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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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Rivedal M, Mikkelsen H, Marti HP, Liu L, Kiryluk K, Knoop T, Bjørneklett R, Haaskjold YL, Furriol J, Leh S, Paunas F, Bábíčková J, Scherer A, Serre C, Eikrem O, Strauss P. Glomerular transcriptomics predicts long term outcome and identifies therapeutic strategies for patients with assumed benign IgA nephropathy. Kidney Int 2024; 105:717-730. [PMID: 38154557 DOI: 10.1016/j.kint.2023.12.010] [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: 10/21/2022] [Revised: 11/17/2023] [Accepted: 12/08/2023] [Indexed: 12/30/2023]
Abstract
Some patients diagnosed with benign IgA nephropathy (IgAN) develop a progressive clinical course, not predictable by known clinical or histopathological parameters. To assess if gene expression can differentiate between progressors and non-progressors with assumed benign IgAN, we tested microdissected glomeruli from archival kidney biopsy sections from adult patients with stable clinical remission (21 non-progressors) or from 15 patients that had undergone clinical progression within a 25-year time frame. Based on 1 240 differentially expressed genes from patients with suitable sequencing results, we identified eight IgAN progressor and nine non-progressor genes using a two-component classifier. These genes, including APOL5 and ZXDC, predicted disease progression with 88% accuracy, 75% sensitivity and 100% specificity on average 21.6 years before progressive disease was clinically documented. APOL lipoproteins are associated with inflammation, autophagy and kidney disease while ZXDC is a zinc-finger transcription factor modulating adaptive immunity. Ten genes from our transcriptomics data overlapped with an external genome wide association study dataset, although the gene set enrichment test was not statistically significant. We also identified 45 drug targets in the DrugBank database, including angiotensinogen, a target of sparsentan (dual antagonist of the endothelin type A receptor and the angiotensin II type 1 receptor) currently investigated for IgAN treatment. Two validation cohorts were used for substantiating key results, one by immunohistochemistry and the other by nCounter technology. Thus, glomerular mRNA sequencing from diagnostic kidney biopsies from patients with assumed benign IgAN can differentiate between future progressors and non-progressors at the time of diagnosis.
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Affiliation(s)
- Mariell Rivedal
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Håvard Mikkelsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans-Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lili Liu
- Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Thomas Knoop
- 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
| | - Yngvar Lunde Haaskjold
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Jessica Furriol
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sabine Leh
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Flavia Paunas
- Department of Medicine, Haugesund Hospital, Haugesund, Norway
| | - Janka Bábíčková
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Andreas Scherer
- Spheromics, Kontiolahti, Finland; Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Camille Serre
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Oystein Eikrem
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Philipp Strauss
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Mao M, Zhou Y, Zhang X, Zhao XY, Wang CD, Chen P. Renin-angiotensin-aldosterone-system inhibitors increase the serum level of complement component 4 in patients with immunoglobulin A nephropathy. Int Immunopharmacol 2024; 130:111669. [PMID: 38387189 DOI: 10.1016/j.intimp.2024.111669] [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: 11/26/2023] [Revised: 01/28/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To investigate the impact of renin-angiotensin-aldosterone-system (RAAS) inhibitors on complement component 4 (C4) serum levels in patients with immunoglobulin A nephropathy (IgAN). METHODS A total of 423 patients diagnosed with IgAN at Shanxi Provincial People's Hospital, China, between 1 January 2017 and 31 December 2021 were divided into two groups, a RAAS inhibitor group and a non-RAAS inhibitor group, for comparative analysis. RESULTS The RAAS inhibitor group exhibited significantly increased C4 and eGFR levels and had a higher proportion of patients with hypertension compared with the non-RAAS inhibitor group. Serum C4 levels were positively correlated with 24-hour urine protein, serum C3 levels and blood uric acid levels but negatively correlated with eGFR levels. In addition, serum C4 levels were positively correlated with the severity of mesangial hypercellularity and interstitial/tubular injury. Through prognostic analysis, serum C4 was identified as an independent risk factor for the progression of IgAN. CONCLUSION Renin-angiotensin-aldosterone-system inhibitors can increase serum C4 levels in patients with IgAN and may represent an independent risk factor for disease progression.
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Affiliation(s)
- Min Mao
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, China
| | - Yun Zhou
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, China; Department of Nephrology, Shanxi Province Integrated TCM and WM Hospital, Taiyuan, China
| | - Xu Zhang
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, China
| | - Xiao-Yu Zhao
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, China
| | - Chen-Dan Wang
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, China
| | - Ping Chen
- Department of Nephrology, The Fifth Clinical Medical College of Shanxi Medical University (Shanxi Provincial People's Hospital), Taiyuan, China.
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Jiang Y, Chen P, Zhao W, Liu L, Shi S, Lv J, Zhang H. Distinct characteristics and prognosis of IgA nephropathy patients with nephrotic syndrome: a propensity score-matched cohort study. Front Med (Lausanne) 2024; 11:1344219. [PMID: 38439903 PMCID: PMC10910015 DOI: 10.3389/fmed.2024.1344219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/07/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction IgA nephropathy (IgAN) is the most prevalent primary glomerulonephritis globally. While nephrotic syndrome (NS) is uncommon in IgAN, its significance remains unclear. Methods We conducted a retrospective analysis of 170 IgAN patients, classifying them into NS (n = 85) and non-NS (n = 5) groups. Our study aims to compare their clinical characteristics, treatment responses, and prognoses. Patients were selected based on renal biopsy from 2003 to 2020. Propensity score matching ensured comparability. Clinical, pathological, and immunological data were analyzed. Composite endpoints were defined as end-stage kidney disease (ESKD) or a 30% decline in estimated glomerular filtration rate (eGFR). Results NS patients showed higher eGFR (74.3 ± 36.8 vs. 61.5 ± 33.6 mL/min.1.73 m2, p = 0.02), severe hematuria (35.0 (4.7,147.5) vs. 4.0 (1.8,45,0) cells/μl, p < 0.001), severe foot process effacement (p = 0.01), and lower C3 levels (1.0 ± 0.3 vs. 1.1 ± 0.2 g/L, p = 0.03). In contrast, the non-NS group had higher BMI (24.3 ± 4.0 vs. 26.8 ± 3.7 kg/m2, p < 0.001) and elevated serum uric acid levels (376 (316,417) vs. 400 (362, 501) mmol/L, p = 0.001), suggesting metabolic factors might contribute to their condition. Both groups exhibited similar MESTC scores. NS patients had higher complete remission rates (26.2% vs. 14.1%, p = 0.04). Cox regression revealed NS independently associated with a higher risk of composite endpoints (HR = 1.97, 95% CI 1.05-3.72, p = 0.04). Linear mixed models did not show significant eGFR trajectory differences. Discussion This study has established that IgAN patients with NS exhibit distinct characteristics, including active disease and increased complement activation. NS is independently associated with a poorer prognosis, emphasizing the need for targeted interventions in this subgroup.
