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Massicotte-Azarniouch D, Detwiler RK, Hu Y, Falk RJ, Saha MK, van Duin D, Hogan SL, Derebail VK. Infections Following Kidney Transplantation After Exposure to Immunosuppression for Treatment of Glomerulonephritis. Am J Kidney Dis 2023:S0272-6386(23)01000-4. [PMID: 38160700 DOI: 10.1053/j.ajkd.2023.10.016] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 01/03/2024]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with glomerulonephritis (GN) as their native disease commonly have received pretransplant immunosuppression (PTI). This may contribute to the immunosuppression burden potentially increasing the risk for infections after transplantation. STUDY DESIGN Single-center, retrospective cohort study. SETTING & PARTICIPANTS Recipients of a kidney transplant from January 2005 until May 2020 at a tertiary care university teaching hospital. EXPOSURE Patients with GN as their native kidney disease who received PTI for treatment of GN (n=184) were compared with nondiabetic recipients of kidney transplants who did not receive PTI (n = 579). OUTCOME First occurrence after transplantation of an infection outcome, either viral (BK or cytomegalovirus [CMV] infection) or bacterial. ANALYTICAL APPROACH Cox regression analysis adjusted for age at transplant, sex, race, donor type, year of transplant surgery, dialysis vintage, receipt of T-cell depleting induction, and CMV transplant status. RESULTS Over a median follow-up period of 5.7 years, patients with GN PTI were not at an increased risk for developing any first viral infection compared with controls (adjusted HR [AHR] 0.69 [95% CI, 0.52-0.91]) nor at increased risk for specific viral infections: BK infection 19.6% vs 26.3% (AHR 0.72 [95% CI, 0.50-1.05]) or CMV infection, 24.5% vs 29.0% (AHR, 0.76 [95% CI, 0.54-1.07]), respectively. There was also no increased risk of developing a first bacterial infection: 54.5% vs 57.5% (AHR, 0.90 [95% CI, 0.71-1.13]). These findings of no increased risk for infection were independent of the type of PTI used (cyclophosphamide, rituximab, mycophenolate mofetil, or calcineurin inhibitor) or the type of T-cell depleting induction therapy (alemtuzumab or antithymocyte globulin) administered. LIMITATIONS Single-center study, no data on methylprednisone use for PTI, unmeasured confounding. CONCLUSIONS Use of PTI for the treatment of GN was not associated with an increased risk of viral (BK or CMV) or bacterial infection after transplantation. Additional surveillance for infection after transplantation for patients who received PTI may not be necessary. PLAIN-LANGUAGE SUMMARY Many kidney transplant patients have glomerular disease as the cause of kidney failure. These patients may be exposed to immunosuppression before transplantation, which could increase the risk for infections after receipt of a transplanted kidney. We identified kidney transplant recipients at a university teaching hospital who received immunosuppression before transplant for the treatment of glomerular kidney disease. We examined their risk for infection after transplantation by comparing it with the risk among transplant patients who were not exposed to immunosuppression before transplant. We observed no increased risk for infection after exposure to prior immunosuppression. Therefore, patients exposed to significant amounts of immunosuppression before transplantation may not require special surveillance or medication adjustment for fear of infection after their receipt of a kidney transplant.
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Affiliation(s)
- David Massicotte-Azarniouch
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada.
| | - Randal K Detwiler
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yichun Hu
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Manish K Saha
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - David van Duin
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Zeitler EM, Li Y, Schroder M, Falk RJ, Sumner S. Characterizing the metabolic response of the zebrafish kidney to overfeeding. Am J Physiol Renal Physiol 2023; 325:F491-F502. [PMID: 37589050 PMCID: PMC10639026 DOI: 10.1152/ajprenal.00113.2023] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023] Open
Abstract
Obesity is a global epidemic and risk factor for the development of chronic kidney disease. Obesity induces systemic changes in metabolism, but how it affects kidney metabolism specifically is not known. Zebrafish have previously been shown to develop obesity-related kidney pathology and dysfunction when fed hypercaloric diets. To understand the direct effects of obesity on kidney metabolic function, we treated zebrafish for 8 wk with a control and an overfeeding diet. At the end of treatment, we assessed changes in kidney and fish weights and used electron microscopy to evaluate cell ultrastructure. We then performed an untargeted metabolomic analysis on the kidney tissue of fish using ultra-high performance liquid chromatography coupled with high-resolution mass spectrometry and used mummichog and gene set enrichment analysis to uncover differentially affected metabolic pathways. Kidney metabolomes differed significantly and consistently between the control and overfed diets. Among 9,593 features, we identified 235 that were significantly different (P < 0.05) between groups (125 upregulated in overfed diet, 110 downregulated). Pathway analysis demonstrated perturbations in glycolysis and fatty acid synthesis pathways, and analysis of specific metabolites points to perturbations in tryptophan metabolism. Our key findings show that diet-induced obesity leads to metabolic changes in the kidney tissue itself and implicates specific metabolic pathways, including glycolysis and tryptophan metabolism in the pathogenesis of obesity-related kidney disease, demonstrating the power of untargeted metabolomics to identify pathways of interest by directly interrogating kidney tissue.NEW & NOTEWORTHY Obesity causes systemic metabolic dysfunction, but how this affects kidney metabolism is less understood. This study used ultra-high performance liquid chromatography coupled with high-resolution mass spectrometry to analyze the kidneys of overfed zebrafish. Metabolites in the kidneys of obese zebrafish revealed perturbations in metabolic pathways including glycolysis and tryptophan metabolism. These data suggest obesity alters metabolism within the kidney, which may play an important role in obesity-related kidney dysfunction.
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Affiliation(s)
- Evan M Zeitler
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Yuanyuan Li
- Department of Nutrition, Nutrition Research Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Madison Schroder
- Department of Nutrition, Nutrition Research Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Susan Sumner
- Department of Nutrition, Nutrition Research Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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Massicotte-Azarniouch D, Detwiler RK, Hu Y, Falk RJ, Saha MK, Hogan SL, Derebail VK. Malignancy risk in kidney transplant recipients exposed to immunosuppression pre-transplant for the treatment of glomerulonephritis. Nephrol Dial Transplant 2023; 38:2009-2018. [PMID: 36549661 PMCID: PMC10468752 DOI: 10.1093/ndt/gfac337] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Kidney transplant patients with glomerulonephritis (GN) as their native disease may receive significant amounts of pre-transplant immunosuppression (PTI), which could increase the risk for development of malignancy post-transplant. METHODS We conducted a single-center, retrospective study of kidney transplant recipients from January 2005 until May 2020. Patients with GN as their native kidney disease who received PTI for treatment of GN (n = 184) were compared with a control cohort (n = 579) of non-diabetic, non-PTI-receiving kidney transplant patients. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) for outcomes of first occurrence of solid or hematologic malignancy, non-melanoma skin cancer (NMSC) and post-transplant lymphoproliferative disorder (PTLD). RESULTS Over a median follow-up of 5.7 years, PTI for GN was associated with significantly increased risk for malignancy compared with controls [13.0% vs 9.7%, respectively; adjusted HR 1.82 (95% CI 1.10-3.00)], but not for NMSC [10.3% vs 11.4%, respectively; adjusted HR 1.09 (95% CI 0.64-1.83)] or PTLD [3.3% vs 3.1%, respectively; adjusted HR 1.02 (95% CI 0.40-2.61)]. The risk for malignancy was significantly increased in those who received cyclophosphamide [HR 2.59 (95% CI 1.48-4.55)] or rituximab [HR 3.82 (95% CI 1.69-8.65)] pre-transplant, and particularly in those who received both cyclophosphamide and rituximab, but not for calcineurin inhibitors or mycophenolate. CONCLUSION The use of PTI for treatment of GN, especially cyclophosphamide or even with rituximab, is associated with increased risk for development of solid or hematologic malignancy post-transplant. These data highlight potential risks with treatment of GN and underscore the importance of post-transplant malignancy surveillance in this patient population.
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Affiliation(s)
- David Massicotte-Azarniouch
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Randal K Detwiler
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yichun Hu
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manish K Saha
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Egbuna O, Zimmerman B, Manos G, Fortier A, Chirieac MC, Dakin LA, Friedman DJ, Bramham K, Campbell K, Knebelmann B, Barisoni L, Falk RJ, Gipson DS, Lipkowitz MS, Ojo A, Bunnage ME, Pollak MR, Altshuler D, Chertow GM. Inaxaplin for Proteinuric Kidney Disease in Persons with Two APOL1 Variants. N Engl J Med 2023; 388:969-979. [PMID: 36920755 DOI: 10.1056/nejmoa2202396] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Persons with toxic gain-of-function variants in the gene encoding apolipoprotein L1 (APOL1) are at greater risk for the development of rapidly progressive, proteinuric nephropathy. Despite the known genetic cause, therapies targeting proteinuric kidney disease in persons with two APOL1 variants (G1 or G2) are lacking. METHODS We used tetracycline-inducible APOL1 human embryonic kidney (HEK293) cells to assess the ability of a small-molecule compound, inaxaplin, to inhibit APOL1 channel function. An APOL1 G2-homologous transgenic mouse model of proteinuric kidney disease was used to assess inaxaplin treatment for proteinuria. We then conducted a single-group, open-label, phase 2a clinical study in which inaxaplin was administered to participants who had two APOL1 variants, biopsy-proven focal segmental glomerulosclerosis, and proteinuria (urinary protein-to-creatinine ratio of ≥0.7 to <10 [with protein and creatinine both measured in grams] and an estimated glomerular filtration rate of ≥27 ml per minute per 1.73 m2 of body-surface area). Participants received inaxaplin daily for 13 weeks (15 mg for 2 weeks and 45 mg for 11 weeks) along with standard care. The primary outcome was the percent change from the baseline urinary protein-to-creatinine ratio at week 13 in participants who had at least 80% adherence to inaxaplin therapy. Safety was also assessed. RESULTS In preclinical studies, inaxaplin selectively inhibited APOL1 channel function in vitro and reduced proteinuria in the mouse model. Sixteen participants were enrolled in the phase 2a study. Among the 13 participants who were treated with inaxaplin and met the adherence threshold, the mean change from the baseline urinary protein-to-creatinine ratio at week 13 was -47.6% (95% confidence interval, -60.0 to -31.3). In an analysis that included all the participants regardless of adherence to inaxaplin therapy, reductions similar to those in the primary analysis were observed in all but 1 participant. Adverse events were mild or moderate in severity; none led to study discontinuation. CONCLUSIONS Targeted inhibition of APOL1 channel function with inaxaplin reduced proteinuria in participants with two APOL1 variants and focal segmental glomerulosclerosis. (Funded by Vertex Pharmaceuticals; VX19-147-101 ClinicalTrials.gov number, NCT04340362.).
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Affiliation(s)
- Ogo Egbuna
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Brandon Zimmerman
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - George Manos
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Anne Fortier
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Madalina C Chirieac
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Leslie A Dakin
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - David J Friedman
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Kate Bramham
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Kirk Campbell
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Bertrand Knebelmann
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Laura Barisoni
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Ronald J Falk
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Debbie S Gipson
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Michael S Lipkowitz
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Akinlolu Ojo
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Mark E Bunnage
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Martin R Pollak
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - David Altshuler
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
| | - Glenn M Chertow
- From Vertex Pharmaceuticals (O.E., B.Z., G.M., A.F., M.C.C., L.A.D., M.E.B., D.A.), and Beth Israel Deaconess Medical Center, Harvard Medical School (D.J.F., M.R.P.) - both in Boston; King's College London, London (K.B.); Icahn School of Medicine at Mount Sinai, New York (K.C.); Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris (B.K.); Duke University, Durham (L.B.), and the University of North Carolina at Chapel Hill, Chapel Hill (R.J.F.) - both in North Carolina; the University of Michigan, Ann Arbor (D.S.G.); Georgetown University Hospital, Washington, DC (M.S.L.); University of Kansas School of Medicine, Kansas City (A.O.); and Stanford University School of Medicine, Palo Alto, CA (G.M.C.)
