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Reynolds ML, Loehr LR, Hogan SL, Hu Y, Isasi CR, Cordero C, Ricardo AC, Lash JP, Derebail VK. Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos. Womens Health (Lond) 2024; 20:17455057231224544. [PMID: 38279825 PMCID: PMC10822089 DOI: 10.1177/17455057231224544] [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] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 12/01/2023] [Accepted: 12/12/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear. OBJECTIVES/DESIGN Using baseline (2008-2011) and second study visit (2014-2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18-45 years). METHODS Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes. RESULTS Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42-2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52-3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61-2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63-7.02) but not statistically significance. CONCLUSION The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.
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Affiliation(s)
- Monica L Reynolds
- Division of Nephrology and Hypertension, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura R Loehr
- Department of Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- Division of Nephrology and Hypertension, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yichun Hu
- Division of Nephrology and Hypertension, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carmen R Isasi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christina Cordero
- Department of Epidemiology, University of Miami, Coral Gables, FL, USA
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Vimal K Derebail
- Division of Nephrology and Hypertension, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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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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Strasma A, Reyes ÁM, Aragón A, López I, Park LP, Hogan SL, Thielman N, Wyatt C, González-Quiroz M. Kidney disease characteristics, prevalence, and risk factors in León, Nicaragua: a population-based study. BMC Nephrol 2023; 24:335. [PMID: 37953252 PMCID: PMC10641961 DOI: 10.1186/s12882-023-03381-1] [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: 07/25/2023] [Accepted: 10/28/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND CKD of unknown etiology (CKDu) disproportionately affects young people in Central America who lack traditional CKD risk factors (diabetes and hypertension) and has instead been variably linked to heat stress, occupational and environmental exposures, nephrotoxic medications, and/or genetic susceptibility. This study aimed to estimate the prevalence of CKD and identify risk factors for traditional CKD and CKDu in Nicaragua. METHODS Surveys and assessment for CKD markers in urine and serum were performed in 15-59 year olds in households of the León municipality of Nicaragua. The survey included questions on demographics, health behaviors, occupation, and medical history. Participants with CKD were subdivided into traditional CKD and suspected CKDu based on history of diabetes, hypertension, or other specified conditions. A multinomial logistic regression model was used to identify factors associated with traditional CKD and suspected CKDu, compared to the non-CKD reference group. RESULTS In 1795 study participants, CKD prevalence was 8.6%. Prevalence in males was twofold higher than females (12% vs 6%). Of those with CKD, 35% had suspected CKDu. Both traditional CKD and CKDu were associated with male sex and increasing age. Traditional CKD was associated with a family history of CKD, history of urinary tract infections, and lower socioeconomic status, while CKDu was associated with drinking well water and a lower body mass index. CONCLUSIONS Both traditional CKD and CKDu are significant burdens in this region. Our study supports previous hypotheses of CKDu etiology and emphasizes the importance of CKD screening.
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Affiliation(s)
- Anna Strasma
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Ángel Mejía Reyes
- Bioanalysis and Immunology Research Group, National Autonomous University of Honduras, Tegucigalpa, Honduras
| | - Aurora Aragón
- WUQU' KAWOQ, Maya Health Alliance, Chimaltenango, Guatemala
| | - Indiana López
- WUQU' KAWOQ, Maya Health Alliance, Chimaltenango, Guatemala
| | - Lawrence P Park
- Duke Global Health Institute, Durham, NC, USA
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Susan L Hogan
- Department of Medicine, Division of Nephrology and Hypertension and the UNC Kidney Center, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Nathan Thielman
- Duke Global Health Institute, Durham, NC, USA
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Marvin González-Quiroz
- WUQU' KAWOQ, Maya Health Alliance, Chimaltenango, Guatemala
- Department of Renal Medicine, University College London, London, UK
- School of Medicine, Universidad Nacional de Chimborazo, Riobamba, Ecuador
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Kim YH, Saha MK, Hu Y, Kumar S, Poulton CJ, Hogan SL, Nachman P, Jennette JC, Nast CC, Mottl AK. Impact of Diabetic Lesions on Pathology, Treatment, and Outcomes of Glomerular Diseases. Kidney360 2023; 4:1445-1453. [PMID: 37642555 PMCID: PMC10615380 DOI: 10.34067/kid.0000000000000247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/18/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
Key Points People with glomerular disease (GD) and comorbid diabetes have similar baseline characteristics irrespective of superimposed diabetic lesions. Immunosuppression for GD with comorbid diabetes is the same regardless of superimposed diabetic glomerular lesions. ESKD or death is more rapid in GD and comorbid diabetes only in the presence of moderate-severe diabetic glomerular lesions. Background We aimed to evaluate whether concomitant diabetic glomerulosclerosis (DGS) and its severity affect the treatment and outcomes of primary glomerular diseases (GDs) with comorbid diabetes. Methods We conducted a retrospective review of people with diabetes and GD. We searched the GD Collaborative Network for biopsies from 2008 to 2015 among persons with diabetes and any of the following diagnoses: FSGS, IgA nephropathy, minimal change disease, membranous nephropathy, or antineutrophil cytoplasmic autoantibody GN. Data were abstracted from health records and histologic diabetic glomerular class scored. The primary composite end point was ESKD or death. Multivariable Cox regression models tested whether any or the severity of diabetes histopathology affected the primary end point. Results Data from 134 cases were available for analysis (78 DGS+GD and 56 GD alone). Diabetes duration and glycemic control were similar between the two groups (P = 0.2; P = 0.09, respectively). Use of immunosuppression did not differ between the two groups (P = 0.3). The composite end point was significantly higher in DGS+GD (22.5 cases per 100 person-years [95% confidence interval (CI), 16.6 to 30.5]) versus GD alone (10.2 cases per 100 person-years [95% CI, 6.4 to 16.2]). Regression analyses demonstrated that compared with the GD-alone group, the risk for the composite end point was similar in the group with mild DGS+GD (DGS class 1, 2a) (hazard ratio, 1.15 [95% CI, 0.54 to 2.43]) while the group with severe DGS+GD (DGS class 2b, 3, 4) had a greater risk (hazard ratio, 3.60 [1.79 to 7.22]). Conclusions Among people with diabetes and GD, mild diabetic glomerular lesions on biopsy do not affect outcomes, but moderate-severe lesions increase the risk for ESKD and death. Whether use of immunosuppression, particularly glucocorticoids, is less successful in inducing GD remission in people with moderate-severe diabetic lesions will be a focus of future study in a larger population.
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Affiliation(s)
- Young Ho Kim
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Manish K. Saha
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Yichun Hu
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Srikar Kumar
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Caroline J. Poulton
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Susan L. Hogan
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Patrick Nachman
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
- University of Minnesota Division of Nephrology and Hypertension, UM School of Medicine, Minneapolis, Minnesota
| | - J. Charles Jennette
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | - Cynthia C. Nast
- Division of Nephropathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy K. Mottl
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
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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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Cao B, Hogan SL, Derebail VK, Ehlert A, Thorpe CT. Polypharmacy in US Medicare beneficiaries with antineutrophil cytoplasmic antibody vasculitis. J Manag Care Spec Pharm 2023; 29:770-781. [PMID: 37404075 PMCID: PMC10387912 DOI: 10.18553/jmcp.2023.29.7.770] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 07/06/2023]
Abstract
BACKGROUND: Treatment requirements of antineutrophil cytoplasmic autoantibody vasculitis (AV) and high comorbidity burden among patients with AV may lead to higher potential for polypharmacy and its associated adverse outcomes, including adverse drug events, nonadherence, drug-drug interactions, and higher costs. Medication burden and risk factors associated with polypharmacy in patients with AV have not been well-characterized. OBJECTIVE: To characterize medication burden and examine prevalence of and risk factors for polypharmacy in the first year after diagnosis with AV. METHODS: We conducted a retrospective cohort study using 2015-2017 Medicare claims to identify incident cases of AV. We counted the number of unique generic products dispensed to patients in each of the 4 quarters after diagnosis and categorized medication count as high (≥10 medications), moderate (5-9 medications), or minimal or no polypharmacy (<5 medications). We used multinomial logistic regression to examine associations of predisposing, enabling, and medical need factors with having high or moderate polypharmacy. RESULTS: In 1,239 Medicare beneficiaries with AV, high or moderate polypharmacy was most common in the first quarter after diagnosis (83.7%), with 43.2% taking 5 - 9 medications and 40.5% taking at least 10. The odds of high polypharmacy were greater in all quarters for patients with eosinophilic granulomatosis with polyangiitis compared with granulomatosis with polyangiitis, ranging from 2.02 (95% CI = 1.18 - 3.46) in the third quarter to 2.96 (95% CI = 1.64-5.33) in the second quarter. Older age, diabetes, chronic kidney disease, obesity, a higher Charlson Comorbidity Index score, coverage with Medicaid/Part D low-income subsidy, and living in areas with low education or persistent poverty were risk factors for high or moderate polypharmacy. CONCLUSIONS: Medicare beneficiaries with newly diagnosed AV experienced a high medication burden, with more than 40% taking at least 10 medications and the highest rates among those with eosinophilic granulomatosis with polyangiitis. Patients with AV may benefit from medication therapy management interventions to manage complex drug regimens and reduce risks associated with polypharmacy. DISCLOSURES: Dr Derebail receives personal fees from Travere Therapeutics, Pfizer, Bayer, Forma Therapeutics, UpToDate, outside of the submitted work. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or the Department of Veterans Affairs. Dr Thorpe receives royalties from SAGE Publishing for activities unrelated to the submitted work. This research is supported by internal funds from the University of North Carolina, as well as the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number R21AI160606 (PI: C. Thorpe).