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Affiliation(s)
- Yuanyuan Jiang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Pei Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Wenjing Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lijun Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
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Di Leo V, Annese F, Papadia F, Russo MS, Giliberti M, Sallustio F, Gesualdo L. Refractory IgA Nephropathy: A Challenge for Future Nephrologists. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:274. [PMID: 38399561 PMCID: PMC10890070 DOI: 10.3390/medicina60020274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
IgA nephropathy (IgAN) represents the most prevalent form of primary glomerulonephritis, and, on a global scale, it ranks among the leading culprits behind end-stage kidney disease (ESKD). Presently, the primary strategy for managing IgAN revolves around optimizing blood pressure and mitigating proteinuria. This is achieved through the utilization of renin-angiotensin system (RAS) inhibitors, namely, angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). As outlined by the KDIGO guidelines, individuals who continue to show a persistent high risk of progressive ESKD, even with comprehensive supportive care, are candidates for glucocorticoid therapy. Despite these therapies, some patients have a disease refractory to treatment, defined as individuals that present a 24 h urinary protein persistently >1 g after at least two rounds of regular steroids (methylprednisolone or prednisone) and/or immunosuppressant therapy (e.g., mycophenolate mofetil), or who do not tolerate regular steroids and/or immunosuppressant therapy. The aim of this Systematic Review is to revise the current literature, using the biomedical database PubMed, to investigate possible therapeutic strategies, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, fecal microbiota transplantation, as well as blockade of complement components.
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Hu H, Zhang Z, Liu Z, Chu F, Ran J, Liang W. Thickened Perirenal Fat Predicts Poor Renal Outcome in Patients with Immunoglobulin A Nephropathy: A Population-Based Retrospective Cohort Study. KIDNEY DISEASES (BASEL, SWITZERLAND) 2024; 10:51-60. [PMID: 38322631 PMCID: PMC10843190 DOI: 10.1159/000533507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/07/2023] [Indexed: 02/08/2024]
Abstract
Introduction Perirenal fat is a pad that fills the retroperitoneal space outside the kidney, which affects kidney function in various ways. However, the association between perirenal fat and IgA nephropathy (IgAN) has not yet been elucidated. This study aimed to investigate the role of perirenal fat in predicting IgAN progression. Methods A total of 473 patients with biopsy-proven IgAN and follow-up information were recruited, and perirenal fat thickness (PFT) was measured using color Doppler ultrasonography at renal biopsy. Patients were divided into two groups according to the median PFT: the low-PFT group (PFT ≤1.34 cm, n = 239) and the high PFT group (PFT >1.35 cm, n = 234). A total of 473 healthy participants were included in the control group. Basic clinical characteristics were assessed at the time of renal biopsy, and the relationship between PFT and combined endpoints was analyzed. The renal composite endpoints were defined as a two-fold increase in blood creatinine level, end-stage renal disease (dialysis over 3 months). Kaplan-Meier survival analysis was used to explore the role of PFT in the progression of IgAN. Three clinicopathological models of multivariate Cox regression analysis were established to evaluate the association between PFT and renal prognosis in patients with IgAN. Results Compared to healthy subjects, patients with IgAN showed significantly higher PFT. After a median follow-up of 50 months, 75 of 473 patients (15.9%) with IgAN reached renal composite endpoints. Among those, 13 of 239 patients (5.4%) were in the low PFT group, and 62 of 234 patients (26.5%) were in the high PFT group (p < 0.001). The results of three Cox regression models (including demographics, pathological and clinical indicators, and PFT) demonstrated that a higher PFT was significantly associated with a higher risk of reaching renal composite endpoints in patients with IgAN. Conclusion This study indicated a positive relationship between PFT at renal biopsy and renal progression in patients with IgAN, suggesting that perirenal fat might act as a marker of poor prognosis in patients with IgAN.
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Affiliation(s)
- Hongtu Hu
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
- Key Clinical Research Center of Kidney Disease, Wuhan, China
| | - Zongwei Zhang
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
- Key Clinical Research Center of Kidney Disease, Wuhan, China
| | - Zikang Liu
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
- Key Clinical Research Center of Kidney Disease, Wuhan, China
| | - Fan Chu
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
- Key Clinical Research Center of Kidney Disease, Wuhan, China
| | - Jialu Ran
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Wei Liang
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
- Key Clinical Research Center of Kidney Disease, Wuhan, China
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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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Zhang H, Rizk DV, Perkovic V, Maes B, Kashihara N, Rovin B, Trimarchi H, Sprangers B, Meier M, Kollins D, Papachristofi O, Milojevic J, Junge G, Nidamarthy PK, Charney A, Barratt J. Results of a randomized double-blind placebo-controlled Phase 2 study propose iptacopan as an alternative complement pathway inhibitor for IgA nephropathy. Kidney Int 2024; 105:189-199. [PMID: 37914086 DOI: 10.1016/j.kint.2023.09.027] [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: 12/07/2022] [Revised: 08/30/2023] [Accepted: 09/27/2023] [Indexed: 11/03/2023]
Abstract
Targeting the alternative complement pathway is an attractive therapeutic strategy given its role in the pathogenesis of immunoglobulin A nephropathy (IgAN). Iptacopan (LNP023) is an oral, proximal alternative complement inhibitor that specifically binds to Factor B. Our randomized, double-blind, parallel-group adaptive Phase 2 study (NCT03373461) enrolled patients with biopsy-confirmed IgAN (within previous three years) with estimated glomerular filtration rates of 30 mL/min/1.73 m2 and over and urine protein 0.75 g/24 hours and over on stable doses of renin angiotensin system inhibitors. Patients were randomized to four iptacopan doses (10, 50, 100, or 200 mg bid) or placebo for either a three-month (Part 1; 46 patients) or a six-month (Part 2; 66 patients) treatment period. The primary analysis evaluated the dose-response relationship of iptacopan versus placebo on 24-hour urine protein-to-creatinine ratio (UPCR) at three months. Other efficacy, safety and biomarker parameters were assessed. Baseline characteristics were generally well-balanced across treatment arms. There was a statistically significant dose-response effect, with 23% reduction in UPCR achieved with iptacopan 200 mg bid (80% confidence interval 8-34%) at three months. UPCR decreased further through six months in iptacopan 100 and 200 mg arms (from a mean of 1.3 g/g at baseline to 0.8 g/g at six months in the 200 mg arm). A sustained reduction in complement biomarker levels including plasma Bb, serum Wieslab, and urinary C5b-9 was observed. Iptacopan was well-tolerated, with no reports of deaths, treatment-related serious adverse events or bacterial infections, and led to strong inhibition of alternative complement pathway activity and persistent proteinuria reduction in patients with IgAN. Thus, our findings support further evaluation of iptacopan in the ongoing Phase 3 trial (APPLAUSE-IgAN; NCT04578834).
