389/fimmu.2024.1368322] [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: 01/10/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Activation of complement through the alternative pathway (AP) has a key role in the pathogenesis of IgA nephropathy (IgAN). We previously showed, by intraperitoneal injection of Lactobacillus casei cell wall extract (LCWE), C57BL/6 mice develop mild kidney damage in association with glomerular IgA deposition. To further address complement activity in causing glomerular histological alterations as suggested in the pathogenesis of IgAN, here we used mice with factor H mutation (FHW/R) to render AP overactivation in conjunction with LCWE injection to stimulate intestinal production of IgA. Methods Dose response to LCWE were examined between two groups of FHW/R mice. Wild type (FHW/W) mice stimulated with LCWE were used as model control. Results The FHW/R mice primed with high dose LCWE showed elevated IgA and IgA-IgG complex levels in serum. In addition to 100% positive rate of IgA and C3, they display elevated biomarkers of kidney dysfunction, coincided with severe pathological lesions, resembling those of IgAN. As compared to wild type controls stimulated by the same high dose LCWE, these FHW/R mice exhibited stronger complement activation in the kidney and in circulation. Discussion The new mouse model shares many disease features with IgAN. The severity of glomerular lesions and the decline of kidney functions are further aggravated through complement overactivation. The model may be a useful tool for preclinical evaluation of treatment response to complement-inhibitors.
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Affiliation(s)
- Jingyi Li
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Yaping Dong
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Feifei Chen
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Hongyu Yang
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Pei Chen
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Hongyu Li
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Sufang Shi
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Xujie Zhou
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Li Zhu
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Yuemiao Zhang
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Lijun Liu
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Xinfang Xie
- Department of Nephrology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an, China
| | - Feng Yu
- Department of Nephrology, Peking University International Hospital, Beijing, China
| | - Jing Jin
- Northwestern University Feinberg School of Medicine, Division of Nephrology, Chicago, IL, United States
| | - Jicheng Lv
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
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19
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Lerma EV, Thakker KM, Bensink ME, Lieblich R, Bunke CM, Gong W, Rava AR, Wang K, Amari DT, Oliveri D, Murphy MV, Cork DM, Velez JCQ. Kidney Failure Events, Cardiovascular Disease Events, and All-Cause Mortality in Patients with IgA Nephropathy in a Real-World Database. KIDNEY360 2024; 5:427-436. [PMID: 38323871 PMCID: PMC11000736 DOI: 10.34067/kid.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/22/2024] [Indexed: 02/08/2024]
Abstract
Key Points In our US real-world cohort study of patients with IgA nephropathy, elevated proteinuria and progression to kidney failure (KF) were associated with a higher risk of cardiovascular disease/mortality events. Elevated pre-KF proteinuria was also associated with progression to KF/mortality events. Incremental costs associated with CKD stage, nephrotic syndrome, and cardiovascular disease events and of these events were high. Background IgA nephropathy (IgAN)–associated glomerular injury leads to proteinuria, hematuria, and progressive loss of GFR, with progression to kidney failure (KF). This retrospective study evaluated the prognostic effects of proteinuria and progression to KF on cardiovascular disease (CVD)/mortality events and KF/mortality events in the United States. Methods We conducted a noninterventional, retrospective cohort study in adult patients with IgAN using Optum's deidentified Market Clarity Data (January 1, 2007, to March 31, 2021). Adult (age ≥18 years) patients with at least two signs, disease, symptoms natural language processing term entries for IgAN, within 180 and ≥30 days apart within the identification period were included. Outcomes were assessed by time-dependent proteinuria (≥1 versus <1 g/d) and KF status (pre versus post). Descriptive statistics were used for categorical and continuous variables. Multivariable Cox proportional hazard models with time-dependent predictors were used to estimate differences across groups. Results Patients with pre-KF status and proteinuria ≥1 g/d were more likely to have a CVD/mortality event during follow-up (adjusted hazard ratio [HR; 95% confidence interval (CI)]: 1.80 [1.12 to 2.89]; P < 0.001) or a KF/mortality event (adjusted HR [95% CI]: 2.10 [1.73 to 2.56]; P < 0.001). Patients with post-KF status were more likely to have a CVD/mortality event during follow-up (adjusted HR [95% CI]: 3.28 [2.82 to 3.81]; P < 0.001). Conclusions Elevated proteinuria and progression to KF were associated with a higher risk of CVD/mortality events. Elevated pre-KF proteinuria was also associated with progression to KF/mortality events. On the basis of our real-world retrospective database analysis, we hypothesize that novel IgAN therapies that reduce proteinuria and slow the rate of progression to KF have the potential to reduce CVD risk, improve kidney outcomes, and prolong/increase overall survival.
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Affiliation(s)
- Edgar V. Lerma
- University of Illinois Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois
| | | | | | | | | | - Wu Gong
- Travere Therapeutics, Inc., San Diego, California
| | | | - Kaijun Wang
- Travere Therapeutics, Inc., San Diego, California
| | | | | | | | | | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
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20
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Cheung CK, Barratt J, Carroll K, Lafayette RA, Liew A, Suzuki Y, Tesař V, Trimarchi H, Wong MG, Zhang H, Perkovic V, Rizk DV. Targeting APRIL in the Treatment of IgA Nephropathy. Clin J Am Soc Nephrol 2024; 19:394-398. [PMID: 37801688 PMCID: PMC10937009 DOI: 10.2215/cjn.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/29/2023] [Indexed: 10/08/2023]
Affiliation(s)
- Chee Kay Cheung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | | | - Richard A. Lafayette
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Adrian Liew
- The Kidney and Transplant Practice, Mount Elizabeth Novena Hospital, Singapore
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Vladimír Tesař
- Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic
| | - Hernán Trimarchi
- Nephrology Service and Kidney Transplant Unit, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Muh Geot Wong
- Concord Repatriation General Hospital, Concord, Australia
- University of Sydney, Camperdown, Australia
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, People's Republic of China
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | - Dana V. Rizk
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Zhang Q, Pan H, Bian XY, Yu JH, Wu LL, Chen YD, Li L, Ji LX, Yu YL, Han F, Huang J, Wang YF, Yang Y. Crescent calculator: A webtool enabling objective decision-making for assessment of IgA nephropathy immune activity throughout the disease course. Clin Chim Acta 2024; 555:117783. [PMID: 38272251 DOI: 10.1016/j.cca.2024.117783] [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: 11/28/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
IgA nephropathy (IgAN) is an immune-mediated glomerulonephritis, posing a challenge for the long-term management. It is crucial to monitor the disease's activity over the disease course. Crescent lesions have been known as an active lesion associated with immune activity. We aimed to develop the Crescent Calculator to aid clinicians in making timely and well-informed decisions throughout the long-term disease course, such as renal biopsies and immunosuppressive therapy. 1,761 patients with biopsy-proven IgAN were recruited from four medical centers in Zhejiang Province, China. 16.9% presented crescent lesions. UPCR, URBC, eGFR and C4 were independently associated with the crescent lesions. By incorporating these variables, the Crescent Calculator was constructed to estimate the likelihood of crescent lesions. The predictor achieved AUC values of over 0.82 in two independent testing datasets. In addition, to fulfill varied clinical needs, multiple classification modes were established. The Crescent Calculator was developed to estimate the risk of crescent lesions for patients with IgAN, assisting clinicians in making timely, objective, and well-informed decisions regarding the need for renal biopsies and more appropriate use of immunosuppressive therapy in patients with IgAN.
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Affiliation(s)
- Qian Zhang
- Department of Nephrology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang University Belt and Road International School of Medicine, Yiwu, China
| | - Hong Pan
- Department of Nephrology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang University Belt and Road International School of Medicine, Yiwu, China
| | - Xue-Yan Bian
- Department of Nephrology, Ningbo First Hospital, Ningbo, China
| | - Jin-Han Yu
- Warshel Institute for Computational Biology and School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Long-Long Wu
- Department of Nephrology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang University Belt and Road International School of Medicine, Yiwu, China
| | - Yi-Dan Chen
- Warshel Institute for Computational Biology and School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Li Li
- Department of Nephrology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang University Belt and Road International School of Medicine, Yiwu, China
| | - Ling-Xi Ji
- Warshel Institute for Computational Biology and School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Ya-Li Yu
- Department of Nephrology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang University Belt and Road International School of Medicine, Yiwu, China
| | - Fei Han
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jian Huang
- Department of Nephrology, Jinhua Municipal Central Hospital, Jinhua, China.
| | - Yong-Fei Wang
- Warshel Institute for Computational Biology and School of Medicine, The Chinese University of Hong Kong, Shenzhen, China; Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China.
| | - Yi Yang
- Department of Nephrology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang University Belt and Road International School of Medicine, Yiwu, China.