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Affiliation(s)
- Binxin Cao
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill
| | - Alexa Ehlert
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Carolyn T Thorpe
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
- Veterans Affairs Pittsburgh Healthcare System, PA
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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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9
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Tuey SM, Prebehalla L, Roque AA, Roda G, Chonchol MB, Shah N, Wempe MF, Hu Y, Hogan SL, Nolin TD, Joy MS. The Impact of Suboptimal 25-Hydroxyvitamin D Levels and Cholecalciferol Replacement on the Pharmacokinetics of Oral Midazolam in Control Subjects and Patients With Chronic Kidney Disease. J Clin Pharmacol 2022; 62:1528-1538. [PMID: 35678297 DOI: 10.1002/jcph.2104] [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: 01/11/2022] [Accepted: 06/03/2022] [Indexed: 11/08/2022]
Abstract
The aim of this study was to investigate the impact of suboptimal 25-hydroxyvitamin D (25-VitD) and cholecalciferol (VitD3 ) supplementation on the pharmacokinetics of oral midazolam (MDZ) in control subjects and subjects with chronic kidney disease (CKD). Subjects with CKD (n = 14) and controls (n = 5) with suboptimal 25-VitD levels (<30 ng/mL) were enrolled in a 2-phase study. In phase 1 (suboptimal), subjects were administered a single oral dose of VitD3 (5000 IU) and MDZ (2 mg). In phase 2 (replete) subjects who achieved 25-VitD repletion after receiving up to 16 weeks of daily cholecalciferol were given the identical single oral doses of VitD3 and MDZ as in phase 1. Concentrations of MDZ and metabolites, 1'-hydroxymidazolam (1'-OHMDZ), and 1'-OHMDZ glucuronide (1'-OHMDZ-G) were measured by liquid chromatography-tandem mass spectrometry and pharmacokinetic analysis was performed. Under suboptimal 25-VitD, reductions in MDZ clearance and renal clearance of 47% and 87%, respectively, and a 72% reduction in renal clearance of 1'-OHMDZ-G were observed in CKD vs controls. In phase 1 versus phase 2, MDZ clearance increased in all control subjects, with a median (interquartile range) increase of 10.5 (0.62-16.7) L/h. No changes in MDZ pharmacokinetics were observed in subjects with CKD between phases 1 and 2. The effects of 25-VitD repletion on MDZ disposition was largely observed in subjects without kidney disease. Impaired MDZ metabolism and/or excretion alterations due to CKD in a suboptimal 25-VitD state may not be reversed by cholecalciferol therapy. Suboptimal 25-VitD may augment the reductions in MDZ and 1'-OHMDZ-G clearance values observed in patients with CKD.
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Affiliation(s)
- Stacey M Tuey
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Linda Prebehalla
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amandla-Atilano Roque
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Gavriel Roda
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Michel B Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Nirav Shah
- Department of Medicine Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael F Wempe
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Yichun Hu
- Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L Hogan
- Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Melanie S Joy
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
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10
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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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11
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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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12
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Huang SP, Li X, Cao B, Nguyen JT, Robinson JE, Derebail VK, Hogan SL, Thorpe CT. Health care costs and utilization prior to diagnosis of antineutrophil cytoplasmic antibody vasculitis in Medicare beneficiaries. J Manag Care Spec Pharm 2022; 28:1292-1303. [PMID: 36282932 PMCID: PMC10372980 DOI: 10.18553/jmcp.2022.28.11.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Antineutrophil cytoplasmic antibody (ANCA) vasculitis (AV) is a complex group of autoimmune disorders affecting blood vessels in multiple organ systems. Delays in diagnosis are common because AV symptoms can be nonspecific and present heterogeneously. This may result in increased health care utilization in the months preceding diagnosis. OBJECTIVE: To examine whether Medicare beneficiaries with AV experienced increased health care utilization and costs in the year before the first diagnosis recorded in claims, relative to beneficiaries without AV. METHODS: This retrospective cohort study used 2015-2016 Medicare Part A/B claims and Part D prescription drug data. Beneficiaries with newly diagnosed AV were identified by having 1 or more inpatient claims or 2 or more noninpatient claims 7 or more days apart in 2016 with an International Classification of Diseases, Tenth Revision, Clinical Modification code for AV, with no AV claims in the year prior. Beneficiaries with AV were matched 1:1 on age and sex to beneficiaries without any diagnoses for any type of systemic vasculitis in 2016. Beneficiaries with Part A/B coverage (AB, n = 1,460) and Part A/B/D coverage (ABD, n = 3,252) were analyzed separately. We estimated generalized linear mixed models with a negative binomial distribution to compare health care costs and utilization by AV status. RESULTS: Beneficiaries with AV had approximately 3 times higher Medicare Part A/B payments (incidence rate ratio [95% CI]: AB: 2.94 [2.44-3.53]; ABD: 2.95 [2.64-3.29]) and 2.5 times higher beneficiary Part A/B payments (AB: 2.47 [2.14-2.84]; ABD: 2.62 [2.40-2.87]) vs beneficiaries without AV. Beneficiaries with AV experienced significantly higher utilization across all categories, with the largest differences observed in hospital outpatient visits (AB: 2.69 [2.22-3.27]; ABD: 3.08 [2.73-3.47]). CONCLUSIONS: In the year prior to AV diagnosis, Medicare beneficiaries have significantly higher health care costs and utilization than beneficiaries without AV. DISCLOSURES: Dr Huang was supported by the University of North Carolina and GlaxoSmithKline Health Outcomes Fellowship during the time of the study and reports current employment at Horizon Therapeutics, Deerfield, IL. Dr Nguyen received predoctoral funding through a fellowship appointment sponsored by Bristol Myers Squibb during the time of the study and reports current employment at GlaxoSmithKline, Collegeville, PA. Dr Derebail receives personal fees from Travere Therapeutics, Bayer, and UpToDate, outside of the submitted work. The views expressed are those of the authors and do not represent the views of the Department of Veteran Affairs. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- Shirley P Huang
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
- Horizon Therapeutics, Deerfield, IL
| | - Xintong Li
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Science, University of Oxford, UK
| | - Binxin Cao
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Joehl T Nguyen
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
- GlaxoSmithKline, Collegeville, PA
| | - Jacob E Robinson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Vimal K Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill
| | - Susan L Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill
| | - Carolyn T Thorpe
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, PA
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13
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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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14
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Abstract
Introduction Lupus nephritis (LN) may present with thrombotic microangiopathy (TMA) on
kidney biopsy, the impact of which on outcomes is unclear. This study
examined the prognostic importance of LN with TMA on kidney biopsy,
including response to therapy and long-term outcomes. Methods We conducted a single-center, retrospective study of all cases of LN with
concomitant TMA on kidney biopsy in the Glomerular Disease Collaborative
Network database. Controls were individuals with LN without TMA matched to
cases based on demographic and clinical variables. Outcomes were remission
at 6- and 12-months, end-stage kidney disease (ESKD) and death. Logistic
regression and Cox proportional hazards models were used to ascertain the
risks for outcomes, with adjustment for serum creatinine and
proteinuria. Results There were 17 cases and 28 controls. Cases had higher creatinine, higher
proteinuria and greater chronicity on biopsy at baseline compared to
controls. The rates of remission at 6-months and 12-months were similar
between cases and controls (6-months 53.9% vs 46.4%, adjusted OR 2.54, 95%
CI 0.48, 13.37; 12-months 53.9% vs 50.0%, adjusted OR 2.95, 95% CI 0.44,
19.78). Cases were at greater risk for ESKD in univariate analysis (HR 3.77;
95% CI 1.24, 11.41) but not when adjusting for serum creatinine and
proteinuria (HR 2.20; 95% CI 0.63, 7.71). There was no significant
difference in the risk of death between cases and controls. Conclusion Lupus nephritis with renal TMA likely responds to therapy similarly to those
without TMA; risk for ESKD is not significantly increased, although the
influence of renal function and proteinuria in larger samples is needed.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth Kotzen
- Division of Nephrology and Hypertension, Department of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah Todd
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yichun Hu
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Koyal Jain
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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15
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Glenn DA, Hogan SL. Big Data and Glomerular Disease: Uncovering Common Outcomes of Rare Disease. J Am Soc Nephrol 2021; 32:2106-2108. [PMID: 34465604 PMCID: PMC8729837 DOI: 10.1681/asn.2021070954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Dorey A Glenn
- Division of Nephrology and Hypertension, University of North Carolina, 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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17
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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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18
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Chen DP, Zaky ZS, Schold JD, Herlitz LC, El-Rifai R, Drawz PE, Bruggeman LA, Barisoni L, Hogan SL, Hu Y, O'Toole JF, Poggio ED, Sedor JR. Podocyte density is reduced in kidney allografts with high-risk APOL1 genotypes at transplantation. Clin Transplant 2021; 35:e14234. [PMID: 33511679 DOI: 10.1111/ctr.14234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 08/07/2020] [Revised: 11/25/2020] [Accepted: 01/20/2021] [Indexed: 01/23/2023]
Abstract
Variants in apolipoprotein L1 (APOL1) gene are associated with nondiabetic kidney diseases in black subjects and reduced kidney transplant graft survival. Living and deceased black kidney donors (n = 107) were genotyped for APOL1 variants. To determine whether allografts from high-risk APOL1 donors have reduced podocyte densities contributing to allograft failure, we morphometrically estimated podocyte number, glomerular volume, and podocyte density. We compared allograft loss and eGFR trajectories stratified by APOL1 high-risk and low-risk genotypes. Demographic characteristics were similar in high-risk (n = 16) and low-risk (n = 91) donors. Podocyte density was significantly lower in high-risk than low-risk donors (108 ± 26 vs 127 ± 40 podocytes/106 um3 , P = .03). Kaplan-Meier graft survival (high-risk 61% vs. low-risk 91%, p-value = 0.049) and multivariable Cox models (hazard ratio = 2.6; 95% CI, 0.9-7.8) revealed higher graft loss in recipients of APOL1 high-risk allografts over 48 months. More rapid eGFR decline was seen in recipients of high-risk APOL1 allografts (P < .001). At 60 months, eGFR was 27 vs. 51 mL/min/1.73 min2 in recipients of APOL1 high-risk vs low-risk kidney allografts, respectively. Kidneys from high-risk APOL1 donors had worse outcomes versus low-risk APOL1 genotypes. Lower podocyte density in kidneys from high-risk APOL1 donors may increase susceptibility to CKD from subsequent stresses in both the recipients and donors.
