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Welte T, Arnold F, Westermann L, Rottmann FA, Hug MJ, Neumann-Haefelin E, Ganner A. Eculizumab as a treatment for C3 glomerulopathy: a single-center retrospective study. BMC Nephrol 2023; 24:8. [PMID: 36631797 PMCID: PMC9832765 DOI: 10.1186/s12882-023-03058-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND C3 Glomerulopathy (C3G) is a rare glomerular disease caused by dysregulation of the complement pathway. Based on its pathophysiology, treatment with the monoclonal antibody eculizumab targeting complement C5 may be a therapeutic option. Due to the rarity of the disease, observational data on the clinical response to eculizumab treatment is scarce. METHODS Fourteen patients (8 female, 57%) treated for C3 glomerulopathy at the medical center of the University of Freiburg between 2013 and 2022 were included. Subjects underwent biopsy before enrollment. Histopathology, clinical data, and response to eculizumab treatment were analyzed. Key parameters to determine the primary outcome were changes of estimated glomerular filtration rate (eGFR) over time. Positive outcome was defined as > 30% increase, stable outcome as ±30%, negative outcome as decrease > 30% of eGFR. RESULTS Eleven patients (78.8%) were treated with eculizumab, three received standard of care (SoC, 27.2%). Median follow-up time was 68 months (IQR: 45-98 months). Median eculizumab treatment duration was 10 months (IQR 5-46 months). After eculizumab treatment, five patients showed a stable outcome, six patients showed a negative outcome. Among patients receiving SoC, one patient showed a stable outcome, two patients showed a negative outcome. CONCLUSIONS The benefit of eculizumab in chronic progressive C3 glomerulopathy is limited.
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Affiliation(s)
- Thomas Welte
- Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Frederic Arnold
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany ,grid.5963.9Institute for Microbiology and Hygiene, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Westermann
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felix A. Rottmann
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin J. Hug
- grid.5963.9Pharmacy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elke Neumann-Haefelin
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Athina Ganner
- Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Zhang X, Yu XJ, Li DY, Wang SX, Zhou FD, Zhao MH. C3 glomerulonephritis associated with monoclonal gammopathy: a retrospective case series study from a single institute in China. Ren Fail 2021; 43:1437-1445. [PMID: 34658305 PMCID: PMC8525950 DOI: 10.1080/0886022x.2021.1990949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the demographic and clinicopathological features and renal outcomes of Chinese patients with C3 glomerulonephritis in the setting of monoclonal gammopathy. Methods Patients with renal biopsy-proven C3 glomerulonephritis and detectable serum and/or urine monoclonal immunoglobulin from 2006 to 2018 in Peking University First Hospital were included, their clinical data, renal pathology type, treatment, and prognosis were collected and analyzed. Results Nineteen patients were enrolled, accounting for 24% of C3GN patients in the study period. The mean age of onset was 55 years old and the gender ratio was 4/15 (female/male). The mean eGFR at biopsy was 49.55 ± 29.81 ml/min/1.73m2. The prominent clinical manifestations included nephrotic syndrome (58%), anemia (68%), microscopic hematuria and leukocyturia (58%), and hypocomplementemia (13, 68%). The IgG was the most common isotype of monoclonal Ig on immunofixation electrophoresis. Kidney biopsies revealed a relatively prominent MPGN pattern. Only two patients had direct evidence of monocle immunoglobulins acting as C3GN pathogenic factors. Two patients had concurrent TMA-like renal injuries. The median renal survival was 12 and 15 months, respectively in patients receiving conservative therapy and immunosuppressant therapy, without statistical significance. The efficacy of clone-targeted therapy needed further investigation. Plasma exchange therapy only improved one patient’s renal outcome. Conclusions This is the first case series report of C3GN combined with monoclonal Ig in northern China. The renal prognosis of these patients is poor, and immunosuppressant therapies show no advantage over supportive therapy in renal prognosis, while the benefit of clone-targeted chemotherapy is still requiring investigation.
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Affiliation(s)
- Xin Zhang
- Renal Division, Department of Medicine, Institute of Nephrology, Peking University First Hospital, Peking University, Beijing, China.,Renal Pathology Center, Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Institute of Nephrology, Peking University First Hospital, Peking University, Beijing, China.,Renal Pathology Center, Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Chinese Academy of Medical Sciences, Beijing, China
| | - Dan-Yang Li
- Renal Division, Department of Medicine, Institute of Nephrology, Peking University First Hospital, Peking University, Beijing, China.,Renal Pathology Center, Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Institute of Nephrology, Peking University First Hospital, Peking University, Beijing, China.,Renal Pathology Center, Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Chinese Academy of Medical Sciences, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Institute of Nephrology, Peking University First Hospital, Peking University, Beijing, China.,Renal Pathology Center, Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Institute of Nephrology, Peking University First Hospital, Peking University, Beijing, China.,Renal Pathology Center, Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Science, Beijing, China
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3
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Abstract
Background: C3 glomerulopathy (C3G) is an uncommon disease characterized by the deposition of complement factors in the glomeruli due to overactivation and dysregulation of the alternative pathway of complement.Objectives: This study aimed to describe the clinicopathological features, laboratory testing, clinical course, treatment, and outcomes of pediatric patients with C3G.Patients and Methods: We reviewed retrospectively the laboratory testing, kidney biopsy reports, and clinical features of 18 patients at our hospital from 2007 to 2019.Results: There were 18 cases, and the majority of the patients were girls (61.1%). The mean age at diagnosis was 11.3 ± 3.7 (5-17) years, and nephritic-nephrotic syndrome presentation in patients was more common (11 cases, 61.1%). Hematuria was found in 66.7% of the patients, of which the majority had microscopic hematuria (58.3%). Hypertension was observed in 10 (55.6%) patients. The mean glomerular filtration rate (eGFR) was 95.7 ± 47.3 mL/min/1.73 m2, and 24-h urinary protein excretion was 76.2 ± 48.6 mg/m2/h. Sixteen patients (88.9%) received renin-angiotensin-aldosterone system blockers (RASB), and two of them were taking RASB only. The majority of patients (83.3%) were treated with immunosuppressive therapy. Eculizumab was also given to one of them. At the last follow-up, two patients had levels of less than 60 mL/min/1.73 m2 for eGFR. Seven patients with immunosuppressive treatment achieved complete remission.Conclusion: C3G shows a variable clinical presentation and response to immunosuppressive therapy. In the present study, we observed that the most common presentation was nephritic and/or nephrotic syndrome and partially responded to treatment to RASB and immunosuppressants.