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Chen DP, Henderson CD, Anguiano J, Aiello CP, Collie MM, Moreno V, Hu Y, Hogan SL, Falk RJ. Kidney Disease Progression in Membranous Nephropathy among Black Participants with High-Risk APOL1 Genotype. Clin J Am Soc Nephrol 2023; 18:337-343. [PMID: 36763808 PMCID: PMC10103220 DOI: 10.2215/cjn.0000000000000070] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/02/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Disparity in CKD progression among Black individuals persists in glomerular diseases. Genetic variants in the apolipoprotein L1 ( APOL1 ) gene in the Black population contribute to kidney disease, but the influence in membranous nephropathy remains unknown. METHODS Longitudinally followed participants enrolled in the Glomerular Disease Collaborative Network or Cure Glomerulonephropathy Network were included if they had DNA or genotyping available for APOL1 (Black participants with membranous nephropathy) or had membranous nephropathy but were not Black. eGFR slopes were estimated using linear mixed-effects models with random effects and adjusting for covariates and interaction terms of covariates. Fisher exact test, Kruskal-Wallis test, and Kaplan-Meier curves with log-rank tests were used to compare groups. RESULTS Among 118 Black membranous nephropathy participants, 16 (14%) had high-risk APOL1 genotype (two risk alleles) and 102 (86%) had low-risk APOL1 genotype (zero or one risk alleles, n =53 and n =49, respectively). High-risk APOL1 membranous nephropathy participants were notably younger at disease onset than low-risk APOL1 and membranous nephropathy participants that were not Black ( n =572). eGFR at disease onset was not different between groups, although eGFR decline (slope) was steeper in participants with high-risk APOL1 genotype (-16±2 [±SE] ml/min per 1.73 m 2 per year) compared with low-risk APOL1 genotype (-4±0.8 ml/min per 1.73 m 2 per year) or membranous nephropathy participants that did not identify themselves as Black (-2.0±0.4 ml/min per 1.73 m 2 per year) ( P <0.0001). Time to kidney failure was faster in the high-risk APOL1 genotype than low-risk APOL1 genotype or membranous nephropathy participants that were not Black. CONCLUSIONS The prevalence of high-risk APOL1 variant among Black membranous nephropathy participants is comparable with the general Black population (10%-15%), yet the high-risk genotype was associated with worse eGFR decline and faster time to kidney failure compared with low-risk genotype and participants that were not Black.
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Affiliation(s)
- Dhruti P. Chen
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Candace D. Henderson
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jaeline Anguiano
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Claudia P. Aiello
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Mary M. Collie
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Vanessa Moreno
- Department of Pathology, University of North Carolina, Chapel Hill, North Carolina
| | - Yichun Hu
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Susan L. Hogan
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ronald J. Falk
- UNC Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Chen DP, Aiello CP, McCoy D, Stamey T, Yang J, Hogan SL, Hu Y, Derebail VK, Wu EY, Jennette JC, Falk RJ, Ciavatta DJ. PRTN3 variant correlates with increased autoantigen levels and relapse risk in PR3-ANCA versus MPO-ANCA disease. JCI Insight 2023; 8:e166107. [PMID: 36626226 PMCID: PMC9977496 DOI: 10.1172/jci.insight.166107] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
A GWAS of patients with anti-neutrophil cytoplasmic antibodies (ANCAs) found an association between proteinase-3 ANCA (PR3-ANCA) and a single nucleotide polymorphism (rs62132293) upstream of PRTN3, encoding PR3. The variant (G allele) was shown to be an expression quantitative trait locus in healthy controls, but the clinical impact remains unknown. Longitudinally followed patients with ANCA and healthy controls were genotyped. Gene expression was quantified by real-time quantitative PCR from leukocyte RNA. Plasma PR3 was quantified by ELISA. Among patients, variant carriers had elevated leukocyte PRTN3 expression compared with noncarriers (C/G vs. C/C and G/G vs. C/C). Healthy controls had low PRTN3 regardless of genotype. Myeloperoxidase (MPO) expression did not differ by genotype. PRTN3 expression correlated with circulating PR3, and variant carriers had higher plasma PR3 compared with noncarriers. Among variant carriers, there was an increased risk of relapse in patients with PR3-ANCA versus MPO-ANCA. The risk allele marked by rs62132293 is clinically significant as it is associated with increased autoantigen and may, in part, explain increased relapse in PR3-ANCA. Our results underscore the role of autoantigen availability in ANCA vasculitis.
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Affiliation(s)
- Dhruti P. Chen
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Claudia P. Aiello
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - DeMoris McCoy
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Taylor Stamey
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jiajin Yang
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eveline Y. Wu
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, and
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, and
| | - Dominic J. Ciavatta
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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7
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Alba MA, Jennette JC, Hu Y, Poulton CJ, Blazek L, Derebail VK, Falk RJ, Hogan SL. Relevance of Combined Clinicopathologic Phenotype and Antineutrophil Cytoplasmic Autoantibody Serotype in the Diagnosis of Antineutrophil Cytoplasmic Autoantibody Vasculitis. Kidney Int Rep 2022; 7:2676-2690. [PMID: 36506241 PMCID: PMC9727534 DOI: 10.1016/j.ekir.2022.09.011] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), 2 major clinicopathologic variants of antineutrophil cytoplasmic autoantibody (ANCA) vasculitides, are mostly associated with proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, respectively. Less is known regarding the uncommon forms of ANCA vasculitis, PR3-ANCA MPA and MPO-ANCA GPA. Methods In this cohort study we detailed the clinical presentation and outcome of patients with PR3-ANCA MPA and MPO-ANCA GPA from the Glomerular Disease Collaborative Network (GDCN) inception cohort. Baseline clinical manifestations, relapses, end-stage kidney disease (ESKD), and survival were compared within MPA cases by PR3-ANCA (n = 116) versus MPO-ANCA (n = 173) and within GPA cases by PR3-ANCA (n = 108) versus MPO-ANCA (n = 43). Fisher's exact test and Wilcoxon two sample test were used for comparisons. Proportional hazards models were used to evaluate the development of relapses, ESKD, and death. Results Patients with PR3-ANCA MPA were younger (53 years vs. 62 years, P = 0.0007) and had increased prevalence of joint involvement (56% vs. 40%, P = 0.0115) and ear, nose, and throat (ENT) involvement (44% vs. 26%, P = 0.002) than MPO-ANCA MPA. Relapses, ESKD, and survival were similar between both MPA subsets. Within the GPA group, patients with MPO-ANCA GPA were older (61 years vs. 46 years, P = 0.0007) and more likely female (56% vs. 35%, P = 0.027) than PR3-ANCA GPA patients. MPO-ANCA GPA was also characterized by less prevalent ENT manifestations (58% vs. 77%, P = 0.028) and neurologic manifestations (5% vs. 25%, P = 0.0029), and increased ESKD and mortality. Conclusions PR3-ANCA MPA and MPO-ANCA GPA are clinicopathologically distinct subsets of ANCA vasculitis that differ from MPO-ANCA MPA and PR3-ANCA GPA. Although the impact of these differences on the clinical management and outcome warrants further evaluation, these results support the recommendation of including both the phenotypic diagnosis and ANCA serotype in the diagnosis of ANCA vasculitis.
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Affiliation(s)
- Marco A. Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Blazek
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Agosto‐Burgos C, Wu EY, Iannone MA, Hu Y, Hogan SL, Henderson CD, Kennedy KB, Blazek L, Herrera CA, Munson D, Falk RJ, Ciavatta DJ, Free ME. The frequency of Treg subsets distinguishes disease activity in ANCA vasculitis. Clin Transl Immunology 2022; 11:e1428. [PMID: 36381498 PMCID: PMC9652144 DOI: 10.1002/cti2.1428] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives T regulatory cells (Tregs) are a heterogeneous group of immunoregulatory cells that dampen self-harming immune responses and prevent the development of autoimmune diseases. In anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis, Tregs possess diminished suppressive capacity, which has been attributed to the expression of a FOXP3 splice-variant lacking exon 2 in T cells (FOXP3Δ2 CD4+ T cells). However, the suppressive capacity of Tregs varies between subsets. We evaluated the frequency of Treg subsets in ANCA vasculitis as a potential explanation for diminished suppressive capacity. Methods We developed a custom mass cytometry panel and performed deep immune profiling of Tregs in healthy controls, patients with active disease and in remission. Using these data, we performed multidimensional reduction and discriminant analysis to identify associations between Treg subsets and disease activity. Results Total Tregs were expanded in ANCA vasculitis, which was associated with remission and the administration of rituximab and/or prednisone. The frequency of FOXP3Δ2 CD4+ T cells did not distinguish disease activity and this population had high expression levels of CD127 and lacked both CD25 and Helios, suggesting that they are not conventional Tregs. The frequency of CXCR3+, CD103+ and CCR7+ Tregs distinguished disease activity, and the combination of the frequency of these three Treg subsets segregated active patients from patients in remission and healthy controls. From these three subsets, the frequency of CXCR3+ Tregs distinguished patients with active disease with renal involvement. Conclusion Treg heterogeneity can discriminate disease activity and should be explored as a biomarker of disease activity in ANCA vasculitis.
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Affiliation(s)
- Christian Agosto‐Burgos
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Eveline Y Wu
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of PediatricsUniversity of North CarolinaChapel HillNCUSA
| | - Marie A Iannone
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Yichun Hu
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Susan L Hogan
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Candace D Henderson
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Kristin B Kennedy
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Lauren Blazek
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Carolina A Herrera
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Dominique Munson
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Dominic J Ciavatta
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of GeneticsUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Meghan E Free
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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9
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Saha MK, Massicotte-Azarniouch D, Reynolds ML, Mottl AK, Falk RJ, Jennette JC, Derebail VK. Glomerular Hematuria and the Utility of Urine Microscopy: A Review. Am J Kidney Dis 2022; 80:383-392. [PMID: 35777984 DOI: 10.1053/j.ajkd.2022.02.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 09/22/2021] [Accepted: 02/16/2022] [Indexed: 01/27/2023]
Abstract
Evaluation of hematuria and microscopic examination of urine sediment are commonly used tools by nephrologists in their assessment of glomerular diseases. Certain morphological aspects of urine red blood cells (RBCs) seen by microscopy may help in identifying the source of hematuria as glomerular or not. Recognized signs of glomerular injury are RBC casts or dysmorphic RBCs, in particular acanthocytes (ring-shaped RBCs with protruding blebs). Despite being a highly operator-dependent test, urine sediment examination revealing these signs of glomerular hematuria has demonstrated specificities and positive predictive values ranging between 90%-100% for diagnosing glomerular disease, although sensitivity can be quite variable. Hematuria is a commonly used tool for diagnosing patients with proliferative glomerulonephritis such as IgA nephropathy, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, and lupus nephritis, sometimes even as a surrogate for kidney involvement. Studies examining the role for hematuria in monitoring and predicting adverse outcomes in these diseases have shown inconsistent results, possibly due to inconsistent definitions that often fail to consider specific markers of glomerular hematuria such as dysmorphic RBCs, acanthocytes, or RBC casts. A consensus definition of what constitutes glomerular hematuria would help standardize use in future studies and likely improve the diagnostic and prognostic value of hematuria as a marker of glomerulonephritis.
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Affiliation(s)
- Manish K Saha
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - David Massicotte-Azarniouch
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Monica L Reynolds
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Amy K Mottl
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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10
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Chen DP, McInnis EA, Wu EY, Stember KG, Hogan SL, Hu Y, Henderson CD, Blazek LN, Mallal S, Karosiene E, Peters B, Sidney J, James EA, Kwok WW, Jennette JC, Ciavatta DJ, Falk RJ, Free ME. Immunological Interaction of HLA-DPB1 and Proteinase 3 in ANCA Vasculitis is Associated with Clinical Disease Activity. J Am Soc Nephrol 2022; 33:1517-1527. [PMID: 35672132 PMCID: PMC9342628 DOI: 10.1681/asn.2021081142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 05/01/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND PR3-ANCA vasculitis has a genetic association with HLA-DPB1. We explored immunologic and clinical features related to the interaction of HLA-DPB1*04:01 with a strongly binding PR3 peptide epitope (PR3225-239). METHODS Patients with ANCA vasculitis with active disease and disease in remission were followed longitudinally. Peripheral blood mononuclear cells from patients and healthy controls with HLA-DPB1*04:01 were tested for HLA-DPB1*04:01 expression and interaction with a PR3 peptide identified via in silico and in vitro assays. Tetramers (HLA/peptide multimers) identified autoreactive T cells in vitro. RESULTS: The HLA-DPB1*04:01 genotype was associated with risk of relapse in PR3-ANCA (HR for relapse 2.06; 95% CI, 1.01 to 4.20) but not in myeloperoxidase (MPO)-ANCA or the combined cohort. In silico predictions of HLA and PR3 peptide interactions demonstrated strong affinity between ATRLFPDFFTRVALY (PR3225-239) and HLA-DPB1*04:01 that was confirmed by in vitro competitive binding studies. The interaction was tested in ex vivo flow cytometry studies of labeled peptide and HLA-DPB1*04:01-expressing cells. We demonstrated PR3225-239 specific autoreactive T cells using synthetic HLA multimers (tetramers). Patients in long-term remission off therapy had autoantigenic peptide and HLA interaction comparable to that of healthy volunteers. CONCLUSIONS The risk allele HLA-DPB1*04:01 has been associated with PR3-ANCA, but its immunopathologic role was unclear. These studies demonstrate that HLA-DPB1*04:01 and PR3225-239 initiate an immune response. Autoreactive T cells specifically recognized PR3225-239 presented by HLA-DPB1*04:01. Although larger studies should validate these findings, the pathobiology may explain the observed increased risk of relapse in our cohort. Moreover, lack of HLA and autoantigen interaction observed during long-term remission signals immunologic nonresponsiveness.