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Affiliation(s)
- Dhruti P Chen
- Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, NC, USA
| | - Ziad S Zaky
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jesse D Schold
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Leal C Herlitz
- Pathology and Lab Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rasha El-Rifai
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Leslie A Bruggeman
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Laura Barisoni
- Departments of Pathology and Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - Susan L Hogan
- Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, NC, USA
| | - Yichun Hu
- Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, NC, USA
| | - John F O'Toole
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emilio D Poggio
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John R Sedor
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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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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20
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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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21
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Weiner M, Bjørneklett R, Hrušková Z, Mackinnon B, Poulton CJ, Sindelar L, Mohammad AJ, Eriksson P, Gesualdo L, Geetha D, Crnogorac M, Jayne D, Hogan SL, Geddes C, Tesar V, Aasarød K, Segelmark M. Proteinase-3 and myeloperoxidase serotype in relation to demographic factors and geographic distribution in anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. Nephrol Dial Transplant 2020; 34:301-308. [PMID: 29718465 DOI: 10.1093/ndt/gfy106] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/21/2018] [Indexed: 01/29/2023] Open
Abstract
Background In anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis, antigen specificity varies between myeloperoxidase (MPO) and proteinase 3 (PR3). This has been reported to vary in relation to age, gender, geography and extrarenal manifestations. However, studies are difficult to compare as criteria for inclusion vary. The aim of this study was to investigate the relationship between ANCA serotype, latitude, ultraviolet (UV) radiation levels, age, gender and renal function at diagnosis in a large study with uniform inclusion criteria. Methods Patients with biopsy-proven ANCA-associated glomerulonephritis were identified from regional or nationwide registries in 14 centres in Norway, Sweden, the UK, the Czech Republic, Croatia, Italy and the USA during the period 2000-13. UV radiation levels for 2000-13 in Europe were obtained from the Swedish Meteorological and Hydrological Institute. Results A total of 1408 patients (45.2% PR3-ANCA) were included in the study. In univariable analysis, PR3-ANCA was significantly associated with male gender {odds ratio [OR] 2.12 [95% confidence interval (CI) 1.71-2.62]}, younger age [OR per year 0.97 (95% CI 0.96-0.98)] and higher glomerular filtration rate [OR per mL/min 1.01 (95% CI 1.01-1.02); P < 0.001] at diagnosis but not with latitude or UV radiation. In multivariable logistic regression analysis, latitude and UV radiation also became significant, with higher odds for PR3-ANCA positivity at northern latitudes/lower UV radiation levels. However, the latitudinal difference in MPO:PR3 ratio is smaller than differences previously reported concerning microscopic polyangiitis and granulomatosis with polyangiitis. Conclusions The ratio between PR3-ANCA and MPO-ANCA varies in glomerulonephritis with respect to age, gender, renal function and geographic latitude/UV radiation levels.
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Affiliation(s)
- Maria Weiner
- Department of Nephrology and Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Rune Bjørneklett
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Zdenka Hrušková
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Caroline J Poulton
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Division of Nephrology and Hypertension, Department of Medicine UNC Kidney Center, Chapel Hill, NC, USA
| | - Leo Sindelar
- Department of Nephrology and Medical and Health Sciences, Linköping University, Linköping, Sweden.,Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Per Eriksson
- Department of Rheumatology and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Susan L Hogan
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Division of Nephrology and Hypertension, Department of Medicine UNC Kidney Center, Chapel Hill, NC, USA
| | - Colin Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Knut Aasarød
- Department of Nephrology, Saint Olavs University Hospital, Trondheim, Norway.,Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mårten Segelmark
- Department of Nephrology and Medical and Health Sciences, Linköping University, Linköping, Sweden
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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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23
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Sanderson KR, Chang E, Bjornstad E, Hogan SL, Hu Y, Askenazi D, Fry RC, O'Shea TM. Albuminuria, Hypertension, and Reduced Kidney Volumes in Adolescents Born Extremely Premature. Front Pediatr 2020; 8:230. [PMID: 32528916 PMCID: PMC7247811 DOI: 10.3389/fped.2020.00230] [Citation(s) in RCA: 19] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Premature birth is associated with decreased nephron number and an increased risk for chronic kidney disease (CKD). To inform the development of guidelines for kidney follow up of children born prematurely, we undertook a study of individuals born extremely preterm, with the aim of characterizing the prevalence and predictors of microalbuminuria, elevated blood pressure, and/or abnormal kidney volume in adolescence. Methods: Study participants (n = 42) were born before 28 weeks of gestation and were enrolled at birth in the Extremely Low Gestational Age Newborns (ELGAN) study. When participants were 15 years old, we obtained 2 manual blood pressures, a spot urine microalbumin measurement, and sonographic measurements of kidney length and volume. Results: Of the 42 participants, 60% were male, 52% were Caucasian (18% Hispanic), and 43% were African-American. Their median age was 15 (IQR 15, 15.3) years. In 33.3% of the cohort, blood pressure was elevated (>120/80 mmHg). Microalbuminuria (>30 mg/g) was present in 11.9% of the cohort, and kidney volume below the 10th percentile of normative data was present in 14%. Twenty-one (50%) of the sample had at least one kidney abnormality (microalbuminuria, elevated blood pressures, and/or kidney hypoplasia); these individuals were more likely to have experienced neonatal hypotension [55% vs. 17% among those with no kidney abnormality, p = 0.02]. Conclusions: Half of adolescents in this subset of ELGAN cohort have at least one risk factor of kidney disease (reduced kidney volume, microalbuminuria, and/or elevated blood pressures) at 15 years of age. This study suggests the importance of monitoring kidney outcomes in children after extremely preterm birth, especially those with a history of neonatal hypotension.