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Affiliation(s)
- Fatma Yazılıtaş
- Department of Pediatric Nephrology, Ankara Dr.Sami Ulus Maternity and Children Hospital, Ankara, Turkey
| | - Evrim Kargın Çakıcı
- Department of Pediatric Nephrology, Ankara Dr.Sami Ulus Maternity and Children Hospital, Ankara, Turkey
| | - Eda Didem Kurt Şükür
- Department of Pediatric Nephrology, Ankara Dr.Sami Ulus Maternity and Children Hospital, Ankara, Turkey
| | - Gökçe Can
- Department of Pediatric Nephrology, Ankara Dr.Sami Ulus Maternity and Children Hospital, Ankara, Turkey
| | - Tülin Güngör
- Department of Pediatric Nephrology, Ankara Dr.Sami Ulus Maternity and Children Hospital, Ankara, Turkey
| | - Diclehan Orhan
- Department of Pediatric Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehmet Bülbül
- Department of Pediatric Nephrology, Ankara Dr.Sami Ulus Maternity and Children Hospital, Ankara, Turkey
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Pinarbasi AS, Dursun I, Poyrazoglu MH, Akgun H, Bozpolat A, Dusunsel R. Evaluation of the children with C3 glomerulopathy. Saudi J Kidney Dis Transpl 2021; 31:79-89. [PMID: 32129200 DOI: 10.4103/1319-2442.279964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
C3 glomerulopathy (C3G) is a clinical spectrum that presents with a variety of symptoms, ranging from a mild disease with asymptomatic microhematuria and/or proteinuria to severe disease with nephritic or nephrotic syndrome and renal impairment. Herein, we aim to document the clinical and laboratory findings, response to immunosuppressive and supportive treatment and prognosis of the children with C3G. We retrospectively reviewed the medical records of patients diagnosed with membranoproliferative glomerulonephritis (MPGN). Kidney biopsy materials were reexamined for the diagnosis of C3G. The inclusion criteria for C3G are the dominant C3 staining with or without scanty immunoglobulins (Ig) deposition on immuno- fluorescence (IF) and MPGN patterns on light microscope. Twelve of 69 patients with MPGN were included in the study based on the definition criteria of C3G. Ten of them had only C3 staining and the rest of the patients had both C3 staining and a small amount of IgG/M staining on IF microscopy. One patient was on remission with only ACEI. The rest of the patients used immunosuppressive treatment and two of them needed eculizumab therapy. One of them did not respond to the treatment of eculizumab and progressed to end-stage renal failure. C3G is a disease characterized by a heterogeneous clinical presentation and outcome. Because of this broad spectrum of disease, treatment may vary widely. We think that complement-targeting therapy with eculizumab should be an alternative option for refractory cases, especially in the early stage of disease, if they did not respond to immunosuppressive treatment.
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Affiliation(s)
- Ayse Seda Pinarbasi
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ismail Dursun
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muammer Hakan Poyrazoglu
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hulya Akgun
- Department of Pathology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Adil Bozpolat
- Department of Pediatrics, Nevsehir State Hospital, Nevsehir, Turkey
| | - Ruhan Dusunsel
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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5
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Mastrangelo A, Serafinelli J, Giani M, Montini G. Clinical and Pathophysiological Insights Into Immunological Mediated Glomerular Diseases in Childhood. Front Pediatr 2020; 8:205. [PMID: 32478016 PMCID: PMC7235338 DOI: 10.3389/fped.2020.00205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
The kidney is often the target of immune system dysregulation in the context of primary or systemic disease. In particular, the glomerulus represents the anatomical entity most frequently involved, generally as the expression of inflammatory cell invasion or circulant or in situ immune-complex deposition. Glomerulonephritis is the most common clinical and pathological manifestation of this involvement. There are no universally accepted classifications for glomerulonephritis. However, recent advances in our understanding of the pathophysiological mechanisms suggest the assessment of immunological features, biomarkers, and genetic analysis. At the same time, more accurate and targeted therapies have been developed. Data on pediatric glomerulonephritis are scarce and often derived from adult studies. In this review, we update the current understanding of the etiologic events and genetic factors involved in the pathogenesis of pediatric immunologically mediated primitive forms of glomerulonephritis, together with the clinical spectrum and prognosis. Possible new therapeutic targets are also briefly discussed.