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Affiliation(s)
- Dhruti P. Chen
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
| | - Elizabeth A. McInnis
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
| | - Eveline Y. Wu
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Katherine G. Stember
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Susan L. Hogan
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
| | - Yichun Hu
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
| | - Candace D. Henderson
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
| | - Lauren N. Blazek
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
| | - Simon Mallal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edita Karosiene
- Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, California
| | - Bjoern Peters
- Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, California
| | - John Sidney
- Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, California
| | - Eddie A. James
- Translational Research Program, Benaroya Research Institute, Seattle, Washington
| | - William W. Kwok
- Department of Genetics, University of North Carolina, Chapel Hill, North Carolina
| | - J. Charles Jennette
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Dominic J. Ciavatta
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
- Department of Genetics, University of North Carolina, Chapel Hill, North Carolina
| | - Ronald J. Falk
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Meghan E. Free
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina
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11
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Massicotte-Azarniouch D, Herrera CA, Jennette JC, Falk RJ, Free ME. Mechanisms of vascular damage in ANCA vasculitis. Semin Immunopathol 2022; 44:325-345. [PMID: 35254509 PMCID: PMC9064952 DOI: 10.1007/s00281-022-00920-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
The discovery of anti-neutrophil cytoplasmic antibodies (ANCA) and their antigenic targets, myeloperoxidase (MPO) and proteinase 3 (PR3), has led to further understanding as to the pathophysiologic processes that underlie vascular and tissue damage in ANCA vasculitis. ANCA trigger neutrophil activation leading to vascular damage in ANCA vasculitis. However, decades of study have determined that neutrophil activation alone is not sufficient to cause disease. Inflammatory stimuli are drivers of ANCA autoantigen expression and ANCA production. Certain infections or bacterial peptides may be crucial players in the initial steps of ANCA immunopathogenesis. Genetic and epigenetic alterations of gene encoding for MPO and PR3 provide additional disturbances to the immune homeostasis which provide a substrate for pathogenic ANCA formation from an adaptive immune system predisposed to autoreactivity. Promoted by inflammatory cytokines, ANCA binding leads to neutrophil activation, a process characterized by conformational changes, production and release of cytotoxic substances, and alternative complement pathway activation, thus creating an intense inflammatory milieu. This cascade of events perpetuates a vicious cycle of further inflammatory cell recruitment and activation, culminating in tissue necrosis. Our understanding of the pathogenic process in ANCA vasculitis paves the way for the development of therapies targeting crucial steps in this process. The greater appreciation of the role for complement, monocytes, and the adaptive immune system has already led to novel complement blockers and is poised to lead to further innovations which will allow for tailored antigen- or cell-specific immunotherapy targeting the autoimmune process without exposure to undue risks or toxicities.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Carolina A Herrera
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Meghan E Free
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Zeitler EM, Jennette JC, Flythe JE, Falk RJ, Poulton JS. High-calorie diet results in reversible obesity-related glomerulopathy in adult zebrafish regardless of dietary fat. Am J Physiol Renal Physiol 2022; 322:F527-F539. [PMID: 35224994 PMCID: PMC8977181 DOI: 10.1152/ajprenal.00018.2022] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 11/22/2022] Open
Abstract
Obesity is a risk factor for the development of kidney disease. The role of diet in this association remains undetermined, in part due to practical limitations in studying nutrition in humans. In particular, the relative importance of calorie excess versus dietary macronutrient content is poorly understood. For example, it is unknown if calorie restriction modulates obesity-related kidney pathology. To study the effects of diet-induced obesity in a novel animal model, we treated zebrafish for 8 wk with diets varied in both calorie and fat content. Kidneys were evaluated by light and electron microscopy. We evaluated glomerular filtration barrier function using a dextran permeability assay. We assessed the effect of diet on podocyte sensitivity to injury using an inducible podocyte injury model. We then tested the effect of calorie restriction on the defects caused by diet-induced obesity. Fish fed a high-calorie diet developed glomerulomegaly (mean: 1,211 vs. 1,010 µm2 in controls, P = 0.007), lower podocyte density, foot process effacement, glomerular basement membrane thickening, tubular enlargement (mean: 1,038 vs. 717 µm2 in controls, P < 0.0001), and ectopic lipid deposition. Glomerular filtration barrier dysfunction and increased susceptibility to podocyte injury were observed with high-calorie feeding regardless of dietary fat content. These pathological changes resolved with 4 wk of calorie restriction. Our findings suggest that calorie excess rather than dietary fat drives obesity-related kidney dysfunction and that inadequate podocyte proliferation in response to glomerular enlargement may cause podocyte dysfunction. We also demonstrate the value of zebrafish as a novel model for studying diet in obesity-related kidney disease.NEW & NOTEWORTHY Obesity is a risk factor for kidney disease. The role of diet in this association is difficult to study in humans. In this study, zebrafish fed a high-calorie diet, regardless of fat macronutrient composition, developed glomerulomegaly, foot process effacement, and filtration barrier dysfunction, recapitulating the changes seen in humans with obesity. Calorie restriction reversed the changes. This work suggests that macronutrient composition may be less important than total calories in the development of obesity-related kidney disease.
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Affiliation(s)
- Evan M Zeitler
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - J Charles Jennette
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Nephropathology Division, Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John S Poulton
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Cooley I, Derebail VK, Gibson KL, Álvarez C, Poulton CJ, Blazek LN, Love A, Hogan SL, Jennette JC, Falk RJ, Sheikh SZ. Association of Lupus Nephritis Histopathologic Classification With Venous Thromboembolism-Modification by Age at Biopsy. Kidney Int Rep 2021; 6:1653-1660. [PMID: 34169206 PMCID: PMC8207328 DOI: 10.1016/j.ekir.2021.02.015] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/21/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Lupus nephritis (LN) is an independent risk factor for venous thromboembolism (VTE). The risk of VTE has not been analyzed by International Society of Nephrology/Renal Pathology Society or World Health Organization LN class. Study goals were to measure VTE incidence in an LN patient cohort, to evaluate associations between VTE and LN class, and to investigate factors modifying associations between VTE and LN class. METHODS A retrospective analysis was performed using Glomerular Disease Collaborative Network data. Image-confirmed VTE was compared between patients with any LN class V lesion and patients with only LN class III or IV. Logistic regression was used to calculate odds ratios and 95% confidence intervals. Effect modification was assessed between main effect and covariates. RESULTS Our cohort consisted of 534 LN patients, 310 (58%) with class III/IV and 224 (42%) with class V with or without class III/IV, including 106 with class V alone. The VTE incidence was 62 of 534 (11.6%). The odds of VTE were not significantly different between patients with class III/IV and class V in adjusted analyses (odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.45-1.48). An age interaction was observed (P = 0.009), with increased odds of VTE with class III/IV diagnosed at a younger age (2.75, 0.90-8.41 estimated at age 16 years) and decreased odds with class III/IV diagnosed at an older age (0.23, 0.07-0.72 estimated at age 46 years), compared to class V. CONCLUSIONS The VTE incidence was similar among patients with LN classes III/IV and V, suggesting that VTE risk is not limited to class V-related nephrotic syndrome and that age may modulate LN class-specific VTE risk.
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Affiliation(s)
- Ian Cooley
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Keisha L. Gibson
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carolina Álvarez
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lauren N. Blazek
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrew Love
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Saira Z. Sheikh
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Chapel Hill Alliance Promoting Excellence in Lupus (CHAPEL) group of investigators
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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14
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Reynolds ML, Poulton CJ, Blazek LN, Hogan SL, Falk RJ, Derebail VK. Subfertility and early menopause in women with glomerular disease. Nephrol Dial Transplant 2021; 36:948-950. [PMID: 33508104 DOI: 10.1093/ndt/gfab005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/06/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Monica L Reynolds
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline J Poulton
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren N Blazek
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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15
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Jain K, Jawa P, Derebail VK, Falk RJ. Treatment Updates in Antineutrophil Cytoplasmic Autoantibodies (ANCA) Vasculitis. Kidney360 2021; 2:763-770. [PMID: 34095854 PMCID: PMC8177081 DOI: 10.34067/kid.0007142020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/03/2021] [Indexed: 02/04/2023]
Abstract
ANCA vasculitis is a small-vessel vasculitis (SVV) resulting in inflammation of small- and medium-sized blood vessels. Since the initial description of SVV, there have been tremendous advances in our understanding of its pathogenesis. Over the last decade, we have made significant progress in understanding the pathogenesis and improving the treatment and prognosis of patients with ANCA vasculitis. Patient and renal survival has improved, and treatment is moving toward individualizing care, minimizing severe adverse events, and preventing relapse. This review focuses on treatment updates in ANCA vasculitis, duration of therapy, and management of relapses. We also describe the existing treatment protocols used at our institution.
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Affiliation(s)
- Koyal Jain
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pankaj Jawa
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Vimal K. Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J. Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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16
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Falk RJ. Should PLEX Be Used for Severe AKI and/or Pulmonary Hemorrhage in ANCA-Associated Vasculitis (AAV)? COMMENTARY. Kidney360 2021; 2:782-783. [PMID: 35373062 PMCID: PMC8791349 DOI: 10.34067/kid.0000072021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 02/04/2023]
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Reynolds ML, Poulton CJ, Blazek LN, Hogan SL, Falk RJ, Derebail VK. Contraceptive Use and Elective Terminations in Women Enrolled in the Glomerular Disease Collaborative Network. Kidney Int Rep 2020; 5:1780-1783. [PMID: 33102971 PMCID: PMC7569683 DOI: 10.1016/j.ekir.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/09/2020] [Accepted: 07/07/2020] [Indexed: 12/05/2022] Open
Affiliation(s)
- Monica L Reynolds
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J Poulton
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren N Blazek
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Jones BE, Herrera CA, Agosto-Burgos C, Starmer J, Bass WA, Poulton CJ, Blazek L, Henderson CD, Hu Y, Hogan SL, Hu P, Xiao H, Wu EY, Chen DP, Jennette JC, Free ME, Falk RJ, Ciavatta DJ. ANCA autoantigen gene expression highlights neutrophil heterogeneity where expression in normal-density neutrophils correlates with ANCA-induced activation. Kidney Int 2020; 98:744-757. [PMID: 32446935 DOI: 10.1016/j.kint.2020.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/13/2019] [Revised: 03/20/2020] [Accepted: 04/02/2020] [Indexed: 12/27/2022]
Abstract
ANCA vasculitis is an autoimmune disease with increased expression of the autoantigen genes, myeloperoxidase (MPO) and proteinase 3 (PRTN3), but the origin and significance of expression is less distinct. To clarify this, we measured MPO and PRTN3 messenger RNA in monocytes, normal-density neutrophils, and in enriched leukocytes from peripheral blood mononuclear cells. Increased autoantigen gene expression was detected in normal-density neutrophils and enriched leukocytes from patients during active disease compared to healthy individuals, with the largest difference in enriched leukocytes. RNA-seq of enriched leukocytes comparing active-remission pairs identified a gene signature for low-density neutrophils. Cell sorting revealed low-density neutrophils contained mature and immature neutrophils depending on the presence or absence of CD10. Both populations contributed to autoantigen expression but the frequency of immature cells in low-density neutrophils did not correlate with low-density neutrophil MPO or PRTN3 expression. Low-density neutrophils were refractory to MPO-ANCA induced oxidative burst, suggesting an alternative role for low-density neutrophils in ANCA vasculitis pathogenesis. In contrast, normal-density neutrophils were activated by MPO-ANCA and monoclonal anti-PR3 antibody. Normal-density neutrophil activation correlated with MPO and PRTN3 mRNA. Increased autoantigen gene expression originating from the mature low-density and normal-density neutrophils suggests transcriptional dysregulation is a hallmark of ANCA vasculitis. Thus, the correlation between autoantigen gene expression and antibody-mediated normal-density neutrophil activation connects autoantigen gene expression with disease pathogenesis.