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Affiliation(s)
- Keia R Sanderson
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, United States
| | - Emily Chang
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, United States
| | - Erica Bjornstad
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Susan L Hogan
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, United States
| | - Yichun Hu
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, United States
| | - David Askenazi
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rebecca C Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States
| | - T Michael O'Shea
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, United States
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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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25
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O'Shaughnessy MM, Hogan SL, Thompson BD, Coppo R, Fogo AB, Jennette JC. Glomerular disease frequencies by race, sex and region: results from the International Kidney Biopsy Survey. Nephrol Dial Transplant 2019; 33:661-669. [PMID: 29106637 DOI: 10.1093/ndt/gfx189] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/19/2017] [Indexed: 12/14/2022] Open
Abstract
Background Large-scale studies comparing glomerular disease frequencies across continents are lacking. Methods We surveyed 29 nephropathology laboratories in four continents using a standardized data collection form. We obtained recent consecutive kidney biopsy diagnosis frequencies at each center and summary demographics for each diagnosis. This report focuses on glomerular disease frequencies by region and race/ethnicity. Results Among 42 603 glomerular disease diagnoses reported (median age 47 years, 52% male, 57% white), from a total of 60 340 diagnoses, glomerular disease subtype frequencies differed considerably by continent. Diabetic glomerulosclerosis (GS; 19.1%) and focal segmental glomerulosclerosis (FSGS; 19.1%) predominated in North America; lupus nephritis (38.1%) and FSGS (15.8%) predominated in Latin America; IgA nephropathy (IgAN; 22.1%) and FSGS (14.9%) predominated in Europe; and IgAN (39.5%) and lupus nephritis (16.8%) predominated in Asia. After stratifying by race, diabetic GS (17.4% versus 4.3%, P < 0.001) and FSGS (17.3% versus 11.8%, P < 0.001) were more, and lupus nephritis less (15.8% versus 45.6%, P < 0.001), frequent among Latinos in North versus Latin America; FSGS was more (13.1% versus 7.1%, P < 0.001), and IgAN less (27.4% versus 40.5%, P < 0.001), frequent among Asians in North America versus Asia; and FSGS (18.9% versus 13.5%, P < 0.001) and diabetic GS (18.7% versus 6.5%, P < 0.001) were more, and IgAN less (14.4% versus 25.4%, P < 0.001), frequent among whites in North America versus Europe. Conclusions We determined that glomerular disease frequencies differed by continent, even among patients of similar race/ethnicity. Regional environmental and lifestyle factors, and local biopsy policies, might influence glomerular disease epidemiology independently of race/ethnicity.
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Affiliation(s)
- Michelle M O'Shaughnessy
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Nephrology and Hypertension, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Susan L Hogan
- Division of Nephrology and Hypertension, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Bawana D Thompson
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Division of Renal Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Charles Jennette
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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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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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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Nguyen JT, Roberts C, Thorpe CT, Thorpe JM, Hogan SL, McGregor J, Geryk L, Carpenter DM. Economic and objective burden of caregiving on informal caregivers of patients with systemic vasculitis. Musculoskeletal Care 2019; 17:282-287. [PMID: 30901158 DOI: 10.1002/msc.1394] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/31/2019] [Accepted: 02/03/2019] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Systemic vasculitis (SV) is associated with substantial economic impact to patients and the healthcare system but little is known about the burden of SV on informal caregivers. We evaluated the objective caregiving burden experienced by informal caregivers of patients with SV. METHODS We surveyed adult patients and their informal caregivers on the physical, emotional, social and economic impacts of SV. We asked patients about the extent to which they felt they were a burden to their identified caregivers. Caregivers reported the direct and indirect economic impact of SV, including employment disturbance, income loss and relative time investment of caregiving for their care recipient's SV. We used the Inventory of Caregiving Activities Questionnaire to compute the objective caregiving burden. RESULTS We analysed data from 68 SV patient-caregiver dyads. Patients reported moderate levels of subjective burden to their caregivers. Over one-quarter of caregivers reported ever having lost some income owing to caregiving for SV. Caregivers reported spending a median of 19 weekly hours on various caregiving tasks, including a median 17 weekly hours on household activities. DISCUSSION Given the extended hours that caregivers spend caring for their care recipient, intervention targets should aim to reduce caregiver burnout in the SV population. Future research should examine the relationship between the objective burden of caregiving for SV and the overall physical health, mental health and quality of life of caregivers.
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Affiliation(s)
- Joehl T Nguyen
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Courtney Roberts
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
| | - Joshua M Thorpe
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
| | - Susan L Hogan
- UNC Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
| | - Julie McGregor
- UNC Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
- Triangle Integrative Medicine Associates, Chapel Hill, North Carolina, United States
| | - Lorie Geryk
- Center for Health Systems Effectiveness, Oregon Health and Sciences University, Portland, Oregon, United States
| | - Delesha M Carpenter
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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Chanouzas D, McGregor JAG, Nightingale P, Salama AD, Szpirt WM, Basu N, Morgan MD, Poulton CJ, Draibe JB, Krarup E, Dospinescu P, Dale JA, Pendergraft WF, Lee K, Egfjord M, Hogan SL, Harper L. Intravenous pulse methylprednisolone for induction of remission in severe ANCA associated Vasculitis: a multi-center retrospective cohort study. BMC Nephrol 2019; 20:58. [PMID: 30777023 PMCID: PMC6378728 DOI: 10.1186/s12882-019-1226-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/23/2019] [Indexed: 11/12/2022] Open
Abstract
Background Intravenous pulse methylprednisolone (MP) is commonly included in the management of severe ANCA associated vasculitis (AAV) despite limited evidence of benefit. We aimed to evaluate outcomes in patients who had, or had not received MP, along with standard therapy for remission induction in severe AAV. Methods We retrospectively studied 114 consecutive patients from five centres in Europe and the United States with a new diagnosis of severe AAV (creatinine > 500 μmol/L or dialysis dependency) and that received standard therapy (plasma exchange, cyclophosphamide and high-dose oral corticosteroids) for remission induction with or without pulse MP between 2000 and 2013. We evaluated survival, renal recovery, relapses, and adverse events over the first 12 months. Results Fifty-two patients received pulse MP in addition to standard therapy compared to 62 patients that did not. There was no difference in survival, renal recovery or relapses. Treatment with MP associated with higher risk of infection during the first 3 months (hazard ratio (HR) 2.7, 95%CI [1.4–5.3], p = 0.004) and higher incidence of diabetes (HR 6.33 [1.94–20.63], p = 0.002), after adjustment for confounding factors. Conclusions The results of this study suggest that addition of pulse intravenous MP to standard therapy for remission induction in severe AAV may not confer clinical benefit and may be associated with more episodes of infection and higher incidence of diabetes. Electronic supplementary material The online version of this article (10.1186/s12882-019-1226-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dimitrios Chanouzas
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter Nightingale
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alan D Salama
- Centre for Nephrology, University College London, London, UK
| | | | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Matthew David Morgan
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Caroline J Poulton
- University of North Carolina Kidney Center, Chapel Hill, North Carolina, USA
| | | | | | - Paula Dospinescu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Jessica Anne Dale
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Keegan Lee
- Centre for Nephrology, University College London, London, UK
| | | | - Susan L Hogan
- University of North Carolina Kidney Center, Chapel Hill, North Carolina, USA
| | - Lorraine Harper
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK. .,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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30
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Ibrahim ME, Chang C, Hu Y, Hogan SL, Mercke N, Gomez M, O'Bryant CL, Bowles DW, George B, Wen X, Buckley B, Aleksunes L, Joy MS. Pharmacokinetic determinants of cisplatin-induced subclinical kidney injury in oncology patients. Eur J Clin Pharmacol 2018; 75:51-57. [PMID: 30220072 DOI: 10.1007/s00228-018-2552-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/30/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The ability to predict and detect clinical and subclinical nephrotoxicity early in the course of therapy has the potential to improve long-term outcomes in cancer patients receiving cisplatin chemotherapy. Pharmacokinetic parameters could serve as predictors of cisplatin-induced nephrotoxicity. METHODS Participants [n = 13] were treated with a 1-h cisplatin infusion [30-75 mg/m2]. Blood was collected pre-dose and up to 6 h post-dose. Urinary biomarkers [KIM-1, calbindin, clusterin, GST-pi, β2M, albumin, NGAL, osteopontin, clusterin, MCP-1, cystatin C, and TFF3] were measured at baseline, days 3 and 10. Total and unbound platinum concentrations were measured using ICP/MS. Noncompartmental analysis was performed, and correlation and regression analyses evaluated the relationships between platinum pharmacokinetics and nephrotoxicity. RESULTS Peak platinum urinary concentrations correlated with urinary levels of KIM-1, calbindin, clusterin, GST-pi, β2M, albumin, NGAL, osteopontin, clusterin, cystatin C, and TFF3 at day 10. Unbound platinum plasma concentrations at 2 h also correlated with urinary clusterin, β2M, cystatin C, NGAL, osteopontin, and TFF3 at day 3. Regression analyses suggested 2-h total plasma platinum concentrations greater than 2000 ng/ml, and peak urinary platinum concentrations above 24,000 ng/ml may serve as potential approximations for elevated risk of nephrotoxicity. Platinum area under the plasma concentration time curve was associated with serum creatinine and estimated glomerular filtration rate. CONCLUSIONS Peak plasma and urinary platinum concentrations and pharmacokinetic parameters were associated with risk of subclinical cisplatin-induced kidney injury as assessed using novel urinary biomarkers. Future studies will examine these relationships in larger clinical populations of cisplatin-induced acute kidney injury.