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Affiliation(s)
- Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Jessica Serafinelli
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marisa Giani
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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6
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Schena FP, Esposito P, Rossini M. A Narrative Review on C3 Glomerulopathy: A Rare Renal Disease. Int J Mol Sci 2020; 21:ijms21020525. [PMID: 31947692 PMCID: PMC7013756 DOI: 10.3390/ijms21020525] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
In April 2012, a group of nephrologists organized a consensus conference in Cambridge (UK) on type II membranoproliferative glomerulonephritis and decided to use a new terminology, "C3 glomerulopathy" (C3 GP). Further knowledge on the complement system and on kidney biopsy contributed toward distinguishing this disease into three subgroups: dense deposit disease (DDD), C3 glomerulonephritis (C3 GN), and the CFHR5 nephropathy. The persistent presence of microhematuria with or without light or heavy proteinuria after an infection episode suggests the potential onset of C3 GP. These nephritides are characterized by abnormal activation of the complement alternative pathway, abnormal deposition of C3 in the glomeruli, and progression of renal damage to end-stage kidney disease. The diagnosis is based on studying the complement system, relative genetics, and kidney biopsies. The treatment gap derives from the absence of a robust understanding of their natural outcome. Therefore, a specific treatment for the different types of C3 GP has not been established. Recommendations have been obtained from case series and observational studies because no randomized clinical trials have been conducted. Current treatment is based on corticosteroids and antiproliferative drugs (cyclophosphamide, mycophenolate mofetil), monoclonal antibodies (rituximab) or complement inhibitors (eculizumab). In some cases, it is suggested to include sessions of plasma exchange.
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Affiliation(s)
- Francesco Paolo Schena
- Department of Emergency and Organ Transplantation, Renal Unit, University of Bari, 70124 Bari, Italy;
- Schena Foundation, European Center for the Study of Renal Diseases, 70010 Valenzano, Italy
- Correspondence:
| | - Pasquale Esposito
- Department of Internal Medicine, Division of Nephrology, Dialysis and Transplantation, University of Genoa and IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Michele Rossini
- Department of Emergency and Organ Transplantation, Renal Unit, University of Bari, 70124 Bari, Italy;
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7
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Drake KA, Ellington N, Gattineni J, Torrealba JR, Hendricks AR. Clinicopathological features of C3 glomerulopathy in children: a single-center experience. Pediatr Nephrol 2020; 35:153-162. [PMID: 31667615 DOI: 10.1007/s00467-019-04388-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/04/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is defined by dominant glomerular deposition of C3 and minimal or no immunoglobulin, with two subtypes-dense deposit disease (DDD) and C3 glomerulonephritis (C3GN)-distinguished by features on electron microscopy (EM). Given that this rare disease has generally unfavorable yet highly variable outcomes, we sought out to review the histopathology, complement/genetic studies, and renal outcomes of pediatric patients with C3G at our institution. METHODS All native kidney biopsies performed in a single pediatric hospital over a 10-year period were reviewed for features of C3G. Of 589 biopsy reports, we identified 9 patients fulfilling the diagnostic criteria for C3G and retrospectively reviewed their clinical chart and renal biopsy findings. RESULTS We identified 4 patients with DDD, 4 with C3GN, and 1 indeterminate case, with features of both C3GN and DDD. Five patients were positive for one or more nephritic factors (C3NeF, C4NeF, C5NeF) with 1 patient additionally positive for complement factor H (CFH) autoantibody. Genetic testing done in 5 of the 9 patients failed to identify any causative mutations. Three patients showed progressive renal dysfunction over a mean follow-up period of 33 months. CONCLUSIONS Complement and genetic studies are now routinely recommended for patients with a histopathological diagnosis of C3G. Careful interpretation of these studies and their prognostic and therapeutic implications in conjunction with biopsy findings is needed to further understand the pathophysiology of this rare disease in children.
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Affiliation(s)
- Keri A Drake
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Natalie Ellington
- Department of Pathology, UT Southwestern Medical Center, 6210 Harry Hines Blvd, Dallas, TX, 75390-9234, USA
| | - Jyothsna Gattineni
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Jose R Torrealba
- Department of Pathology, UT Southwestern Medical Center, 6210 Harry Hines Blvd, Dallas, TX, 75390-9234, USA
| | - Allen R Hendricks
- Department of Pathology, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Suite HP3-378, Dallas, TX, 75390-9234, USA.
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8
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Kumar A, Ramachandran R, Rawat A, Das R, Rayat CS, Kenwar DB, Sharma A, Gupta KL, Nada R. Poor allograft outcome in Indian patients with post-transplant C3 glomerulopathy. Clin Kidney J 2019; 14:291-300. [PMID: 33564431 PMCID: PMC7857824 DOI: 10.1093/ckj/sfz135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 09/07/2019] [Indexed: 11/12/2022] Open
Abstract
Background Complement 3 glomerulopathy (C3G) results from dysfunction of the alternative complement pathway (ACP). No data are available on post-transplant C3G in South Asia. Methods In this study, renal allograft biopsies of C3G patients performed from 2012 to 2017 were analysed for ACP functional assay (APFA), serum complement levels, complement factor H (CFH), complement factor B (CFB) and autoantibodies to CFH and CFB. Limited genetic screening for CFH/CFHR5 genes was carried out. All study patients were also followed up. Results A total of 21 cases of C3G were included, of which 11 had native C3G disease (that is, recurrent C3G). Of these 11 recurrent cases, 7 presented with allograft dysfunction and 4 with proteinuria and renal dysfunction. Early post-transplant recurrence (<1 month) was noted in six patients, whereas recurrence in five patients occurred within 8–17 months of transplant. Biopsies showed mild focal mesangial expansion with or without endocapillary proliferation and thrombotic microangiopathy. Rejection was also noted in six patients. APFA/C3 levels were low in all cases. Serum CFH levels were low [dense deposit disease (DDD), 44%; C3 glomerulonephritis (C3GN), 25%], whereas CFB levels were normal. Autoantibodies to CFH, CFB and C3 nephritic factor were present in 11, 0 and 44% of DDD cases, respectively, and in 17, 17 and 33% of C3GN cases, respectively. Genetic analysis revealed only non-pathogenic CFH gene variants (93%). No novel mutation was found. At follow-up (140 months), stable graft was noted in 28% of cases, progressive renal failure in 19%, graft loss in 34%, and 19% of patients died. Conclusion Post-transplant C3G can present with graft dysfunction and/or proteinuria. Subtle histological findings demand careful interpretation of immunofluorescence results. Autoantibodies to complement pathway regulatory proteins are common, and no novel mutation has been found from limited genetic workup. Clinical outcome is poor.