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Affiliation(s)
- Britta E Jones
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Carolina A Herrera
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christian Agosto-Burgos
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joshua Starmer
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William A Bass
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J Poulton
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Blazek
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Candace D Henderson
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Peiqi Hu
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hong Xiao
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eveline Y Wu
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dhruti P Chen
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J Charles Jennette
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Meghan E Free
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominic J Ciavatta
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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Affiliation(s)
- Mitchell Howard Rosner
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ronald J Falk
- Department of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
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Affiliation(s)
- Vimal K Derebail
- From the School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Ronald J Falk
- From the School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
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Hu P, Su H, Xiao H, Gou SJ, Herrera CA, Alba MA, Kakoki M, Falk RJ, Jennette JC. Kinin B1 Receptor Is Important in the Pathogenesis of Myeloperoxidase-Specific ANCA GN. J Am Soc Nephrol 2020; 31:297-307. [PMID: 31772138 PMCID: PMC7003314 DOI: 10.1681/asn.2019010032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 10/17/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Myeloperoxidase-specific ANCA (MPO-ANCA) are implicated in the pathogenesis of vasculitis and GN. Kinins play a major role during acute inflammation by regulating vasodilatation and vascular permeability and by modulating adhesion and migration of leukocytes. Kinin system activation occurs in patients with ANCA vasculitis. Previous studies in animal models of GN and sclerosing kidney diseases have demonstrated protective effects of bradykinin receptor 1 (B1R) blockade via interference with myeloid cell trafficking. METHODS To investigate the role of B1R in a murine model of MPO-ANCA GN, we evaluated effects of B1R genetic ablation and pharmacologic blockade. We used bone marrow chimeric mice to determine the role of B1R in bone marrow-derived cells (leukocytes) versus nonbone marrow-derived cells. We elucidated mechanisms of B1R effects using in vitro assays for MPO-ANCA-induced neutrophil activation, endothelial adherence, endothelial transmigration, and neutrophil adhesion molecule surface display. RESULTS B1R deficiency or blockade prevented or markedly reduced ANCA-induced glomerular crescents, necrosis, and leukocyte influx in mice. B1R was not required for in vitro MPO-ANCA-induced neutrophil activation. Leukocyte B1R deficiency, but not endothelial B1R deficiency, decreased glomerular neutrophil infiltration induced by MPO-ANCA in vivo. B1R enhanced ANCA-induced neutrophil endothelial adhesion and transmigration in vitro. ANCA-activated neutrophils exhibited changes in Mac-1 and LFA-1, important regulators of neutrophil endothelial adhesion and transmigration: ANCA-activated neutrophils increased surface expression of Mac-1 and increased shedding of LFA-1, whereas B1R blockade reduced these effects. CONCLUSIONS The leukocyte B1R plays a critical role in the pathogenesis of MPO-ANCA-induced GN in a mouse model by modulating neutrophil-endothelial interaction. B1R blockade may have potential as a therapy for ANCA GN and vasculitis.
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Affiliation(s)
- Peiqi Hu
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Xiao
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
| | - Shen-Ju Gou
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
| | - Carolina A Herrera
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Marco A Alba
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
| | - Masao Kakoki
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
| | - Ronald J Falk
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - J Charles Jennette
- Nephropathology Division, Department of Pathology and Laboratory Medicine and
- Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
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22
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Free ME, Stember KG, Hess JJ, McInnis EA, Lardinois O, Hogan SL, Hu Y, Mendoza C, Le AK, Guseman AJ, Pilkinton MA, Bortone DS, Cowens K, Sidney J, Karosiene E, Peters B, James E, Kwok WW, Vincent BG, Mallal SA, Jennette JC, Ciavatta DJ, Falk RJ. Restricted myeloperoxidase epitopes drive the adaptive immune response in MPO-ANCA vasculitis. J Autoimmun 2020; 106:102306. [PMID: 31383567 PMCID: PMC6930338 DOI: 10.1016/j.jaut.2019.102306] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatment of autoimmune diseases has relied on broad immunosuppression. Knowledge of specific interactions between human leukocyte antigen (HLA), the autoantigen, and effector immune cells, provides the foundation for antigen-specific therapies. These studies investigated the role of HLA, specific myeloperoxidase (MPO) epitopes, CD4+ T cells, and ANCA specificity in shaping the immune response in patients with anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis. METHODS HLA sequence-based typing identified enriched alleles in our patient population (HLA-DPB1*04:01 and HLA-DRB4*01:01), while in silico and in vitro binding studies confirmed binding between HLA and specific MPO epitopes. Class II tetramers with MPO peptides were utilized to detect autoreactive CD4+ T cells. TCR sequencing was performed to determine the clonality of T cell populations. Longitudinal peptide ELISAs assessed the temporal nature of anti-MPO447-461 antibodies. Solvent accessibility combined with chemical modification determined the buried regions of MPO. RESULTS We identified a restricted region of MPO that was recognized by both CD4+ T cells and ANCA. The autoreactive T cell population contained CD4+CD25intermediateCD45RO+ memory T cells and secreted IL-17A. T cell receptor (TCR) sequencing demonstrated that autoreactive CD4+ T cells had significantly less TCR diversity when compared to naïve and memory T cells, indicating clonal expansion. The anti-MPO447-461 autoantibody response was detectable at onset of disease in some patients and correlated with disease activity in others. This region of MPO that is targeted by both T cells and antibodies is not accessible to solvent or chemical modification, indicating these epitopes are buried. CONCLUSIONS These observations reveal interactions between restricted MPO epitopes and the adaptive immune system within ANCA vasculitis that may inform new antigen-specific therapies in autoimmune disease while providing insight into immunopathogenesis.
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Affiliation(s)
- Meghan E Free
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA.
| | - Katherine G Stember
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA; UNC Department of Pathology and Laboratory Medicine, CB #7525, Brinkhous-Bullitt Building, Chapel Hill, NC, 27599, USA
| | - Jacob J Hess
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Elizabeth A McInnis
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Olivier Lardinois
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Susan L Hogan
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Yichun Hu
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Carmen Mendoza
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Andrew K Le
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA
| | - Alex J Guseman
- UNC Department of Chemistry, CB #3290, Chapel Hill, NC, 27599, USA
| | - Mark A Pilkinton
- Vanderbilt Center for Translational Immunology and Infectious Diseases, A2200 MCN, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Dante S Bortone
- UNC Lineberger Comprehensive Cancer Center, CB #7295, Chapel Hill, NC, 27599, USA
| | - Kristen Cowens
- UNC Lineberger Comprehensive Cancer Center, CB #7295, Chapel Hill, NC, 27599, USA
| | - John Sidney
- La Jolla Institute for Allergy and Immunology, 9420 Athena Circle, La Jolla, CA, 92037, USA
| | - Edita Karosiene
- La Jolla Institute for Allergy and Immunology, 9420 Athena Circle, La Jolla, CA, 92037, USA
| | - Bjoern Peters
- La Jolla Institute for Allergy and Immunology, 9420 Athena Circle, La Jolla, CA, 92037, USA
| | - Eddie James
- Benaroya Research Institute, 1201 Ninth Avenue, Seattle, WA, 98101, USA
| | - William W Kwok
- Benaroya Research Institute, 1201 Ninth Avenue, Seattle, WA, 98101, USA
| | - Benjamin G Vincent
- UNC Lineberger Comprehensive Cancer Center, CB #7295, Chapel Hill, NC, 27599, USA; UNC Division of Hematology/Oncology, Department of Medicine, Physician's Office Building, 3rd Floor, 170 Manning Drive, CB #7305, Chapel Hill, NC, 27599, USA; UNC Curriculum in Bioinformatics and Computational Biology, CB #7264, Chapel Hill, NC, 27599, USA
| | - Simon A Mallal
- Vanderbilt Center for Translational Immunology and Infectious Diseases, A2200 MCN, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - J Charles Jennette
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA; UNC Department of Pathology and Laboratory Medicine, CB #7525, Brinkhous-Bullitt Building, Chapel Hill, NC, 27599, USA
| | - Dominic J Ciavatta
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA; UNC Department of Genetics and Molecular Biology, Coker Hall, 120 South Road, CB #3280, Chapel Hill, NC, 27599, USA
| | - Ronald J Falk
- UNC Kidney Center, Department of Medicine, 7024 Burnett-Womack, CB #7155, Chapel Hill, NC, 27599, USA; UNC Department of Pathology and Laboratory Medicine, CB #7525, Brinkhous-Bullitt Building, Chapel Hill, NC, 27599, USA
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Wu EY, McInnis EA, Boyer-Suavet S, Mendoza CE, Aybar LT, Kennedy KB, Poulton CJ, Henderson CD, Hu Y, Hogan SL, Hu P, Xiao H, Nachman PH, Jennette JC, Falk RJ, Bunch DO. Measuring Circulating Complement Activation Products in Myeloperoxidase- and Proteinase 3-Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2019; 71:1894-1903. [PMID: 31215772 DOI: 10.1002/art.41011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 06/12/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE There is accumulating evidence that complement activation is important in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) pathogenesis. This study was undertaken to investigate complement activation in AAV with myeloperoxidase (MPO) positivity and AAV with proteinase 3 (PR3) positivity after determining optimal methods for measuring activated complement factors in circulation. METHODS Participants included 98 patients with AAV (45 MPO-ANCA positive, 53 PR3-ANCA positive) and 35 healthy controls. Plasma was obtained from blood collected using EDTA tubes, with or without 100 μg/ml Futhan. Levels of Bb, C3a, C5a, soluble C5b-9 (sC5b-9), properdin, and C4d were measured by enzyme-linked immunosorbent assay. Group comparisons were made using Wilcoxon's 2-sample test. Paired data were analyzed using a matched pairs signed rank test. RESULTS Compared to healthy controls, certain complement analyte levels were high in patients with active AAV with MPO positivity, including C3a (P < 0.0001), C5a (P = 0.0004), and sC5b-9 (P = 0.0007). During remission, levels of Bb (P = 0.001), C3a (P < 0.0001), and sC5b-9 (P = 0.003) were higher. Compared to healthy controls, C3a (P < 0.0001), C5a (P = 0.002), sC5b-9 (P = 0.0001), and C4d (P = 0.005) levels were higher in patients with active AAV with PR3 positivity; levels of C3a (P < 0.0001) and C4d (P = 0.007) were also higher duriing remission. There were no significant differences in any complement analyte for either ANCA serotype between patients with active disease and those with disease in remission. Among patients with paired samples, sC5-9 levels were significantly lower during disease remission compared to active disease. C5a was significantly lower among patients with disease in long-term remission who were not receiving therapy. For Bb, C5a, and sC5b-9, median levels and individual values were considerably higher in control and patient samples processed without Futhan compared to those processed with Futhan. CONCLUSION Complement activation occurs in both MPO-positive AAV and PR3-positive AAV. The complement activation profile differs according to disease activity and possibly ANCA serotype. Futhan reduces in vitro complement activation and provides a more accurate measurement.
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Affiliation(s)
| | - Elizabeth A McInnis
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,Parexel International, Research Triangle Park, North Carolina
| | | | - Carmen E Mendoza
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,Parexel International, Research Triangle Park, North Carolina
| | - Lydia T Aybar
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,Parexel International, Research Triangle Park, North Carolina
| | - Kristin B Kennedy
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Caroline J Poulton
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Candace D Henderson
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Yichun Hu
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Susan L Hogan
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Peiqi Hu
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Hong Xiao
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | - Patrick H Nachman
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill.,University of Minnesota, Minneapolis
| | | | - Ronald J Falk
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill
| | - Donna O Bunch
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill
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24
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Mendoza CE, Brant EJ, McDermott ML, Froment A, Hu Y, Hogan SL, Jennette JC, Falk RJ, Nachman PH, Derebail VK, Bunch DO. Elevated Microparticle Tissue Factor Activity Differentiates Patients With Venous Thromboembolism in Anti-neutrophil Cytoplasmic Autoantibody Vasculitis. Kidney Int Rep 2019; 4:1617-1629. [PMID: 31891003 PMCID: PMC6933462 DOI: 10.1016/j.ekir.2019.07.006] [Citation(s) in RCA: 14] [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: 09/28/2018] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 01/12/2023] Open
Abstract
Introduction Venous thromboembolism (VTE) is a life-threatening complication of anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis whose mechanism remains incompletely elucidated. We tested the hypothesis that elevated microparticle tissue factor activity (MPTFa) or anti-plasminogen antibodies (anti-Plg) may identify patients at risk for VTE. Methods In this prospective study, patients were enrolled during active disease and followed longitudinally. Twelve patients who experienced a VTE (VTEpos) were compared with patients without VTE (VTEneg, n = 29) and healthy controls (HC, n = 70). MPTFa, anti-Plg, interleukin-6, high-sensitivity C-reactive protein (hs-CRP), D-dimer, serum creatinine, and serum albumin were assessed. Fisher’s exact tests and Wilcoxon tests compared categorical and continuous variables, respectively. Cox regression for time to VTE or last follow-up was performed. Results VTEpos patients had higher MPTFa (peak median = 14.0, interquartile range = 4.3–36.6) than HC (0, 0–3.5) and VTEneg patients (0, 0–1.4). In time-to-event analysis, MPTFa was associated with VTE when measured during both active disease (hazard ratio [HR]; 95% confidence interval [CI]: 1.04; 1.01–1.08) and remission (1.4; 1.11–1.77). Anti-Plg during remission was also associated with VTE (1.17; 1.03–1.33). Each g/dl decrease of serum albumin was associated with a 4-fold increase in VTE risk (4.4; 1.5–12.9). Adjusting for estimated glomerular filtration rate (eGFR), anti-Plg during remission remained significantly associated with VTE. Conclusion Elevated MPTFa and increased anti-Plg in remission are strong indicators of VTE independent of renal function. Association of anti-Plg during remission with VTE implies hypercoagulability even during disease quiescence. Hypoalbuminemia strongly portends VTE risk, which is a novel finding in ANCA vasculitis. A thrombotic signature would allow improved management of patients to minimize VTE risk and complications of anticoagulation.