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Kor A, Sungu N, Karabulut Ş, Erten Ş. Renal tubular estrogen ß receptors are expressed at high levels in small vessel vasculitis and are primarily localized in the distal tubule. FASEB J 2024; 38:e23497. [PMID: 38376916 DOI: 10.1096/fj.202302362rr] [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: 11/16/2023] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
This study investigated the possible roles of renal estrogen receptors (ER) in glomerulonephritis associated with small vessel vasculitis. The relationships of ERs were investigated in antineutrophilic cytoplasmic antibody (ANCA)-associated glomerulonephritis and immunoglobulin A (IgA) nephropathy groups, which are small vessel vasculitis subtypes with two different glomerulonephritis development pathophysiologies. The design of this study was prepared as a retrospective cohort study. The study included 42 patients with ANCA-associated vasculitis and 18 with IgA nephropathy in the small vessel vasculitis group. For the control group, intact renal tissues of 28 patients who underwent nephrectomy due to renal cell carcinoma were used. Renal biopsy samples of the groups were stained with ER beta (ß) and ER alpha (α). Tubular ER ß expression score (TERßES) median values were found to be significantly higher in ANCA- associated vasculitis (B = 0.724, OR [95%CI]: 2.064 [1.141-3.731], p = .016) and IgA nephropathy (B = 0.898, OR [95%CI]: 2.454 [1.307-4.609], p = .005) than in intact kidney tissue. It was determined that tubular ERß was most frequently localized in the distal tubule at 57.9% and the second most common in the proximal tubule at 20.4%. The expression of tubular ERß is increased in glomerulonephritis due to small vessel vasculitis. Tubular ERßs are most commonly localized in the distal tubule. Further studies are needed to understand the physiological and pathophysiological effects of altered renal ER levels in small vessel vasculitis.
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Affiliation(s)
- Ahmet Kor
- Department of Rheumatology, Ministry of Health, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Nuran Sungu
- Department of Medical Pathology, Faculty of Medicine Ankara Bilkent City Hospital, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Şefika Karabulut
- Gulhane Department of Microbiology, Virology, Health Sciences University, Ankara, Turkey
| | - Şükran Erten
- Department of Rheumatology, Faculty of Medicine Ankara Bilkent City Hospital, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Duan ZY, Bu R, Liang S, Chen XZ, Zhang C, Zhang QY, Li JJ, Chen XM, Cai GY. Urinary miR-185-5p is a biomarker of renal tubulointerstitial fibrosis in IgA nephropathy. Front Immunol 2024; 15:1326026. [PMID: 38426107 PMCID: PMC10902439 DOI: 10.3389/fimmu.2024.1326026] [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: 10/22/2023] [Accepted: 01/31/2024] [Indexed: 03/02/2024] Open
Abstract
Background For IgA nephropathy (IgAN), tubular atrophy/interstitial fibrosis is the most important prognostic pathological indicator in the mesangial and endocapillary hypercellularity, segmental sclerosis, interstitial fibrosis/tubular atrophy, and presence of crescents (MEST-C) score. The identification of non-invasive biomarkers for tubular atrophy/interstitial fibrosis would aid clinical monitoring of IgAN progression and improve patient prognosis. Methods The study included 188 patients with primary IgAN in separate confirmation and validation cohorts. The associations of miR-92a-3p, miR-425-5p, and miR-185-5p with renal histopathological lesions and prognosis were explored using Spearman correlation analysis and Kaplan-Meier survival curves. Bioinformatics analysis and dual luciferase experiments were used to identify hub genes for miR-185-5p. The fibrotic phenotypes of tubular epithelial cells were evaluated in vivo and in HK-2 cells. Results miRNA sequencing and cohort validation revealed that the expression levels of miR-92a-3p, miR-425-5p, and miR-185-5p in urine were significantly increased among patients with IgAN; these levels could predict the extent of tubular atrophy/interstitial fibrosis in such patients. The combination of the three biomarkers resulted in an area under the receiver operating characteristic curve of 0.742. The renal prognosis was significantly worse in the miR-185-5p high expression group than in the low expression group (P=0.003). Renal tissue in situ hybridization, bioinformatics analysis, and dual luciferase experiments confirmed that miR-185-5p affects prognosis in patients with IgAN mainly by influencing expression of the target gene tight junction protein 1 (TJP1) in renal tubular epithelial cells. In vitro experiment revealed that an miR-185-5p mimic could reduce TJP1 expression in HK-2 cells, while increasing the levels of α-smooth muscle actin, fibronectin, collagen I, and collagen III; these changes promoted the transformation of renal tubular epithelial cells to a fibrotic phenotype. An miR-185-5p inhibitor can reverse the fibrotic phenotype in renal tubular epithelial cells. In a unilateral ureteral obstruction model, the inhibition of miR-185-5p expression alleviated tubular atrophy/interstitial fibrosis. Conclusion Urinary miR-185-5p, a non-invasive biomarker of tubular atrophy/interstitial fibrosis in IgAN, may promote the transformation of renal tubular epithelial cells to a fibrotic phenotype via TJP1.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Guang-Yan Cai
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing, China
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Tang C, Chen P, Si FL, Lv JC, Shi SF, Zhou XJ, Liu LJ, Zhang H. Time-Varying Proteinuria and Progression of IgA Nephropathy: A Cohort Study. Am J Kidney Dis 2024:S0272-6386(24)00609-7. [PMID: 38364955 DOI: 10.1053/j.ajkd.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 02/18/2024]
Abstract
RATIONALE & OBJECTIVE Proteinuria is a surrogate end point for predicting long-term kidney outcomes in IgA nephropathy (IgAN) with levels<1g/day identified as a therapeutic target. However, this threshold has not been sufficiently studied. We quantified the associations of progression of IgAN with various levels of proteinuria. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 1,530 patients with IgAN and at least 12 months of follow-up at Peking University First Hospital. EXPOSURE Proteinuria levels updated over time (time-varying proteinuria, TVP). OUTCOME A composite kidney outcome of a 50% reduction in the estimated glomerular filtration rate or end-stage kidney disease. ANALYTICAL APPROACH Marginal structural models. RESULTS After a median follow-up period of 43.5 (IQR, 27.2-72.8) months, 254 patients (16.6%) developed the composite kidney outcome. A graded association was observed between TVP and composite kidney outcomes with higher risk among those with proteinuria of≥0.5g/day. Compared with TVP<0.3g/day, the HRs for proteinuria levels of 0.3 to<0.5g/day, 0.5 to<1.0g/day, 1.0 to<2.0g/day, and≥2.0g/day were 2.22 (95% CI, 0.88-5.58), 4.04 (95% CI, 1.93-8.46), 8.46 (95% CI, 3.80-18.83), and 38.00 (95% CI, 17.62-81.95), respectively. The trend was more pronounced in patients with baseline proteinuria of≥1.0g/day, among whom a higher risk was observed with TVP of 0.3 to<0.5g/day compared with TVP<0.3g/day (HR, 3.26 [95% CI, 1.07-9.92], P=0.04). However, in patients with baseline proteinuria levels of<1g/day, the risk of composite kidney outcome only began to increase when TVP was≥1.0g/day (HR, 3.25 [95% CI, 1.06-9.90]). LIMITATIONS Single-center observational study, selection bias, and unmeasured confounders. CONCLUSIONS This study showed that patients with IgAN and proteinuria levels of>0.5g/day, have an elevated risk of kidney failure especially among patients with proteinuria levels≥1.0g/day before initiating treatment. These data may serve to inform the selection of proteinuria targets in the treatment of IgAN. PLAIN-LANGUAGE SUMMARY The presence of proteinuria has often been considered a surrogate end point and a possible therapeutic target in clinical trials in IgA nephropathy (IgAN). Some guidelines recommend a reduction in proteinuria to<1g/day as a treatment goal based on the results of previous longitudinal studies. However, these findings may have been biased because they did not properly adjust for time-dependent confounders. Using marginal structural models to appropriately account for these confounding influences, we observed that patients with IgAN and proteinuria levels≥0.5g/day have an elevated risk of kidney failure, especially among patients who had proteinuria levels of≥1.0g/day before initiating treatment. These data may serve to inform the selection of proteinuria targets in the treatment of IgAN.