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Affiliation(s)
- Ashwani Kumar
- Department of Histopathology, PGIMER, Chandigarh, India
| | | | - Amit Rawat
- Department of Pediatrics, PGIMER, Chandigarh, India
| | - Reena Das
- Department of Hematology, PGIMER, Chandigarh, India
| | | | | | - Ashish Sharma
- Department of Transplant Surgery, PGIMER, Chandigarh, India
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9
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Bharati J, Tiewsoh K, Kumar A, Nada R, Rathi M, Gupta KL, Kohli HS, Jha V, Ramachandran R. Usefulness of mycophenolate mofetil in Indian patients with C3 glomerulopathy. Clin Kidney J 2019; 12:483-487. [PMID: 31384438 PMCID: PMC6671524 DOI: 10.1093/ckj/sfy127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Indexed: 02/07/2023] Open
Abstract
Background C3 glomerulopathy (C3G) is a heterogeneous disease caused by alternative complement pathway abnormalities without any standardized treatment. An immunosuppressive agent, mycophenolate mofetil (MMF), has been recently shown to be useful in treating C3G, mainly in studies from the west. We report the clinical outcome of 17 Indian C3G patients treated with MMF with or without steroids. Methods The clinical and histology details of the C3G patients treated with MMF for at least 6 months with a follow-up of at least 12 months were retrieved from the medical records of our center. Results The median serum creatinine and proteinuria at presentation were 0.8 mg/dL and 3.7 g/day, respectively, with the majority (88.2%) presenting as nephrotic syndrome. The mean dose of MMF was 1.65 (±0.56) g/day, and the median duration of MMF therapy was 18 months. Two-thirds (64%) of the patients responded to the treatment, with complete remission in 4 (23%) and partial remission in 7 (41%) (median time: 9 months). Three patients progressed to end-stage renal disease (ESRD) on follow-up. Of the three patients, one (33%) had an initial response in proteinuria to MMF but did not respond after a relapse and subsequently progressed to ESRD and two (67%) other patients were nonresponsive to MMF from the start of the therapy. Conclusion Despite a small sample size and lack of a control arm, this study describes the effectiveness of MMF in treating C3G patients from Asia and forms a basis for future randomized trials.
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Affiliation(s)
- Joyita Bharati
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karalanglin Tiewsoh
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Kumar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekananda Jha
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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10
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Corvillo F, Okrój M, Nozal P, Melgosa M, Sánchez-Corral P, López-Trascasa M. Nephritic Factors: An Overview of Classification, Diagnostic Tools and Clinical Associations. Front Immunol 2019; 10:886. [PMID: 31068950 PMCID: PMC6491685 DOI: 10.3389/fimmu.2019.00886] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 04/05/2019] [Indexed: 12/18/2022] Open
Abstract
Nephritic factors comprise a heterogeneous group of autoantibodies against neoepitopes generated in the C3 and C5 convertases of the complement system, causing its dysregulation. Classification of these autoantibodies can be clustered according to their stabilization of different convertases either from the classical or alternative pathway. The first nephritic factor described with the capacity to stabilize C3 convertase of the alternative pathway was C3 nephritic factor (C3NeF). Another nephritic factor has been characterized by the ability to stabilize C5 convertase of the alternative pathway (C5NeF). In addition, there are autoantibodies against assembled C3/C5 convertase of the classical and lectin pathways (C4NeF). These autoantibodies have been mainly associated with kidney diseases, like C3 glomerulopathy and immune complex-associated-membranoproliferative glomerulonephritis. Other clinical situations where these autoantibodies have been observed include infections and autoimmune disorders such as systemic lupus erythematosus and acquired partial lipodystrophy. C3 hypocomplementemia is a common finding in all patients with nephritic factors. The methods to measure nephritic factors are not standardized, technically complex, and lack of an appropriate quality control. This review will be focused in the description of the mechanism of action of the three known nephritic factors (C3NeF, C4NeF, and C5NeF), and their association with human diseases. Moreover, we present an overview regarding the diagnostic tools for its detection, and the main therapeutic approach for the patients with nephritic factors.