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Affiliation(s)
- Carmen E Mendoza
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elizabeth J Brant
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew L McDermott
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anne Froment
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Susan L Hogan
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - J Charles Jennette
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Patrick H Nachman
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Vimal K Derebail
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Donna O'Dell Bunch
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
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25
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Hogan SL, Nachman PH, Poulton CJ, Hu Y, Blazek LN, Free ME, Jennette JC, Falk RJ. Understanding Long-term Remission Off Therapy in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Kidney Int Rep 2019; 4:551-560. [PMID: 30993230 PMCID: PMC6451087 DOI: 10.1016/j.ekir.2019.01.004] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/03/2018] [Accepted: 01/07/2019] [Indexed: 10/29/2022] Open
Abstract
Introduction In antineutrophil cytoplasmic antibody-associated (ANCA) vasculitis, relapse risk and long-term immunosuppressive therapy are problematic. Stopping immunotherapy has not been well described. Methods The Glomerular Disease Collaborative Network ANCA vasculitis inception cohort was evaluated. Patients who stopped all immunotherapy and those continuously on immunotherapy (≥2 years) were included. Time to first period off therapy was modeled with end-stage kidney disease and death as competing risks to understand influences of stopping therapy. Cause-specific hazard ratios (HRs) with 95% confidence intervals (CI) and P values are reported. Models controlled for age, sex, ANCA specificity, organ involvement, diagnosis era, and treatments (yes/no). Repeated events analysis was used to assess the time-dependent variable of time off treatment on recurrent relapse with HRs, 95% CIs, and P values are reported (same control variables without treatments). Results In 427 patients, 277 (65%) stopped therapy (median 20 months from initial induction); 14% for ≥2 different periods of time and 23% for periods ≥5 years. In multivariable models of time to discontinuation of treatment, women (HR 1.33; 95% CI 1.04-1.70; P = 0.024) and those treated with pulse methylprednisolone (HR 1.39; 95% CI 1.05-1.84; P = 0.020) were more likely to stop. The time-dependent variable of time off treatment was associated with fewer recurrent relapses (HR 0.51; 95% CI 0.41-0.63; P < 0.001). Conclusions Stopping immunotherapy was common. Women and those treated with methylprednisolone stop treatment more often, but underlying mechanisms are unknown. Stopping treatment was associated with fewer relapses, suggesting that even without guidelines there may be benefits without an untoward detriment of relapse.
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Affiliation(s)
- Susan L Hogan
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Patrick H Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caroline J Poulton
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Lauren N Blazek
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Meghan E Free
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - J Charles Jennette
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Hu P, Xiao H, Alba MA, Falk RJ, Jennette JC. 193. DEFICIENCY OF β2-INTEGRIN LFA-1 AMELIORATES MPO-ANCA INDUCED GLOMERULONEPHRITIS IN MICE. Rheumatology (Oxford) 2019. [DOI: 10.1093/rheumatology/kez061.007] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Peiqi Hu
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Hong Xiao
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Marco A Alba
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC USA
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27
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Lardinois OM, Deterding LJ, Hess JJ, Poulton CJ, Henderson CD, Jennette JC, Nachman PH, Falk RJ. Immunoglobulins G from patients with ANCA-associated vasculitis are atypically glycosylated in both the Fc and Fab regions and the relation to disease activity. PLoS One 2019; 14:e0213215. [PMID: 30818380 PMCID: PMC6395067 DOI: 10.1371/journal.pone.0213215] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/15/2019] [Indexed: 02/07/2023] Open
Abstract
Background Anti-neutrophil cytoplasmic autoantibodies (ANCA) directed against myeloperoxidase (MPO) and proteinase 3 (PR3) are pathogenic in ANCA-associated vasculitis (AAV). The respective role of IgG Fc and Fab glycosylation in mediating ANCA pathogenicity is incompletely understood. Herein we investigate in detail the changes in Fc and Fab glycosylation in MPO-ANCA and Pr3-ANCA and examine the association of glycosylation aberrancies with disease activity. Methodology Total IgG was isolated from serum or plasma of a cohort of 30 patients with AAV (14 MPO-ANCA; 16 PR3-ANCA), and 19 healthy control subjects. Anti-MPO specific IgG was affinity-purified from plasma of an additional cohort of 18 MPO-ANCA patients undergoing plasmapheresis. We used lectin binding assays, liquid chromatography, and mass spectrometry-based methods to analyze Fc and Fab glycosylation, the degree of sialylation of Fc and Fab fragments and to determine the exact localization of N-glycans on Fc and Fab fragments. Principal findings IgG1 Fc glycosylation of total IgG was significantly reduced in patients with active AAV compared to controls. Clinical remission was associated with complete glycan normalization for PR3-ANCA patients but not for MPO-ANCA patients. Fc-glycosylation of anti-MPO specific IgG was similar to total IgG purified from plasma. A major fraction of anti-MPO specific IgG harbor extensive glycosylation within the variable domain on the Fab portion. Conclusions/Significance Significant differences exist between MPO and PR3-ANCA regarding the changes in amounts and types of glycans on Fc fragment and the association with disease activity. These differences may contribute to significant clinical difference in the disease course observed between the two diseases.
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Affiliation(s)
- Olivier M. Lardinois
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Mass Spectrometry Research and Support Group, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, North Carolina, United States of America
- * E-mail:
| | - Leesa J. Deterding
- Mass Spectrometry Research and Support Group, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, North Carolina, United States of America
| | - Jacob J. Hess
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Caroline J. Poulton
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Candace D. Henderson
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - J. Charles Jennette
- Department of Pathology and Laboratory of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Ronald J. Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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28
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Mariani LH, Bomback AS, Canetta PA, Flessner MF, Helmuth M, Hladunewich MA, Hogan JJ, Kiryluk K, Nachman PH, Nast CC, Rheault MN, Rizk DV, Trachtman H, Wenderfer SE, Bowers C, Hill-Callahan P, Marasa M, Poulton CJ, Revell A, Vento S, Barisoni L, Cattran D, D'Agati V, Jennette JC, Klein JB, Laurin LP, Twombley K, Falk RJ, Gharavi AG, Gillespie BW, Gipson DS, Greenbaum LA, Holzman LB, Kretzler M, Robinson B, Smoyer WE, Guay-Woodford LM. CureGN Study Rationale, Design, and Methods: Establishing a Large Prospective Observational Study of Glomerular Disease. Am J Kidney Dis 2018; 73:218-229. [PMID: 30420158 PMCID: PMC6348011 DOI: 10.1053/j.ajkd.2018.07.020] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [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: 03/08/2018] [Accepted: 07/31/2018] [Indexed: 01/01/2023]
Abstract
RATIONALE & OBJECTIVES Glomerular diseases, including minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and immunoglobulin A (IgA) nephropathy, share clinical presentations, yet result from multiple biological mechanisms. Challenges to identifying underlying mechanisms, biomarkers, and new therapies include the rarity of each diagnosis and slow progression, often requiring decades to measure the effectiveness of interventions to prevent end-stage kidney disease (ESKD) or death. STUDY DESIGN Multicenter prospective cohort study. SETTING & PARTICIPANTS Cure Glomerulonephropathy (CureGN) will enroll 2,400 children and adults with minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy (including IgA vasculitis) and a first diagnostic kidney biopsy within 5 years. Patients with ESKD and those with secondary causes of glomerular disease are excluded. EXPOSURES Clinical data, including medical history, medications, family history, and patient-reported outcomes, are obtained, along with a digital archive of kidney biopsy images and blood and urine specimens at study visits aligned with clinical care 1 to 4 times per year. OUTCOMES Patients are followed up for changes in estimated glomerular filtration rate, disease activity, ESKD, and death and for nonrenal complications of disease and treatment, including infection, malignancy, cardiovascular, and thromboembolic events. ANALYTICAL APPROACH The study design supports multiple longitudinal analyses leveraging the diverse data domains of CureGN and its ancillary program. At 2,400 patients and an average of 2 years' initial follow-up, CureGN has 80% power to detect an HR of 1.4 to 1.9 for proteinuria remission and a mean difference of 2.1 to 3.0mL/min/1.73m2 in estimated glomerular filtration rate per year. LIMITATIONS Current follow-up can only detect large differences in ESKD and death outcomes. CONCLUSIONS Study infrastructure will support a broad range of scientific approaches to identify mechanistically distinct subgroups, identify accurate biomarkers of disease activity and progression, delineate disease-specific treatment targets, and inform future therapeutic trials. CureGN is expected to be among the largest prospective studies of children and adults with glomerular disease, with a broad goal to lessen disease burden and improve outcomes.
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Affiliation(s)
- Laura H Mariani
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI; Arbor Research Collaborative for Health, Ann Arbor, MI.
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Michael F Flessner
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | | | - Michelle A Hladunewich
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jonathan J Hogan
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Patrick H Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michelle N Rheault
- Division of Nephrology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, New York University Langone Medical Center, New York, NY
| | - Scott E Wenderfer
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Corinna Bowers
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | | | - Maddalena Marasa
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Caroline J Poulton
- Division of Nephrology and Hypertension, Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Adelaide Revell
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Suzanne Vento
- Division of Nephrology, Department of Pediatrics, New York University Langone Medical Center, New York, NY
| | | | - Dan Cattran
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vivette D'Agati
- Department of Pathology, Columbia University Medical Center, New York, NY
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC
| | - Jon B Klein
- Department of Medicine, The University of Louisville School of Medicine, and Robley Rex VA Medical Center, Louisville, KY
| | | | - Katherine Twombley
- Pediatric Nephrology, Medical University of South Carolina, Charleston, SC
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Kidney Center, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Ali G Gharavi
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Brenda W Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Lawrence B Holzman
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthias Kretzler
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Bruce Robinson
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI; Arbor Research Collaborative for Health, Ann Arbor, MI
| | - William E Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Lisa M Guay-Woodford
- Center for Translational Science, Children's National Health System, Washington, DC
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Abstract
Antineutrophil cytoplasmic antibodies (ANCAs) are autoantibodies specific for antigens located in the cytoplasmic granules of neutrophils and lysosomes of monocytes. ANCAs are associated with a spectrum of necrotizing vasculitis that includes granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. Pulmonary vasculitis and related extravascular inflammation and fibrosis are frequent components of ANCA vasculitis. In this review, we detail the factors that have been associated with the origin of the ANCA autoimmune response and summarize the most relevant clinical observations, in vitro evidence, and animal studies strongly indicating the pathogenic potential of ANCA. In addition, we describe the putative sequence of pathogenic mechanisms driven by ANCA-induced activation of neutrophils that result in small vessel necrotizing vasculitis and extravascular granulomatous necrotizing inflammation.
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Affiliation(s)
- Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- University of North Carolina Kidney Center, Chapel Hill, North Carolina.,UNC Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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30
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McCall AS, Bhave G, Pedchenko V, Hess J, Free M, Little DJ, Baker TP, Pendergraft WF, Falk RJ, Olson SW, Hudson BG. Inhibitory Anti-Peroxidasin Antibodies in Pulmonary-Renal Syndromes. J Am Soc Nephrol 2018; 29:2619-2625. [PMID: 30279272 PMCID: PMC6218858 DOI: 10.1681/asn.2018050519] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/04/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Goodpasture syndrome (GP) is a pulmonary-renal syndrome characterized by autoantibodies directed against the NC1 domains of collagen IV in the glomerular and alveolar basement membranes. Exposure of the cryptic epitope is thought to occur via disruption of sulfilimine crosslinks in the NC1 domain that are formed by peroxidasin-dependent production of hypobromous acid. Peroxidasin, a heme peroxidase, has significant structural overlap with myeloperoxidase (MPO), and MPO-ANCA is present both before and at GP diagnosis in some patients. We determined whether autoantibodies directed against peroxidasin are also detected in GP. METHODS We used ELISA and competitive binding assays to assess the presence and specificity of autoantibodies in serum from patients with GP and healthy controls. Peroxidasin activity was fluorometrically measured in the presence of partially purified IgG from patients or controls. Clinical disease severity was gauged by Birmingham Vasculitis Activity Score. RESULTS We detected anti-peroxidasin autoantibodies in the serum of patients with GP before and at clinical presentation. Enriched anti-peroxidasin antibodies inhibited peroxidasin-mediated hypobromous acid production in vitro. The anti-peroxidasin antibodies recognized peroxidasin but not soluble MPO. However, these antibodies did crossreact with MPO coated on the polystyrene plates used for ELISAs. Finally, peroxidasin-specific antibodies were also found in serum from patients with anti-MPO vasculitis and were associated with significantly more active clinical disease. CONCLUSIONS Anti-peroxidasin antibodies, which would previously have been mischaracterized, are associated with pulmonary-renal syndromes, both before and during active disease, and may be involved in disease activity and pathogenesis in some patients.