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Affiliation(s)
- Mustafa E Ibrahim
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, 12850 E. Montview Blvd, Mail Stop C238, Room V20-4108, Aurora, CO, 80045, USA
| | - Cara Chang
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, 12850 E. Montview Blvd, Mail Stop C238, Room V20-4108, Aurora, CO, 80045, USA
| | - Yichun Hu
- Kidney Center, University of North Carolina School of Medicine, Division of Nephology and Hypertension, Chapel Hill, NC, 27516, USA
| | - Susan L Hogan
- Kidney Center, University of North Carolina School of Medicine, Division of Nephology and Hypertension, Chapel Hill, NC, 27516, USA
| | - Nickie Mercke
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, 12850 E. Montview Blvd, Mail Stop C238, Room V20-4108, Aurora, CO, 80045, USA
| | - Madeleine Gomez
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, 12850 E. Montview Blvd, Mail Stop C238, Room V20-4108, Aurora, CO, 80045, USA
| | - Cindy L O'Bryant
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, 12850 E. Montview Blvd, Mail Stop C238, Room V20-4108, Aurora, CO, 80045, USA.,Cancer Center, University of Colorado, Anschutz Medical Campus, 1665 Aurora Ct, Aurora, CO, 80045, USA
| | - Daniel W Bowles
- Cancer Center, University of Colorado, Anschutz Medical Campus, 1665 Aurora Ct, Aurora, CO, 80045, USA
| | - Blessy George
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Davidson Hall, 96 Davidson Rd, Piscataway, NJ, 08854, USA
| | - Xia Wen
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Davidson Hall, 96 Davidson Rd, Piscataway, NJ, 08854, USA
| | - Brian Buckley
- Environmental and Occupational Health Sciences Institute, Rutgers University, 170 Frelinghuysen Rd, Piscataway, NJ, 08854, USA
| | - Lauren Aleksunes
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Davidson Hall, 96 Davidson Rd, Piscataway, NJ, 08854, USA.,Environmental and Occupational Health Sciences Institute, Rutgers University, 170 Frelinghuysen Rd, Piscataway, NJ, 08854, USA
| | - Melanie S Joy
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, 12850 E. Montview Blvd, Mail Stop C238, Room V20-4108, Aurora, CO, 80045, USA. .,Cancer Center, University of Colorado, Anschutz Medical Campus, 1665 Aurora Ct, Aurora, CO, 80045, USA. .,Division of Renal Diseases and Hypertension, University of Colorado, Anschutz Medical Campus, School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA.
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Thorpe CT, Thorpe JM, Jiang T, Atkinson D, Kang Y, Schleiden LJ, Carpenter DM, McGregor JAG, Hogan SL. Healthcare utilization and expenditures for United States Medicare beneficiaries with systemic vasculitis. Semin Arthritis Rheum 2018; 47:507-519. [PMID: 28918956 PMCID: PMC5743622 DOI: 10.1016/j.semarthrit.2017.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 02/21/2017] [Revised: 07/21/2017] [Accepted: 08/04/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The Medicare federal insurance program is the most common United States insurer of patients with systemic vasculitis (SV). We compared healthcare utilization and expenditures for Medicare beneficiaries with versus without SV. METHODS This national, retrospective study used 2010 claims and enrollment data for a 100% cohort of Medicare Part A and B beneficiaries with ≥1 claim including a diagnosis for a form of SV (n = 176,498), and a randomly selected group of non-SV beneficiaries (n = 46,561). Outcomes included annual counts of events in 16 categories of medical services (e.g., inpatient stays, physician visits, tests, and imaging events), and total annual Medicare and patient medical expenditures. We used linear regression with bootstrapped standard errors to compare utilization and expenditures by SV status, before and after matching on age and sex. Prescription drug fills and expenditures for SV (n = 95,157) and non-SV (n = 24,992) beneficiaries with Part D drug benefits were also compared. RESULTS After matching, Medicare spent $11,004 more per patient in 2010 for medical services, and $773 more on prescription drugs, for SV versus non-SV beneficiaries. SV beneficiaries spent $1547 more for medical services and $211 more for prescription drugs. Except for hospice, SV beneficiaries had greater utilization of all services, including two-to-three times more dialysis events, hospital readmissions, inpatient stays, skilled nursing facility stays, and medical tests. CONCLUSIONS The average Medicare beneficiary with SV incurs about double the annual healthcare expenditures compared to their non-SV counterparts, attributable to increased utilization of almost all categories of care.
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Affiliation(s)
- Carolyn T Thorpe
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261; Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA 15240.
| | - Joshua M Thorpe
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261; Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA 15240
| | - Tao Jiang
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, 3471 Fifth Ave., Kaufmann Medical Building, Suite 500, Pittsburgh, PA 15261; First Coast Service Options, Inc., Department of Statistical Medical Data Analysis, 532 Riverside Ave., Jacksonville, FL 32202
| | - Dylan Atkinson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261
| | - Yihuang Kang
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, 3471 Fifth Ave., Kaufmann Medical Building, Suite 500, Pittsburgh, PA 15261; Department of Information Management, National Sun-Yat-sen University, 70 Lienhai Rd, Kaohsiung 80424, Taiwan
| | - Loren J Schleiden
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261; Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA 15240
| | - Delesha M Carpenter
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, One University Heights, CPO 2125, Asheville, NC 28804
| | - Julie Anne G McGregor
- UNC Kidney Center and Division of Nephrology & Hypertension, University of North Carolina School of Medicine, 7009 Burnett-Womack, Chapel Hill, NC 27599; Triangle Integrative Medicine Associates, 55 Vilcom Center Dr. #100, Chapel Hill, NC 27514
| | - Susan L Hogan
- UNC Kidney Center and Division of Nephrology & Hypertension, University of North Carolina School of Medicine, 7009 Burnett-Womack, Chapel Hill, NC 27599
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Mottl AK, Gasim A, Schober FP, Hu Y, Dunnon AK, Hogan SL, Jennette JC. Segmental Sclerosis and Extracapillary Hypercellularity Predict Diabetic ESRD. J Am Soc Nephrol 2017; 29:694-703. [PMID: 29180393 DOI: 10.1681/asn.2017020192] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 10/24/2017] [Indexed: 01/11/2023] Open
Abstract
Pathogenetic markers of diabetic kidney disease (DKD) progression to ESRD are lacking. We characterized the prognostic value of histologic findings in DKD for time to ESRD in native kidney specimens from biopsies performed from 1995 to 2011 with diabetic glomerulosclerosis as the only glomerular disease diagnosis (n=109). Biopsy specimens were analyzed according to standard methods, including determination of diabetic nephropathy class, as defined by the Renal Pathology Society. Clinical data were extracted from electronic medical records. We used competing risk models, with death as the competing risk, to estimate subdistribution hazard ratios (HRs) for ESRD. All multivariable models included age, sex, black race, baseline eGFR, and baseline proteinuria. Pathologic characteristics achieving P<0.1 were added into successively complex models. ESRD occurred in 56% of patients, and 26% of patients died before reaching ESRD. In univariate analyses, diabetic nephropathy class was not statistically significant in predicting time to ESRD. The final multivariable model (n=106) showed a borderline association between mild mesangial expansion and decreased risk for ESRD (subdistribution HR, 0.64; 95% confidence interval, 0.40 to 1.00). Poor prognostic factors in the final model included segmental sclerosis and extracapillary hypercellularity (subdistribution HR, 2.04; 95% confidence interval, 1.36 to 3.05; and subdistribution HR, 2.21; 95% confidence interval, 1.19 to 4.11, respectively). In conclusion, we identified segmental sclerosis and extracapillary hypercellularity as novel, poor prognostic indicators of time from DKD to ESRD. Whether these indicators represent a distinct pathogenetic phenotype of DKD will require a large study with a broad spectrum of disease severity.
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Affiliation(s)
- Amy K Mottl
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Adil Gasim
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina
| | | | - Yichun Hu
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Askia K Dunnon
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Susan L Hogan
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - J Charles Jennette
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina
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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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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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Carpenter DM, Thorpe CT, Alexander DS, Sage AJ, Lewis M, Hogan SL, Geryk LL, DeVellis RF. The Relationship Between Social Support, Social Constraint, and Psychological Adjustment for Patients with Rare Autoimmune Disease. Curr Rheumatol Rev 2017; 12:232-238. [PMID: 27448594 DOI: 10.2174/1573397112666160719163145] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 02/26/2016] [Accepted: 07/11/2016] [Indexed: 01/07/2023]
Abstract
Our goals were to describe the balance of social support to negative social interactions (i.e. social constraint) for autoimmune disease patients and determine whether support and constraint from spouses and non-spousal family and friends interact to influence patients' psychological adjustment. Using crosssectional survey data from 109 married vasculitis and lupus patients, we found that patients reported that spouses and family/friends provided more social support than social constraint. In regression models, constraint from spouses (β= -0.45, p<0.01) and family/friends (β= -0.89, p<0.001) were associated with worse patient psychological adjustment. A significant 3-way interaction revealed that patients with low spousal support had worse psychological adjustment as the levels of family and friend support increased. In contrast, patients with high levels of spousal support reported better psychological adjustment as family and friend support increased. Future longitudinal studies may help to elucidate the complex interplay between constraint and support from spouses, family, and friends.