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Affiliation(s)
- Fernando Corvillo
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Center for Biomedical Network Research on Rare Diseases (CIBERER U754), Madrid, Spain
| | - Marcin Okrój
- Department of Medical Biotechnology, Intercollegiate Faculty of Biotechnology, University of Gdansk and Medical University of Gdansk, Gdansk, Poland
| | - Pilar Nozal
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Center for Biomedical Network Research on Rare Diseases (CIBERER U754), Madrid, Spain.,Immunology Unit, La Paz University Hospital, Madrid, Spain
| | - Marta Melgosa
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Pediatric Nephrology Unit, La Paz University Hospital, Madrid, Spain
| | - Pilar Sánchez-Corral
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Center for Biomedical Network Research on Rare Diseases (CIBERER U754), Madrid, Spain
| | - Margarita López-Trascasa
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
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11
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Abstract
Complement activation has been identified to play a vital role in the pathogenesis of many glomerulonephritis, either as direct complement activation-driven factor in thrombotic microangiopathy and C3 glomerulopathy, and/or as an important contributor in lupus nephritis and anti-neutrophil cytoplasmic antibody-associated vasculitis. Recent studies indicated that complement activation may also play roles in the pathogenesis of immunoglobulin A nephropathy and focal segmental glomerulosclerosis. Interestingly, monoclonal immunoglobulins/light chains from patients with monoclonal gammopathy may interfere with complement activation and thus indirectly result in complement-mediated glomerulonephritis. Understanding of the pathogenic roles of complement activation in various glomerulonephritis will facilitate the identification of potential novel therapeutic targets in complement system.
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Affiliation(s)
- Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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12
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Holle J, Berenberg-Goßler L, Wu K, Beringer O, Kropp F, Müller D, Thumfart J. Outcome of membranoproliferative glomerulonephritis and C3-glomerulopathy in children and adolescents. Pediatr Nephrol 2018; 33:2289-2298. [PMID: 30238151 DOI: 10.1007/s00467-018-4034-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/22/2018] [Accepted: 07/23/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Membranoproliferative glomerulonephritis (MPGN) is a rare cause of glomerulopathy in children. Recently, a new classification based on immunohistological features has been established. Infections and anomalies in complement-regulating genes, leading to alternative complement pathway activation, are suspected to trigger the disease. Nevertheless, little is known about optimal treatment and outcome in children with immune-complex-MPGN (IC-MPGN) and C3-glomerulopathy (C3G). METHODS The method used is retrospective analysis of clinical, histological, and genetic characteristics of 14 pediatric patients with MPGN in two medical centers. RESULTS Mean age of the patients was 10.6 ± 4.5 years. Patients were grouped into C3G (n = 6) and IC-MPGN (n = 8). One patient showed a likely pathogenic variant in the CFHR5 gene. All 10 patients had risk polymorphisms in complement-regulating genes. Most patients were treated with ACE inhibition, steroids, and mycophenolate mofetil. Three patients with C3G received eculizumab. Median follow-up was 2.3 years. After 1 year of disease, three patients (two C3G, one IC-MPGN) reached complete, five patients partial (three IC-MPGN, two C3G), and five patients no remission (four IC-MPGN, one C3G). One patient progressed to end-stage renal disease (ESRD) 6 years after disease onset. CONCLUSIONS IC-MPGN and C3G are rare disorders in children. Most patients have signs of complement activation associated with risk polymorphisms or likely pathogenic variants in complement-regulating genes. Steroids and mycophenolate mofetil seem to be effective and for some patients, eculizumab might be a treatment option. Outcome is heterogeneous and precise differentiation between IC-MPGN and C3G is still pending.
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Affiliation(s)
- Johannes Holle
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Lena Berenberg-Goßler
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kaiyin Wu
- Department of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ortraud Beringer
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Ulm University Medical Center, Ulm, Germany
| | - Florian Kropp
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Ulm University Medical Center, Ulm, Germany
| | - Dominik Müller
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
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13
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Spartà G, Gaspert A, Neuhaus TJ, Weitz M, Mohebbi N, Odermatt U, Zipfel PF, Bergmann C, Laube GF. Membranoproliferative glomerulonephritis and C3 glomerulopathy in children: change in treatment modality? A report of a case series. Clin Kidney J 2018; 11:479-490. [PMID: 30094012 PMCID: PMC6070093 DOI: 10.1093/ckj/sfy006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/27/2017] [Indexed: 12/11/2022] Open
Abstract
Background Membranoproliferative glomerulonephritis (MPGN) with immune complexes and C3 glomerulopathy (C3G) in children are rare and have a variable outcome, with some patients progressing to end-stage renal disease (ESRD). Mutations in genes encoding regulatory proteins of the alternative complement pathway and of complement C3 (C3) have been identified as concausative factors. Methods Three children with MPGN type I, four with C3G, i.e. three with C3 glomerulonephritis (C3GN) and one with dense deposit disease (DDD), were followed. Clinical, autoimmune data, histological characteristics, estimated glomerular filtration rate (eGFR), proteinuria, serum C3, genetic and biochemical analysis were assessed. Results The median age at onset was 7.3 years and the median eGFR was 72 mL/min/1.73 m2. Six children had marked proteinuria. All were treated with renin-angiotensin-aldosterone system (RAAS) blockers. Three were given one or more immunosuppressive drugs and two eculizumab. At the last median follow-up of 9 years after diagnosis, three children had normal eGFR and no or mild proteinuria on RAAS blockers only. Among four patients without remission of proteinuria, genetic analysis revealed mutations in complement regulator proteins of the alternative pathway. None of the three patients with immunosuppressive treatment achieved partial or complete remission of proteinuria and two progressed to ESRD and renal transplantation. Two patients treated with eculizumab revealed relevant decreases in proteinuria. Conclusions In children with MPGN type I and C3G, the outcomes of renal function and response to treatment modality show great variability independent from histological diagnosis at disease onset. In case of severe clinical presentation at disease onset, early genetic and biochemical analysis of the alternative pathway dysregulation is recommended. Treatment with eculizumab appears to be an option to slow disease progression in single cases.