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Affiliation(s)
- A Scott McCall
- Department of Nephrology and Hypertension,
- Center for Matrix Biology
| | - Gautam Bhave
- Department of Nephrology and Hypertension
- Center for Matrix Biology
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee
| | - Vadim Pedchenko
- Department of Nephrology and Hypertension
- Center for Matrix Biology
| | - Jacob Hess
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Meghan Free
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Dustin J Little
- Department of Nephrology, Walter Reed Army Medical Center, Bethesda, Maryland
| | - Thomas P Baker
- Department of Nephrology, Walter Reed Army Medical Center, Bethesda, Maryland
| | - William F Pendergraft
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Ronald J Falk
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Stephen W Olson
- Department of Nephrology, Walter Reed Army Medical Center, Bethesda, Maryland
| | - Billy G Hudson
- Department of Nephrology and Hypertension,
- Center for Matrix Biology
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee
- Department of Cancer Biology
- Vanderbilt Ingram Cancer Center
- Department of Pathology, Microbiology, and Immunology, and
- Vanderbilt Institute of Chemical Biology, Vanderbilt University Medical Center, Nashville, Tennessee
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Falk RJ, Husseini JS, Fenves AZ, Rosales IA. Case 24-2018: A 71-Year-Old Man with Acute Renal Failure and Hematuria. N Engl J Med 2018; 379:568-578. [PMID: 30089061 DOI: 10.1056/nejmcpc1802829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ronald J Falk
- From the Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (R.J.F.); and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Jad S Husseini
- From the Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (R.J.F.); and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Andrew Z Fenves
- From the Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (R.J.F.); and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Ivy A Rosales
- From the Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (R.J.F.); and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Radiology (J.S.H.), Medicine (A.Z.F.), and Pathology (I.A.R.), Harvard Medical School - both in Boston
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Selewski DT, Ambruzs JM, Appel GB, Bomback AS, Matar RB, Cai Y, Cattran DC, Chishti AS, D'Agati VD, D'Alessandri-Silva CJ, Gbadegesin RA, Hogan JJ, Iragorri S, Jennette JC, Julian BA, Khalid M, Lafayette RA, Liapis H, Lugani F, Mansfield SA, Mason S, Nachman PH, Nast CC, Nester CM, Noone DG, Novak J, O'Shaughnessy MM, Reich HN, Rheault MN, Rizk DV, Saha MK, Sanghani NS, Sperati CJ, Sreedharan R, Srivastava T, Swiatecka-Urban A, Twombley K, Vasylyeva TL, Weaver DJ, Yin H, Zee J, Falk RJ, Gharavi AG, Gillespie BW, Gipson DS, Greenbaum LA, Holzman LB, Kretzler M, Robinson BM, Smoyer WE, Flessner M, Guay-Woodford LM, Kiryluk K. Clinical Characteristics and Treatment Patterns of Children and Adults With IgA Nephropathy or IgA Vasculitis: Findings From the CureGN Study. Kidney Int Rep 2018; 3:1373-1384. [PMID: 30450464 PMCID: PMC6224619 DOI: 10.1016/j.ekir.2018.07.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/27/2018] [Accepted: 07/30/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction The Cure Glomerulonephropathy Network (CureGN) is a 66-center longitudinal observational study of patients with biopsy-confirmed minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy (IgAN), including IgA vasculitis (IgAV). This study describes the clinical characteristics and treatment patterns in the IgA cohort, including comparisons between IgAN versus IgAV and adult versus pediatric patients. Methods Patients with a diagnostic kidney biopsy within 5 years of screening were eligible to join CureGN. This is a descriptive analysis of clinical and treatment data collected at the time of enrollment. Results A total of 667 patients (506 IgAN, 161 IgAV) constitute the IgAN/IgAV cohort (382 adults, 285 children). At biopsy, those with IgAV were younger (13.0 years vs. 29.6 years, P < 0.001), more frequently white (89.7% vs. 78.9%, P = 0.003), had a higher estimated glomerular filtration rate (103.5 vs. 70.6 ml/min per 1.73 m2, P < 0.001), and lower serum albumin (3.4 vs. 3.8 g/dl, P < 0.001) than those with IgAN. Adult and pediatric individuals with IgAV were more likely than those with IgAN to have been treated with immunosuppressive therapy at or prior to enrollment (79.5% vs. 54.0%, P < 0.001). Conclusion This report highlights clinical differences between IgAV and IgAN and between children and adults with these diagnoses. We identified differences in treatment with immunosuppressive therapies by disease type. This description of baseline characteristics will serve as a foundation for future CureGN studies.
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Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Correspondence: David T. Selewski, University of Michigan, 1540 East Hospital Drive, Room 12-250, Ann Arbor, Michigan 48109-4297, USA.
| | | | - Gerald B. Appel
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yi Cai
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Daniel C. Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aftab S. Chishti
- Division of Nephrology, Hypertension and Renal Transplantation, University of Kentucky, Lexington, Kentucky, USA
| | - Vivette D. D'Agati
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York, USA
| | | | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan J. Hogan
- Renal Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sandra Iragorri
- Division of Nephrology and Hypertension, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bruce A. Julian
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myda Khalid
- Division of Nephrology, Department of Pediatrics, JW Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard A. Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California, USA
| | | | | | | | - Sherene Mason
- Section of Pediatric Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia C. Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carla M. Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, USA
| | - Damien G. Noone
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Heather N. Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Rheault
- Division of Nephrology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Manish K. Saha
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neil S. Sanghani
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C. John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajasree Sreedharan
- Division of Nephrology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tarak Srivastava
- Children's Mercy Hospital and University of Missouri−Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Agnieszka Swiatecka-Urban
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Katherine Twombley
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tetyana L. Vasylyeva
- Department of Pediatrics, Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Donald J. Weaver
- Division of Nephrology and Hypertension, Levine Children's Hospital at Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Hong Yin
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ronald J. Falk
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ali G. Gharavi
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Brenda W. Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lawrence B. Holzman
- Department of Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania, USA
| | - Matthias Kretzler
- Department of Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, Michigan USA
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - William E. Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Michael Flessner
- Division of Kidney, Urology, and Hematology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa M. Guay-Woodford
- Center for Translational Science, Children’s National Health System, Washington, DC, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Krzysztof Kiryluk, Columbia University, Department of Medicine, Division of Nephrology, 1150 St Nicholas Avenue, Russ Berrie Pavilion #412, New York, New York 10032, USA.
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Sunderkötter CH, Zelger B, Chen KR, Requena L, Piette W, Carlson JA, Dutz J, Lamprecht P, Mahr A, Aberer E, Werth VP, Wetter DA, Kawana S, Luqmani R, Frances C, Jorizzo J, Watts JR, Metze D, Caproni M, Alpsoy E, Callen JP, Fiorentino D, Merkel PA, Falk RJ, Jennette JC. Nomenclature of Cutaneous Vasculitis: Dermatologic Addendum to the 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheumatol 2018; 70:171-184. [PMID: 29136340 DOI: 10.1002/art.40375] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 11/08/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To prepare a dermatologic addendum to the 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides (CHCC2012) to address vasculitides affecting the skin (D-CHCC). The goal was to standardize the names and definitions for cutaneous vasculitis. METHODS A nominal group technique with a facilitator was used to reach consensus on the D-CHCC nomenclature, using multiple face-to-face meetings, e-mail discussions, and teleconferences. RESULTS Standardized names, definitions, and descriptions were adopted for cutaneous components of systemic vasculitides (e.g., cutaneous IgA vasculitis as a component of systemic IgA vasculitis), skin-limited variants of systemic vasculitides (e.g., skin-limited IgA vasculitis, drug-induced skin-limited antineutrophil cytoplasmic antibody-associated vasculitis), and cutaneous single-organ vasculitides that have no systemic counterparts (e.g., nodular vasculitis). Cutaneous vasculitides that were not included in the CHCC2012 nomenclature were introduced. CONCLUSION Standardized names and definitions are a prerequisite for developing validated classification and diagnostic criteria for cutaneous vasculitis. Accurate identification of specifically defined variants of systemic and skin-limited vasculitides requires knowledgeable integration of data from clinical, laboratory, and pathologic studies. This proposed nomenclature of vasculitides affecting the skin, the D-CHCC, provides a standard framework both for clinicians and for investigators.
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Affiliation(s)
- Cord H Sunderkötter
- University Hospital of Halle, Halle (Saale), Germany, and University of Münster, Münster, Germany
| | | | - Ko-Ron Chen
- Meguro Chen Dermatology Clinic, Tokyo, Japan
| | | | - Warren Piette
- John H. Stroger Jr. Hospital of Cook County and Rush University Medical Center, Chicago, Illinois
| | | | - Jan Dutz
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Alfred Mahr
- Hospital Saint-Louis, University Paris 7, Paris, France
| | | | - Victoria P Werth
- University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | | | | | | | | | - Joseph Jorizzo
- Wake Forest School of Medicine, Winston Salem, North Carolina
| | - J Richard Watts
- Ipswich Hospital NHS Trust, Ipswich, UK, and Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | - Erkan Alpsoy
- Akdeniz University School of Medicine, Antalya, Turkey
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Rhee RL, Hogan SL, Poulton CJ, McGregor JAG, Landis JR, Falk RJ, Merkel PA. Trends in Long-Term Outcomes Among Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Renal Disease. Arthritis Rheumatol 2017; 68:1711-20. [PMID: 26814428 DOI: 10.1002/art.39614] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 01/21/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE It is still not clear how advances in the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have impacted long-term outcomes. We undertook this study to examine changes over 25 years in long-term clinical outcomes, including the impact of renal function at diagnosis (a potential marker of time to disease detection) and the duration of cyclophosphamide use in AAV patients with renal involvement. METHODS We included ANCA-positive patients with biopsy-proven AAV diagnosed between 1985 and 2009 who were followed up in the Glomerular Disease Collaborative Network inception cohort. Outcomes included the composite outcome of end-stage renal disease (ESRD) or death as well as relapse. Cox proportional hazards or competing risks regression models were adjusted for potential baseline confounders. RESULTS Data from 554 patients were included in the analysis. There was a decreasing 5-year risk of ESRD or death over time (P < 0.001 by log rank test for trend). After adjustment for baseline characteristics, the risk of relapse was similar across the time periods (P = 0.45 by test for trend). Serum creatinine level at baseline was the only significant predictor of an increased risk of ESRD or death (hazard ratio 1.11 per 1 mg/dl of serum creatinine [95% confidence interval 1.04-1.18], P = 0.002). CONCLUSION In patients with renal disease secondary to AAV, over 25 years the risk of ESRD or death has decreased but the risk of relapse has not changed. A higher serum creatinine level at diagnosis is associated with a higher risk of ESRD or death, suggesting that earlier disease detection is potentially an important measure to improve outcomes in AAV.
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Alba MA, Flores-Suárez LF, Henderson AG, Xiao H, Hu P, Nachman PH, Falk RJ, Charles Jennette J. Interstital lung disease in ANCA vasculitis. Autoimmun Rev 2017; 16:722-729. [PMID: 28479484 DOI: 10.1016/j.autrev.2017.05.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 04/07/2017] [Indexed: 02/03/2023]
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA) vasculitides are immune-mediated disorders that primarily affect small blood vessels of the airway and kidneys. Lung involvement, one of the hallmarks of microscopic polyangiitis and granulomatosis with polyangiitis, is associated with increased mortality and morbidity. In recent years, several retrospective series and case reports have described the association of interstitial lung disease (ILD) and ANCA vasculitis, particularly those positive for ANCA specific for myeloperoxidase. In the majority of these patients pulmonary fibrosis occurs concurrently or predates the diagnosis of ANCA vasculitis. More importantly, these studies have shown that ILD has an adverse impact on the long-term prognosis of ANCA vasculitis. This review focuses on the main clinical and radiologic features of pulmonary fibrosis associated with anti-neutrophil cytoplasmic antibodies. Major histopathology features, prognosis and therapeutic options are summarized.
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Affiliation(s)
- Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitis Clinic, Instituto Nacional de Enfermedades Respiratorias (INER), Mexico City, Mexico
| | - Ashley G Henderson
- Division of Pulmonary & Critical Care Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hong Xiao
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peiqi Hu
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Patrick H Nachman
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Merkel PA, Xie G, Monach PA, Ji X, Ciavatta DJ, Byun J, Pinder BD, Zhao A, Zhang J, Tadesse Y, Qian D, Weirauch M, Nair R, Tsoi A, Pagnoux C, Carette S, Chung S, Cuthbertson D, Davis JC, Dellaripa PF, Forbess L, Gewurz-Singer O, Hoffman GS, Khalidi N, Koening C, Langford CA, Mahr AD, McAlear C, Moreland L, Seo EP, Specks U, Spiera RF, Sreih A, St Clair EW, Stone JH, Ytterberg SR, Elder JT, Qu J, Ochi T, Hirano N, Edberg JC, Falk RJ, Amos CI, Siminovitch KA. Identification of Functional and Expression Polymorphisms Associated With Risk for Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis. Arthritis Rheumatol 2017; 69:1054-1066. [PMID: 28029757 PMCID: PMC5434905 DOI: 10.1002/art.40034] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/20/2016] [Indexed: 01/28/2023]
Abstract
Objective To identify risk alleles relevant to the causal and biologic mechanisms of antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV). Methods A genome‐wide association study and subsequent replication study were conducted in a total cohort of 1,986 cases of AAV (patients with granulomatosis with polyangiitis [Wegener's] [GPA] or microscopic polyangiitis [MPA]) and 4,723 healthy controls. Meta‐analysis of these data sets and functional annotation of identified risk loci were performed, and candidate disease variants with unknown functional effects were investigated for their impact on gene expression and/or protein function. Results Among the genome‐wide significant associations identified, the largest effect on risk of AAV came from the single‐nucleotide polymorphism variants rs141530233 and rs1042169 at the HLA–DPB1 locus (odds ratio [OR] 2.99 and OR 2.82, respectively) which, together with a third variant, rs386699872, constitute a triallelic risk haplotype associated with reduced expression of the HLA–DPB1 gene and HLA–DP protein in B cells and monocytes and with increased frequency of complementary proteinase 3 (PR3)–reactive T cells relative to that in carriers of the protective haplotype. Significant associations were also observed at the SERPINA1 and PTPN22 loci, the peak signals arising from functionally relevant missense variants, and at PRTN3, in which the top‐scoring variant correlated with increased PRTN3 expression in neutrophils. Effects of individual loci on AAV risk differed between patients with GPA and those with MPA or between patients with PR3‐ANCAs and those with myeloperoxidase‐ANCAs, but the collective population attributable fraction for these variants was substantive, at 77%. Conclusion This study reveals the association of susceptibility to GPA and MPA with functional gene variants that explain much of the genetic etiology of AAV, could influence and possibly be predictors of the clinical presentation, and appear to alter immune cell proteins and responses likely to be key factors in the pathogenesis of AAV.
