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Neves PD, Watanabe A, Watanabe EH, Narcizo AM, Nunes K, Lerario AM, Ferreira FM, Cavalcante LB, Wongboonsin J, Malheiros DM, Jorge LB, Sampson MG, Noronha IL, Onuchic LF. Idiopathic collapsing glomerulopathy is associated with APOL1 high-risk genotypes or Mendelian variants in most affected individuals in a highly admixed population. Kidney Int 2024; 105:593-607. [PMID: 38143038 DOI: 10.1016/j.kint.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/04/2023] [Accepted: 11/16/2023] [Indexed: 12/26/2023]
Abstract
Collapsing glomerulopathy (CG) is most often associated with fast progression to kidney failure with an incidence apparently higher in Brazil than in other countries. However, the reason for this occurrence is unknown. To better understand this, we performed an integrated analysis of clinical, histological, therapeutic, causative genetic and genetic ancestry data in a highly genetically admixed cohort of 70 children and adult patients with idiopathic CG (ICG). The disease onset occurred at 23 (interquartile range: 17-31) years and approximately half of patients progressed to chronic kidney disease requiring kidney replacement therapy (CKD-KRT) 36 months after diagnosis. Causative genetic bases, assessed by targeted-gene panel or whole-exome sequencing, were identified in 58.6% of patients. Among these cases, 80.5% harbored APOL1 high-risk genotypes (HRG) and 19.5% causative Mendelian variants (MV). Self-reported non-White patients more frequently had HRG. MV was an independent risk factor for progression to CKD-KRT by 36 months and the end of follow-up, while remission was an independent protective factor. All patients with HRG manifested CG at 9-44 years of age, whereas in those with APOL1 low-risk genotype, the disease arose throughout life. HRGs were associated with higher proportion of African genetic ancestry. Novel causative MVs were identified in COL4A5, COQ2 and PLCE1 and previously described causative MVs were identified in MYH9, TRPC6, COQ2, COL4A3 and TTC21B. Three patients displayed HRG combined with a variant of uncertain significance (ITGB4, LAMA5 or PTPRO). MVs were associated with worse kidney prognosis. Thus, our data reveal that the genetic status plays a major role in ICG pathogenesis, accounting for more than half of cases in a highly admixed Brazilian population.
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Affiliation(s)
- Precil D Neves
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil; Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil; Nephrology and Dialysis Center, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Andreia Watanabe
- Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil; Division of Pediatric Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Elieser H Watanabe
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil; Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Amanda M Narcizo
- Large-Scale Sequencing Laboratory, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Kelly Nunes
- Human Genome Center, Institute of Biosciences/University of São Paulo, São Paulo, Brazil
| | - Antonio M Lerario
- Division of Endocrinology, University of Michigan, Ann Arbor, Michigan, USA
| | - Frederico M Ferreira
- Department of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lívia B Cavalcante
- Department of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Janewit Wongboonsin
- Division of Pediatric Nephrology, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Denise M Malheiros
- Department of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lectícia B Jorge
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Matthew G Sampson
- Division of Pediatric Nephrology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Irene L Noronha
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz F Onuchic
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil; Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil.
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Ekrikpo U, Obiagwu P, Chika-Onu U, Yadla M, Karam S, Tannor EK, Bello AK, Okpechi IG. Epidemiology and Outcomes of Glomerular Diseases in Low- and Middle-Income Countries. Semin Nephrol 2023; 42:151316. [PMID: 36773418 DOI: 10.1016/j.semnephrol.2023.151316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Glomerular diseases account for a significant proportion of chronic kidney disease in low-income and middle-income countries (LMICs). The epidemiology of glomerulonephritis is characterized inadequately in LMICs, largely owing to unavailable nephropathology services or uncertainty of the safety of the kidney biopsy procedure. In contrast to high-income countries where IgA nephropathy is the dominant primary glomerular disease, focal segmental glomerulosclerosis is common in large populations across Latin America, Africa, Middle East, and South East Asia, while IgA nephropathy is common in Chinese populations. Despite having a high prevalence of known genetic and viral risk factors that trigger focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis also is common in adults and children in some African countries. Treatment of glomerular diseases in adults and children in LMICs largely is dependent on corticosteroids in combination with other immunosuppressive therapy, which often is cyclophosphamide because of its ready availability and low cost of treatment, despite significant adverse effects. Partial and/or complete remission status reported from studies of glomerular disease subtypes vary across LMIC regions, with high rates of kidney failure, mortality, and disease, and treatment complications often reported. Improving the availability of nephropathology services and ensuring availability of specific therapies are key measures to improving glomerular disease outcomes in LMICs.