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Affiliation(s)
- Giuseppina Spartà
- Pediatric Nephrology Unit, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ariana Gaspert
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas J Neuhaus
- Children's Hospital of Lucerne, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Marcus Weitz
- Pediatric Nephrology Unit, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nilufar Mohebbi
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Urs Odermatt
- Nephrology Unit, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Peter F Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology e. V. Hans-Knöll-Institute, Jena, Germany.,Friedrich Schiller University, Jena, Germany
| | - Carsten Bergmann
- Bioscientia Center of Human Genetics, Ingelheim am Rhein, Germany
| | - Guido F Laube
- Pediatric Nephrology Unit, University Children's Hospital Zurich, Zurich, Switzerland
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14
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Michelfelder S, Fischer F, Wäldin A, Hörle KV, Pohl M, Parsons J, Reski R, Decker EL, Zipfel PF, Skerka C, Häffner K. The MFHR1 Fusion Protein Is a Novel Synthetic Multitarget Complement Inhibitor with Therapeutic Potential. J Am Soc Nephrol 2018; 29:1141-1153. [PMID: 29335241 DOI: 10.1681/asn.2017070738] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022] Open
Abstract
The complement system is essential for host defense, but uncontrolled complement system activation leads to severe, mostly renal pathologies, such as atypical hemolytic uremic syndrome or C3 glomerulopathy. Here, we investigated a novel combinational approach to modulate complement activation by targeting C3 and the terminal pathway simultaneously. The synthetic fusion protein MFHR1 links the regulatory domains of complement factor H (FH) with the C5 convertase/C5b-9 inhibitory fragment of the FH-related protein 1. In vitro, MFHR1 showed cofactor and decay acceleration activity and inhibited C5 convertase activation and C5b-9 assembly, which prevented C3b deposition and reduced C3a/C5a and C5b-9 generation. Furthermore, this fusion protein showed the ability to escape deregulation by FH-related proteins and form multimeric complexes with increased inhibitory activity. In addition to substantially inhibiting alternative and classic pathway activation, MFHR1 blocked hemolysis mediated by serum from a patient with aHUS expressing truncated FH. In FH-/- mice, MFHR1 administration augmented serum C3 levels, reduced abnormal glomerular C3 deposition, and ameliorated C3 glomerulopathy. Taking the unique design of MFHR1 into account, we suggest that the combination of proximal and terminal cascade inhibition together with the ability to form multimeric complexes explain the strong inhibitory capacity of MFHR1, which offers a novel basis for complement therapeutics.
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Affiliation(s)
- Stefan Michelfelder
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Friedericke Fischer
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Astrid Wäldin
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Kim V Hörle
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine
| | | | - Ralf Reski
- Plant Biotechnology, Faculty of Biology, and.,Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany; and
| | | | - Peter F Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Friedrich Schiller University, Jena, Germany
| | - Christine Skerka
- Leibniz Institute for Natural Product Research and Infection Biology, Friedrich Schiller University, Jena, Germany
| | - Karsten Häffner
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine,
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15
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Welte T, Arnold F, Kappes J, Seidl M, Häffner K, Bergmann C, Walz G, Neumann-Haefelin E. Treating C3 glomerulopathy with eculizumab. BMC Nephrol 2018; 19:7. [PMID: 29329521 PMCID: PMC5767001 DOI: 10.1186/s12882-017-0802-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022] Open
Abstract
Background C3 glomerulopathy (C3G) is a rare, but severe glomerular disease with grim prognosis. The complex pathogenesis is just unfolding, and involves acquired as well as inherited dysregulation of the alternative pathway of the complement cascade. Currently, there is no established therapy. Treatment with the C5 complement inhibitor eculizumab may be a therapeutic option. However, due to rarity of the disease, parameters predicting treatment response remain largely unknown. Methods Seven patients with C3G (five with C3 glomerulonephritis and two with dense deposit disease) were treated with eculizumab. Subjects underwent biopsy before enrollment. The histopathology, clinical data, and response to eculizumab treatment were analyzed. The key parameters to determine outcome were changes of serum creatinine and urinary protein over time. Results After treatment with eculizumab, four subjects showed significantly improved or stable renal function and urinary protein. A positive response occurred between 2 weeks and 6 months after therapy initiation. One subject (with allograft recurrent C3 glomerulonephritis) initially showed a positive response, but relapsed when eculizumab was discontinued, and did not respond after re-initiation of treatment. Two subjects showed impaired renal function and increasing urinary protein despite therapy with eculizumab. Conclusions Eculizumab may be a therapeutic option for a subset of C3G patients. The response to eculizumab is heterogeneous, and early as well as continuous treatment may be necessary to prevent disease progression. These findings emphasize the need for studies identifying genetic and functional complement abnormalities that may help to guide eculizumab treatment and predict response. Electronic supplementary material The online version of this article (10.1186/s12882-017-0802-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Welte
- Department of Nephrology, Medical Center-University of Freiburg, Germany, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Frederic Arnold
- Department of Nephrology, Medical Center-University of Freiburg, Germany, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Julia Kappes
- Department of Pneumology, Medical Center-University of Freiburg, Germany, Killianstrasse 4, 79106, Freiburg, Germany
| | - Maximilian Seidl
- Department of Pathology, Medical Center-University of Freiburg, Germany, Breisacher Strasse 115A, 79106, Freiburg, Germany
| | - Karsten Häffner
- Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Germany, Heiliggeiststrasse 1, 79106, Freiburg, Germany
| | - Carsten Bergmann
- Center for Human Genetics, Bioscientia, Ingelheim, Germany, Konrad-Adenauer-Strasse 17, 55218, Ingelheim, Germany
| | - Gerd Walz
- Department of Nephrology, Medical Center-University of Freiburg, Germany, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Elke Neumann-Haefelin
- Department of Nephrology, Medical Center-University of Freiburg, Germany, Hugstetter Strasse 55, 79106, Freiburg, Germany.
