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Salehi T, Krishnan A, Al Jurdi A, So P, Lerma E, Wiegley N. Rituximab Resistance in Glomerular Diseases: A GlomCon Mini Review. Kidney Med 2024; 6:100791. [PMID: 38495600 PMCID: PMC10943057 DOI: 10.1016/j.xkme.2024.100791] [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: 03/19/2024] Open
Abstract
Resistance to rituximab B-cell depletion therapy is a clinically pertinent adverse sequela that can have significant implications for the treatment of immune-mediated glomerular diseases. The true incidence of rituximab resistance remains unknown; however, it is an increasingly recognized treatment complication. Resistance typically presents with suboptimal treatment response, rapid B-cell reconstitution, and a relapsing disease course. Although the diverse mechanisms resulting in rituximab resistance are ongoing topics of research, both primary and secondary mechanisms have been identified as key catalysts. The emergence of human antichimeric antibodies (HACAs) is a major cause of secondary resistance to rituximab therapy and typically appears following repeated drug exposure. Frequently, HACAs develop in the setting of underlying autoimmune disease and contribute to poor B-cell depletion, reduced rituximab therapeutic efficacy, and enhanced drug clearance. The clinical challenge of rituximab resistance necessitates heightened awareness among clinicians. Screening for HACAs should be considered in individuals with poor clinical response to rituximab, more rapid B-cell reconstitution, and relapsing disease. Detection of HACAs may guide treatment alterations, including addition of further immunosuppressive therapy and transitioning to a humanized B-cell depleting monoclonal antibody.
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Affiliation(s)
- Tania Salehi
- Central Northern Adelaide Renal and Transplantation Service, Adelaide, Australia
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Anoushka Krishnan
- Department of Renal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Paolo So
- Private Practice, Manila, Philippines
| | - Edgar Lerma
- University of Illinois at Chicago, Chicago, Illinois
- Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Nasim Wiegley
- University of California Davis School of Medicine, Sacramento, California
| | - GlomCon Editorial Team
- Central Northern Adelaide Renal and Transplantation Service, Adelaide, Australia
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
- Department of Renal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Massachusetts General Hospital, Boston, Massachusetts
- Private Practice, Manila, Philippines
- University of Illinois at Chicago, Chicago, Illinois
- Advocate Christ Medical Center, Oak Lawn, Illinois
- University of California Davis School of Medicine, Sacramento, California
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Efe O, So PNH, Anandh U, Lerma EV, Wiegley N. An Updated Review of Membranous Nephropathy. Indian J Nephrol 2024; 34:105-118. [PMID: 38681023 PMCID: PMC11044666 DOI: 10.25259/ijn_317_23] [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] [Received: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 05/01/2024] Open
Abstract
Membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in adults. The discovery of phospholipase A2 receptor (PLA2R) as a target antigen has led to a paradigm shift in the understanding and management of MN. At present, serum PLA2R antibodies are used for diagnosis, prognostication, and guiding treatment. Now, with the discovery of more than 20 novel target antigens, antigen mapping is almost complete. The clinical association of certain antigens provides clues for clinicians, such as the association of nerve epidermal growth factor-like 1 with malignancies and indigenous medicines. Serum antibodies are detected for most target antigens, except exostosin 1 and 2 and transforming growth factor-beta receptor 3, but their clinical utility is yet to be defined. Genome-wide association studies and studies investigating environmental factors, such as air pollution, shed more light on the underpinnings of MN. The standard therapy of MN diversified from cyclical cyclophosphamide and steroids to include rituximab and calcineurin inhibitors over the past decades. Here, we provide a cutting-edge review of MN, focusing on genetics, immune system and environmental factors, novel target antigens and their clinical characteristics, and currently available and emerging novel therapies in MN.