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Affiliation(s)
- Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, People's Republic of China.
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Brad Rovin
- Division of Nephrology, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hernán Trimarchi
- Nephrology Service and Kidney Transplantation Unit, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium; Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Julie Milojevic
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Guido Junge
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Alan Charney
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; The John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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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: 23] [Impact Index Per Article: 23.0] [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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Rajasekaran A, Larkina M, Julian BA, Canetta PA, Roehm BA, Khalid M, Mariani LH, Rizk DV. Optimal Conservative Therapy Use among Adult Cure Glomerulonephropathy Participants with IgA Nephropathy. KIDNEY360 2023; 4:1763-1769. [PMID: 37962551 PMCID: PMC10758511 DOI: 10.34067/kid.0000000000000306] [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: 07/07/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023]
Abstract
Optimal supportive therapy with BP and proteinuria control is pivotal in treating patients with IgA nephropathy. Suboptimal treatment of hypertension and proteinuria persisted in many patients with IgA nephropathy in the Cure Glomerulonephropathy Network study. Many patients had above-target proteinuria despite optimal BP control and may benefit from novel therapies or clinical trials.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Maria Larkina
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Bruce A. Julian
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pietro A. Canetta
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Bethany A. Roehm
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Myda Khalid
- Division of Pediatric Nephrology, Indiana University, Indianapolis, Indiana
| | - Laura H. Mariani
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Dana V. Rizk
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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12
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Haaskjold YL, Lura NG, Bjørneklett R, Bostad LS, Knoop T, Bostad L. Long-term follow-up of IgA nephropathy: clinicopathological features and predictors of outcomes. Clin Kidney J 2023; 16:2514-2522. [PMID: 38046027 PMCID: PMC10689167 DOI: 10.1093/ckj/sfad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Indexed: 12/05/2023] Open
Abstract
Background The establishment of the Oxford classification and newly developed prediction models have improved the prognostic information for immunoglobulin A nephropathy (IgAN). Considering new treatment options, optimizing prognostic information and improving existing prediction models are favorable. Methods We used random forest survival analysis to select possible predictors of end-stage kidney disease among 37 candidate variables in a cohort of 232 patients with biopsy-proven IgAN retrieved from the Norwegian Kidney Biopsy Registry. The predictive value of variables with relative importance >5% was assessed using concordance statistics and the Akaike information criterion. Pearson's correlation coefficient was used to identify correlations between the selected variables. Results The median follow-up period was 13.7 years. An isolated analysis of histological variables identified six variables with relative importance >5%: T %, segmental glomerular sclerosis without characteristics associated with other subtypes (not otherwise specified, NOS), normal glomeruli, global sclerotic glomeruli, segmental adherence and perihilar glomerular sclerosis. When histopathological and clinical variables were combined, estimated glomerular filtration rate (eGFR), proteinuria and serum albumin were added to the list. T % showed a better prognostic value than tubular atrophy/interstitial fibrosis (T) lesions with C-indices at 0.74 and 0.67 and was highly correlated with eGFR. Analysis of the subtypes of segmental glomerulosclerosis (S) lesions revealed that NOS and perihilar glomerular sclerosis were associated with adverse outcomes. Conclusions Reporting T lesions as a continuous variable, normal glomeruli and subtypes of S lesions could provide clinicians with additional prognostic information and contribute to the improved performance of the Oxford classification and prognostic tools.
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Affiliation(s)
- Yngvar Lunde Haaskjold
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Njål Gjærde Lura
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Lars Sigurd Bostad
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Thomas Knoop
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Leif Bostad
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
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13
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Wu L, Du X, Lu X. Role of telitacicept in the treatment of IgA nephropathy. Eur J Med Res 2023; 28:369. [PMID: 37737205 PMCID: PMC10515419 DOI: 10.1186/s40001-023-01320-2] [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: 04/10/2023] [Accepted: 08/27/2023] [Indexed: 09/23/2023] Open
Abstract
IgA nephropathy (IgAN) is the most common primary glomerular disease in the world, and up to 40% of patients with IgAN develop end-stage renal disease (ESRD). At present, an increasing amount of evidence indicates that the pathogenesis of IgAN is related to autoimmunity. In recent years, several studies have shown that B cell activating factors (BAFF), also known as B lymphocyte stimulators (BLyS), and proliferation-inducing ligand APRIL are extremely important for the activation of autoimmune signalling pathways, which have become key targets for the treatment of IgAN. As a dual-target biological agent, telitacicept can inhibit both BLyS and APRIL cytokines, improve the function of renal immune complexes, and reduce haematuria and proteinuria, which play important roles in IgAN pathogenesis and long-term prognosis. This article reviews the role of telitacicept in IgA nephropathy and discusses its potential for use in the treatment of IgAN and other autoimmune diseases where pathogenesis is driven by B cells.
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Affiliation(s)
- Lijun Wu
- The Second Hospital of Jilin University Nephropathy of Internal Medicine, Changchun, 130022 China
| | - Xinru Du
- The Second Hospital of Jilin University Nephropathy of Internal Medicine, Changchun, 130022 China
| | - Xuehong Lu
- The Second Hospital of Jilin University Nephropathy of Internal Medicine, Changchun, 130022 China
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14
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Zhu J, Wu F, Li C, Mao J, Wang Y, Zhou X, Xie H, Wen C. Application of Single Extracellular Vesicle Analysis Techniques. Int J Nanomedicine 2023; 18:5365-5376. [PMID: 37750091 PMCID: PMC10518151 DOI: 10.2147/ijn.s421342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
Extracellular vesicles (EVs) are lipid containers that are actively released by cells and contain complex molecular cargoes. These cargoes include abundant material such as genomes and proteins from cells of origin. They are involved in intercellular communication and various pathological processes, showing excellent potential for diagnosing and treating diseases. Given the significant heterogeneity of EVs in complex physiopathological processes, unveiling their composition is essential to understanding their function. Bulk detection methods have been previously used to analyze EVs, but they often mask their heterogeneity, leading to the loss of valuable information. To overcome this limitation, single extracellular vesicle (SEV) analysis techniques have been developed and advanced. These techniques allow for analyzing EVs' physical information and biometric molecules at the SEV level. This paper reviews recent advances in SEV detection methods and summarizes some clinical applications for SEV detection strategies.