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Affiliation(s)
- Udeme Ekrikpo
- Department of Medicine, University of Uyo, Uyo, Nigeria
| | - Patience Obiagwu
- Department of Paediatrics, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ugochi Chika-Onu
- Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Manjusha Yadla
- Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India
| | - Sabine Karam
- Division of Nephrology, University of Minnesota, Minnesota, MN; Division of Nephrology, Faculty of Medicine and Medical Sciences, University of Balamand, Balamand, Lebanon
| | - Elliot K Tannor
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Canada; Division of Nephrology, University of Cape Town, Cape Town, South Africa.
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Resistant and Relapsing Collapsing Glomerulopathy Successfully Treated with Rituximab—A Case Report. J Pers Med 2022; 12:jpm12091415. [PMID: 36143201 PMCID: PMC9502673 DOI: 10.3390/jpm12091415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Collapsing glomerulopathy (CG) or collapsing focal segmental glomerulosclerosis (cFSGS) is an aggressive disease with a high tendency of progression to end-stage renal disease due to common resistance to conventional immunosuppressants. Rituximab (RTX), a monoclonal antibody against CD20 B cells, showed some benefit in the treatment of CG. We are reporting about female patients with an idiopathic form of CG presenting with nephrotic syndrome (NS) and renal insufficiency resistant to several immunosuppressive agents such as steroids (ST), calcineurin inhibitors (CNI), and cyclophosphamide (CYC). This multidrug-resistant disease responded to RTX with complete remission. Forty-four months after initial RTX administration, a relapse of CG with severe NS and acute renal insufficiency occurred. Repeated application of RTX led to complete remission again. To the best of our knowledge, we are reporting the first case of the relapsing multidrug-resistant form of CG, which responded to RTX. Current data about the treatment of CG with RTX is lacking and is based on rare case reports and small case series. Thus, our report can contribute to determining the role of RTX in the treatment of CG.
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Caster DJ, Magalhaes B, Pennese N, Zaffalon A, Faiella M, Campbell KN, Radhakrishnan J, Tesar V, Trachtman H. Efficacy and Safety of Immunosuppressive Therapy in Primary Focal Segmental Glomerulosclerosis: A Systematic Review and Meta-analysis. Kidney Med 2022; 4:100501. [PMID: 36032548 PMCID: PMC9399559 DOI: 10.1016/j.xkme.2022.100501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Rationale & Objective Focal segmental glomerulosclerosis (FSGS) is a rare condition that can lead to kidney function decline and chronic kidney failure. Immunosuppressants are used to treat primary FSGS. However, their efficacy and safety in FSGS are not clearly established. We assessed current knowledge on clinical effectiveness and safety of immunosuppressants for primary FSGS. Study Design Systematic review of randomized controlled trials, interventional nonrandomized controlled trials, observational studies, retrospective studies, and registries. Setting & Participants Patients with primary and genetic FSGS. Selection Criteria for Studies Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for English-language, primary-FSGS studies from inception to 2019. Clinical outcomes were changes from baseline in proteinuria, kidney function, and kidney survival. Data Extraction 2 investigators independently screened studies and extracted data. Analytical Approach Study results were summarized using random-effects models either as ratios of means between follow-up and baseline measurements or as HRs. Results We included 98 articles. Substantial heterogeneity was observed in patient baseline characteristics and study designs. Most studies assessed treatment with corticosteroids alone or combined with other drugs, mainly immunosuppressants. Patients treated with immunosuppressants showed reduced proteinuria (14 studies; ratio of means, 0.36; 95% CI, 0.20-0.47), decreased creatinine clearance (mean difference, −25.03; 95% CI, −59.33 to −9.27) and (significantly) lower estimated glomerular filtration rates (mean difference, −7.61 mL/min/1.73 m2; 95% CI, −14.98 to 0.25 mL/min/1.73 m2). Immunosuppressant therapy had an uncertain effect on reducing the chronic kidney failure risk. Hypertension and infections were the most commonly reported adverse events. Limitations Heterogeneity in study designs, patient populations, and treatment regimens; no access to individual patient–level data. Conclusions This systematic review supports proteinuria reduction with immunosuppressant therapy in primary FSGS over varying follow-up periods. The effects of immunosuppressants on kidney survival remain uncertain. This review underscores the need for better-designed and adequately controlled studies to assess immunosuppressant therapy in patients with primary FSGS.