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Affiliation(s)
- Orhan Efe
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital; Harvard Medical School, Boston, USA
| | | | - Urmila Anandh
- Department of Nephrology, Amrita Hospitals, Faridabad, Delhi, NCR, India
| | - Edgar V. Lerma
- Department of Medicine, University of Illinois at Chicago; Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Nasim Wiegley
- Division of Nephrology, Department of Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
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Rodriguez-Ramirez S, Wiegley N, Mejia-Vilet JM. Kidney Biopsy in Management of Lupus Nephritis: A Case-Based Narrative Review. Kidney Med 2024; 6:100772. [PMID: 38317756 PMCID: PMC10840121 DOI: 10.1016/j.xkme.2023.100772] [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: 02/07/2024] Open
Abstract
Kidney involvement in patients with lupus highly increases morbidity and mortality. In recent years, several reports have emphasized the dissociation between clinical and histological findings and highlighted the role of kidney biopsy as an instrument for diagnosis and follow-up of lupus nephritis. The kidney biopsy at initial diagnosis allows an early diagnosis, assessment of activity and chronicity, and detection of nonimmune complex nephritis. A kidney biopsy repeated months after treatment aids in the detection of persistent histological inflammation, which has been linked to the occurrence of future kidney relapses. A kidney biopsy at a relapse detects histological changes including chronic scarring. Finally, a kidney biopsy in patients with a clinical response undergoing maintenance immunosuppression may aid therapy tapering and/or suspension. The evidence supporting the use of a kidney biopsy in different scenarios across the course of lupus nephritis is heterogeneous, with most reports assessing the value for the diagnosis of a first or relapsing flare. In contrast, less evidence suggests additional therapeutic-modifying information derived from repeat posttreatment biopsies and biopsies to evaluate treatment tapering or suspension. In this clinical case-based review, we examine the role of kidney biopsy as a tool to improve clinical outcomes of patients with lupus nephritis.
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Affiliation(s)
- Sonia Rodriguez-Ramirez
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Nasim Wiegley
- University of California, Davis School of Medicine, Division of Nephrology, Sacramento, California, United States
| | - Juan Manuel Mejia-Vilet
- Department of Nephrology and Mineral Metabolism. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Tan B, So PN, Krishnan A, Carriazo S, Bahamonde JR, Lamech TM, Hassanein M, Lerma E, Wiegley N. Approach to Pregnancy in Patients With Lupus Nephritis. Kidney Med 2023; 5:100724. [PMID: 37915962 PMCID: PMC10616386 DOI: 10.1016/j.xkme.2023.100724] [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: 11/03/2023] Open
Abstract
Active lupus nephritis (LN) in pregnancy is strongly associated with poor maternal and fetal outcomes and, therefore, has implications on the planning, timing, and management. Prepregnancy evaluation is essential for all LN patients with childbearing potential to ensure pregnancies proceed in a safe and timely manner. Both maternal and fetal risks are communicated to patient during the evaluation. Stratification into different risk profile groups is then made based on disease activity and organ impairment severity. Patients with LN are generally divided into 3 main groups. Patients with LN who become pregnant receive treatments that are nonteratogenic and optimal for fetal and maternal outcomes. Throughout the pregnancy period, these patients are monitored closely under surveillance by a multidisciplinary team of clinicians. The management of patients with LN in pregnancy can be challenging both diagnostically (distinguishing LN from pre-eclampsia and determining the role and timing of kidney biopsy) and therapeutically (LN flares during pregnancy and managing a newly diagnosed LN during pregnancy).
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Affiliation(s)
- Benjamin Tan
- Nephrology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | | | | | - Sol Carriazo
- Department of Nephrology and Hypertension Department, Fundacion Jimenez Diaz Hospital, Madrid, Spain
| | | | | | - Mohamed Hassanein
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Nasim Wiegley
- Division of Nephrology, University of California Davis School of Medicine, Sacramento, CA
| | - GlomCon Editorial Team
- Nephrology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
- Private Practice, Manila, Philippines
- Royal Perth Hospital, Perth, Australia
- Department of Nephrology and Hypertension Department, Fundacion Jimenez Diaz Hospital, Madrid, Spain
- Department of Nephrology, St Luke’s University Health Network, PA
- Institute of Nephrology, Madras Medical College, India
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
- Division of Nephrology, University of California Davis School of Medicine, Sacramento, CA
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Abstract
Lupus nephritis is a severe, organ-threatening manifestation of systemic lupus erythematosus. The current standard of care in the treatment of lupus nephritis is limited to broad-spectrum immunosuppressants, which have significant concerns of short- and long-term toxicity. With traditional approaches, kidney survival and patient outcomes have remained suboptimal. Robust research in the therapeutics of lupus nephritis has resulted in development of many novel drugs targeting specific inflammatory response pathways. Some newer agents have shown a definitive signal of benefit when added to standard of care. With the advent of precision medicine in nephrology, lupus nephritis treatment may undergo a shift toward incorporating approaches using these newer drugs and individualizing care of our patients. This review highlights major advances in management of lupus nephritis over the last 25 years and explores the ongoing trials of emerging therapies in lupus nephritis.