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Affiliation(s)
- Junquan Zhu
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Feifeng Wu
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Cuifang Li
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jueyi Mao
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Yang Wang
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xin Zhou
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Haotian Xie
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Chuan Wen
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
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15
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Yau K, Wang C, Al Batran R, Macphee A, Beaucage M, Farragher JF. Knowledge Translation in Glomerulonephritis: Successes in Translational Research From the Bench to Bedside. Can J Kidney Health Dis 2023; 10:20543581231191839. [PMID: 37637870 PMCID: PMC10457520 DOI: 10.1177/20543581231191839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/28/2023] [Indexed: 08/29/2023] Open
Abstract
Purpose of review Glomerulonephritis refers to a rare group of diseases characterized by glomerular inflammation, which collectively are a common cause of kidney failure. Until recently, there was a lack of high-quality clinical trials to inform the care of patients with glomerulonephritides. We identified examples of successful translational research spanning from basic science to clinical applications, and highlight gaps in implementation science. Sources of information The focus of our review was derived from discussions between health care professionals, researchers, and patient partners. We also performed literature searches pertaining to the treatment of glomerulonephritis in PubMed and Google Scholar. Methods Examples of successful knowledge translation were generated through review of new evidence in the past 5 years and by iterative discussions by the authors. We then conducted a narrative review of several themes related to knowledge translation in glomerulonephritis. This was complemented by an interview with a patient partner to provide an example of a patient's perspective living with glomerulonephritis. Key findings We summarized selected recent advances in glomerulonephritis and its knowledge translation in the following domains: (1) identification of auto-antibodies in membranous nephropathy and minimal change disease; (2) clinical trials of novel targeted therapies for IgA nephropathy and lupus nephritis, which have led to approval of new treatments; (3) developments in research networks and clinical trials in glomerulonephritis; (4) recognition of the importance in developing standardized patient reported outcome measures in clinical trials; and (5) barriers in knowledge translation including access to medication. Limitations A systematic search of the literature and formal assessment of quality of evidence were beyond the scope of this review.
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Affiliation(s)
- Kevin Yau
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Carol Wang
- Division of Nephrology, Western University, London, ON, Canada
| | - Rami Al Batran
- Faculte de Pharmacie, Universite de Montreal, Montreal, QC, Canada
| | - Anne Macphee
- Kidney Research Scientist Core Education and National Training Patient Community Advisory Network, Montreal, QC, Canada
| | - Mary Beaucage
- Kidney Research Scientist Core Education and National Training Patient Community Advisory Network, Montreal, QC, Canada
- Patient Governance Council, Indigenous Peoples’ Engagement and Research Council, Can-SOLVE CKD, Vancouver, BC, Canada
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Provincial Patient and Family Advisory Council, Ontario Renal Network, Toronto, Ontario, Canada
| | - Janine F. Farragher
- Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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16
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Liu Y, Gong Y, Xu G. The role of mononuclear phagocyte system in IgA nephropathy: pathogenesis and prognosis. Front Immunol 2023; 14:1192941. [PMID: 37529043 PMCID: PMC10390225 DOI: 10.3389/fimmu.2023.1192941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/12/2023] [Indexed: 08/03/2023] Open
Abstract
Although the "multiple hits" theory is a widely accepted pathogenesis in IgA nephropathy (IgAN), increasing evidence suggests that the mononuclear/macrophage system plays important roles in the progression of IgAN; however, the exact mechanism is unclear. In the present study, we explored 1,067 patients in 15 studies and found that the number of macrophages per glomerulus was positively related with the degree of hematuria, and the macrophages in the glomeruli were mainly related to mesangial proliferation (M) in renal biopsy. In the tubulointerstitium, macrophages were significantly paralleled to tubulointerstitial α-SMA and NF-kB expression, tubulointerstitial lesion, tubule atrophy/interstitial fibrosis (T), and segmental glomerulosclerosis (S). In the glomeruli and tubulointerstitium, M1 accounted for 85.41% in the M classification according to the Oxford MEST-C, while in the blood, M1 accounted for 100%, and the patients with low CD89+ monocyte mean fluorescence intensity displayed more severe pathological characteristics (S1 and T1-2) and clinical symptoms. M1 (CD80+) macrophages were associated with proinflammation in the acute phase; however, M2 (CD163+) macrophages participated in tissue repair and remodeling, which correlated with chronic inflammation. In the glomeruli, M2 macrophages activated glomerular matrix expansion by secreting cytokines such as IL-10 and tumor necrosis factor-β (TGF-β), and M0 (CD68+) macrophages stimulated glomerular hypercellularity. In the tubulointerstitium, M2 macrophages played pivotal roles in renal fibrosis and sclerosis. It is assumed that macrophages acted as antigen-presenting cells to activate T cells and released diverse cytokines to stimulate an inflammatory response. Macrophages infiltrating glomeruli destroy the integrity of podocytes through the mesangio-podocytic-tubular crosstalk as well as the injury of the tubule.
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Affiliation(s)
- Yiwen Liu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The Second Clinical Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Yan Gong
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Barratt J, Lafayette RA, Zhang H, Tesar V, Rovin BH, Tumlin JA, Reich HN, Floege J. IgA Nephropathy: the Lectin Pathway and Implications for Targeted Therapy. Kidney Int 2023:S0085-2538(23)00395-2. [PMID: 37263354 DOI: 10.1016/j.kint.2023.04.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 06/03/2023]
Abstract
Many patients with IgA nephropathy (IgAN) progress to end-stage kidney disease even with optimal supportive care. An improved understanding of the pathophysiology of IgAN in recent years has led to the investigation of targeted therapies with acceptable tolerability that may address the underlying causes of IgAN or the pathogenesis of kidney injury. The complement system - particularly the lectin and alternative pathways of complement - have emerged as key mediators of kidney injury in IgAN and possible targets for investigational therapy. This review will focus on the lectin pathway. Examination of kidney biopsies has consistently shown glomerular deposition of mannan-binding lectin (one of six pattern-recognition molecules that activate the lectin pathway) together with IgA1 in up to 50% of patients with IgAN. Glomerular deposition of pattern-recognition molecules for the lectin pathway is associated with more severe glomerular damage and more severe proteinuria and hematuria. Emerging research suggests that the lectin pathway may also contribute to tubulointerstitial fibrosis in IgAN, and that collectin-11 is a key mediator of this association. This review summarizes the growing scientific and clinical evidence supporting the role of the lectin pathway in IgAN and examines the possible therapeutic role of lectin pathway inhibition for these patients.