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Affiliation(s)
- Chen Tang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Pei Chen
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Feng-Lei Si
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xu-Jie Zhou
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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25
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Lim RS, Yeo SC, Barratt J, Rizk DV. An Update on Current Therapeutic Options in IgA Nephropathy. J Clin Med 2024; 13:947. [PMID: 38398259 PMCID: PMC10889409 DOI: 10.3390/jcm13040947] [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: 01/01/2024] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
Immunoglobulin A nephropathy (IgAN) remains the leading cause of primary glomerular disease worldwide. Outcomes are poor with high rates of progressive chronic kidney disease and kidney failure, which contributes to global healthcare costs. Although this disease entity has been described, there were no disease-specific treatments until recently, with the current standard of care focusing on optimal supportive measures including lifestyle modifications and optimization of the renin-angiotensin-aldosterone blockade. However, with significant advances in the understanding of the pathogenesis of IgAN in the past decade, and the acceptance of surrogate outcomes for accelerated drug approval, there have been many new investigational agents tested to target this disease. As these agents become available, we envision a multi-pronged treatment strategy that simultaneously targets the consequences of ongoing nephron loss, stopping any glomerular inflammation, inhibiting pro-fibrotic signals in the glomerulus and tubulo-interstitium, and inhibiting the production of pathogenic IgA molecules. This review is an update on a previous review published in 2021, and we aim to summarize the developments and updates in therapeutic strategies in IgAN and highlight the promising discoveries that are likely to add to our armamentarium.
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Affiliation(s)
- Regina Shaoying Lim
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; (R.S.L.); (S.C.Y.)
| | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; (R.S.L.); (S.C.Y.)
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK;
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester LE5 4PW, UK
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, ZRB 614, 1720 2nd Avenue South, Birmingham, AL 35294, USA
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Joshi A, Mariani LH. Reaping the rewards of mechanistic discovery in glomerular disease. Nat Rev Nephrol 2024; 20:77-78. [PMID: 38123699 DOI: 10.1038/s41581-023-00804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Arpita Joshi
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Laura H Mariani
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA.
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Cheung CK, Barratt J, Liew A, Zhang H, Tesar V, Lafayette R. The role of BAFF and APRIL in IgA nephropathy: pathogenic mechanisms and targeted therapies. FRONTIERS IN NEPHROLOGY 2024; 3:1346769. [PMID: 38362118 PMCID: PMC10867227 DOI: 10.3389/fneph.2023.1346769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/31/2023] [Indexed: 02/17/2024]
Abstract
Immunoglobulin A nephropathy (IgAN), characterized by mesangial deposition of galactose-deficient-IgA1 (Gd-IgA1), is the most common biopsy-proven primary glomerulonephritis worldwide. Recently, an improved understanding of its underlying pathogenesis and the substantial risk of progression to kidney failure has emerged. The "four-hit hypothesis" of IgAN pathogenesis outlines a process that begins with elevated circulating levels of Gd-IgA1 that trigger autoantibody production. This results in the formation and deposition of immune complexes in the mesangium, leading to inflammation and kidney injury. Key mediators of the production of Gd-IgA1 and its corresponding autoantibodies are B-cell activating factor (BAFF), and A proliferation-inducing ligand (APRIL), each playing essential roles in the survival and maintenance of B cells and humoral immunity. Elevated serum levels of both BAFF and APRIL are observed in patients with IgAN and correlate with disease severity. This review explores the complex pathogenesis of IgAN, highlighting the pivotal roles of BAFF and APRIL in the interplay between mucosal hyper-responsiveness, B-cell activation, and the consequent overproduction of Gd-IgA1 and its autoantibodies that are key features in this disease. Finally, the potential therapeutic benefits of inhibiting BAFF and APRIL in IgAN, and a summary of recent clinical trial data, will be discussed.
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Affiliation(s)
- Chee Kay Cheung
- Division of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, United Kingdom
| | - Jonathan Barratt
- Division of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, United Kingdom
| | - Adrian Liew
- The Kidney & Transplant Practice, Mount Elizabeth Novena Hospital, Singapore
| | - Hong Zhang
- Renal Division in the Department of Medicine, Peking University First Hospital, Beijing, China
| | - Vladimir Tesar
- Department of Nephrology, First School of Medicine and General University Hospital, Charles University, Prague, Czechia
| | - Richard Lafayette
- Department of Medicine, Stanford University, Stanford, CA, United States
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Rivedal M, Haaskjold YL, Eikrem Ø, Bjørneklett R, Marti HP, Knoop T. Use of corticosteroids in Norwegian patients with immunoglobulin a nephropathy progressing to end-stage kidney disease: a retrospective cohort study. BMC Nephrol 2024; 25:42. [PMID: 38287343 PMCID: PMC10826102 DOI: 10.1186/s12882-024-03481-6] [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: 07/17/2023] [Accepted: 01/24/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Despite several clinical trials, the use of corticosteroid therapy for treating immunoglobulin A nephropathy (IgAN) remains controversial. We aimed to describe the use of corticosteroid therapy combined with supportive therapy in Norwegian patients with IgAN who had progressed to end-stage kidney disease. METHODS We conducted a retrospective cohort study using data from the Norwegian Renal Registry. Overall, 143 patients with primary IgAN who progressed to end-stage kidney disease were divided into two groups: the corticosteroid group, who had been treated with corticosteroids and supportive therapy, and the non-corticosteroid group, which had underwent only supportive therapy. The kidney function, time to end-stage kidney disease, and adverse effects were described. The observation period lasted from the diagnostic kidney biopsy until the initiation of kidney replacement therapy. RESULTS Of the 143 included patients, 103 underwent supportive therapy alone, and 40 were treated with corticosteroids. Most patients (94%) were treated with renin-angiotensin-system blockade, and all patients reached end-stage kidney disease after a median of 5 years (interquartile range; 2-9 years). Time from diagnosis until end-stage kidney disease was similar in the two study groups (p = 0.98). During 6 months of corticosteroid therapy, median eGFR declined from 21 (interquartile range; 13-46) mL/min/1.73 m2 to 20 (interquartile range; 12-40) mL/min/1.73 m2, and median proteinuria decreased from 5.5 g/24 h to 3.0 g/24 h. Most patients (87.5%) treated with corticosteroids reported adverse events. In our linear regression analysis investigating the time to ESKD, we found that age (β = -0.079, p = 0.008) and proteinuria at diagnosis (β = -0.50, p = 0.01) exhibited statistically significant associations with a delay in the progression to ESKD. CONCLUSIONS In this cohort of Norwegian patients with IgAN, corticosteroid therapy did not affect the time from diagnosis until end-stage kidney disease among a cohort of patients who all reached end-stage kidney disease. The treatment was also associated with adverse effects.
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Affiliation(s)
- Mariell Rivedal
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Yngvar Lunde Haaskjold
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Eikrem
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Hans Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Knoop
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
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29
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He WJ, Wang J, Liu N, Li GY, Zhu XW, Yao L, Liu LL. The efficacy and safety of hydroxychloroquine versus leflunomide in patients with IgA nephropathy: a single-center experience. J Nephrol 2024:10.1007/s40620-023-01839-x. [PMID: 38225440 DOI: 10.1007/s40620-023-01839-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/18/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE To date, our understanding of IgA nephropathy (IgAN) pathophysiology has remained incomplete; therefore, treatment remains largely empiric, and the efficacy and safety of immunosuppressants remain controversial. We aimed to assess the efficacy and safety of hydroxychloroquine and leflunomide therapy in a retrospective cohort of patients with IgAN. METHODS We screened the IgAN registration database in our department, and a total of 159 kidney patients with biopsy-confirmed IgAN were enrolled, with 57 patients receiving hydroxychloroquine plus a renin-angiotensin system inhibitor (hydroxychloroquine group), 52 patients receiving leflunomide plus a renin-angiotensin system inhibitor (leflunomide group), and 50 patients receiving only a renin-angiotensin system inhibitor (renin-angiotensin system inhibitor-only group). Changes in proteinuria, hematuria, and the estimated glomerular filtration rate (eGFR), as well as adverse events, were analyzed during the follow-up period. RESULTS At the end of 6-month follow-up, proteinuria significantly decreased by 70.36 (57.54, 79.33)%, 57.29 (46.79, 67.29)% and 41.20 (25.76, 48.94)% in the hydroxychloroquine, leflunomide and renin-angiotensin system inhibitor-only groups, respectively, compared to baseline (all P values < 0.001). Hematuria significantly decreased by 71.07 (56.48, 82.47)% in the leflunomide group (P < 0.001). The eGFR improved by 3.72 ± 2.97%, 3.16 ± 2.00% and 1.91 ± 2.41%, respectively, in the hydroxychloroquine, leflunomide and renin-angiotensin system inhibitor-only groups, but without statistical significance. No serious adverse events occurred during the follow-up period. CONCLUSION Both hydroxychloroquine combined with a renin-angiotensin system inhibitor and leflunomide combined with a renin-angiotensin system inhibitor were more effective than a renin-angiotensin system inhibitor alone in improving proteinuria in IgAN patients. Hydroxychloroquine was more effective in reducing proteinuria, and leflunomide showed superiority in reducing hematuria. Our results need to be verified in large-scale randomized controlled trials.