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Affiliation(s)
| | | | - Sonia Rodriguez
- Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Mohamed Hassanein
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Nasim Wiegley
- University of California Davis School of Medicine, Sacramento, CA
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Panchal H, Ali S, Hallett R, Young B, Wiegley N. Successful Prolonged Desensitization to Epoetin-Alfa Hypersensitivity in an Adult Patient With Advanced Chronic Kidney Disease. Cureus 2023; 15:e40424. [PMID: 37456430 PMCID: PMC10348604 DOI: 10.7759/cureus.40424] [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] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
The use of erythropoiesis-stimulating agents (ESAs) reduces the need for recurrent blood transfusions in patients with advanced kidney disease. Rarely, allergic reactions to recombinant human erythropoietin can develop, complicating anemia management due to cross-reactivity between these agents. We report the use of an outpatient desensitization protocol, which was successfully completed in an adult patient who developed a maculopapular rash as a form of delayed-type hypersensitivity reaction (DTH) to epoetin-alfa (EPO) use, followed by successful re-introduction of EPO and continued tolerance.
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Affiliation(s)
- Hemali Panchal
- Internal Medicine, University of California Davis School of Medicine, Sacramento, USA
| | - Saiyed Ali
- Nephrology, University of California Davis School of Medicine, Sacramento, USA
| | - Rosemary Hallett
- Allergy and Immunology, University of California Davis School of Medicine, Sacramento, USA
| | - Brian Young
- Nephrology, University of California Davis School of Medicine, Sacramento, USA
| | - Nasim Wiegley
- Nephrology, University of California Davis School of Medicine, Sacramento, USA
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Krishnan A, Shankar M, Lerma EV, Wiegley N. Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors and CKD: Are You a #Flozinator? Kidney Med 2023; 5:100608. [PMID: 36915368 PMCID: PMC10006698 DOI: 10.1016/j.xkme.2023.100608] [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: 02/04/2023] Open
Abstract
Sodium/glucose cotransporter 2 (SGLT2) inhibitors have rapidly emerged as a novel therapy to reduce the rate of progression of chronic kidney disease (CKD). With humble beginnings in the 19th century for treating malaria, this class of drugs initially developed for the treatment of diabetes has now revolutionized the management of heart failure and CKD. SGLT2 inhibitors trigger glucosuria, thus modestly improving glycemic control. In addition, they have pleiotropic effects, such as reducing intraglomerular pressure and improving tubuloglomerular feedback, which lead to their beneficial effects on CKD progression. Recent data from randomized controlled trials have demonstrated the efficacy of this class of drugs in CKD. We briefly review the evidence from major trials on SGLT2 inhibitors in CKD, discuss the mechanisms of action and provide an overview of the safe and successful prescription of these medications.
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Affiliation(s)
| | - Mythri Shankar
- Department of Nephrology, Institute of Nephro-urology, Bengaluru, India
| | - Edgar V. Lerma
- Department of Medicine; University of Illinois at Chicago; Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Nasim Wiegley
- Department of Medicine, University of California, Davis School of Medicine, Sacramento, California
- Address for Correspondence: Nasim Wiegley, MD, University of California, Davis School of Medicine, Sacramento, CA.
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Wiegley N, So PN. Sodium-Glucose Cotransporter 2 Inhibitors and Urinary Tract Infection: Is There Room for Real Concern? Kidney360 2022; 3:1991-1993. [PMID: 36514393 PMCID: PMC9717627 DOI: 10.34067/kid.0005722022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 06/17/2023]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have revolutionized our armamentarium for kidney and heart protection in patients with or without diabetes. Based on early reports of a limited number of cases, a concern for increased risk of urinary tract infections arose, which has become one of the main areas of concern for some clinicians. However, data from large randomized clinical trials and real-world population-based studies have not shown a significantly increased risk of UTI in patients on SGLT2 inhibitors. The goal of this brief review article is to review the literature and provide reassurance to patients and prescribers for the broader use of these agents.
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Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, School of Medicine, University of California, Davis, Sacramento, California
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Goodson DA, Chalupsky MR, Wiegley N, Huang Y, Chiu M, Bang H, Roshanravan B, Young BY, Chen LX. GFR Estimation in Potential Living Kidney Donors: Race and Non-race Based Equations and Measured GFR. Kidney Med 2022; 4:100558. [DOI: 10.1016/j.xkme.2022.100558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Wiegley N, Chin AI. Does Rescheduling a Missed In-Center Hemodialysis Treatment Improve Clinical Outcomes? Kidney Med 2020; 2:3-4. [PMID: 32734942 PMCID: PMC7380335 DOI: 10.1016/j.xkme.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Andrew I. Chin
- Division of Nephrology, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA
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