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Affiliation(s)
| | | | - Hong Zhang
- Peking University Institute of Nephrology, Beijing, China
| | - Vladimir Tesar
- Charles University and General University Hospital, Prague, Czech Republic
| | - Brad H Rovin
- The Ohio State University Wexner Medical Center, Columbus OH, USA
| | | | - Heather N Reich
- University of Toronto and University Health Network, Toronto ON, Canada
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Wang F, Li N, Ni S, Min Y, Wei K, Sun H, Fu Y, Liu Y, Lv D. The Effects of Specific Gut Microbiota and Metabolites on IgA Nephropathy-Based on Mendelian Randomization and Clinical Validation. Nutrients 2023; 15:nu15102407. [PMID: 37242290 DOI: 10.3390/nu15102407] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Although recent research suggests that alterations in gut microbiota and metabolites play a critical role in the pathophysiology of immunoglobulin A nephropathy (IgAN), the causal relationship between specific intestinal flora and metabolites and the risk of IgAN remains unclear. METHOD This study employed Mendelian randomization (MR) to investigate the causal association between gut microbiota and IgAN. To explore potential associations between gut microbiota and various outcomes, four MR methods were applied: inverse variance weighted (IVW), MR-Egger, weighted median, and weighted mode. If the results of the four methods are inconclusive, we prefer the IVW as the primary outcome. Additionally, MR-Egger, MR-PRESSO-Global, and Cochrane's Q tests were used to detect heterogeneity and pleiotropy. The stability of MR findings was assessed using the leave-one-out approach, and the strength of the causal relationship between exposure and outcome was tested using Bonferroni correction. Additional clinical samples were utilized to validate the results of Mendelian randomization, and the outcomes were visualized through an ROC curve, confusion matrix, and correlation analysis. RESULT This study examined a total of 15 metabolites and 211 microorganisms. Among them, eight bacteria and one metabolite were found to be associated with the risk of IgAN (p < 0.05). The Bonferroni-corrected test reveals that only Class. Actinobacteria (OR: 1.20, 95% CI: 1.07-1.36, p = 0.0029) have a significant causal relationship with IgAN. According to Cochrane's Q test, there is no substantial heterogeneity across different single-nucleotide polymorphisms (p > 0.05). Furthermore, MR-Egger and MR-PRESSO-Global tests (p > 0.05) showed no evidence of pleiotropy. No reverse causal association was found between the risk of IgAN and microbiota or metabolites (p > 0.05). Clinical specimens demonstrated the effectiveness and accuracy of Actinobacteria in distinguishing IgAN patients from those with other glomerular diseases (AUC = 0.9, 95% CI: 0.78-1.00). Additionally, our correlation analysis revealed a potential association between Actinobacteria abundance and increased albuminuria (r = 0.85) and poorer prognosis in IgAN patients (p = 0.01). CONCLUSION Through MR analysis, we established a causal link between Actinobacteria and the incidence of IgAN. Moreover, clinical validation using fecal samples indicated that Actinobacteria might be associated with the onset and poorer prognosis of IgAN. This finding could provide valuable biomarkers for early, noninvasive detection of the disease and potential therapeutic targets in IgAN.
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Affiliation(s)
- Fang Wang
- Institute of Nephrology, Liyang Hospital of Chinese Medicine, Liyang 213300, China
- Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Ning Li
- Institute of Nephrology, Southeast University School of Medicine, Nanjing 210009, China
| | - Siming Ni
- Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Yu Min
- Department of Biotherapy and National Clinical Research Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Kang Wei
- Yangzhou People's Hospital, Yangzhou University, Yangzhou 225000, China
| | - Hongbin Sun
- Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Yuqi Fu
- Institute of Nephrology, Southeast University School of Medicine, Nanjing 210009, China
| | - Yalan Liu
- Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Dan Lv
- Institute of Nephrology, Liyang Hospital of Chinese Medicine, Liyang 213300, China
- Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210000, China
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Liu L, Khan A, Sanchez-Rodriguez E, Zanoni F, Li Y, Steers N, Balderes O, Zhang J, Krithivasan P, LeDesma RA, Fischman C, Hebbring SJ, Harley JB, Moncrieffe H, Kottyan LC, Namjou-Khales B, Walunas TL, Knevel R, Raychaudhuri S, Karlson EW, Denny JC, Stanaway IB, Crosslin D, Rauen T, Floege J, Eitner F, Moldoveanu Z, Reily C, Knoppova B, Hall S, Sheff JT, Julian BA, Wyatt RJ, Suzuki H, Xie J, Chen N, Zhou X, Zhang H, Hammarström L, Viktorin A, Magnusson PKE, Shang N, Hripcsak G, Weng C, Rundek T, Elkind MSV, Oelsner EC, Barr RG, Ionita-Laza I, Novak J, Gharavi AG, Kiryluk K. Genetic regulation of serum IgA levels and susceptibility to common immune, infectious, kidney, and cardio-metabolic traits. Nat Commun 2022; 13:6859. [PMID: 36369178 PMCID: PMC9651905 DOI: 10.1038/s41467-022-34456-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 10/25/2022] [Indexed: 11/13/2022] Open
Abstract
Immunoglobulin A (IgA) mediates mucosal responses to food antigens and the intestinal microbiome and is involved in susceptibility to mucosal pathogens, celiac disease, inflammatory bowel disease, and IgA nephropathy. We performed a genome-wide association study of serum IgA levels in 41,263 individuals of diverse ancestries and identified 20 genome-wide significant loci, including 9 known and 11 novel loci. Co-localization analyses with expression QTLs prioritized candidate genes for 14 of 20 significant loci. Most loci encoded genes that produced immune defects and IgA abnormalities when genetically manipulated in mice. We also observed positive genetic correlations of serum IgA levels with IgA nephropathy, type 2 diabetes, and body mass index, and negative correlations with celiac disease, inflammatory bowel disease, and several infections. Mendelian randomization supported elevated serum IgA as a causal factor in IgA nephropathy. African ancestry was consistently associated with higher serum IgA levels and greater frequency of IgA-increasing alleles compared to other ancestries. Our findings provide novel insights into the genetic regulation of IgA levels and its potential role in human disease.