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Affiliation(s)
- Wei-Jie He
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Juan Wang
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Nan Liu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Gu-Yue Li
- Department of Pharmacy, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Xin-Wang Zhu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Li Yao
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Lin-Lin Liu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China.
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30
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Mathur M, Barratt J, Chacko B, Chan TM, Kooienga L, Oh KH, Sahay M, Suzuki Y, Wong MG, Yarbrough J, Xia J, Pereira BJG. A Phase 2 Trial of Sibeprenlimab in Patients with IgA Nephropathy. N Engl J Med 2024; 390:20-31. [PMID: 37916620 PMCID: PMC7615905 DOI: 10.1056/nejmoa2305635] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND A proliferation-inducing ligand (APRIL) is implicated in the pathogenesis of IgA nephropathy. Sibeprenlimab is a humanized IgG2 monoclonal antibody that binds to and neutralizes APRIL. METHODS In this phase 2, multicenter, double-blind, randomized, placebo-controlled, parallel-group trial, we randomly assigned adults with biopsy-confirmed IgA nephropathy who were at high risk for disease progression, despite having received standard-care treatment, in a 1:1:1:1 ratio to receive intravenous sibeprenlimab at a dose of 2, 4, or 8 mg per kilogram of body weight or placebo once monthly for 12 months. The primary end point was the change from baseline in the log-transformed 24-hour urinary protein-to-creatinine ratio at month 12. Secondary end points included the change from baseline in the estimated glomerular filtration rate (eGFR) at month 12. Safety was also assessed. RESULTS Among 155 patients who underwent randomization, 38 received sibeprenlimab at a dose of 2 mg per kilogram, 41 received sibeprenlimab at a dose of 4 mg per kilogram, 38 received sibeprenlimab at a dose of 8 mg per kilogram, and 38 received placebo. At 12 months, the geometric mean ratio reduction (±SE) from baseline in the 24-hour urinary protein-to-creatinine ratio was 47.2±8.2%, 58.8±6.1%, 62.0±5.7%, and 20.0±12.6% in the sibeprenlimab 2-mg, 4-mg, and 8-mg groups and the placebo group, respectively. At 12 months, the least-squares mean (±SE) change from baseline in eGFR was -2.7±1.8, 0.2±1.7, -1.5±1.8, and -7.4±1.8 ml per minute per 1.73 m2 in the sibeprenlimab 2-mg, 4-mg, and 8-mg groups and the placebo group, respectively. The incidence of adverse events that occurred after the start of administration of sibeprenlimab or placebo was 78.6% in the pooled sibeprenlimab groups and 71.1% in the placebo group. CONCLUSIONS In patients with IgA nephropathy, 12 months of treatment with sibeprenlimab resulted in a significantly greater decrease in proteinuria than placebo. (Funded by Visterra; ENVISION ClinicalTrials.gov number, NCT04287985; EudraCT number, 2019-002531-29.).
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MESH Headings
- Adult
- Humans
- Administration, Intravenous
- Creatinine/urine
- Double-Blind Method
- Glomerular Filtration Rate
- Glomerulonephritis, IGA/complications
- Glomerulonephritis, IGA/drug therapy
- Glomerulonephritis, IGA/genetics
- Proteinuria/drug therapy
- Proteinuria/etiology
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Tumor Necrosis Factor Ligand Superfamily Member 13/antagonists & inhibitors
- Tumor Necrosis Factor Ligand Superfamily Member 13/genetics
- Immunoglobulin G
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Affiliation(s)
- Mohit Mathur
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Jonathan Barratt
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Bobby Chacko
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Tak Mao Chan
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Laura Kooienga
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Kook-Hwan Oh
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Manisha Sahay
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Yusuke Suzuki
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Muh Geot Wong
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Jill Yarbrough
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Jing Xia
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
| | - Brian J G Pereira
- From Visterra, Waltham, MA (M.M., J.Y., B.J.G.P.); John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom (J.B.); Nephrology and Transplantation, John Hunter Hospital and University of Newcastle, Newcastle, NSW (B.C.), and the University of Sydney, Sydney (M.G.W.) - both in Australia; the University of Hong Kong, Queen Mary Hospital, Hong Kong (T.M.C.); Colorado Kidney Care, Denver (L.K.); Seoul National University College of Medicine, Seoul, South Korea (K.-H.O.); Osmania General Hospital, Hyderabad, India (M.S.); the Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo (Y.S.); and Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ (J.X.)
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Gholizadeh Ghozloujeh Z, Srinivasan V, Al Jurdi A, Abdipour A, Norouzi S. Delayed-Release Budesonide in a Patient With Progressive IgA Nephropathy and Stage 4 Chronic Kidney Disease: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241260964. [PMID: 38869105 DOI: 10.1177/23247096241260964] [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: 06/14/2024] Open
Abstract
Delayed-release (DR) budesonide received expedited approval from the US Food and Drug Administration (FDA) as a treatment for reducing proteinuria in individuals with primary IgA nephropathy (IgAN) who are at significant risk of disease progression. The approval was based on clinical trials primarily involving patients with an estimated glomerular filtration rate (eGFR) greater than 30 mL/min/1.73 m2. However, the efficacy of DR budesonide in reducing kidney function decline, especially in patients with an eGFR less than 30 mL/min/1.73 m2 and proteinuria less than 1 g/d, remains unclear. We report the case of a 43-year-old man with a long-term history of hypertension and biopsy-proven IgAN who experienced a progressive increase in proteinuria and serum creatinine, along with a decline in eGFR to 28 mL/min/1.73 m2 despite maximal supportive management. Following therapy with DR budesonide, a decreasing trend in proteinuria and a stabilization of eGFR were observed in the recent measurements. While initial data suggested the effectiveness of DR budesonide primarily in patients with an eGFR over 30 mL/min/1.73 m2, our case demonstrates the potential of DR budesonide for use in scenarios beyond its currently approved indications. This underscores the need for additional research on patients with advanced stages of chronic kidney disease.
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32
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El Karoui K, Fervenza FC, De Vriese AS. Treatment of IgA Nephropathy: A Rapidly Evolving Field. J Am Soc Nephrol 2024; 35:103-116. [PMID: 37772889 PMCID: PMC10786616 DOI: 10.1681/asn.0000000000000242] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
The pivotal event in the pathophysiology of IgA nephropathy is the binding of circulating IgA-containing immune complexes to mesangial cells, with secondary glomerular and tubulointerstitial inflammation and fibrosis. The paramount difficulty in the management of IgA nephropathy is the heterogeneity in its clinical presentation and prognosis, requiring an individualized treatment approach. Goal-directed supportive care remains the bedrock of therapy for all patients, regardless of risk of progression. Sodium-glucose transporter 2 inhibitors and sparsentan should be integral to contemporary supportive care, particularly in patients with chronic kidney damage. Pending the development of reliable biomarkers, it remains a challenge to identify patients prone to progression due to active disease and most likely to derive a net benefit from immunosuppression. The use of clinical parameters, including the degree of proteinuria, the presence of persistent microscopic hematuria, and the rate of eGFR loss, combined with the mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, crescents score, is currently the best approach. Systemic glucocorticoids are indicated in high-risk patients, but the beneficial effects wane after withdrawal and come at the price of substantial treatment-associated toxicity. Therapies with direct effect on disease pathogenesis are increasingly becoming available. While targeted-release budesonide has garnered the most attention, anti-B-cell strategies and selective complement inhibition will most likely prove their added value. We propose a comprehensive approach that tackles the different targets in the pathophysiology of IgA nephropathy according to their relevance in the individual patient.
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Affiliation(s)
- Khalil El Karoui
- Department of Nephrology, Hôpital Tenon, Sorbonne Université, Paris, France
| | | | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
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33
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Floege J. [IgA nephropathy]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:103-111. [PMID: 38170257 DOI: 10.1007/s00120-023-02268-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
IgA nephropathy (IgAN) is the most frequent primary form of glomerulonephritis. The origin of IgAN is only partially understood and appears to involve the occurrence of IgA1, which is normally secreted by mucous membranes, in the circulation followed by its glomerular deposition and inflammatory changes. Clinically, IgAN mostly follows an inapparent course and the disease is often only first diagnosed by kidney biopsy when kidney function disorders are already manifested. Key prognostic indicators include the extent of proteinuria and the already manifested evidence of irreversible kidney damage. Treatment includes supportive measures. The effectiveness of high-dose systemic corticosteroid treatment in European patients is uncertain and controversial due to the adverse side effects. Nefecon (encapsulated budesonide) is the first specific drug licensed for treatment of high risk IgAN patients. A number of further approaches are currently in clinical trials.