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Affiliation(s)
- Dawn J. Caster
- Division of Nephrology and Hypertension, School of Medicine, University of Louisville, Louisville, Kentucky
- Address for Correspondence: Dawn J. Caster, MD, Assistant Professor of Medicine, Division of Nephrology and Hypertension, University of Louisville, 550 South Jackson Street, 3rd Floor, Louisville, KY 40202.
| | | | | | | | | | | | | | - Vladmir Tesar
- General University Hospital, Charles University, Prague, Czech Republic
| | - Howard Trachtman
- School of Medicine, Langone Medical Center, New York University, New York, NY
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Neves PD, Bridi RA, Ramalho JA, Jorge LB, Watanabe EH, Watanabe A, Yu L, Woronik V, Pinheiro RB, Testagrossa LA, Cavalcante LB, Malheiros DM, Dias CB, Onuchic LF. Schistosoma mansoni infection as a trigger to collapsing glomerulopathy in a patient with high-risk APOL1 genotype. PLoS Negl Trop Dis 2020; 14:e0008582. [PMID: 33119586 PMCID: PMC7595310 DOI: 10.1371/journal.pntd.0008582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Schistosoma mansoni schistosomiasis (SM) remains a public health problem in Brazil. Renal involvement is classically manifested as a glomerulopathy, most often membranoproliferative glomerulonephritis or focal and segmental glomerulosclerosis. We report a case of collapsing glomerulopathy (CG) associated with SM and high-risk APOL1 genotype (HRG). Case report A 35-year-old male was admitted for hypertension and an eight-month history of lower-limb edema, foamy urine, and increased abdominal girth. He had a recent diagnosis of hepatosplenic SM, treated with praziquantel, without clinical improvement. Laboratory tests revealed serum creatinine 1.89mg/dL, blood urea nitrogen (BUN) 24mg/dL, albumin 1.9g/dL, cholesterol 531mg/dL, low-density lipoprotein 426mg/dL, platelets 115000/mm3, normal C3/C4, antinuclear antibody (ANA), rheumatoid factor (RF), and antineutrophil cytoplasmic antibodies (ANCA), negative serologies for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), HBsAg negative and AntiHBc IgG positive, no hematuria or leukocyturia, 24 hour proteinuria 6.56g and negative serum and urinary immunofixation. Kidney biopsy established the diagnosis of CG. A treatment with prednisone was started without therapeutic response, progressing to end-stage kidney disease 19 months later. Molecular genetics investigation revealed an HRG. Conclusions This is the first report of CG associated with SM in the setting of an HRG. This case highlights the two-hit model as a mechanism for CG pathogenesis, where the high-risk APOL1 genotype exerts a susceptibility role and SM infection serves as a trigger to CG. Schistosomiasis mansoni is still a public health problem in Brazil and renal involvement is described. In such cases, a glomerulopathy is the typical manifestation, most often membranoproliferative glomerulonephritis. In the current article, we report a patient with a recent diagnosis of hepatosplenic SM who was admitted for nephrotic syndrome associated with reduced renal function and hypertension. Kidney biopsy established the diagnosis of collapsing glomerulopathy (CG) and molecular genetics investigation identified a high-risk APOL1 genotype (HRG). Of note, HRG has been associated with increased risk to develop CG, and a two-hit model has been proposed for the genesis of this glomerulopathy. According to this model, a HRG represents the increased-susceptibility component, while an infection or other environmental factors could act as triggers for the development of CG. Based on those data and model, our case raises SM infection as a new trigger for this severe form of glomerulopathy. This is the first description of a case of CG associated with SM in a patient with an HRG. This case corroborates the interactive role between genetic and environmental factors in the pathogenesis of CG but also identifies SM infection as an additional trigger for its development.
