Repetitive administration of rituximab can achieve and maintain clinical remission in patients with MCD or FSGS

Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are glomerulopathies associated with nephrotic syndrome. Primary forms of these diseases are treated with various regimes of immunosuppression. Frequently relapsing or glucocorticoid-dependent courses remain challenging. Here, a B-cell-depleting strategy with rituximab represents a salvage option although data are sparse in the adult population. In particular, there is limited evidence on the efficacy of restoring remission after initial successful treatment with rituximab and whether patients benefit from an individualized, relapse-based approach. We identified 13 patients who received multiple therapies with rituximab from the FOrMe-registry (NCT03949972), a nationwide registry for MCD and FSGS in Germany, or from the University Hospital of Cologne. Disease status, changes in serum creatinine, proteinuria, and time to relapse were evaluated. Relapse-free survival was compared to the patients' previous therapy regimens. Through all treatment cycles, an improvement of disease activity was shown leading to a complete remission in 72% and partial remission in 26% after 3 ([Formula: see text]0.001) and 6 months ([Formula: see text]0.001). Relapse-free survival increased from 4.5 months (95%-CI 3-10 months) to 21 months (95%-CI 16-32 months) ([Formula: see text]0.001) compared to previous immunosuppression regimens with no loss in estimated glomerular filtration over time (p = 0.53). Compared to continuous B-cell depletion, an individualized relapse-based approach led to a reduced rituximab exposure and significant cost savings. Relapse-based administration of rituximab in patients with MCD/FSGS with an initial good clinical response did not result in a decreased efficacy at a median follow-up duration of 110 months. Thus, reinduction therapies may provide an alternative to continuous B-cell-depletion and reduce the long-term side effects of continuous immunosuppression.

Impact of first-line use of caplacizumab on treatment outcomes in immune thrombotic thrombocytopenic purpura

BACKGROUND

The von Willebrand factor-directed nanobody caplacizumab has greatly changed the treatment of immune thrombotic thrombocytopenic purpura (iTTP) in recent years. Data from randomized controlled trials established efficacy and safety.

OBJECTIVES

This study aims to address open questions regarding patient selection, tailoring of therapy duration, obstacles in prescribing caplacizumab in iTTP, effect on adjunct treatment, and outcomes in the real-world setting.

METHODS

We report retrospective, observational cohorts of 113 iTTP episodes treated with caplacizumab and 119 historical control episodes treated without caplacizumab. We aggregated data from the caplacizumab phase II/III trials and real-world data from France, the United Kingdom, Germany, and Austria (846 episodes, 396 treated with caplacizumab, and 450 historical controls).

RESULTS

Caplacizumab was efficacious in iTTP, independent of the timing of therapy initiation, but curtailed the time of active iTTP only when used in the first-line therapy within 72 hours after diagnosis and until at least partial ADAMTS13-activity remission. Aggregated data from multiple study populations showed that caplacizumab use resulted in significant absolute risk reduction of 2.87% for iTTP-related mortality (number needed to treat 35) and a relative risk reduction of 59%.

CONCLUSION

Caplacizumab should be used in first line and until ADAMTS13-remission, lowers iTTP-related mortality and refractoriness, and decreases the number of daily plasma exchange and hospital stay. This trial is registered at www.

CLINICALTRIALS

gov as #NCT04985318.

Alternate-day dosing of caplacizumab for immune-mediated thrombotic thrombocytopenic purpura

BACKGROUND

The anti-von Willebrand factor (VWF) nanobody caplacizumab directly prevents the fatal microthrombi formation in immune-mediated thrombotic thrombocytopenic purpura (iTTP), thereby adding a new therapeutic principle to the treatment of this disorder. However, real-world treatment modalities beyond clinical trials remain heterogeneous.

METHODS

Here, we describe the risks and benefits of an alternate-day dosing regimen for caplacizumab by thoroughly analyzing the timing and outcome of this approach in a retrospective cohort of 25 iTTP patients treated with caplacizumab at seven different medical centers in Austria and Germany between 2018 and 2021.

RESULTS

Alternate-day dosing of caplacizumab appeared feasible and led to persisting normal platelet counts in most patients. Five patients experienced iTTP exacerbations or relapses that led to the resumption of daily caplacizumab application. VWF activity was repeatedly measured in 16 of 25 patients and documented sufficient suppression by caplacizumab after 24 and 48 h in line with published pharmacodynamics.