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Affiliation(s)
- Delesha M Carpenter
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, One University Heights CPO 2125, Asheville, NC, USA
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George B, Wen X, Mercke N, Gomez M, O'Bryant C, Bowles DW, Hu Y, Hogan SL, Joy MS, Aleksunes LM. Profiling of Kidney Injury Biomarkers in Patients Receiving Cisplatin: Time-dependent Changes in the Absence of Clinical Nephrotoxicity. Clin Pharmacol Ther 2017; 101:510-518. [PMID: 28002630 DOI: 10.1002/cpt.606] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/05/2016] [Accepted: 12/11/2016] [Indexed: 12/29/2022]
Abstract
The success of cisplatin-containing regimens to treat solid tumors is limited, in part, by nephrotoxicity. In rodents, several urinary proteins have emerged that are sensitive indicators of cisplatin-induced kidney injury. We sought to characterize time-dependent changes in the urinary concentrations of 12 proteins, including kidney injury molecule-1 (KIM-1), calbindin, beta 2-microglobulin (β2M), and trefoil factor 3 (TFF3) after cisplatin therapy. Urine was collected at baseline, 3 days (range, 2-5 days), and 10 days (range, 9-11 days) from 57 patients with solid tumors receiving outpatient cisplatin therapy (≥25 mg/m2 ). Serum creatinine was largely unchanged after cisplatin infusion. However, compared with baseline values, several novel biomarkers were significantly increased in the urine, including β2M, which was threefold higher by day 3 (P < 0.0001). Urinary KIM-1 and TFF3 were elevated twofold by day 10 (P = 0.002 and P = 0.002, respectively), whereas calbindin levels were increased eightfold (P < 0.0001). We report novel time-dependent changes in the urinary excretion of noninvasive markers of subclinical kidney injury after cisplatin treatment.
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Affiliation(s)
- Blessy George
- Department of Pharmacology and Toxicology, Rutgers University Ernest Mario School of Pharmacy, 170 Frelinghuysen Road, Piscataway, NJ, 08854, USA
| | - Xia Wen
- Department of Pharmacology and Toxicology, Rutgers University Ernest Mario School of Pharmacy, 170 Frelinghuysen Road, Piscataway, NJ, 08854, USA
| | - Nickie Mercke
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, 80045, USA
| | - Madeleine Gomez
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, 80045, USA
| | - Cindy O'Bryant
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, 80045, USA.,Division of Medical Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Daniel W Bowles
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Yichun Hu
- UNC Kidney Center and Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Susan L Hogan
- UNC Kidney Center and Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Melanie S Joy
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, 80045, USA.,Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Lauren M Aleksunes
- Department of Pharmacology and Toxicology, Rutgers University Ernest Mario School of Pharmacy, 170 Frelinghuysen Road, Piscataway, NJ, 08854, USA.,Environmental and Occupational Health Sciences Institute, 170 Frelinghuysen Road, Piscataway, NJ 08854, USA 8
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Alexander DS, Hogan SL, Jordan JM, DeVellis RF, Carpenter DM. Examining whether the information-motivation-behavioral skills model predicts medication adherence for patients with a rare disease. Patient Prefer Adherence 2017; 11:75-83. [PMID: 28138225 PMCID: PMC5238767 DOI: 10.2147/ppa.s115272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The information-motivation-behavioral skills (IMB) model has been used to explain and promote medication adherence among patients with diabetes and HIV. The objective of this study was to examine whether the IMB model predicted medication adherence among vasculitis patients. Adult vasculitis patients (n=228) completed online questionnaires at baseline and 3-month follow-up. Linear regressions were calculated to determine the direct effects of information and motivation on medication adherence (P<0.05). A mediation analysis using a bootstrapping approach was used to test whether behavioral skills significantly mediated the effect of information and motivation on medication adherence. Participants reported high levels of information (M=4.0; standard deviation [SD]=0.68), moderate levels of motivation (M=2.7; SD=1.00), and high levels of behavioral skills (M=4.1; SD=0.74). In the regression model, only behavioral skills (B=0.38; P<0.001) were significantly associated with medication adherence; however, mediation analysis revealed that behavioral skills significantly mediated the effects of information and motivation on medication adherence. The results support the IMB-hypothesized relationships between information, motivation, behavioral skills, and medication adherence in our sample. Findings suggest that providers should work with vasculitis patients to increase their medication-related skills to improve medication adherence.
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Affiliation(s)
- Dayna S Alexander
- UNC Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Asheville
- Correspondence: Dayna S Alexander, UNC Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, One University Heights, CPO #2125, Asheville, NC 28804, USA, Email
| | | | - Joanne M Jordan
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Robert F DeVellis
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Delesha M Carpenter
- UNC Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Asheville
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Joy MS, Dornbrook-Lavender KA, Chin H, Hogan SL, Denu-Ciocca C. Effects of Atorvastatin on Lp(a) and Lipoprotein Profiles in Hemodialysis Patients. Ann Pharmacother 2016; 42:9-15. [DOI: 10.1345/aph.1k407] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Dialysis patients have many underlying traditional and nontraditional risk factors that may predispose them to a high prevalence of cardiovascular disease. The effects of statins (eg, atorvastatin) on altering nontraditional lipoprotein measures in dialysis patients have not been extensively investigated. Objective: To evaluate the efficacy of atorvastatin compared with a control group in inducing changes in lipoprotein(a) [Lp(a)], apolipoprotein (Apo) A-1, Apo-B, and fibrinogen levels, as well as the conventional lipoprotein profile, in hemodialysis patients over 36 weeks; secondary objectives were to assess changes in C-reactive protein, albumin, and safety measures. Methods: Forty-five hemodialysis patients with low-density lipoprotein cholesterol (LDL-C) levels greater than 100 mg/dL were randomized to parallel groups: atorvastatin (n = 19) or no treatment (n = 26). The atorvastatin dose was titrated from 10 mg to achieve an LDL-C goal of 100 mg/dL or less and therapy was continued for 36 weeks. Biochemical and lipoprotein laboratory tests for efficacy outcomes were obtained at baseline, 12 weeks, and 36 weeks. Results: The atorvastatin group exhibited clinically significant reductions (mean ± SD) compared with controls in total cholesterol (–21.7 ± 41.7 vs –3.2 ± 40.0 mg/dL, respectively; p = 0.017) and LDL-C (–13.1 ± 32.0 vs –1.1 ± 38.4 mg/dL. respectively; p = 0.056) levels, as well as Lp(a) (–10.6 ± 27 vs 3.5 ± 17.8 mg/dL, respectively; p = 0.046). Statistical analyses included analysis of variance on ranked measures for multivariable modeling and paired t-test to determine changes in efficacy measures between baseline and 36 weeks within groups. Conclusions: Atorvastatin was safe and effective in reducing Lp(a), total cholesterol, and LDL-C levels. Given the prevalence of atherosclerosis in hemodialysis patients, therapy aimed at reducing traditional and nontraditional risk factors may be beneficial.
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Affiliation(s)
- Melanie S Joy
- Division of Nephrology and Hypertension, School of Medicine; Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina Kidney Center, University of North Carolina, Chapel Hill, NC
| | | | - Hyunsook Chin
- Division of Nephrology and Hypertension, School of Medicine, University of North Carolina Kidney Center, University of North Carolina
| | - Susan L Hogan
- Division of Nephrology and Hypertension, School of Medicine, University of North Carolina Kidney Center, University of North Carolina
| | - Cynthia Denu-Ciocca
- Division of Nephrology and Hypertension, School of Medicine, University of North Carolina Kidney Center
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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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O'Shaughnessy MM, Hogan SL. Distinguishing the Signals From the Noise: Can Epidemiologic Studies Inform Our Understanding of Glomerular Disease? Am J Kidney Dis 2016; 68:503-507. [PMID: 27664473 DOI: 10.1053/j.ajkd.2016.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 05/22/2016] [Indexed: 11/11/2022]
Affiliation(s)
| | - Susan L Hogan
- University of North Carolina, Chapel Hill, North Carolina
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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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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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Laurin LP, Gasim AM, Poulton CJ, Hogan SL, Jennette JC, Falk RJ, Foster BJ, Nachman PH. Treatment with Glucocorticoids or Calcineurin Inhibitors in Primary FSGS. Clin J Am Soc Nephrol 2016; 11:386-94. [PMID: 26912551 DOI: 10.2215/cjn.07110615] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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: 06/29/2015] [Accepted: 11/30/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In primary FSGS, calcineurin inhibitors have primarily been studied in patients deemed resistant to glucocorticoid therapy. Few data are available about their use early in the treatment of FSGS. We sought to estimate the association between choice of therapy and ESRD in primary FSGS. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used an inception cohort of patients diagnosed with primary FSGS by kidney biopsy between 1980 and 2012. Factors associated with initiation of therapy were identified using logistic regression. Time-dependent Cox models were performed to compare time to ESRD between different therapies. RESULTS In total, 458 patients were studied (173 treated with glucocorticoids alone, 90 treated with calcineurin inhibitors with or without glucocorticoids, 12 treated with other agents, and 183 not treated with immunosuppressives). Tip lesion variant, absence of severe renal dysfunction (eGFR≥30 ml/min per 1.73 m(2)), and hypoalbuminemia were associated with a higher likelihood of exposure to any immunosuppressive therapy. Only tip lesion was associated with initiation of glucocorticoids alone over calcineurin inhibitors. With adjusted Cox regression, immunosuppressive therapy with glucocorticoids and/or calcineurin inhibitors was associated with better renal survival than no immunosuppression (hazard ratio, 0.49; 95% confidence interval, 0.28 to 0.86). Calcineurin inhibitors with or without glucocorticoids were not significantly associated with a lower likelihood of ESRD compared with glucocorticoids alone (hazard ratio, 0.42; 95% confidence interval, 0.15 to 1.18). CONCLUSIONS The use of immunosuppressive therapy with calcineurin inhibitors and/or glucocorticoids as part of the early immunosuppressive regimen in primary FSGS was associated with improved renal outcome, but the superiority of calcineurin inhibitors over glucocorticoids alone remained unproven.