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Affiliation(s)
- Lili Liu
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Atlas Khan
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Elena Sanchez-Rodriguez
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Francesca Zanoni
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Yifu Li
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Nicholas Steers
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Olivia Balderes
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Junying Zhang
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Priya Krithivasan
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Robert A. LeDesma
- grid.16750.350000 0001 2097 5006Lewis Thomas Laboratory, Department of Molecular Biology, Princeton University, Princeton, NJ USA
| | - Clara Fischman
- grid.25879.310000 0004 1936 8972Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Scott J. Hebbring
- grid.280718.40000 0000 9274 7048Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, WI USA
| | - John B. Harley
- grid.239573.90000 0000 9025 8099Center of Autoimmune Genomics and Etiology, Cincinnati Children’s Hospital, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA ,grid.413848.20000 0004 0420 2128US Department of Veterans Affairs Medical Center, Cincinnati, OH USA
| | - Halima Moncrieffe
- grid.239573.90000 0000 9025 8099Center of Autoimmune Genomics and Etiology, Cincinnati Children’s Hospital, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Leah C. Kottyan
- grid.239573.90000 0000 9025 8099Center of Autoimmune Genomics and Etiology, Cincinnati Children’s Hospital, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Bahram Namjou-Khales
- grid.239573.90000 0000 9025 8099Center of Autoimmune Genomics and Etiology, Cincinnati Children’s Hospital, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Theresa L. Walunas
- grid.16753.360000 0001 2299 3507Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Rachel Knevel
- grid.62560.370000 0004 0378 8294Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Soumya Raychaudhuri
- grid.62560.370000 0004 0378 8294Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Elizabeth W. Karlson
- grid.62560.370000 0004 0378 8294Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Joshua C. Denny
- grid.152326.10000 0001 2264 7217Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Ian B. Stanaway
- grid.34477.330000000122986657Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA USA
| | - David Crosslin
- grid.34477.330000000122986657Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, WA USA
| | - Thomas Rauen
- grid.1957.a0000 0001 0728 696XDepartment of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Jürgen Floege
- grid.1957.a0000 0001 0728 696XDepartment of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Frank Eitner
- grid.1957.a0000 0001 0728 696XDepartment of Nephrology, RWTH University of Aachen, Aachen, Germany ,grid.420044.60000 0004 0374 4101Kidney Diseases Research, Bayer Pharma AG, Wuppertal, Germany
| | - Zina Moldoveanu
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Colin Reily
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Barbora Knoppova
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Stacy Hall
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Justin T. Sheff
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Bruce A. Julian
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Robert J. Wyatt
- grid.267301.10000 0004 0386 9246Division of Pediatric Nephrology, University of Tennessee Health Sciences Center, Memphis, TN USA
| | - Hitoshi Suzuki
- grid.258269.20000 0004 1762 2738Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Jingyuan Xie
- grid.16821.3c0000 0004 0368 8293Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Chen
- grid.16821.3c0000 0004 0368 8293Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xujie Zhou
- grid.11135.370000 0001 2256 9319Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Hong Zhang
- grid.11135.370000 0001 2256 9319Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Lennart Hammarström
- grid.4714.60000 0004 1937 0626Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Viktorin
- grid.4714.60000 0004 1937 0626Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Patrik K. E. Magnusson
- grid.4714.60000 0004 1937 0626Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ning Shang
- grid.21729.3f0000000419368729Department of Biomedical Informatics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - George Hripcsak
- grid.21729.3f0000000419368729Department of Biomedical Informatics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Chunhua Weng
- grid.21729.3f0000000419368729Department of Biomedical Informatics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Tatjana Rundek
- grid.26790.3a0000 0004 1936 8606Department of Neurology, University of Miami, Miami, FL USA ,grid.26790.3a0000 0004 1936 8606Evelyn F. McKnight Brain Institute, University of Miami, Miami, FL USA
| | - Mitchell S. V. Elkind
- grid.21729.3f0000000419368729Department of Neurology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Elizabeth C. Oelsner
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - R. Graham Barr
- grid.21729.3f0000000419368729Division of General Medicine, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA ,grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
| | - Iuliana Ionita-Laza
- grid.21729.3f0000000419368729Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY USA
| | - Jan Novak
- grid.265892.20000000106344187Department of Microbiology and Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Ali G. Gharavi
- grid.21729.3f0000000419368729Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.
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20
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Chen M, Zhang P, Li L, Yu Z, Liu N, Wang L. Efficacy and Safety of Glycosides of Tripterygium wilfordii Combined with Renin-Angiotensin System in the Treatment of IgA Nephropathy: A Systematic Review and Meta-Analysis. Emerg Med Int 2022; 2022:5314105. [PMID: 36212998 PMCID: PMC9546686 DOI: 10.1155/2022/5314105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background IgA nephropathy (IgAN) is currently the most common primary glomerular disease, accounting for approximately 36.7% to 58.2% of primary glomerular disease in kidney biopsies in China. Definitive diagnosis depends on immunopathological examination of the kidney. The prognosis of this disease was generally considered to be good, but recent studies have found that about half of patients can progress to end-stage renal disease within 30 years of onset. Because the pathogenesis is unknown, there is no specific treatment. Objective To evaluate the efficacy and safety of glycosides of Tripterygium wilfordii (GTW) in combination with renin-angiotensin system (RAS) inhibitors for the treatment of IgAN. Methods Search Embase, Pubmed, Cochrane, CNKI, Web of Science, Wanfang, and VIP for all randomized controlled trials (RCTs) on treating IgAN with RASI from the self-built database to December 2021. Relevant data were searched and collected separately by two reviewers. The Cochrane risk of bias model was used for quality assessment, and RevMan 5.3 was used for data analysis. Results Thirteen Chinese publications with a total of 958 patients were finally included. There was no statistically significant difference in baseline information (including laboratory data and clinical parameters) between the two groups of patients. The urine protein quantification in both groups showed a significant decreasing trend as the treatment duration increased. At 3, 6, 9, and 12 months after treatment, urine protein was significantly lower than the baseline value in both the observation and control groups (P < 0.05). During the follow-up period, there was no statistical difference in blood creatinine (Scr) and eGFR values between the two groups compared with the baseline values (P > 0.05). Patients with CKD stage 2 achieved a higher remission rate compared with patients with CKD stage 3, with a statistically significant difference (P < 0.05), and the difference between the two groups was not significant for patients in the same stage. There was no statistically significant difference in the total effective rate between the two groups (P > 0.05). During the follow-up period, there was no statistically significant difference in urine protein quantification, Scr, and eGFR between the two groups. In terms of the incidence of adverse reactions, the observation group was less than the control group, and there was a significant difference between the two groups (P < 0.05). Conclusion GTW combined with RASI is one of the safe and effective treatment modes for IgAN nephropathy. It can not only effectively reduce the excretion of urinary protein in patients and delay the progression of chronic kidney disease but also has less serious side effects and is well tolerated by patients, so it can be a new choice of therapeutic drugs for this group of patients.