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Affiliation(s)
- Jürgen Floege
- Medizinische Klinik II, Uniklinik der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
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34
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Bulanov NM, Moiseev SV. [State-of-the-art trends in the treatment of immune-mediated inflammatory kidney diseases: Translation of the fundamental science into clinical practice. A review]. TERAPEVT ARKH 2023; 95:625329. [PMID: 38158941 DOI: 10.26442/00403660.2023.12.202502] [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: 12/26/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
Immune-mediated kidney diseases like glomerulonephritis and tubulointerstitial nephritis are not the most common cause of chronic kidney disease in the population, however the difficulties in their management, as well as a more rapid deterioration of kidney function, compared to diabetes mellitus and hypertension, justify the importance of this problem for internal medicine. Due to the fundamental discoveries in pathology and to the introduction of various methods of laboratory and instrumental investigation in the second half of the XX century substantial progress was made in the diagnostic approaches and treatment of these conditions. State-of-the-art diagnostic approach requires complex evaluation of the clinical, laboratory and morphological data to identify the nosological form of the disease. The accumulation of knowledge in the field of diseases' pathogenesis led to the revision of the current classification of glomerulonephritis that should be based on the immunopathogenesis of these conditions. The following phenotypes were suggested: autoimmunity-related, autoinflammation-related, alloimmunity-related, infections-related, and monoclonal gammopathy-related. The assessment of disease activity and chronicity in the kidney tissue should be mandatory. Personalized selection of the optimal treatment modality on the basis of the diagnosis, severity, and individual features of the patient is currently possible. The leading trends include rational prescription of glucocorticoids (steroid-sparing regimens) and cytotoxic agents, e.g. cyclophosphamide, as well as the introduction of multitarget regimens that include biologic agents or small molecules selectively suppressing B-cells or various complement pathways. Another mandatory component of treatment on par with immune suppression is nephroprotective therapy, which currently comprises not only traditional renin-angiotensin-aldosterone antagonists, but also endothelin receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Current guidelines emphasize the importance of the non-pharmacological interventions for the implementation of the nephroprotective strategy. Rational combination of the aforementioned approaches allows for the optimization of the management of patients with immune-mediated kidney diseases, although it requires high competencies and strict adherence to the principles of the evidence-based medicine from the healthcare providers.
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Affiliation(s)
- N M Bulanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S V Moiseev
- Sechenov First Moscow State Medical University (Sechenov University)
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35
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Campbell KN, Griffin S, Trachtman H, Geletka R, Wong MG. Practical Considerations for the Use of Sparsentan in the Treatment of Patients with IgAN in Clinical Practice. Int J Nephrol Renovasc Dis 2023; 16:281-291. [PMID: 38149041 PMCID: PMC10750480 DOI: 10.2147/ijnrd.s430377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/12/2023] [Indexed: 12/28/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. It is characterized by the mesangial deposition of IgA-containing immune complexes, triggering damage to the glomerular filtration barrier that is amplified by the tandem action of endothelin-1 and angiotensin II at their receptors. Proteinuria and progressive glomerular damage cause loss of kidney function in up to 50% of patients within 10-20 years. The risk of progression is strongly associated with persistent proteinuria (>0.75-1 g/day). Current standard of care involves interventions to decrease proteinuria and control blood pressure. Immunosuppressive agents, used in selected patients at high risk for progression, can be associated with significant side effects. Sparsentan, a novel non-immunosuppressive single-molecule Dual Endothelin Angiotensin Receptor Antagonist (DEARA), received FDA accelerated approval based on interim results from the PROTECT trial, which demonstrated that sparsentan-treated patients achieved a significantly greater reduction in proteinuria from baseline versus the active control irbesartan and that sparsentan was generally safe and well tolerated. Sparsentan is the first non-immunosuppressive treatment to be FDA-approved for the reduction of proteinuria in adults with IgAN at high risk of disease progression. We provide practical guidance for the clinical use of sparsentan in adults with IgAN.
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Affiliation(s)
- Kirk N Campbell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Siân Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, UK
| | - Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Rob Geletka
- Travere Therapeutics, Inc., San Diego, CA, USA
| | - Muh Geot Wong
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia
- Concord Clinical School, University of Sydney, Concord, NSW, Australia
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36
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Rovin BH, Barratt J, Heerspink HJL, Alpers CE, Bieler S, Chae DW, Diva UA, Floege J, Gesualdo L, Inrig JK, Kohan DE, Komers R, Kooienga LA, Lafayette R, Maes B, Małecki R, Mercer A, Noronha IL, Oh SW, Peh CA, Praga M, Preciado P, Radhakrishnan J, Rheault MN, Rote WE, Tang SCW, Tesar V, Trachtman H, Trimarchi H, Tumlin JA, Wong MG, Perkovic V. Efficacy and safety of sparsentan versus irbesartan in patients with IgA nephropathy (PROTECT): 2-year results from a randomised, active-controlled, phase 3 trial. Lancet 2023; 402:2077-2090. [PMID: 37931634 DOI: 10.1016/s0140-6736(23)02302-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Sparsentan, a novel, non-immunosuppressive, single-molecule, dual endothelin angiotensin receptor antagonist, significantly reduced proteinuria versus irbesartan, an angiotensin II receptor blocker, at 36 weeks (primary endpoint) in patients with immunoglobulin A nephropathy in the phase 3 PROTECT trial's previously reported interim analysis. Here, we report kidney function and outcomes over 110 weeks from the double-blind final analysis. METHODS PROTECT, a double-blind, randomised, active-controlled, phase 3 study, was done across 134 clinical practice sites in 18 countries throughout the Americas, Asia, and Europe. Patients aged 18 years or older with biopsy-proven primary IgA nephropathy and proteinuria of at least 1·0 g per day despite maximised renin-angiotensin system inhibition for at least 12 weeks were randomly assigned (1:1) to receive sparsentan (target dose 400 mg oral sparsentan once daily) or irbesartan (target dose 300 mg oral irbesartan once daily) based on a permuted-block randomisation method. The primary endpoint was proteinuria change between treatment groups at 36 weeks. Secondary endpoints included rate of change (slope) of the estimated glomerular filtration rate (eGFR), changes in proteinuria, a composite of kidney failure (confirmed 40% eGFR reduction, end-stage kidney disease, or all-cause mortality), and safety and tolerability up to 110 weeks from randomisation. Secondary efficacy outcomes were assessed in the full analysis set and safety was assessed in the safety set, both of which were defined as all patients who were randomly assigned and received at least one dose of randomly assigned study drug. This trial is registered with ClinicalTrials.gov, NCT03762850. FINDINGS Between Dec 20, 2018, and May 26, 2021, 203 patients were randomly assigned to the sparsentan group and 203 to the irbesartan group. One patient from each group did not receive the study drug and was excluded from the efficacy and safety analyses (282 [70%] of 404 included patients were male and 272 [67%] were White) . Patients in the sparsentan group had a slower rate of eGFR decline than those in the irbesartan group. eGFR chronic 2-year slope (weeks 6-110) was -2·7 mL/min per 1·73 m2 per year versus -3·8 mL/min per 1·73 m2 per year (difference 1·1 mL/min per 1·73 m2 per year, 95% CI 0·1 to 2·1; p=0·037); total 2-year slope (day 1-week 110) was -2·9 mL/min per 1·73 m2 per year versus -3·9 mL/min per 1·73 m2 per year (difference 1·0 mL/min per 1·73 m2 per year, 95% CI -0·03 to 1·94; p=0·058). The significant reduction in proteinuria at 36 weeks with sparsentan was maintained throughout the study period; at 110 weeks, proteinuria, as determined by the change from baseline in urine protein-to-creatinine ratio, was 40% lower in the sparsentan group than in the irbesartan group (-42·8%, 95% CI -49·8 to -35·0, with sparsentan versus -4·4%, -15·8 to 8·7, with irbesartan; geometric least-squares mean ratio 0·60, 95% CI 0·50 to 0·72). The composite kidney failure endpoint was reached by 18 (9%) of 202 patients in the sparsentan group versus 26 (13%) of 202 patients in the irbesartan group (relative risk 0·7, 95% CI 0·4 to 1·2). Treatment-emergent adverse events were well balanced between sparsentan and irbesartan, with no new safety signals. INTERPRETATION Over 110 weeks, treatment with sparsentan versus maximally titrated irbesartan in patients with IgA nephropathy resulted in significant reductions in proteinuria and preservation of kidney function. FUNDING Travere Therapeutics.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | | | - Dong-Wan Chae
- Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea
| | | | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | | | - Donald E Kohan
- Division of Nephrology, School of Medicine, University of Utah Health, Salt Lake City, UT, USA
| | | | | | - Richard Lafayette
- Division of Nephrology, Stanford University Medical Center, Stanford, CA, USA
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Robert Małecki
- Department of Nephrology, Międzyleski Specialist Hospital, Warsaw, Poland
| | | | - Irene L Noronha
- Division of Nephrology, University of Sao Paulo, Sao Paulo, Brazil
| | - Se Won Oh
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Chen Au Peh
- Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Manuel Praga
- Research Institute Hospital 12 de Octubre (i+12), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain
| | | | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michelle N Rheault
- Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital, Charles University, Prague, Czechia
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Hernán Trimarchi
- Nephrology Service, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - James A Tumlin
- Renal Division, Emory University, Atlanta, GA, USA; NephroNet Clinical Trials Consortium, Atlanta, GA, USA
| | - Muh Geot Wong
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia; Concord Clinical School, University of Sydney, Concord, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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Reich HN, Barbour SJ. PROTECTing the kidneys in IgA nephropathy. Lancet 2023; 402:2046-2047. [PMID: 37931627 DOI: 10.1016/s0140-6736(23)02418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Heather N Reich
- Department of Medicine, Divison of Nephrology, University of Toronto, University Health Network, Toronto, ON M5G 2C4, Canada.