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Affiliation(s)
- Precil D. Neves
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
- Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ramaiane A. Bridi
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Janaína A. Ramalho
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lectícia B. Jorge
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Elieser H. Watanabe
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
- Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Andreia Watanabe
- Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luis Yu
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Viktoria Woronik
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rafaela B. Pinheiro
- Division of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Lívia B. Cavalcante
- Division of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Denise M. Malheiros
- Division of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Cristiane B. Dias
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz F. Onuchic
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
- Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
- * E-mail:
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Girimaji N, Bharati J, Nada R, Rathi M, Kohli HS, Ramachandran R. Rituximab in treatment of collapsing FSGS-A case series. Nephrology (Carlton) 2020; 26:134-141. [PMID: 32662534 DOI: 10.1111/nep.13757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Collapsing focal segmental glomerulosclerosis (cFSGS) is an aggressive glomerular disease presenting as a nephrotic syndrome that has lower rates of remission with conventional immunosuppressive therapy and rapidly progresses to end-stage-renal-disease (ESRD). We report eight cases of HIV-negative cFSGS treated with rituximab. METHODS The current report is a retrospective case series of cFSGS treated with rituximab from January 2011 to March 2020, at varying phases of the disease. RESULTS Eight out of the 70 cFSGS patients received rituximab. The median age of patients was 30 years (IQR 24.25-37.5); five patients were males. The median serum creatinine, mean serum albumin and median 24 hours urinary protein at presentation was 0.9 (IQR 0.66-1.27) mg/dL, 2.95 ± 1.15 g/dL, 4.87 (IQR 1.64-5.75) g/day, respectively. Two patients were steroid-resistant, one steroid and tacrolimus dependent, one steroid and cyclosporine dependent, two steroids and tacrolimus resistant, one steroid, tacrolimus, cyclophosphamide, mycophenolate mofetil resistant and one steroid-resistant and tacrolimus dependent before rituximab therapy. Rituximab was given either as targeted therapy (after an initial dose of 375 mg/m2 ; patients having CD-19 levels >5/μL or >1% at 1 month received additional low-dose [100 mg] of rituximab), or weekly regimen. Five patients received CD-19 targeted rituximab; three received weekly doses of 375 mg/m2 , cumulative doses being 820 ± 228.03 mg, and 1800 ± 721.11 mg, respectively. At the end of median follow-up of 15 months, five (62.5%) patients were in remission (three partial, two complete remissions), two (25%) were resistant to therapy; one (12.5%) progressed to ESRD. CONCLUSION Rituximab is reasonably safe and achieves/maintains remission in 60% of cFSGS cases.
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Affiliation(s)
- Niveditha Girimaji
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joyita Bharati
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Merchant ML, Barati MT, Caster DJ, Hata JL, Hobeika L, Coventry S, Brier ME, Wilkey DW, Li M, Rood IM, Deegens JK, Wetzels JF, Larsen CP, Troost JP, Hodgin JB, Mariani LH, Kretzler M, Klein JB, McLeish KR. Proteomic Analysis Identifies Distinct Glomerular Extracellular Matrix in Collapsing Focal Segmental Glomerulosclerosis. J Am Soc Nephrol 2020; 31:1883-1904. [PMID: 32561683 DOI: 10.1681/asn.2019070696] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 04/13/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The mechanisms leading to extracellular matrix (ECM) replacement of areas of glomerular capillaries in histologic variants of FSGS are unknown. This study used proteomics to test the hypothesis that glomerular ECM composition in collapsing FSGS (cFSGS) differs from that of other variants. METHODS ECM proteins in glomeruli from biopsy specimens of patients with FSGS not otherwise specified (FSGS-NOS) or cFSGS and from normal controls were distinguished and quantified using mass spectrometry, verified and localized using immunohistochemistry (IHC) and confocal microscopy, and assessed for gene expression. The analysis also quantified urinary excretion of ECM proteins and peptides. RESULTS Of 58 ECM proteins that differed in abundance between cFSGS and FSGS-NOS, 41 were more abundant in cFSGS and 17 in FSGS-NOS. IHC showed that glomerular tuft staining for cathepsin B, cathepsin C, and annexin A3 in cFSGS was significantly greater than in other FSGS variants, in minimal change disease, or in membranous nephropathy. Annexin A3 colocalized with cathepsin B and C, claudin-1, phosphorylated ERK1/2, and CD44, but not with synaptopodin, in parietal epithelial cells (PECs) infiltrating cFSGS glomeruli. Transcripts for cathepsins B and C were increased in FSGS glomeruli compared with normal controls, and urinary excretion of both cathepsins was significantly greater in cFSGS compared with FSGS-NOS. Urinary excretion of ECM-derived peptides was enhanced in cFSGS, although in silico analysis did not identify enhanced excretion of peptides derived from cathepsin B or C. CONCLUSIONS ECM differences suggest that glomerular sclerosis in cFSGS differs from that in other FSGS variants. Infiltration of activated PECs may disrupt ECM remodeling in cFSGS. These cells and their cathepsins may be therapeutic targets.