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Affiliation(s)
- Louis-Philippe Laurin
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada; Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Nephrology and Hypertension, University of North Carolina Kidney Center and
| | - Adil M Gasim
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Caroline J Poulton
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center and
| | - Susan L Hogan
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center and
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ronald J Falk
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center and
| | - Bethany J Foster
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Nephrology, Montreal Children's Hospital, Montreal, Quebec, Canada; and Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Patrick H Nachman
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center and
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45
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Gipson DS, Troost JP, Lafayette RA, Hladunewich MA, Trachtman H, Gadegbeku CA, Sedor JR, Holzman LB, Moxey-Mims MM, Perumal K, Kaskel FJ, Nelson PJ, Tuttle KR, Bagnasco SM, Hogan MC, Dell KM, Appel GB, Lieske JC, Ilori TO, Sethna CB, Fervenza FC, Hogan SL, Nachman PH, Rosenberg AZ, Greenbaum LA, Meyers KEC, Hewitt SM, Choi MJ, Kopp JB, Zhdanova O, Hodgin JB, Johnstone DB, Adler SG, Avila-Casado C, Neu AM, Hingorani SR, Lemley KV, Nast CC, Brady TM, Barisoni-Thomas L, Fornoni A, Jennette JC, Cattran DC, Palmer MB, Gibson KL, Reich HN, Mokrzycki MH, Sambandam KK, Zilleruelo GE, Licht C, Sampson MG, Song P, Mariani LH, Kretzler M. Complete Remission in the Nephrotic Syndrome Study Network. Clin J Am Soc Nephrol 2015; 11:81-9. [PMID: 26656320 DOI: 10.2215/cjn.02560315] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [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: 03/05/2015] [Accepted: 09/24/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES This analysis from the Nephrotic Syndrome Study Network (NEPTUNE) assessed the phenotypic and pathology characteristics of proteinuric patients undergoing kidney biopsy and defined the frequency and factors associated with complete proteinuria remission (CRever). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We enrolled adults and children with proteinuria ≥0.5 g/d at the time of first clinically indicated renal biopsy at 21 sites in North America from April 2010 to June 2014 into a prospective cohort study. NEPTUNE central pathologists assigned participants to minimal-change disease (MCD), FSGS, membranous nephropathy, or other glomerulopathy cohorts. Outcome measures for this analysis were (1) CRever with urine protein-to-creatinine ratio (UPC) <0.3 g/g with preserved native kidney function and (2) ESRD. Continuous variables are reported as median and interquartile range (IQR; 25th, 75th percentile). Cox proportional hazards modeling was used to assess factors associated with CRever. RESULTS We enrolled 441 patients: 116 (27%) had MCD, 142 (32%) had FSGS, 66 (15%) had membranous nephropathy, and 117 (27%) had other glomerulopathy. The baseline UPC was 4.1 g/g (IQR, 1.9, 7.7) and the eGFR was 81 ml/min per 1.73 m(2) (IQR, 50, 105). Median duration of observation was 19 months (IQR, 11, 30). CRever occurred in 46% of patients, and 4.6% progressed to ESRD. Multivariate analysis demonstrated that higher prebiopsy proteinuria (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.5) and pathology diagnosis (FSGS versus MCD; hazard ratio, 0.2; 95% confidence interval, 0.1 to 0.5) were inversely associated with CRever. The effect of immunosuppressive therapy on remission varied by pathology diagnosis. CONCLUSIONS In NEPTUNE, the high frequency of other pathology in proteinuric patients affirms the value of the diagnostic kidney biopsy. Clinical factors, including level of proteinuria before biopsy, pathology diagnosis, and immunosuppression, are associated with complete remission.
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Affiliation(s)
- Debbie S Gipson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
| | - Jonathan P Troost
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Richard A Lafayette
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Michelle A Hladunewich
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Howard Trachtman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Crystal A Gadegbeku
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - John R Sedor
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Lawrence B Holzman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Marva M Moxey-Mims
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Kalyani Perumal
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Frederick J Kaskel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Peter J Nelson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Katherine R Tuttle
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Serena M Bagnasco
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Marie C Hogan
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Katherine M Dell
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Gerald B Appel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - John C Lieske
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Titilayo O Ilori
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Christine B Sethna
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Fernando C Fervenza
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Susan L Hogan
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Patrick H Nachman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Avi Z Rosenberg
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Larry A Greenbaum
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Kevin E C Meyers
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Stephen M Hewitt
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Michael J Choi
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jeffrey B Kopp
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Olga Zhdanova
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jeffrey B Hodgin
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Duncan B Johnstone
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Sharon G Adler
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Carmen Avila-Casado
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Alicia M Neu
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Sangeeta R Hingorani
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Kevin V Lemley
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Cynthia C Nast
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Tammy M Brady
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Laura Barisoni-Thomas
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Alessia Fornoni
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - J Charles Jennette
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Daniel C Cattran
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Matthew B Palmer
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Keisha L Gibson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Heather N Reich
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Michele H Mokrzycki
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Kamalanathan K Sambandam
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Gaston E Zilleruelo
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Christoph Licht
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Matthew G Sampson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Peter Song
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Laura H Mariani
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Matthias Kretzler
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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46
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Jobson MA, Hogan SL, Maxwell CS, Hu Y, Hladik GA, Falk RJ, Beuhler MC, Pendergraft WF. Clinical Features of Reported Ethylene Glycol Exposures in the United States. PLoS One 2015; 10:e0143044. [PMID: 26566024 PMCID: PMC4643878 DOI: 10.1371/journal.pone.0143044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ethylene glycol is highly toxic and represents an important cause of poisonings worldwide. Toxicity can result in central nervous system dysfunction, cardiovascular compromise, elevated anion gap metabolic acidosis and acute kidney injury. Many states have passed laws requiring addition of the bittering agent, denatonium benzoate, to ethylene glycol solutions to reduce severity of exposures. The objectives of this study were to identify differences between unintentional and intentional exposures and to evaluate the utility of denatonium benzoate as a deterrent. METHODS AND FINDINGS Using the National Poison Data System, we performed a retrospective analysis of reported cases of ethylene glycol exposures from January 2006 to December 2013. Outcome classification was summed for intentionality and used as a basis for comparison of effect groups. There were 45,097 cases of ethylene glycol exposures resulting in 154 deaths. Individuals more likely to experience major effects or death were older, male, and presented with more severe symptoms requiring higher levels of care. Latitude and season did not correlate with increased exposures; however, there were more exposures in rural areas. Denatonium benzoate use appeared to have no effect on exposure severity or number. CONCLUSION Deaths due to ethylene glycol exposure were uncommon; however, there were major clinical effects and more exposures in rural areas. Addition of denatonium benzoate was not associated with a reduction in exposures. Alternative means to deter ingestion are needed. These findings suggest the need to consider replacing ethylene glycol with alternative and less toxic agents.