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Affiliation(s)
- Ming Chen
- Heilongjiang Academy of Traditional Chinese Medicine, Department of Nephropathy, Heilongjiang 150036, China
| | - Peiqing Zhang
- Heilongjiang Academy of Traditional Chinese Medicine, Department of Nephropathy, Heilongjiang 150036, China
| | - Lianhua Li
- Heilongjiang Academy of Traditional Chinese Medicine, Department of Nephropathy, Heilongjiang 150036, China
| | - Zhuo Yu
- Heilongjiang Academy of Traditional Chinese Medicine, Department of Nephropathy, Heilongjiang 150036, China
| | - Na Liu
- Heilongjiang Academy of Traditional Chinese Medicine, Department of Nephropathy, Heilongjiang 150036, China
| | - Lifan Wang
- Heilongjiang Academy of Traditional Chinese Medicine, Department of Nephropathy, Heilongjiang 150036, China
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21
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Sanchez-Russo L, Rajasekaran A, Bin S, Faith J, Cravedi P. The Gut and Kidney Crosstalk in Immunoglobulin A Nephropathy. KIDNEY360 2022; 3:1630-1639. [PMID: 36245664 PMCID: PMC9528376 DOI: 10.34067/kid.0002382022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Abstract
Immunoglobulin A nephropathy(IgAN) is the most common primary glomerulonephritis worldwide. The working model for the pathogenesis of IgAN involves a multistep process starting from the production of galactose-deficient and polymeric immunoglobulin A-1 (gd-IgA1) that enters systemic circulation from gut-associated lymphoid tissue (GALT). Galactose-deficient IgA are targeted by endogenous IgG, leading to the formation of circulating immune complexes that deposit in the mesangium and resulting in glomerular inflammation. Disease onset and relapses are often associated with gut infections, supporting the hypothesis that the gut plays an important pathogenic role. In the presence of microbial pathogens or food antigens, activated dendritic cells in the gut mucosa induce T cell dependent and independent B cell differentiation into IgA secreting plasma cells. In IgAN patients, this promotes the systemic release of mucosal gd-IgA1. Not all bacterial strains have the same capacity to elicit IgA production, and little is known about the antigen specificity of the pathogenic gd-IgA1. However, efficacy of treatments targeting gut inflammation support a pathogenic link between the bowel immune system and IgAN. Herein, we review the evidence supporting the role of gut inflammation in IgAN pathogenesis.
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22
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Qing J, Hu X, Li C, Song W, Tirichen H, Yaigoub H, Li Y. Fucose as a potential therapeutic molecule against the immune-mediated inflammation in IgA nepharopathy: An unrevealed link. Front Immunol 2022; 13:929138. [PMID: 36059518 PMCID: PMC9428610 DOI: 10.3389/fimmu.2022.929138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background IgA nephropathy (IgAN) is an autoimmune disease that affects people of any age and is an important cause of end-stage renal disease. However, the pathogenesis and pathophysiology of IgAN is not clear. This article aimed to explore the immune-mediated inflammation and genetic mechanisms in IgAN. Methods The transcriptome sequencing data of IgAN glomeruli in the Gene Expression Omnibus database were downloaded. Single-sample gene set enrichment analysis was used to estimate the immune microenvironment of the merged microarray data and GSE141295. IgAN samples were divided into two clusters by cluster analysis. “limma” and “DEseq2” package in R were used to identify differentially expressed genes (DEGs). The weighted gene co-expression network analysis (WGCNA) was used to identify the co-expression modules related to inflammation in IgAN. R software package “clusterProfiler” was used for enrichment analysis, whereas Short Time-Series Expression Miner (STEM) analysis was used to identify the trend of gene expression. Machine-learn (ML) was performed using the shiny app. Finally, Drug Signatures Database (DSigDB) was used to identify potential molecules for treating IgAN. Results The infiltration of macrophages in IgAN glomeruli was increased, whereas CD4+ T cells, especially inducedregulatory T cells (iTregs) were decreased. A total of 1,104 common DEGs were identified from the merged data and GSE141295. Brown module was identified to have the highest inflammatory correlation with IgAN using WGCNA, and 15 hub genes were screened from this module. Among these 15 hub genes, 14 increased with the severity of IgAN inflammation based on STEM analysis. Neural network (nnet) is considered as the best model to predict the severity of IgAN. Fucose identified from DSigDB has a potential biological activity to treat IgAN. Conclusion The increase of macrophages and the decrease of iTregs in glomeruli represent the immune-mediated inflammation of IgAN, and fucose may be a potential therapeutic molecule against IgAN because it affects genes involved in the severe inflammation of IgAN.
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Affiliation(s)
- Jianbo Qing
- The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan, China
- Department of Nephrology, Shanxi Provincial People’s Hospital (Fifth Hospital) of Shanxi Medical University, Taiyuan, China
| | - Xueli Hu
- School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Changqun Li
- The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Wenzhu Song
- School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Hasna Tirichen
- Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China
| | - Hasnaa Yaigoub
- Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China
| | - Yafeng Li
- Department of Nephrology, Shanxi Provincial People’s Hospital (Fifth Hospital) of Shanxi Medical University, Taiyuan, China
- Core Laboratory , Shanxi Provincial People’s Hospital (Fifth Hospital) of Shanxi Medical University, Taiyuan, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Taiyuan, China
- Academy of Microbial Ecology, Shanxi Medical University, Taiyuan, China
- *Correspondence: Yafeng Li,
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23
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Haaskjold YL, Lura NG, Bjørneklett R, Bostad L, Bostad LS, Knoop T. Validation of two IgA nephropathy risk-prediction tools using a cohort with a long follow-up. Nephrol Dial Transplant 2022; 38:1183-1191. [PMID: 35904322 PMCID: PMC10157756 DOI: 10.1093/ndt/gfac225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recently, two immunoglobulin A nephropathy prediction tools were developed that combine clinical and histopathological parameters. The International IgAN Prediction Tool predicts the risk for 50% declines in the estimated glomerular filtration rate or end-stage renal disease up to 80 months after diagnosis. The IgA Nephropathy Clinical Decision Support System uses artificial neural networks to estimate the risk for end-stage renal disease. We aimed to externally validate both prediction tools using a Norwegian cohort with a long-term follow-up. METHODS We included 306 patients with biopsy-proven primary immunoglobulin A nephropathy in this study. Histopathologic samples were retrieved from the Norwegian Kidney Biopsy Registry and reclassified according to the Oxford classification. We used discrimination and calibration as principles for externally validating the prognostic models. RESULTS The median patient follow-up was 17.1 years. A cumulative dynamic time-dependent receiver operating characteristic analysis showed area under the curve values of ranging from 0.90 at 5 years to 0.83 at 20 years for the International IgAN Prediction Tool, while time-naive analysis showed an area under the curve value at 0.83 for the IgA Nephropathy Clinical Decision Support System. The International IgAN Prediction Tool was well calibrated, while the IgA Nephropathy Clinical Decision Support System tends to underestimate risk for patients with higher risk, and overestimates risk in the lower risk categories. CONCLUSIONS We have externally validated two prediction tools for IgA nephropathy. The International IgAN Prediction Tool performed well, while the IgA Nephropathy Clinical Decision Support System has some limitations.