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
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Trachtman H, Komers R, Inrig J. Status of current trials and potential future trials with sparsentan. Expert Opin Emerg Drugs 2023; 28:145-147. [PMID: 37466432 DOI: 10.1080/14728214.2023.2239151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor Michigan, USA
| | - Radko Komers
- Travere Therapeutics, Inc. San Diego, California, USA
| | - Jula Inrig
- Travere Therapeutics, Inc. San Diego, California, USA
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Yeo SC, Barratt J. The contribution of a proliferation-inducing ligand (APRIL) and other TNF superfamily members in pathogenesis and progression of IgA nephropathy. Clin Kidney J 2023; 16:ii9-ii18. [PMID: 38053976 PMCID: PMC10695512 DOI: 10.1093/ckj/sfad200] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Indexed: 12/07/2023] Open
Abstract
Advances in our understanding of the pathogenesis of immunoglobulin A nephropathy (IgAN) have led to the identification of novel therapeutic targets and potential disease-specific treatments. Specifically, a proliferation-inducing ligand (APRIL) has been implicated in the pathogenesis of IgAN, mediating B-cell dysregulation and overproduction of pathogenic galactose-deficient IgA1 (Gd-IgA1). Animal and clinical studies support the involvement of APRIL in the pathogenesis and progression of IgAN. An elevated level of APRIL is found in IgAN when compared with controls, which correlates with the level of Gd-IgA1 and associates with more severe disease presentation and worse outcomes. Conversely, anti-APRIL therapy reduces pathogenic Gd-IgA1 and IgA immune complex formation and ameliorates the severity of kidney inflammation and injury. Genome-wide association studies in IgAN have identified TNFSF13 and TNFRSF13B, a cytokine ligand-receptor gene pair encoding APRIL and its receptor, respectively, as risk susceptibility loci in IgAN, further supporting the causal role of the APRIL signalling pathway in IgAN. Several novel experimental agents targeting APRIL, including atacicept, telitacicept, zigakibart and sibeprenlimab, are currently under investigation as potential therapies in IgAN. Preliminary results suggest that these agents are well-tolerated, and reduce levels of Gd-IgA1, with corresponding improvement in proteinuria. Further studies are ongoing to confirm the safety and efficacy of anti-APRIL approaches as an effective therapeutic strategy in IgAN.
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Affiliation(s)
- See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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40
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Schena FP, Manno C, Strippoli G. Understanding patient needs and predicting outcomes in IgA nephropathy using data analytics and artificial intelligence: a narrative review. Clin Kidney J 2023; 16:ii55-ii61. [PMID: 38053972 PMCID: PMC10695518 DOI: 10.1093/ckj/sfad206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Indexed: 12/07/2023] Open
Abstract
This narrative review explores two case scenarios related to immunoglobulin A nephropathy (IgAN) and the application of predictive monitoring, big data analysis and artificial intelligence (AI) in improving treatment outcomes. The first scenario discusses how online service providers accurately understand consumer preferences and needs through the use of AI-powered big data analysis. The author, a clinical nephrologist, contemplates the potential application of similar methodologies, including AI, in his medical practice to better understand and meet patient needs. The second scenario presents a case study of a 20-year-old man with IgAN. The patient exhibited recurring symptoms, including gross haematuria and tonsillitis, over a 2-year period. Through histological examination and treatment with renin-angiotensin system blockade and corticosteroids, the patient experienced significant improvement in kidney function and reduced proteinuria over 15 years of follow-up. The case highlights the importance of individualized treatment strategies and the use of predictive tools, such as AI-based predictive models, in assessing treatment response and predicting long-term outcomes in IgAN patients. The article further discusses the collection and analysis of real-world big data, including electronic health records, for studying disease natural history, predicting treatment responses and identifying prognostic biomarkers. Challenges in integrating data from various sources and issues such as missing data and data processing limitations are also addressed. Mathematical models, including logistic regression and Cox regression analysis, are discussed for predicting clinical outcomes and analysing changes in variables over time. Additionally, the application of machine learning algorithms, including AI techniques, in analysing big data and predicting outcomes in IgAN is explored. In conclusion, the article highlights the potential benefits of leveraging AI-powered big data analysis, predictive monitoring and machine learning algorithms to enhance patient care and improve treatment outcomes in IgAN.
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Affiliation(s)
- Francesco Paolo Schena
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
- Schena Foundation, Policlinic, Bari, Italy
| | - Carlo Manno
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Giovanni Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
- School of Public Health, University of Sydney, Sydney, NSW, Australia
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41
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Duval A, Caillard S, Frémeaux-Bacchi V. The complement system in IgAN: mechanistic context for therapeutic opportunities. Nephrol Dial Transplant 2023; 38:2685-2693. [PMID: 37385820 DOI: 10.1093/ndt/gfad140] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
The complement system plays a crucial role in innate immunity, providing essential defense against pathogens. However, uncontrolled or prolonged activation of the complement cascade can significantly contribute to kidney damage, especially in cases of glomerulonephritis. Immunoglobulin A nephropathy (IgAN), the most prevalent form of primary glomerulonephritis, has growing evidence supporting the involvement of complement alternative and lectin pathways. In fact, patients with IgAN experience complement activation within their kidney tissue, which may be involved in the development of glomerular damage and the progression of IgAN. Complement activation has emerged as a significant area of interest in IgAN, with numerous complement-targeting agents currently being explored within this field. Nevertheless, the exact mechanisms of complement activation and their role in IgAN progression require comprehensive elucidation. This review seeks to contextualize the proposed mechanisms of complement activation within the various stages ("hits") of IgAN pathogenesis, while also addressing the clinical implications and anticipated outcomes of complement inhibition in IgAN.
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Affiliation(s)
- Anna Duval
- Centre de Recherche des Cordeliers, Inserm UMR S1138, Paris, France
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Sophie Caillard
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Véronique Frémeaux-Bacchi
- Centre de Recherche des Cordeliers, Inserm UMR S1138, Paris, France
- Service d'Immunologie Biologique, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
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42
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Stamellou E, Seikrit C, Tang SCW, Boor P, Tesař V, Floege J, Barratt J, Kramann R. IgA nephropathy. Nat Rev Dis Primers 2023; 9:67. [PMID: 38036542 DOI: 10.1038/s41572-023-00476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.
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Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Claudia Seikrit
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Peter Boor
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
- Department of Pathology, RWTH Aachen University, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rafael Kramann
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany.
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands.