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16
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Cortina G, Ojinaga V, Giner T, Riedl M, Waldegger S, Rosales A, Trojer R, Hofer J. Therapeutic plasma exchange in children: One center's experience. J Clin Apher 2017; 32:494-500. [DOI: 10.1002/jca.21547] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/17/2017] [Accepted: 04/04/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Gerard Cortina
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Violeta Ojinaga
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Thomas Giner
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Magdalena Riedl
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Siegfried Waldegger
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Alejandra Rosales
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Raphaela Trojer
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
| | - Johannes Hofer
- Department of Pediatrics; Medical University of Innsbruck; Innsbruck Austria
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17
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18
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Abstract
Recent advances in our understanding of the disease pathology of membranoproliferative glomerulonephritis has resulted in its re-classification as complement C3 glomerulopathy (C3G) and immune complex-mediated glomerulonephritis (IC-GN). The new consensus is based on its underlying pathomechanism, with a key pathogenetic role for the complement alternative pathway (AP), rather than on histomorphological characteristics. In C3G, loss of AP regulation leads to predominant glomerular C3 deposition, which distinguishes C3G from IC-GN with predominant immunoglobulin G staining. Electron microscopy further subdivides C3G into C3 glomerulonephritis and dense deposit disease depending on the presence and distribution pattern of electron-dense deposits within the glomerular filter. Mutations or autoantibodies affecting the function of AP activators or regulators, in particular the decay of the C3 convertase (C3 nephritic factor), have been detected in up to 80 % of C3G patients. The natural outcome of C3G is heterogeneous, but 50 % of patients progress slowly and reach end-stage renal disease within 10-15 years. The new classification not only marks significant advancement in the pathogenic understanding of this rare disease, but also opens doors towards more specific treatment with the potential for improved outcomes.
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Affiliation(s)
- Magdalena Riedl
- Cell Biology Program of the Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Paul Thorner
- Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Cell Biology Program of the Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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19
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Michelfelder S, Parsons J, Bohlender LL, Hoernstein SNW, Niederkrüger H, Busch A, Krieghoff N, Koch J, Fode B, Schaaf A, Frischmuth T, Pohl M, Zipfel PF, Reski R, Decker EL, Häffner K. Moss-Produced, Glycosylation-Optimized Human Factor H for Therapeutic Application in Complement Disorders. J Am Soc Nephrol 2016; 28:1462-1474. [PMID: 27932477 DOI: 10.1681/asn.2015070745] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/07/2016] [Indexed: 01/15/2023] Open
Abstract
Genetic defects in complement regulatory proteins can lead to severe renal diseases, including atypical hemolytic uremic syndrome and C3 glomerulopathies, and age-related macular degeneration. The majority of the mutations found in patients with these diseases affect the glycoprotein complement factor H, the main regulator of the alternative pathway of complement activation. Therapeutic options are limited, and novel treatments, specifically those targeting alternative pathway activation, are highly desirable. Substitution with biologically active factor H could potentially treat a variety of diseases that involve increased alternative pathway activation, but no therapeutic factor H is commercially available. We recently reported the expression of full-length recombinant factor H in moss (Physcomitrella patens). Here, we present the production of an improved moss-derived recombinant human factor H devoid of potentially immunogenic plant-specific sugar residues on protein N-glycans, yielding approximately 1 mg purified moss-derived human factor H per liter of initial P. patens culture after a multistep purification process. This glycosylation-optimized factor H showed full in vitro complement regulatory activity similar to that of plasma-derived factor H and efficiently blocked LPS-induced alternative pathway activation and hemolysis induced by sera from patients with atypical hemolytic uremic syndrome. Furthermore, injection of moss-derived factor H reduced C3 deposition and increased serum C3 levels in a murine model of C3 glomerulopathy. Thus, we consider moss-produced recombinant human factor H a promising pharmaceutical product for therapeutic intervention in patients suffering from complement dysregulation.
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Affiliation(s)
- Stefan Michelfelder
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
| | - Juliana Parsons
- Plant Biotechnology, Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Lennard L Bohlender
- Plant Biotechnology, Faculty of Biology, University of Freiburg, Freiburg, Germany
| | | | | | | | | | - Jonas Koch
- Greenovation Biotech GmbH, Freiburg, Germany
| | | | | | | | - Martin Pohl
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
| | - Peter F Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Friedrich Schiller University, Jena, Germany
| | - Ralf Reski
- Plant Biotechnology, Faculty of Biology, University of Freiburg, Freiburg, Germany.,BIOSS Centre for Biological Signalling Studies, University of Freiburg, Freiburg, Germany; and.,FRIAS Freiburg Institute for Advanced Studies, University of Freiburg, Freiburg, Germany
| | - Eva L Decker
- Plant Biotechnology, Faculty of Biology, University of Freiburg, Freiburg, Germany;
| | - Karsten Häffner
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany;
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20
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Abstract
C3 glomerulopathy (C3G) is a recently identified disease entity caused by dysregulation of the alternative complement pathway, and dense deposit disease (DDD) and C3 glomerulonephritis (C3GN) are its components. Because laboratory detection of complement dysregulation is still uncommon in practice, "dominant C3 deposition by two orders greater than that of immunoglobulins in the glomeruli by immunofluorescence", as stated in the consensus report, defines C3G. However, this morphological definition possibly includes the cases with glomerular diseases of different mechanisms such as post-infectious glomerulonephritis. In addition, the differential diagnosis between DDD and C3GN is often difficult because the distinction between these two diseases is based solely on electron microscopic features. Recent molecular and genetic advances provide information to characterize C3G. Some C3G cases are found with genetic abnormalities in complement regulatory factors, but majority of cases seem to be associated with acquired factors that dysregulate the alternative complement pathway. Because clinical courses and prognoses among glomerular diseases with dominant C3 deposition differ, further understanding the background mechanism, particularly complement dysregulation in C3G, is needed. This may resolve current dilemmas in practice and shed light on novel targeted therapies to remedy the dysregulated alternative complement pathway in C3G.