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Affiliation(s)
| | - Gang Xie
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - Paul A Monach
- Boston University and VA Boston Healthcare System, Boston, Massachusetts
| | - Xuemei Ji
- Dartmouth College, Lebanon, New Hampshire
| | | | | | - Benjamin D Pinder
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - Ai Zhao
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - Jinyi Zhang
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, Toronto General Research Institute and University of Toronto, Toronto, Ontario, Canada
| | - Yohannes Tadesse
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - David Qian
- Dartmouth College, Lebanon, New Hampshire
| | | | | | | | - Christian Pagnoux
- Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Simon Carette
- Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - James T Elder
- University of Michigan and Ann Arbor VA Hospital, Ann Arbor, Michigan
| | - Jia Qu
- Wenzhou Medical University, Wenzhou, China
| | - Toshiki Ochi
- University of Toronto and Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Naoto Hirano
- University of Toronto and Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | | | | | - Katherine A Siminovitch
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, Toronto General Research Institute and University of Toronto, Toronto, Ontario, Canada
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O’Shaughnessy MM, Hogan SL, Poulton CJ, Falk RJ, Singh HK, Nickeleit V, Jennette JC. Temporal and Demographic Trends in Glomerular Disease Epidemiology in the Southeastern United States, 1986-2015. Clin J Am Soc Nephrol 2017; 12:614-623. [PMID: 28325866 PMCID: PMC5383393 DOI: 10.2215/cjn.10871016] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/21/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Large-scale, contemporary studies exploring glomerular disease epidemiology in the United States are lacking. We aimed to determine 30-year temporal and demographic trends in renal biopsy glomerular disease diagnosis frequencies in the southeastern United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this cross-sectional, observational study, we identified all patients with a native kidney biopsy specimen showing one of 18 widely recognized glomerular disease diagnoses referred to the University of North Carolina Chapel Hill Division of Nephropathology between 1986 and 2015. Biopsy era (1986-1995, 1996-2005, and 2006-2015) and demographics (age, sex, and race) were our primary and secondary predictors, respectively, and the relative frequency of each glomerular disease diagnosis was our primary outcome. RESULTS Among 21,374 patients (mean age =48.3±18.3 years old; 50.8% men; 56.8% white; 38.3% black; 2.8% Latino; 1.4% Asian; 0.8% other), the frequency of diabetic glomerulosclerosis in renal biopsy specimens increased dramatically over the three decades (5.5%, 11.4%, and 19.1% of diagnoses, respectively; P for trend <0.001). The frequency of FSGS initially increased but then declined (22.6%, 27.2%, and 24.7%, respectively; P for trend =0.64). The frequencies of other common glomerular disease subtypes remained stable (IgA nephropathy and ANCA/pauci-immune GN) or declined (minimal change disease, membranous nephropathy, membranoproliferative GN, and lupus nephritis). These temporal trends were largely preserved within all demographic subgroups, although cross-sectional frequency distributions differed according to age, sex, and race. CONCLUSIONS We identified significant changes in relative renal biopsy frequencies of many glomerular disease subtypes over three decades. Temporal trends were consistently observed within all major demographic groups, although relative predominance of individual glomerular disease subtypes differed according to patient age, sex, and race. We propose that exploration of behavioral and environmental exposures that likely underlie these findings should be the focus of future hypothesis-driven research.
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MESH Headings
- Adolescent
- Adult
- Aged
- Child
- Child, Preschool
- Cross-Sectional Studies
- Diabetic Nephropathies/epidemiology
- Diabetic Nephropathies/pathology
- Female
- Glomerulonephritis/epidemiology
- Glomerulonephritis/pathology
- Glomerulonephritis, IGA/epidemiology
- Glomerulonephritis, IGA/pathology
- Glomerulonephritis, Membranoproliferative/epidemiology
- Glomerulonephritis, Membranoproliferative/pathology
- Glomerulonephritis, Membranous/epidemiology
- Glomerulonephritis, Membranous/pathology
- Glomerulosclerosis, Focal Segmental/epidemiology
- Glomerulosclerosis, Focal Segmental/pathology
- Humans
- Incidence
- Infant
- Kidney Glomerulus/pathology
- Lupus Nephritis/epidemiology
- Lupus Nephritis/pathology
- Male
- Middle Aged
- Nephrosis, Lipoid/epidemiology
- Nephrosis, Lipoid/pathology
- Southeastern United States/epidemiology
- Time Factors
- Young Adult
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Affiliation(s)
- Michelle M. O’Shaughnessy
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, and
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Susan L. Hogan
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
| | - Caroline J. Poulton
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
| | - Ronald J. Falk
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, and
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
| | - Harsharan K. Singh
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, and
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
| | - Volker Nickeleit
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, and
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
| | - J. Charles Jennette
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, and
- Division of Nephrology, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
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Brown LC, Jobson MA, Payan Schober F, Chang EH, Falk RJ, Nachman PH, Pendergraft WF. The Evolving Role of Rituximab in Adult Minimal Change Glomerulopathy. Am J Nephrol 2017; 45:365-372. [PMID: 28315862 DOI: 10.1159/000464475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Minimal-change glomerulopathy is defined histologically by the presence of normal glomeruli on light microscopy and diffuse podocyte effacement on electron microscopy. Although effective in children, corticosteroid treatment in adults is more variable and time to response can be prolonged. Data to support rituximab use in adults with corticosteroid-dependent or resistant minimal-change glomerulopathy are limited. Here, we describe the clinical course of adults with corticosteroid-dependent or -resistant minimal-change glomerulopathy who received rituximab. METHODS Demographic and clinical data were collected and analyzed from all adult patients with native kidney, biopsy-proven, minimal-change glomerulopathy who were administered rituximab between 2009 and 2014 and cared for at the UNC Kidney Center. RESULTS Ten patients with corticosteroid-resistant (n = 5) or corticosteroid-dependent (n = 5) idiopathic minimal-change glomerulopathy were treated with rituximab between 2009 and 2014. Rituximab treatment induced remission in all 10 patients with a median time to remission of 2 months. The median time from rituximab to corticosteroid discontinuation was 3.5 months. The median remission time was 29 months and follow-up time was 39.5 months. No serious adverse events attributable to rituximab were observed. CONCLUSION Rituximab induced remission in all patients with corticosteroid-dependent or -resistant minimal-change glomerulopathy, and may hold great therapeutic potential with good efficacy and minimal toxicity. Mounting evidence implies that a well-conducted randomized controlled clinical trial using rituximab in adults with minimal-change glomerulopathy in both corticosteroid-resistant and corticosteroid-dependent patients is warranted.
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Affiliation(s)
- Landon C Brown
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Alba MA, Hong X, Hu P, Falk RJ, Jennette C. P2_23 Induction of Cutaneous and Ear, Nose and Throat (ENT) Manifestations in a Mouse Model of MPO-ANCA Granulomatosis with Polyangiitis. Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex131] [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: 11/14/2022] Open
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Hu P, Xiao H, Alba MA, Falk RJ, Jennette JC. WS6_1 Anti-MPO antibodies cause granulomatosis in mice: an animal model of GPA. Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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42
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Payan Schober F, Jobson MA, Poulton CJ, Singh HK, Nickeleit V, Falk RJ, Jennette JC, Nachman PH, Pendergraft Iii WF. Clinical Features and Outcomes of a Racially Diverse Population with Fibrillary Glomerulonephritis. Am J Nephrol 2017; 45:248-256. [PMID: 28161700 DOI: 10.1159/000455390] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/10/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fibrillary glomerulonephritis is characterized by randomly arranged fibrils, approximately 20 nm in diameter by electron microscopy. Patients present with proteinuria, hematuria and kidney insufficiency, and about half of the reported patients progress to end-stage kidney disease within 4 years. The dependence of patient characteristics and outcomes on race has not been explored. In this study, we describe a cohort of patients with fibrillary glomerulonephritis and compare their clinical characteristics and outcomes with those of patients previously described. METHODS The University of North Carolina (UNC) Nephropathology Database was used to retrospectively identify patients diagnosed with fibrillary glomerulonephritis between 1985 and 2015. Of these patients, those treated at UNC were selected. Their demographic and clinical characteristics - including signs and symptoms, comorbidities, laboratory values, treatments and outcomes - were compared with those of patients described earlier. RESULTS Among the 287 patients identified, 42 were treated at the UNC Kidney Center. When compared to earlier cohorts, a higher frequency of black race, hepatitis C virus (HCV) infection and use of hemodialysis were noted in both black and HCV-positive patients. Autoimmune diseases, infections and malignancies were frequently observed, present in over half of all cases. CONCLUSION According to this study, fibrillary glomerulonephritis represents a secondary glomerular disease process (associated with autoimmune disease, infection or malignancy) in many cases and hence screening is essential. As the screening for comorbidities increased over time, more underlying causes were identified. We noted a high frequency of HCV among black patients, suggesting a possible causative association. Treatment of underlying disease is essential for patients for the best outcome.
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Affiliation(s)
- Fernanda Payan Schober
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
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Jones BE, Yang J, Muthigi A, Hogan SL, Hu Y, Starmer J, Henderson CD, Poulton CJ, Brant EJ, Pendergraft WF, Jennette JC, Falk RJ, Ciavatta DJ. Gene-Specific DNA Methylation Changes Predict Remission in Patients with ANCA-Associated Vasculitis. J Am Soc Nephrol 2016; 28:1175-1187. [PMID: 27821628 DOI: 10.1681/asn.2016050548] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [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: 05/16/2016] [Accepted: 09/19/2016] [Indexed: 12/14/2022] Open
Abstract
ANCA-associated vasculitis is an autoimmune condition characterized by vascular inflammation and organ damage. Pharmacologically induced remission of this condition is complicated by relapses. Potential triggers of relapse are immunologic challenges and environmental insults, both of which associate with changes in epigenetic silencing modifications. Altered histone modifications implicated in gene silencing associate with aberrant autoantigen expression. To establish a link between DNA methylation, a model epigenetic gene silencing modification, and autoantigen gene expression and disease status in ANCA-associated vasculitis, we measured gene-specific DNA methylation of the autoantigen genes myeloperoxidase (MPO) and proteinase 3 (PRTN3) in leukocytes of patients with ANCA-associated vasculitis observed longitudinally (n=82) and of healthy controls (n=32). Patients with active disease demonstrated hypomethylation of MPO and PRTN3 and increased expression of the autoantigens; in remission, DNA methylation generally increased. Longitudinal analysis revealed that patients with ANCA-associated vasculitis could be divided into two groups, on the basis of whether DNA methylation increased or decreased from active disease to remission. In patients with increased DNA methylation, MPO and PRTN3 expression correlated with DNA methylation. Kaplan-Meier estimate of relapse revealed patients with increased DNA methylation at the PRTN3 promoter had a significantly greater probability of a relapse-free period (P<0.001), independent of ANCA serotype. Patients with decreased DNA methylation at the PRTN3 promoter had a greater risk of relapse (hazard ratio, 4.55; 95% confidence interval, 2.09 to 9.91). Thus, changes in the DNA methylation status of the PRTN3 promoter may predict the likelihood of stable remission and explain autoantigen gene regulation.