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Affiliation(s)
- Michael L Merchant
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Michelle T Barati
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Dawn J Caster
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Jessica L Hata
- Pathology Department, Norton Children's Hospital, Louisville, Kentucky
| | - Liliane Hobeika
- Division of Nephrology, Department of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Susan Coventry
- Pathology Department, Norton Children's Hospital, Louisville, Kentucky
| | - Michael E Brier
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Daniel W Wilkey
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Ming Li
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Ilse M Rood
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen K Deegens
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey B Hodgin
- Division of Pathology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jon B Klein
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky.,Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky
| | - Kenneth R McLeish
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky
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Gupta KL, Bharati J, Anakutti H, Pattanashetti N, Rathi M, Ramachandran R, Nada R. Contribution of Clinically Indicated Repeat Renal Biopsy in Indian Patients with Lupus Nephritis. Indian J Nephrol 2020; 30:377-381. [PMID: 33840956 PMCID: PMC8023033 DOI: 10.4103/ijn.ijn_166_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/05/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Repeat renal biopsy is usually done for lupus nephritis (LN) flare or resistant disease. We analyzed the changes between first and repeat biopsy and the contribution of repeat biopsy on renal outcome in LN patients. Methods: This was a retrospective study carried out at a tertiary care center in India. Sixty-two LN patients who underwent repeat biopsy for clinical indications, between January 2012 to December 2016, were included. Clinical and histological parameters at first and second biopsies were compared. Logistic regression analysis was done to determine parameters on repeat biopsy predicting response at last visit. Results: Repeat biopsy was done for relapse in 56% and for resistant disease in 44% patients. Seven (13.7%) out of 51 patients with baseline proliferative histology converted to non-proliferative lesion on second biopsy, while 2 (18.2%) out of 11 with baseline non-proliferative lesion converted to proliferative lesion on second biopsy. On repeat biopsy, the presence of endocapillary proliferation decreased, whereas glomerulosclerosis, interstitial fibrosis/tubular atrophy (IFTA), and glomerular basement membrane thickening increased. At the last visit (median follow-up of 38.6 months after first biopsy and 13.8 months after second biopsy), 79% of patients were in remission and 6.5% needed renal replacement therapy. The presence of IFTA >30% and thrombotic microangiopathy (TMA) on second biopsy independently predicted response at last visit. Conclusion: In Indian patients with LN, chronicity markers and superimposed membranous pattern increased on repeat biopsy done for clinical indications. The presence of IFTA and TMA on second biopsy predicted response at last visit.
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Affiliation(s)
| | | | | | | | - Manish Rathi
- Department of Nephrology, PGIMER, Chandigarh, India
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9
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Bharati J, Tiewsoh K, Kumar A, Nada R, Rathi M, Gupta KL, Kohli HS, Jha V, Ramachandran R. Usefulness of mycophenolate mofetil in Indian patients with C3 glomerulopathy. Clin Kidney J 2019; 12:483-487. [PMID: 31384438 PMCID: PMC6671524 DOI: 10.1093/ckj/sfy127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Indexed: 02/07/2023] Open
Abstract
Background C3 glomerulopathy (C3G) is a heterogeneous disease caused by alternative complement pathway abnormalities without any standardized treatment. An immunosuppressive agent, mycophenolate mofetil (MMF), has been recently shown to be useful in treating C3G, mainly in studies from the west. We report the clinical outcome of 17 Indian C3G patients treated with MMF with or without steroids. Methods The clinical and histology details of the C3G patients treated with MMF for at least 6 months with a follow-up of at least 12 months were retrieved from the medical records of our center. Results The median serum creatinine and proteinuria at presentation were 0.8 mg/dL and 3.7 g/day, respectively, with the majority (88.2%) presenting as nephrotic syndrome. The mean dose of MMF was 1.65 (±0.56) g/day, and the median duration of MMF therapy was 18 months. Two-thirds (64%) of the patients responded to the treatment, with complete remission in 4 (23%) and partial remission in 7 (41%) (median time: 9 months). Three patients progressed to end-stage renal disease (ESRD) on follow-up. Of the three patients, one (33%) had an initial response in proteinuria to MMF but did not respond after a relapse and subsequently progressed to ESRD and two (67%) other patients were nonresponsive to MMF from the start of the therapy. Conclusion Despite a small sample size and lack of a control arm, this study describes the effectiveness of MMF in treating C3G patients from Asia and forms a basis for future randomized trials.
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Affiliation(s)
- Joyita Bharati
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karalanglin Tiewsoh
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Kumar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekananda Jha
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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