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Obrișcă B, Vornicu A, Mocanu V, Dimofte G, Andronesi A, Bobeică R, Jurubiță R, Sorohan B, Caceaune N, Ismail G. An open-label study evaluating the safety and efficacy of budesonide in patients with IgA nephropathy at high risk of progression. Sci Rep 2023; 13:20119. [PMID: 37978255 PMCID: PMC10656480 DOI: 10.1038/s41598-023-47393-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
We sought to evaluate the efficacy and safety of budesonide (Budenofalk) in the treatment of patients with IgA Nephropathy. We conducted a prospective, interventional, open-label, single-arm, non-randomized study that enrolled 32 patients with IgAN at high risk of progression (BUDIGAN study, ISRCTN47722295, date of registration 14/02/2020). Patients were treated with Budesonide at a dose of 9 mg/day for 12 months, subsequently tapered to 3 mg/day for another 12 months. The primary endpoints were change of eGFR and proteinuria at 12, 24 and 36 months. The study cohort had a mean eGFR and 24-h proteinuria of 59 ± 24 ml/min/1.73m2 and 1.89 ± 1.5 g/day, respectively. Treatment with budesonide determined a reduction in proteinuria at 12-, 24- and 36-months by -32.9% (95% CI - 53.6 to - 12.2), - 49.7% (95% CI - 70.1 to - 29.4) and - 68.1% (95% CI - 80.6 to - 55.7). Budesonide determined an eGFR preservation corresponding to a 12-, 24- and 36-months change of + 7.68% (95% CI - 4.7 to 20.1), + 7.42% (95% CI - 7.23 to 22.1) and + 4.74% (95%CI - 13.5 to 23), respectively. The overall eGFR change/year was + 0.83 ml/min/y (95% CI - 0.54 to 4.46). Budesonide was well-tolerated, and treatment emergent adverse events were mostly mild in severity and reversible. Budesonide was effective in the treatment of patients with IgAN at high-risk of progression in terms of reducing proteinuria and preserving renal function over 36 months of therapy.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.
| | - Alexandra Vornicu
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Valentin Mocanu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - George Dimofte
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicu Caceaune
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
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Mathur M, Chan TM, Oh KH, Kooienga L, Zhuo M, Pinto CS, Chacko B. A PRoliferation-Inducing Ligand (APRIL) in the Pathogenesis of Immunoglobulin A Nephropathy: A Review of the Evidence. J Clin Med 2023; 12:6927. [PMID: 37959392 PMCID: PMC10650434 DOI: 10.3390/jcm12216927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
A PRoliferation-Inducing Ligand (APRIL), the thirteenth member of the tumor necrosis factor superfamily, plays a key role in the regulation of activated B cells, the survival of long-lived plasma cells, and immunoglobulin (Ig) isotype class switching. Several lines of evidence have implicated APRIL in the pathogenesis of IgA nephropathy (IgAN). Globally, IgAN is the most common primary glomerulonephritis, and it can progress to end-stage kidney disease; yet, disease-modifying treatments for this condition have historically been lacking. The preliminary data in ongoing clinical trials indicate that APRIL inhibition can reduce proteinuria and slow the rate of kidney disease progression by acting at an upstream level in IgAN pathogenesis. In this review, we examine what is known about the physiologic roles of APRIL and evaluate the experimental and epidemiological evidence describing how these normal biologic processes are thought to be subverted in IgAN. The weight of the preclinical, clinical, and genetic data supporting a key role for APRIL in IgAN has galvanized pharmacologic research, and several anti-APRIL drug candidates have now entered clinical development for IgAN. Herein, we present an overview of the clinical results to date. Finally, we explore where more research and evidence are needed to transform potential therapies into clinical benefits for patients with IgAN.
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Affiliation(s)
| | - Tak Mao Chan
- Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China;
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea;
| | - Laura Kooienga
- Colorado Kidney and Vascular Care, Denver, CO 80012, USA;
| | - Min Zhuo
- Visterra, Inc., Waltham, MA 02451, USA;
- Division of Renal Medicine, Department of Medicine Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Cibele S. Pinto
- Otsuka Pharmaceutical Development & Commercialization, Princeton, NJ 08540, USA;
| | - Bobby Chacko
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, NSW 2305, Australia;
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
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Kohan DE, Barratt J, Heerspink HJ, Campbell KN, Camargo M, Ogbaa I, Haile-Meskale R, Rizk DV, King A. Targeting the Endothelin A Receptor in IgA Nephropathy. Kidney Int Rep 2023; 8:2198-2210. [PMID: 38025243 PMCID: PMC10658204 DOI: 10.1016/j.ekir.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/09/2023] [Accepted: 07/24/2023] [Indexed: 12/01/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and carries a substantial risk of kidney failure. New agency-approved therapies, either specifically for IgAN or for chronic kidney disease (CKD) in general, hold out hope for mitigating renal deterioration in patients with IgAN. The latest addition to this therapeutic armamentarium targets the endothelin-A receptor (ETAR). Activation of ETAR on multiple renal cell types elicits a host of pathophysiological effects, including vasoconstriction, cell proliferation, inflammation, apoptosis, and fibrosis. Blockade of ETAR is renoprotective in experimental models of IgAN and reduces proteinuria in patients with IgAN. This review discusses the evidence supporting the use of ETAR blockade in IgAN as well as addressing the potential role for this class of agents among the current and emerging therapies for treating this disorder.
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Affiliation(s)
- Donald E. Kohan
- Division of Nephrology, University of Utah Health, Salt Lake City, Utah, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kirk N. Campbell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Ike Ogbaa
- Chinook Therapeutics, Seattle, Washington, USA
| | | | - Dana V. Rizk
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew King
- Chinook Therapeutics, Seattle, Washington, USA
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46
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Gleeson PJ, O'Shaughnessy MM, Barratt J. IgA nephropathy in adults-treatment standard. Nephrol Dial Transplant 2023; 38:2464-2473. [PMID: 37418237 DOI: 10.1093/ndt/gfad146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Indexed: 07/08/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary form of glomerular disease worldwide and carries a high lifetime risk of kidney failure. The underlying pathogenesis of IgAN has been characterized to a sub-molecular level; immune complexes containing specific O-glycoforms of IgA1 are central. Kidney biopsy remains the gold-standard diagnostic test for IgAN and histological features (i.e. MEST-C score) have also been shown to independently predict outcome. Proteinuria and blood pressure are the main modifiable risk factors for disease progression. No IgAN-specific biomarker has yet been validated for diagnosis, prognosis or tracking response to therapy. There has been a recent resurgence of investigation into IgAN treatments. Optimized supportive care with lifestyle interventions and non-immunomodulatory drugs remains the backbone of IgAN management. The menu of available reno-protective medications is rapidly expanding beyond blockade of the renin-angiotensin-aldosterone system to include sodium-glucose cotransporter 2 and endothelin type A receptor antagonism. Systemic immunosuppression can further improve kidney outcomes, although recent randomized controlled trials have raised concerns regarding infectious and metabolic toxicity from systemic corticosteroids. Studies evaluating more refined approaches to immunomodulation in IgAN are ongoing: drugs targeting the mucosal immune compartment, B-cell promoting cytokines and the complement cascade are particularly promising. We review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of IgAN.
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Affiliation(s)
- Patrick J Gleeson
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Department of Medicine, School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland
| | | | - Jonathan Barratt
- The Mayer IgA Nephropathy Laboratories, University of Leicester, Leicester, UK
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47
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Mizerska-Wasiak M, Płatos E, Małdyk J, Miklaszewska M, Drożdż D, Firszt-Adamczyk A, Stankiewicz R, Bieniaś B, Sikora P, Rybi-Szumińska A, Wasilewska A, Szczepańska M, Drożynska-Duklas M, Żurowska A, Pukajło-Marczyk A, Zwolińska D, Tkaczyk M, Pańczyk-Tomaszewska M. The Outcome of Childhood Immunoglobulin A Nephropathy with Acute Kidney Injury at the Onset of the Disease-National Study. J Clin Med 2023; 12:6454. [PMID: 37892592 PMCID: PMC10607644 DOI: 10.3390/jcm12206454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
Introduction: IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. Decreased glomerular filtration rate is a known risk factor for disease progression. Aim: We aimed to examine factors that may contribute to disease progression in children that present with impaired eGFR at the onset of IgAN. Materials and methods: Of the 175 patients with IgAN from the Polish Registry of Children with IgAN and IgAVN, 54 (31%) patients with IgAN who had an onset of renal function impairment (GFR < 90 mL/min) were eligible for the study. All of them were analyzed for initial symptoms (GFR according to Schwartz formula, creatinine, proteinuria, IgA, C3), renal biopsy result with assessment by Oxford classification, treatment used (R-renoprotection, P-prednisone+R, Aza-azathioprine+P+R, Cyc-cyclophosphamide+P+R, CsA-cyclosporine+P+R, MMF-mycophenolate mofetil+P+R), and distant follow-up. Based on the GFR score obtained at the end, patients were divided into two groups: A-GFR > 90 mL/min and B-GFR < 90 mL/min. Results: In the study group, the mean age of onset was 12.87 ± 3.57 years, GFR was 66.1 ± 17.3 mL/min, and proteinuria was 18.1 (0-967) mg/kg/d. Renal biopsy was performed 0.2 (0-7) years after the onset of the disease, and MESTC score averaged 2.57 ± 1.6. Treatment was R only in 39% of children, P+R in 20%, Aza+P+R in 28%, Cyc+P+R in 9%, CsA+P+R in 7%, and MMF+P+R in 3%. The length of the observation period was 2.16 (0.05-11) years. At the follow-up, Group A had 30 patients (56%) and Group B had 24 patients (44%). There were no significant differences in any of the other biochemical parameters (except creatinine) or proteinuria values between the groups and the frequency of the MESTC score ≥ 2 and <2 was not significantly different between Groups A and B. Patients with normal GFR at the follow-up (Group A) were significantly more likely to have received prednisone and/or immunosuppressive treatment than those in Group B (p < 0.05) Conclusions: In a population of Polish children with IgAN and decreased renal function at the onset of the disease, 56% had normal GFR in remote observation. The use of immunosuppressive/corticosteroids treatment in children with IgAN and impaired glomerular filtration rate at the beginning of the disease may contribute to the normalization of GFR in the outcome, although this requires confirmation in a larger group of pediatric patients.