CONCLUSION

Extension of caplacizumab application intervals from daily to alternate-day dosing may be safely considered in selected patients after 3 to 4 weeks of daily treatment. Earlier modifications may be discussed in low-risk patients but require close monitoring for clinical and laboratory features of thrombotic microangiopathy.

Mental wellbeing and engagement in health risk behaviours in German university students during the COVID-19 pandemic: Findings of a cross-sectional study

Background

Daily life of higher education students across the world changed profoundly in 2020 with the implementation of governmental and institutional measures to control the COVID-19 pandemic. We investigated mental wellbeing and engagement in health risk behaviours (HRB) in German university students at the start of the COVID-19 pandemic.

Methods

Data stem from the COVID-19 International Student Wellbeing Study (C19 ISWS). The web-based survey was conducted in May 2020 at four German universities. HRBs included tobacco and cannabis use, alcohol consumption, and engagement in physical activity. All HRBs were assessed retrospectively and at the time of data collection. Mental wellbeing was assessed using the 8-item Center for Epidemiologic Studies-Depression Scale (CES-D 8). We conducted multinomial regression analyses to investigate factors associated with changes in HRBs and latent transition analysis to identify substance use profiles.

Results

5021 students completed the survey (69% female; mean age 24.4 years, SD = 5.1). The mean score for depressive symptoms was 9.25 (SD = 0.67, range 0-24). Sixty-one percent of students reported consuming alcohol, 46% binge drinking, 44% inactivity, 19% smoking and 11% cannabis use. While smoking and cannabis use remained unchanged during the COVID-19 pandemic, 24% reported a decrease in binge drinking. Changes to physical activity were frequently reported, with 31% reporting an increase and 19% reporting a decrease in vigorous physical activity. Higher depressive symptoms were found to be associated with changes in HRBs. Five substance use behaviour profiles were identified, which remained fairly unchanged.

Conclusions

Engagement in HRBs remains at high level during the COVID-19 pandemic among German students. Depressive symptoms were found to be associated with changes in HRBs. Efforts to promote student health and wellbeing are needed in times of the COVID-19 pandemic and thereafter to prevent longer-term consequences.

CALINCA-A Novel Pipeline for the Identification of lncRNAs in Podocyte Disease

Diseases of the renal filtration unit-the glomerulus-are the most common cause of chronic kidney disease. Podocytes are the pivotal cell type for the function of this filter and focal-segmental glomerulosclerosis (FSGS) is a classic example of a podocytopathy leading to proteinuria and glomerular scarring. Currently, no targeted treatment of FSGS is available. This lack of therapeutic strategies is explained by a limited understanding of the defects in podocyte cell biology leading to FSGS. To date, most studies in the field have focused on protein-coding genes and their gene products. However, more than 80% of all transcripts produced by mammalian cells are actually non-coding. Here, long non-coding RNAs (lncRNAs) are a relatively novel class of transcripts and have not been systematically studied in FSGS to date. The appropriate tools to facilitate lncRNA research for the renal scientific community are urgently required due to a row of challenges compared to classical analysis pipelines optimized for coding RNA expression analysis. Here, we present the bioinformatic pipeline CALINCA as a solution for this problem. CALINCA automatically analyzes datasets from murine FSGS models and quantifies both annotated and de novo assembled lncRNAs. In addition, the tool provides in-depth information on podocyte specificity of these lncRNAs, as well as evolutionary conservation and expression in human datasets making this pipeline a crucial basis to lncRNA studies in FSGS.

A fast and simple clearing and swelling protocol for 3D in-situ imaging of the kidney across scales

In recent years, many light-microscopy protocols have been published for visualization of nanoscale structures in the kidney. These protocols present researchers with new tools to evaluate both foot process anatomy and effacement, as well as protein distributions in foot processes, the slit diaphragm and in the glomerular basement membrane. However, these protocols either involve the application of different complicated super resolution microscopes or lengthy sample preparation protocols. Here, we present a fast and simple, five-hour long procedure for three-dimensional visualization of kidney morphology on all length scales. The protocol combines optical clearing and tissue expansion concepts to produce a mild swelling, sufficient for resolving nanoscale structures using a conventional confocal microscope. We show that the protocol can be applied to visualize a wide variety of pathologic features in both mouse and human kidneys. Thus, our fast and simple protocol can be beneficial for conventional microscopic evaluation of kidney tissue integrity both in research and possibly in future clinical routines.