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21
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Blom AM, Corvillo F, Magda M, Stasiłojć G, Nozal P, Pérez-Valdivia MÁ, Cabello-Chaves V, Rodríguez de Córdoba S, López-Trascasa M, Okrój M. Testing the Activity of Complement Convertases in Serum/Plasma for Diagnosis of C4NeF-Mediated C3 Glomerulonephritis. J Clin Immunol 2016; 36:517-27. [PMID: 27146825 PMCID: PMC4896984 DOI: 10.1007/s10875-016-0290-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/25/2016] [Indexed: 12/31/2022]
Abstract
Autoantibodies termed C3-nephritic factor (C3NeF), which stabilize convertases of the alternative complement pathway, often stimulate autoinflammatory diseases. However, knowledge about analogous autoantibodies acting on the classical pathway (C4NeF) is limited to a few reports, which indicate association with kidney dysfunction, systemic lupus erythematous, and infections. C4NeF may appear independently from C3NeF, but the lack of a routine diagnostic method predisposes C4NeF for being an underestimated player in autoinflammatory episodes. We tested the activity of classical convertases directly in serum/plasma to screen samples from 13 patients with C3 glomerulopathies and identified one patient showing significantly prolonged half-life of these enzymes. Observed effect was reproduced by immunoglobulins purified from patient's plasma and additionally confirmed on classical convertase built from purified components. Isolated immunoglobulins protected classical convertases from both spontaneous and inhibitor-driven decay but not from C4b proteolysis. The patient had a decreased serum level of C3, elevated sC5b-9, and normal concentrations of factor B and C4. Neither C3NeF nor other autoantibodies directed against alternative pathway proteins (factor H, factor B, factor I, C3, and properdin) were found. Genetic analysis showed no mutations in C3, CFB, CFH, CFI, MCP, THBD, and DGKE genes. Renal biopsy revealed a membranoproliferative pattern with intense C3 deposits. Our results underline the importance of C4NeF as an independent pathogenic factor and a need for the implementation of routine examination of classical convertase activity. Proposed method may enable robust inspection of such atypical cases.
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Affiliation(s)
- Anna M Blom
- Department of Translational Medicine, Lund University, 20502, Malmö, Sweden
| | | | - Michal Magda
- Department of Translational Medicine, Lund University, 20502, Malmö, Sweden
| | - Grzegorz Stasiłojć
- Department of Medical Biotechnology, Intercollegiate Faculty of Biotechnology UG‑MUG, Medical University of Gdańsk, Dębinki 1 street, 80-210, Gdańsk, Poland
| | - Pilar Nozal
- Immunology Unit, University Hospital La Paz, IdiPAZ, Madrid, Spain.,Unit 754, Centre for Biomedical Research on Rare Diseases (CIBERER), Madrid, Spain
| | | | | | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CIB-CSIC), Centro de Investigación Médica en Red (CIBERER U738), Madrid, Spain
| | - Margarita López-Trascasa
- Immunology Unit, University Hospital La Paz, IdiPAZ, Madrid, Spain.,Unit 754, Centre for Biomedical Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Marcin Okrój
- Department of Medical Biotechnology, Intercollegiate Faculty of Biotechnology UG‑MUG, Medical University of Gdańsk, Dębinki 1 street, 80-210, Gdańsk, Poland.
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22
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Fakhouri F. [Clinical approach to primary membranoproliferative glomerulonephritis]. Nephrol Ther 2016; 12 Suppl 1:S65-9. [PMID: 26972096 DOI: 10.1016/j.nephro.2016.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Membranoproliferative glomerulonephritis represent a heterogeneous group of nephropathies. During the last five years, our understanding of membranoproliferative glomerulonephritis has greatly improved. Animal models and the study of complement genetics led to the dissection of the physiopathology of membranoproliferative glomerulonephritis, to the individualization of a new entity, C3 glomerulopathy, and to a new classification of these nephropathies. The study of large cohorts has also changed the clinical picture of membranoproliferative glomerulonephritis that has been long dominated by the severity of a single type of dense deposits disease. Finally, the rediscovery of complement through the study of the atypical haemolytic uremic syndrome and the availability in clinical practice of complement inhibitors have paved the way for new therapeutic approaches of membranoproliferative glomerulonephritis.
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Affiliation(s)
- Fadi Fakhouri
- Service de néphrologie et d'immunologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; Inserm UMR S-1064, 30, boulevard Jean-Monnet, 44093 Nantes cedex 01, France; Institut de transplantation urologie-néphrologie (Itun), 30, boulevard Jean-Monnet, 44093 Nantes cedex 01, France.
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