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Affiliation(s)
- M. Mizerska-Wasiak
- Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - E. Płatos
- Scientific Group in Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - J. Małdyk
- Department of Pathology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - M. Miklaszewska
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, 30-663 Krakow, Poland; (M.M.); (D.D.)
| | - D. Drożdż
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, 30-663 Krakow, Poland; (M.M.); (D.D.)
| | - A. Firszt-Adamczyk
- Department of Pediatrics and Nephrology, Ludwik Rydygier Hospital, 87-100 Toruń, Poland; (A.F.-A.); (R.S.)
| | - R. Stankiewicz
- Department of Pediatrics and Nephrology, Ludwik Rydygier Hospital, 87-100 Toruń, Poland; (A.F.-A.); (R.S.)
| | - B. Bieniaś
- Department of Pediatric Nephrology, Medical University of Lublin, 20-090 Lublin, Poland; (B.B.); (P.S.)
| | - P. Sikora
- Department of Pediatric Nephrology, Medical University of Lublin, 20-090 Lublin, Poland; (B.B.); (P.S.)
| | - A. Rybi-Szumińska
- Department of Pediatrics and Nephrology, Medical University of Bialystok, 15-269 Bialystok, Poland; (A.R.-S.); (A.W.)
| | - A. Wasilewska
- Department of Pediatrics and Nephrology, Medical University of Bialystok, 15-269 Bialystok, Poland; (A.R.-S.); (A.W.)
| | - M. Szczepańska
- Department of Pediatrics, FMS in Zabrze, Silesian Medical University, 40-055 Katowice, Poland;
| | - M. Drożynska-Duklas
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (M.D.-D.); (A.Ż.)
| | - A. Żurowska
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (M.D.-D.); (A.Ż.)
| | - A. Pukajło-Marczyk
- Department of Pediatric Nephrology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (A.P.-M.); (D.Z.)
| | - D. Zwolińska
- Department of Pediatric Nephrology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (A.P.-M.); (D.Z.)
| | - M. Tkaczyk
- Department of Pediatrics, Immunology and Nephrology, Polish Mothers Memorial Hospital Research Institute, 93-338 Lodz, Poland;
- Department of Pediatrics, Immunology and Nephrology, Medical University of Lodz, 92-215 Lodz, Poland
| | - M. Pańczyk-Tomaszewska
- Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland;
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48
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Floege J. [IgA nephropathy]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:961-969. [PMID: 37672089 DOI: 10.1007/s00108-023-01588-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Abstract
IgA nephropathy (IgAN) is the most frequent primary form of glomerulonephritis. The origin of IgAN is only partially understood and appears to involve the occurrence of IgA1, which is normally secreted by mucous membranes, in the circulation followed by its glomerular deposition and inflammatory changes. Clinically, IgAN mostly follows an inapparent course and the disease is often only first diagnosed by kidney biopsy when kidney function disorders are already manifested. Key prognostic indicators include the extent of proteinuria and the already manifested evidence of irreversible kidney damage. Treatment includes supportive measures. The effectiveness of high-dose systemic corticosteroid treatment in European patients is uncertain and controversial due to the adverse side effects. Nefecon (encapsulated budesonide) is the first specific drug licensed for treatment of high risk IgAN patients. A number of further approaches are currently in clinical trials.
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Affiliation(s)
- Jürgen Floege
- Medizinische Klinik II, Uniklinik der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
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49
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Haraldsson B. Phase 3 trial results bring hope for patients with IgA nephropathy. Lancet 2023; 402:827-829. [PMID: 37591290 DOI: 10.1016/s0140-6736(23)01633-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Börje Haraldsson
- Institute of Neuroscience and Physiology, University of Gothenburg, 405 30 Gothenburg, Sweden.
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50
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Lafayette R, Kristensen J, Stone A, Floege J, Tesař V, Trimarchi H, Zhang H, Eren N, Paliege A, Reich HN, Rovin BH, Barratt J. Efficacy and safety of a targeted-release formulation of budesonide in patients with primary IgA nephropathy (NefIgArd): 2-year results from a randomised phase 3 trial. Lancet 2023; 402:859-870. [PMID: 37591292 DOI: 10.1016/s0140-6736(23)01554-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND IgA nephropathy is a chronic immune-mediated kidney disease and a major cause of kidney failure worldwide. The gut mucosal immune system is implicated in its pathogenesis, and Nefecon is a novel, oral, targeted-release formulation of budesonide designed to act at the gut mucosal level. We present findings from the 2-year, phase 3 NefIgArd trial of Nefecon in patients with IgA nephropathy. METHODS In this phase 3, multicentre, randomised, double-blind, placebo-controlled trial, adult patients (aged ≥18 years) with primary IgA nephropathy, estimated glomerular filtration rate (eGFR) 35-90 mL/min per 1·73 m2, and persistent proteinuria (urine protein-creatinine ratio ≥0·8 g/g or proteinuria ≥1 g/24 h) despite optimised renin-angiotensin system blockade were enrolled at 132 hospital-based clinical sites in 20 countries worldwide. Patients were randomly assigned (1:1) to receive 16 mg/day oral capsules of Nefecon or matching placebo for 9 months, followed by a 15-month observational follow-up period off study drug. Randomisation via an interactive response technology system was stratified according to baseline proteinuria (<2 or ≥2 g/24 h), baseline eGFR (<60 or ≥60 mL/min per 1·73 m2), and region (Asia-Pacific, Europe, North America, or South America). Patients, investigators, and site staff were masked to treatment assignment throughout the 2-year trial. Optimised supportive care was also continued throughout the trial. The primary efficacy endpoint was time-weighted average of eGFR over 2 years. Efficacy and safety analyses were done in the full analysis set (ie, all randomly assigned patients). The trial was registered on ClinicalTrials.gov, NCT03643965, and is completed. FINDINGS Patients were recruited to the NefIgArd trial between Sept 5, 2018, and Jan 20, 2021, with 364 patients (182 per treatment group) randomly assigned in the full analysis set. 240 (66%) patients were men and 124 (34%) were women, and 275 (76%) identified as White. The time-weighted average of eGFR over 2 years showed a statistically significant treatment benefit with Nefecon versus placebo (difference 5·05 mL/min per 1·73 m2 [95% CI 3·24 to 7·38], p<0·0001), with a time-weighted average change of -2·47 mL/min per 1·73 m2 (95% CI -3·88 to -1·02) reported with Nefecon and -7·52 mL/min per 1·73 m2 (-8·83 to -6·18) reported with placebo. The most commonly reported treatment-emergent adverse events during treatment with Nefecon were peripheral oedema (31 [17%] patients, vs placebo, seven [4%] patients), hypertension (22 [12%] vs six [3%]), muscle spasms (22 [12%] vs seven [4%]), acne (20 [11%] vs two [1%]), and headache (19 [10%] vs 14 [8%]). No treatment-related deaths were reported. INTERPRETATION A 9-month treatment period with Nefecon provided a clinically relevant reduction in eGFR decline and a durable reduction in proteinuria versus placebo, providing support for a disease-modifying effect in patients with IgA nephropathy. Nefecon was also well tolerated, with a safety profile as expected for a locally acting oral budesonide product. FUNDING Calliditas Therapeutics.
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Affiliation(s)
- Richard Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA.
| | | | | | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Hernán Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Necmi Eren
- Department of Nephrology, Kocaeli University, Kocaeli, Turkey
| | - Alexander Paliege
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heather N Reich
- Division of Nephrology, University Health Network, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jonathan Barratt
- College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK
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