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Affiliation(s)
- Yngvar Lunde Haaskjold
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Renal Research Group, Department of Clinical Medicine, University of Bergen, Norway
| | - Njål Gjærde Lura
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Norway.,Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Leif Bostad
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Lars Sigurd Bostad
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Norway.,Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Thomas Knoop
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Renal Research Group, Department of Clinical Medicine, University of Bergen, Norway
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24
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Suzuki H, Novak J. Special Issue: New Insights into the Pathogenesis and Therapies of IgA Nephropathy. J Clin Med 2022; 11:jcm11154378. [PMID: 35955995 PMCID: PMC9369139 DOI: 10.3390/jcm11154378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/24/2022] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hitoshi Suzuki
- Department of Nephrology, Juntendo University Urayasu Hospital, Chiba 279-0021, Japan
- Correspondence: (H.S.); (J.N.)
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
- Correspondence: (H.S.); (J.N.)
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25
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Person T, King RG, Rizk DV, Novak J, Green TJ, Reily C. Cytokines and Production of Aberrantly O-Glycosylated IgA1, the Main Autoantigen in IgA Nephropathy. J Interferon Cytokine Res 2022; 42:301-315. [PMID: 35793525 PMCID: PMC9536348 DOI: 10.1089/jir.2022.0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/16/2022] [Indexed: 01/09/2023] Open
Abstract
Immunoglobulin A (IgA) nephropathy is the most common primary glomerulonephritis worldwide, with no disease-specific treatment and up to 40% of patients progressing to kidney failure. IgA nephropathy (IgAN), characterized by IgA1-containing immunodeposits in the glomeruli, is considered to be an autoimmune disease in which the kidneys are injured as innocent bystanders. Glomerular immunodeposits are thought to originate from the circulating immune complexes that contain aberrantly O-glycosylated IgA1, the main autoantigen in IgAN, bound by IgG autoantibodies. A common clinical manifestation associated with IgAN includes synpharyngitic hematuria at disease onset or during disease activity. This observation suggests a connection of disease pathogenesis with an activated mucosal immune system of the upper-respiratory and/or gastrointestinal tract and IgA1 glycosylation. In fact, some cytokines can enhance production of aberrantly O-glycosylated IgA1. This process involves abnormal cytokine signaling in IgA1-producing cells from patients with IgAN. In this article, we present our view of pathogenesis of IgAN and review how some cytokines can contribute to the disease process by enhancing production of aberrantly glycosylated IgA1. We also review current clinical trials of IgAN based on cytokine-targeting therapeutic approaches.
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Affiliation(s)
- Taylor Person
- Department of Microbiology and Birmingham, Alabama, USA
| | - R. Glenn King
- Department of Microbiology and Birmingham, Alabama, USA
| | - Dana V. Rizk
- Department of Medicine University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan Novak
- Department of Microbiology and Birmingham, Alabama, USA
| | - Todd J. Green
- Department of Microbiology and Birmingham, Alabama, USA
| | - Colin Reily
- Department of Microbiology and Birmingham, Alabama, USA
- Department of Medicine University of Alabama at Birmingham, Birmingham, Alabama, USA
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26
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Exploiting protease activation for therapy. Drug Discov Today 2022; 27:1743-1754. [PMID: 35314338 PMCID: PMC9132161 DOI: 10.1016/j.drudis.2022.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/14/2022] [Accepted: 03/15/2022] [Indexed: 02/08/2023]
Abstract
Proteases have crucial roles in homeostasis and disease; and protease inhibitors and recombinant proteases in enzyme replacement therapy have become key therapeutic applications of protease biology across several indications. This review briefly summarises therapeutic approaches based on protease activation and focuses on how recent insights into the spatial and temporal control of the proteolytic activation of growth factors and interleukins are leading to unique strategies for the discovery of new medicines. In particular, two emerging areas are covered: the first is based on antibody therapies that target the process of proteolytic activation of the pro-form of proteins rather than their mature form; the second covers a potentially new class of biopharmaceuticals using engineered, proteolytically activable and initially inactive pro-forms of antibodies or effector proteins to increase specificity and improve the therapeutic window.
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27
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Campbell KN. Oral Glucocorticoids for IgA Nephropathy. JAMA 2022; 327:1872-1874. [PMID: 35579657 DOI: 10.1001/jama.2022.4638] [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] [Indexed: 11/14/2022]
Affiliation(s)
- Kirk N Campbell
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Pathogenesis of IgA Nephropathy: Current Understanding and Implications for Development of Disease-Specific Treatment. J Clin Med 2021; 10:jcm10194501. [PMID: 34640530 PMCID: PMC8509647 DOI: 10.3390/jcm10194501] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/22/2021] [Indexed: 12/20/2022] Open
Abstract
IgA nephropathy, initially described in 1968 as a kidney disease with glomerular “intercapillary deposits of IgA-IgG”, has no disease-specific treatment and is a common cause of kidney failure. Clinical observations and laboratory analyses suggest that IgA nephropathy is an autoimmune disease wherein the kidneys are damaged as innocent bystanders due to deposition of IgA1-IgG immune complexes from the circulation. A multi-hit hypothesis for the pathogenesis of IgA nephropathy describes four sequential steps in disease development. Specifically, patients with IgA nephropathy have elevated circulating levels of IgA1 with some O-glycans deficient in galactose (galactose-deficient IgA1) and these IgA1 glycoforms are recognized as autoantigens by unique IgG autoantibodies, resulting in formation of circulating immune complexes, some of which deposit in glomeruli and activate mesangial cells to induce kidney injury. This proposed mechanism is supported by observations that (i) glomerular immunodeposits in patients with IgA nephropathy are enriched for galactose-deficient IgA1 glycoforms and the corresponding IgG autoantibodies; (ii) circulatory levels of galactose-deficient IgA1 and IgG autoantibodies predict disease progression; and (iii) pathogenic potential of galactose-deficient IgA1 and IgG autoantibodies was demonstrated in vivo. Thus, a better understanding of the structure–function of these immunoglobulins as autoantibodies and autoantigens will enable development of disease-specific treatments.
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