Ödeme – Kardinalsymptom des nephrotischen Syndroms

Edema is a common symptom with mostly extrarenal causes. Nevertheless, it may also be a sign of glomerular disease. So renal causes should always be clarified to avoid serious complications, such as renal insufficiency, cardiovascular or thrombembolic events. The determination of the albumin-creatinine ratio in spot urine is easy to perform and the method of choice to diagnose nephrotic-range proteinuria. Renal biopsy then usually allows the definitive assignement to either glomerular or systemic disease. Salt restriction in combination with diuretics and antiproteinuric treatment are essential for an effective therapy. Depending on the underlying disease and individual risk factors, anticoagulation should also be considered.

B-cell activating factor BAFF reflects patients' immunological risk profile after kidney transplantation

The B-cell activating factor BAFF plays an important role in the development and maturation of B-lymphocytes, which can contribute to the generation of donor-specific antibodies and thus may influence graft function and graft survival. Inconsistent data on the role of BAFF levels after renal transplantation for the formation of donor-specific antibodies and the contribution for allograft rejection exist. The aim of the current study was to determine to what extent the degree of pre-immunization is reflected by each patient's BAFF levels before transplantation and in the follow-up. Furthermore, the impact of BAFF on allograft rejection frequency as well as severity and resulting allograft function over time was analyzed. Additionally, the impact of viral infections on BAFF levels after transplantation - as a potential confounder - was examined. For this purpose, a group of pre-sensitized patients (PRA>0%, (52±24% on average), n=40) was compared with non-sensitized patients (PRA=0%, n=62) and in a subsequent analysis stratification in accordance to the detected BAFF level was performed. Pre-sensitized patients had significantly higher BAFF levels before transplantation and suffered significantly more often from early steroid-resistant, mainly antibody-mediated rejections. A result which was confirmed also in highly sensitized patients with PRA levels >50%. Additionally, in the follow-up patients with either rising BAFF levels over time or BAFF levels above the median also had significantly more often antibody mediated rejections. Additionally, patients with BAFF levels above detected median even displayed impaired creatinine values as well as an induced eGFR slope up to month 48 after transplantation. The occurrence of viral infections (CMV, BKV) was only an additional influencing factor in the absence of concomitant allograft rejections. Therefore, the B-cell proliferation factor BAFF appears not only to reflect the immunological risk profile of patients in the context of kidney transplantation, it may possibly be further developed as a predictor of patients with an increased risk profile for subsequent allograft rejection and impaired allograft function.

mTOR Regulates Endocytosis and Nutrient Transport in Proximal Tubular Cells

Renal proximal tubular cells constantly recycle nutrients to ensure minimal loss of vital substrates into the urine. Although most of the transport mechanisms have been discovered at the molecular level, little is known about the factors regulating these processes. Here, we show that mTORC1 and mTORC2 specifically and synergistically regulate PTC endocytosis and transport processes. Using a conditional mouse genetic approach to disable nonredundant subunits of mTORC1, mTORC2, or both, we showed that mice lacking mTORC1 or mTORC1/mTORC2 but not mTORC2 alone develop a Fanconi-like syndrome of glucosuria, phosphaturia, aminoaciduria, low molecular weight proteinuria, and albuminuria. Interestingly, proteomics and phosphoproteomics of freshly isolated kidney cortex identified either reduced expression or loss of phosphorylation at critical residues of different classes of specific transport proteins. Functionally, this resulted in reduced nutrient transport and a profound perturbation of the endocytic machinery, despite preserved absolute expression of the main scavenger receptors, MEGALIN and CUBILIN. Our findings highlight a novel mTOR-dependent regulatory network for nutrient transport in renal proximal tubular cells.

Medium to long-term results with the cementless threaded Acetabular Munich II type cup

Compared to pressfit cups, little information exists about the results of screwed cups in hip arthroplasty. 51 cementless or hybrid (cemented stem) primary total hip replacements with a cementless corundium blasted titaniumn alloy threaded Aesculap Munich II type cup were examined with a mean follow up of 7.9 years. 23 of the patients were male and 28 patients were female. From these cups 22 were implanted on the right side and 29 on the left. The results were compared to 53 patients (28 male, 25 female, 29 right side, 24 left side) with the threaded Aesculap Munich I type cup, that has a smooth surface and a direct contact of bone with the polyethylene inlay. The mean follow up ws 10.2 years. The early and medium to long-term clinical and radiographic results show an encouraging improvement of the Merle d'Aubigné Score of the type II cup compared to the type I cup. Two of the Aesculap type Munich II cups had to be revised; four showed radiologic signs of loosening. In conclusion, the threaded Aesculap cup type Munich II seems to be a decisive advance in the development of threaded acetabular hip cups. The intermediate results exceed those from smooth-surface screwed rings and compare favourably with those from cemented cups and with those from cementless press-fit metal-backed cups.