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Affiliation(s)
- Meghan A. Jobson
- University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Chapel Hill, North Carolina, United States of America
| | - Susan L. Hogan
- University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Chapel Hill, North Carolina, United States of America
| | - Colin S. Maxwell
- Department of Biology, Duke Center for Systems Biology, Duke University, Durham, North Carolina, United States of America
| | - Yichun Hu
- University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Chapel Hill, North Carolina, United States of America
| | - Gerald A. Hladik
- University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Chapel Hill, North Carolina, United States of America
| | - Ronald J. Falk
- University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Chapel Hill, North Carolina, United States of America
| | - Michael C. Beuhler
- Carolinas Poison Center, Carolinas Medical Center, Charlotte, North Carolina, United States of America
| | - William F. Pendergraft
- University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Lebov JF, Engel LS, Richardson D, Hogan SL, Sandler DP, Hoppin JA. Pesticide exposure and end-stage renal disease risk among wives of pesticide applicators in the Agricultural Health Study. Environ Res 2015; 143:198-210. [PMID: 26505650 PMCID: PMC4662544 DOI: 10.1016/j.envres.2015.10.002] [Citation(s) in RCA: 39] [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: 03/02/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 05/08/2023]
Abstract
BACKGROUND Pesticide exposure has been found to cause renal damage and dysfunction in experimental studies, but epidemiological research on the renal effects of chronic low-level pesticide exposure is limited. We investigated the relationships between end-stage renal disease (ESRD) among wives of licensed pesticide applicators (N=31,142) in the Agricultural Health Study (AHS) and (1) personal pesticide use, (2) exposure to the husband's pesticide use, and (3) other pesticide-associated farming and household activities. METHODS AHS participants reported pesticide exposure via self-administered questionnaires at enrollment (1993-1997). ESRD cases were identified via linkage to the United States Renal Data System. Associations between ESRD and pesticide exposures were estimated with Cox proportional hazard regression models controlling for age at enrollment. Models of associations with farming and household factors were additionally adjusted for personal use of pesticides. RESULTS We identified 98 ESRD cases diagnosed between enrollment and 31 December 2011. Although women who ever applied pesticides (56% of cohort) were less likely than those who did not apply to develop ESRD (Hazard Ratio (HR): 0.42; 95% CI: 0.28, 0.64), among women who did apply pesticides, the rate of ESRD was significantly elevated among those who reported the highest (vs. lowest) cumulative general pesticide use (HR: 4.22; 95% CI: 1.26, 14.20). Among wives who never applied pesticides, ESRD was associated with husbands' ever use of paraquat (HR=1.99; 95% CI: 1.14, 3.47) and butylate (HR=1.71; 95% CI: 1.00, 2.95), with a positive exposure-response pattern for husband's cumulative use of these pesticides. CONCLUSIONS ESRD may be associated with direct and/or indirect exposure to pesticides among farm women. Future studies should evaluate indirect exposure risk among other rural populations.
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Affiliation(s)
- Jill F Lebov
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
| | - Lawrence S Engel
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
| | - David Richardson
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
| | - Susan L Hogan
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC, USA.
| | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
| | - Jane A Hoppin
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, USA.
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McGregor JG, Hogan SL, Kotzen ES, Poulton CJ, Hu Y, Negrete-Lopez R, Kidd JM, Katsanos SL, Bunch DO, Nachman PH, Falk RJ. Rituximab as an immunosuppressant in antineutrophil cytoplasmic antibody-associated vasculitis. Nephrol Dial Transplant 2015; 30 Suppl 1:i123-31. [PMID: 25805743 DOI: 10.1093/ndt/gfv076] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 12/20/2022] Open
Abstract
BACKGROUND Rituximab has been used in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) since 2003. Our objective was to describe outcomes and adverse events following rituximab since that time in an inception cohort. METHODS Patients with AAV (diagnosed 1991-2012) who received rituximab (n = 120) were evaluated and incidence per person-year (PPY) with 95% confidence interval was calculated for relapse and infections. Time to remission and relapse by number of rituximab infusions given per treatment course (≤2 versus >2) and by ever having been exposed to cyclophosphamide were compared using Kaplan-Meier curves. Rituximab-treated patients were characterized in comparison with AAV patients treated with cyclophosphamide but not exposed to rituximab (n = 351) using Fisher's exact or rank tests. RESULTS Rituximab resulted in 86% achieving remission and 41% having a subsequent relapse in a median of 19 months (range 9-29). Time to remission and relapse were similar between rituximab infusion courses (≤2 versus >2; remission P = 0.86 and relapse P = 0.78, respectively). Incidence of relapse was 0.22 PPY (0.14, 0.31) and of severe infection was 0.12 PPY (0.08, 0.24). Time to relapse was shorter in those never exposed to cyclophosphamide (n = 20): 50% by 8 months versus 50% by 24 and 30 months for those with prior or concurrent exposure to cyclophosphamide (n = 100). Compared with those who never received rituximab, rituximab-treated patients were younger (P < 0.001), more likely to have granulomatosis with polyangiitis (P = 0.001) and had more upper airway (P = 0.01) and less kidney involvement (P = 0.007). CONCLUSIONS Rituximab is beneficial when prescribed outside of a trial setting. Response to treatment and relapse is similar regardless of infusion number. Rituximab without cyclophosphamide may result in a shorter time to relapse supporting combination of these therapies.
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Affiliation(s)
| | - Susan L Hogan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth S Kotzen
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Duke University Medical Center, Durham, NC, USA
| | | | - Yichun Hu
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roberto Negrete-Lopez
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Hospital Universitario-UANL Monterrey, Nuevo Leon, Mexico
| | - Jason M Kidd
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Medical College of Virginia, Richmond, VA, USA
| | | | - Donna O Bunch
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Ronald J Falk
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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McGregor JG, Negrete-Lopez R, Poulton CJ, Kidd JM, Katsanos SL, Goetz L, Hu Y, Nachman PH, Falk RJ, Hogan SL. Adverse events and infectious burden, microbes and temporal outline from immunosuppressive therapy in antineutrophil cytoplasmic antibody-associated vasculitis with native renal function. Nephrol Dial Transplant 2015; 30 Suppl 1:i171-81. [PMID: 25805747 DOI: 10.1093/ndt/gfv045] [Citation(s) in RCA: 53] [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] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Disease control in anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) with immunosuppression is effective but burdened by adverse events, especially infections. The study goal was to evaluate risks and types of infections in patients with AAV. METHODS Biopsy-proven AAV patients (diagnosed 1/1991-6/2011) followed in an inception cohort were evaluated for adverse events. Severe infections (requiring intravenous antibiotics, intensive care unit, or causing death) were recorded. Infection number was grouped as none, 1-2 or ≥3. Cox regression was used to estimate hazard ratios with 95% confidence intervals. RESULTS A total of 489 patients (median age 59; 47% female, 55% myeloperoxidase-ANCA) were followed for 2.8 years (median). At 1, 2 and 5 years cumulative incidence of infection was 51, 58 and 65% and severe infection was 22, 23 and 26%. Pulmonary and upper respiratory infections were most common (42 and 30% ever experienced each, respectively), highest in the first 3 months. Staphylococcus aureus was most frequently seen among positive cultures (41%, 78 S. aureus/192 total positive cultures), and only one Pneumocystis jiroveci pneumonia (6 weeks into treatment). All-cause death in 12 months was associated with infections (% deaths: 0 infections 3%; 1-2 infections 10%, ≥3 infections 13%, P = 0.002). Controlling for age, sex and kidney function, patients with severe infections were 4.2 times more likely to die within 12 months (95% CI 2.0-8.7; P = 0.001). CONCLUSIONS More infections increase the risk of a severe infection which increases risk of all-cause mortality. Respiratory and S. aureus infections are dominant. Targeted prophylactic therapy could decrease morbidity.
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Affiliation(s)
| | | | | | - Jason M Kidd
- Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Yichun Hu
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Ronald J Falk
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Lebov JF, Engel LS, Richardson D, Hogan SL, Hoppin JA, Sandler DP. Pesticide use and risk of end-stage renal disease among licensed pesticide applicators in the Agricultural Health Study. Occup Environ Med 2015; 73:3-12. [PMID: 26177651 DOI: 10.1136/oemed-2014-102615] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 06/22/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Experimental studies suggest a relationship between pesticide exposure and renal impairment, but epidemiological evidence is limited. We evaluated the association between exposure to 39 specific pesticides and end-stage renal disease (ESRD) incidence in the Agricultural Health Study, a prospective cohort study of licensed pesticide applicators in Iowa and North Carolina. METHODS Via linkage to the US Renal Data System, we identified 320 ESRD cases diagnosed between enrolment (1993-1997) and December 2011 among 55 580 male licensed pesticide applicators. Participants provided information on use of pesticides via self-administered questionnaires. Lifetime pesticide use was defined as the product of duration and frequency of use and then modified by an intensity factor to account for differences in pesticide application practices. Cox proportional hazards models, adjusted for age and state, were used to estimate associations between ESRD and: (1) ordinal categories of intensity-weighted lifetime use of 39 pesticides, (2) poisoning and high-level pesticide exposures and (3) pesticide exposure resulting in a medical visit or hospitalisation. RESULTS Positive exposure-response trends were observed for the herbicides alachlor, atrazine, metolachlor, paraquat, and pendimethalin, and the insecticide permethrin. More than one medical visit due to pesticide use (HR=2.13; 95% CI 1.17 to 3.89) and hospitalisation due to pesticide use (HR=3.05; 95% CI 1.67 to 5.58) were significantly associated with ESRD. CONCLUSIONS Our findings support an association between ESRD and chronic exposure to specific pesticides, and suggest pesticide exposures resulting in medical visits may increase the risk of ESRD. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT00352924.
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Affiliation(s)
- Jill F Lebov
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lawrence S Engel
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David Richardson
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Susan L Hogan
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jane A Hoppin
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina, USA
| | - Dale P Sandler
- Epidemiology Branch/Chronic Disease Epidemiology Group, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
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