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Affiliation(s)
- Britta E Jones
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension.,Department of Pathology and Laboratory Medicine, and
| | - Jiajin Yang
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Akhil Muthigi
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Susan L Hogan
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Yichun Hu
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Joshua Starmer
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Candace D Henderson
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Caroline J Poulton
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Elizabeth J Brant
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | | | - J Charles Jennette
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension.,Department of Pathology and Laboratory Medicine, and
| | - Ronald J Falk
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension
| | - Dominic J Ciavatta
- Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, .,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Laurin LP, Gasim AM, Derebail VK, McGregor JG, Kidd JM, Hogan SL, Poulton CJ, Detwiler RK, Jennette JC, Falk RJ, Nachman PH. Renal Survival in Patients with Collapsing Compared with Not Otherwise Specified FSGS. Clin J Am Soc Nephrol 2016; 11:1752-1759. [PMID: 27445167 PMCID: PMC5053801 DOI: 10.2215/cjn.13091215] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 06/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Idiopathic collapsing FSGS has historically been associated with poor renal outcomes. Minimal clinical data exist on the efficacy of immunosuppressive therapy. Our study sought to provide a comprehensive description of renal survival in patients with collapsing and not otherwise specified FSGS after controlling for factors affecting renal prognosis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective analysis of an inception cohort study of patients diagnosed between 1989 and 2012. All potential patients with collapsing FSGS fulfilling the inclusion criteria were identified and compared with patients with not otherwise specified FSGS (approximately 1:2 ratio) on the basis of biopsy report and record availability. Time to ESRD was analyzed using Cox proportional hazards models. RESULTS In total, 187 patients were studied (61 collapsing and 126 not otherwise specified), with a mean follow-up of 96 months. At baseline, patients with collapsing FSGS had higher median proteinuria (12.2 [5.6-14.8] versus 4.4 [2.3-8.1] g/d, respectively; P<0.001), lower median albuminemia (2.4 [1.9-3.0] versus 2.9 [1.8-3.7] g/dl, respectively; P=0.12), and lower median eGFR (48 [26-73] versus 60 [42-92] ml/min per 1.73 m2, respectively; P=0.01) than patients with not otherwise specified FSGS. The proportion of patients with remission of proteinuria was similar in patients with collapsing FSGS and patients with not otherwise specified FSGS (65.7% [23 of 35] versus 63.2% [72 of 114], respectively; P=0.84). The overall renal outcome (ESRD defined as eGFR<15 ml/min per 1.73 m2, dialysis, or transplantation) of patients with collapsing FSGS was not poorer than that of patients with not otherwise specified FSGS in multivariate analyses after adjusting for baseline characteristics and immunotherapy (hazard ratio, 1.78; 95% confidence interval, 0.92 to 3.45). CONCLUSIONS Compared with not otherwise specified FSGS, idiopathic collapsing FSGS presented with more severe nephrotic syndrome and lower eGFR but had a similar renal survival after controlling for exposure to immunosuppressive treatment. These results highlight the importance of early diagnosis and institution of immunosuppressive therapy in patients with collapsing FSGS.
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Affiliation(s)
- Louis-Philippe Laurin
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Adil M. Gasim
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Vimal K. Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
| | - JulieAnne G. McGregor
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
- Triangle Integrative Medicine Associates, Chapel Hill, North Carolina; and
| | - Jason M. Kidd
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia
| | - Susan L. Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
| | - Caroline J. Poulton
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
| | - Randal K. Detwiler
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
| | - Patrick H. Nachman
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension and
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Affiliation(s)
- Carla M. Nester
- Stead Family Department of Pediatrics and Department of Internal Medicine, The University of Iowa, Iowa City, Iowa; and
| | - Ronald J. Falk
- Division of Nephrology, Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina
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46
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Yang J, Ge H, Poulton CJ, Hogan SL, Hu Y, Jones BE, Henderson CD, McInnis EA, Pendergraft WF, Jennette JC, Falk RJ, Ciavatta DJ. Histone modification signature at myeloperoxidase and proteinase 3 in patients with anti-neutrophil cytoplasmic autoantibody-associated vasculitis. Clin Epigenetics 2016; 8:85. [PMID: 27752292 PMCID: PMC5057507 DOI: 10.1186/s13148-016-0251-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 04/06/2016] [Accepted: 08/02/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is a systemic autoimmune disease characterized by destructive vascular inflammation. Two prominent ANCA autoantigens are myeloperoxidase (MPO) and proteinase 3 (PR3), and transcription of MPO and PRTN3, the genes encoding the autoantigens, is associated with disease activity. We investigated whether patients with AAV have alterations in histone modifications, particularly those associated with transcriptional activation, at MPO and PRTN3. RESULTS We identified a network of genes regulating histone modifications that were differentially expressed in AAV patients compared to healthy controls. We focused on four genes (EHMT1 and EHMT2, ING4, and MSL1) and found their expression correlated with expression of MPO and PRTN3. Methylation of histone H3K9, catalyzed by EHMT1 and EHMT2 and associated with gene silencing, was most depleted at MPO and PRTN3 in patients with active disease and the highest MPO and PRTN3 expression. Acetylation of histone H4K16, modified by complexes containing ING4 and MSL1 and associated with gene activation, was most enriched at MPO and PRTN3 in patients with active disease and the highest MPO and PRTN3 expression. Methylation at H3K4, a mark of transcriptional activation, was enriched at MPO and PRTN3 in patients and healthy controls. CONCLUSIONS MPO and PRTN3 in neutrophils of AAV patients with active disease have a distinct pattern of histone modifications, which implicates epigenetic mechanisms in regulating expression of autoantigen genes and suggests that the epigenome may be involved in AAV pathogenesis.
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Affiliation(s)
- Jiajin Yang
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Heng Ge
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA.,Department of Nephrology, The Second Affiliated Hospital, School of Medicine, Xian Jiaotong University, 157 Xiwu Road, Xian, Shaanxi 710004 People's Republic of China
| | - Caroline J Poulton
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Susan L Hogan
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Yichun Hu
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Britta E Jones
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Candace D Henderson
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Elizabeth A McInnis
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - William F Pendergraft
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - J Charles Jennette
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Ronald J Falk
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Dominic J Ciavatta
- UNC Kidney Center, Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC USA.,Department of Genetics, University of North Carolina at Chapel Hill, 120 Mason Farm Road, Campus Box 7264, Chapel Hill, NC 27599 USA
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Flythe JE, Katsanos SL, Hu Y, Kshirsagar AV, Falk RJ, Moore CR. Predictors of 30-Day Hospital Readmission among Maintenance Hemodialysis Patients: A Hospital's Perspective. Clin J Am Soc Nephrol 2016; 11:1005-1014. [PMID: 27151893 PMCID: PMC4891757 DOI: 10.2215/cjn.11611115] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/23/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Over 35% of patients on maintenance dialysis are readmitted to the hospital within 30 days of hospital discharge. Outpatient dialysis facilities often assume responsibility for readmission prevention. Hospital care and discharge practices may increase readmission risk. We undertook this study to elucidate risk factors identifiable from hospital-derived data for 30-day readmission among patients on hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were taken from patients on maintenance hemodialysis discharged from University of North Carolina Hospitals between May of 2008 and June of 2013 who received in-patient hemodialysis during their index hospitalizations. Multivariable logistic regression models with 30-day readmission as the dependent outcome were used to identify readmission risk factors. Models considered variables available at hospital admission and discharge separately. RESULTS Among 349 patients, 112 (32.1%) had a 30-day hospital readmission. The discharge (versus admission) model was more predictive of 30-day readmission. In the discharge model, malignancy comorbid condition (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.04 to 3.11), three or more hospitalizations in the prior year (OR, 1.97; 95% CI, 1.06 to 3.64), ≥10 outpatient medications at hospital admission (OR, 1.69; 95% CI, 1.00 to 2.88), catheter vascular access (OR, 1.82; 95% CI, 1.01 to 3.65), outpatient dialysis at a nonuniversity-affiliated dialysis facility (OR, 3.59; 95% CI, 2.03 to 6.36), intradialytic hypotension (OR, 3.10; 95% CI, 1.45 to 6.61), weekend discharge day (OR, 1.82; 95% CI, 1.01 to 3.31), and serum albumin <3.3 g/dl (OR, 4.28; 95% CI, 2.37 to 7.73) were associated with higher readmission odds. A decrease in prescribed medications from admission to discharge (OR, 0.20; 95% CI, 0.08 to 0.51) was associated with lower readmission odds. Findings were robust across different model-building approaches. CONCLUSIONS Models containing discharge day data had greater predictive capacity of 30-day readmission than admission models. Identified modifiable readmission risk factors suggest that improved medication education and improved transitions from hospital to community may potentially reduce readmissions. Studies evaluating targeted transition programs among patients on dialysis are needed.
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Affiliation(s)
- Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Suzanne L. Katsanos
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Abhijit V. Kshirsagar
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Carlton R. Moore
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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Affiliation(s)
- Meghan E Free
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
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Linde PG, Archdeacon P, Breyer MD, Ibrahim T, Inrig JK, Kewalramani R, Lee CC, Neuland CY, Roy-Chaudhury P, Sloand JA, Meyer R, Smith KA, Snook J, West M, Falk RJ. Overcoming Barriers in Kidney Health-Forging a Platform for Innovation. J Am Soc Nephrol 2016; 27:1902-10. [PMID: 27127187 DOI: 10.1681/asn.2015090976] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 11/03/2022] Open
Abstract
Innovation in kidney diseases is not commensurate with the effect of these diseases on human health and mortality or innovation in other key therapeutic areas. A primary cause of the dearth in innovation is that kidney diseases disproportionately affect a demographic that is largely disenfranchised, lacking sufficient advocacy, public attention, and funding. A secondary and likely consequent cause is that the existing infrastructure supporting nephrology research pales in comparison with those for other internal medicine specialties, especially cardiology and oncology. Citing such inequities, however, is not enough. Changing the status quo will require a coordinated effort to identify and redress the existing deficits. Specifically, these deficits relate to the need to further develop and improve the following: understanding of the disease mechanisms and pathophysiology, patient engagement and activism, clinical trial infrastructure, and investigational clinical trial designs as well as coordinated efforts among critical stakeholders. This paper identifies potential solutions to these barriers, some of which are already underway through the Kidney Health Initiative. The Kidney Health Initiative is unique and will serve as a current and future platform from which to overcome these barriers to innovation in nephrology.
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Affiliation(s)
- Peter G Linde
- AbbVie, Inc., Global Pharmaceutical Research and Development, North Chicago, Illinois;
| | | | - Matthew D Breyer
- Eli Lilly, Biotechnology Discovery Research, Indianapolis, Indiana
| | - Tod Ibrahim
- American Society of Nephrology, Washington, DC
| | - Jula K Inrig
- Quintiles Therapeutic Science and Strategy Unit, San Diego, California
| | | | | | - Carolyn Y Neuland
- Center for Devices and Radiological Health, Office of Device Evaluation, Division of Reproductive, Gastro-Renal and Urological Devices, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | - Kimberly A Smith
- Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | | | | | - Ronald J Falk
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Lee T, Derebail VK, Kshirsagar AV, Chung Y, Fine JP, Mahoney S, Poulton CJ, Lionaki S, Hogan SL, Falk RJ, Cattran DC, Hladunewich M, Reich HN, Nachman PH. Patients with primary membranous nephropathy are at high risk of cardiovascular events. Kidney Int 2016; 89:1111-1118. [PMID: 26924046 DOI: 10.1016/j.kint.2015.12.041] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [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: 09/30/2014] [Revised: 11/18/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
Abstract
Here we conducted a retrospective study to examine the risk of cardiovascular events (CVEs) relative to that of end-stage renal disease (ESRD) in patients with primary membranous nephropathy, in a discovery cohort of 404 patients. The cumulative incidence of CVEs was estimated in the setting of the competing risk of ESRD with risk factors for CVEs assessed by multivariable survival analysis. The observed cumulative incidences of CVEs were 4.4%, 5.4%, 8.2%, and 8.8% at 1, 2, 3, and 5 years respectively in the primary membranous nephropathy cohort. In the first 2 years after diagnosis, the risk for CVEs was similar to that of ESRD in the entire cohort, but exceeded it among patients with preserved renal function. Accounting for traditional risk factors and renal function, the severity of nephrosis at the time of the event (hazard ratio 2.1, 95% confidence interval 1.1 to 4.3) was a significant independent risk factor of CVEs. The incidence and risk factors of CVEs were affirmed in an external validation cohort of 557 patients with primary membranous nephropathy. Thus early in the course of disease, patients with primary membranous nephropathy have an increased risk of CVEs commensurate to, or exceeding that of ESRD. Hence, reduction of CVEs should be considered as a therapeutic outcome measure and focus of intervention in primary membranous nephropathy.
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Affiliation(s)
- Taewoo Lee
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Korea
| | - Vimal K Derebail
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Abhijit V Kshirsagar
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yunro Chung
- Biostatistics Department, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jason P Fine
- Biostatistics Department, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shannon Mahoney
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J Poulton
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Susan L Hogan
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel C Cattran
- Division of Nephrology, Department of Medicine, University of Toronto, and Toronto Glomerulonephritis Registry, University Health Network, Toronto, Ontario, Canada
| | - Michelle Hladunewich
- Division of Nephrology, Department of Medicine, University of Toronto, and Toronto Glomerulonephritis Registry, University Health Network, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University of Toronto, and Toronto Glomerulonephritis Registry, University Health Network, Toronto, Ontario, Canada
| | - Patrick H Nachman
- UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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