Specific dose-dependent effects of ethane 1,2-dimethanesulfonate in rat and mouse Leydig cells and non-steroidogenic cells on programmed cell death

The mechanism by which ethane 1,2-dimethanesulfonate (EDS) selectively kills Leydig cells is poorly understood. To characterize further the cell-specific actions of EDS, we studied biochemical and morphological changes during apoptosis in different Leydig cell and non-steroidogenic cell models. Rat testicular and H540 tumor Leydig cells were killed by 1-2 mM EDS, whereas 20 mM EDS were required for MA-10 cells. This higher concentration of EDS was also necessary for activation of apoptosis in non-steroidogenic Chinese hamster ovary cells, whereas COS-1 monkey kidney cells were resistant. These variable effects of EDS on apoptosis were independent of new protein synthesis and, interestingly, could be delayed by co-incubation with dibutyrl cyclic AMP. Along with cell death, we also observed chromosomal fragmentation and other hallmarks indicative of apoptosis as evidenced by DNA laddering and fluorescent microscopy. Time-lapse photography with a confocal microscope showed that the time of onset, duration and even the sequence of apoptotic events between individual H540 cells was heterogeneous. When the dose of EDS was gradually increased from 2 to 10 mM, the proportion of cells showing normal apoptotic features gradually decreased. Intriguingly, treatment with 10 mM EDS did not result in death for most cells and was marked by an absence of DNA laddering and ultrastructural features of apoptosis and necrosis. However, incubation with 20 mM EDS resulted in necrosis.These results demonstrated that the effects of EDS on cell survival are not specific to Leydig cells, that different cell types have different sensitivities to EDS and that stimulation of the cAMP pathway may mitigate EDS action. The data obtained with H540 cells further revealed that EDS can induce two types of programmed cell death.

The Traveling Shutter Wave analyses non-linear compliance during mechanical ventilation

Mechanical ventilation is an important, often life-saving component of modern intensive care medicine. However, it may further aggravate pulmonary pathology by endinspiratory overdistension of the alveoli or by their endexpiratory collapse. To prevent both the ventilator may be adjusted based on the slope of the pressure-volume curve, named as compliance, which is often determined by a stepwise inflation of the lungs. This maneuver gained no widespread clinical acceptance because of being cumbersome and invasive. Therefore, we developed a modification of the well known interrupter technique - the Traveling Shutter Wave. A wave of short-term (300 ms) occlusions "travels" over the tidal volume range. Differential compliance is calculated by division of volume and pressure differences between two adjacent occlusion maneuvers. The technique is well suited for the clinical setting because the ventilatory pattern does not need to be changed. This manuscript describes the realization of the Traveling Shutter Wave as well as its application in two patients.

Expression cloning and characterization of a novel sodium-dicarboxylate cotransporter from winter flounder kidney

A cDNA coding for a Na+-dicarboxylate cotransporter, fNaDC-3, from winter flounder (Pseudopleuronectes americanus) kidney was isolated by functional expression in Xenopus laevis oocytes. The fNaDC-3 cDNA is 2384 nucleotides long and encodes a protein of 601 amino acids with a calculated molecular mass of 66.4 kDa. Secondary structure analysis predicts at least eight membrane-spanning domains. Transport of succinate by fNaDC-3 was sodium-dependent, could be inhibited by lithium, and evoked an inward current. The apparent affinity constant (Km) of fNaDC-3 for succinate of 30 microM resembles that of Na+-dicarboxylate transport in the basolateral membrane of mammalian renal proximal tubules. The substrates specific for the basolateral transporter, 2,3-dimethylsuccinate and cis-aconitate, not only inhibited succinate uptake but also evoked inward currents, proving that they are transported by fNaDC-3. Succinate transport via fNaDC-3 decreased by lowering pH, as did citrate transport, although much more moderately. These characteristics suggest that fNaDC-3 is a new type of Na+-dicarboxylate transporter that most likely corresponds to the Na+-dicarboxylate cotransporter in the basolateral membrane of mammalian renal proximal tubules.