Podocyte Antigens Research Articles

Overview of Immunological Response in Urological Membranous Nephropathy: Focus on Cytokine and Treatment Options.

Membranous nephropathy (MN) is an autoimmune disease that is caused by the production of autoantibody against glomerular podocyte antigens by immune cells due to the lack of self-tolerance mechanisms. Similar to many autoimmune diseases, the pathogenesis of MN is still vague and many experiments are being conducted to detect the antigens and genetic reasons for MN illness. Recently, new antigens, such as exotosin 1/exotosin 2, neural EGF-like-1, semaphorin 3B, and protocadherin 7 have been identified in MN patients who did not have presence of antiphospholipase A2 receptor antigen. What is more, cytokines, which are molecules that regulate immune responses, have been found to have harmful effects in various autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and MN. The role of cytokines and treatment strategies in MN patients is discussed in this article. As the understanding of the disease improves, targeted therapies that focus on specific antigens or cytokines may be developed to effectively manage MN.

Diagnosis and Treatment of Membranous Nephropathy in Integrative Medicine

Membranous nephropathy (MN) is a common glomerular disease. The related pathological changes are primarily characterized by the deposition of immune complexes beneath the epithelial cells of the glomerular basement membrane, accompanied by diffuse thickening of the basement membrane. Its etiology and pathogenesis are not fully understood yet; however, they are associated with genetics, infections, tumors, drugs, heavy metals poisoning, environmental pollution, and the loss of immune tolerance. Over 10 target antigens, including the phospholipase A2 receptor (PLA2R) and thrombospondin type 1 domain containing 7A (THSD7A), associated with MN have been identified, each having different clinical implications. Clinical manifestations of MN patients mainly include proteinuria and nephrotic syndrome, with a propensity to form thrombi. Its diagnostic accuracy can be enhanced by combining clinical manifestations, serum antibody testing, and renal biopsy. Proteinuria, estimated glomerular filtration rate (eGFR), and PLA2R antibody levels are vital for the prognostic risk stratification of MN. Low-risk patients primarily undergo non-immunosuppressive treatment (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin II receptor blocker [ARB], sodium-glucose cotransporter 2 inhibitor [SGLT2i], anticoagulants, and traditional Chinese medicine [TCM] treatments), while high-risk patients need to consider using steroids and immunosuppressants, such as cyclophosphamide (CTX), calcineurin inhibitors (CNIs), and anti-cluster of differentiation 20 (anti-CD20) monoclonal antibodies. TCM holds that MN is the imbalance of Fei (lung), Pi (spleen), and Shen (kidney) function, leading to the generation of Neixie such as Shi, Re, Du, and Yu. This disease is difficult to heal because of Shire and Yu. The treatment is based on the use of Jianpi Bushen, simultaneously emphasizing the use of drugs for Qingre Qushi Huoxue. Dialectical use of TCM can obviously improve the clinical response rate and alleviate symptoms such as edema and fatigue by increasing the serum albumin level more rapidly while introducing fewer adverse reactions. Combined with Western medicine, TCM can also reduce toxicity and increase efficiency. This article systematically reviews the etiology, podocyte antigens, clinical manifestations, diagnostic approaches, risk assessment, and integrative medicine therapeutic strategies for MN, aiming to deepen the understanding of MN and guide clinical practice.

#2553 Circulating anti-slit diaphragm NEPHRIN and KIRREL-2 antibodies associate with nephrotic syndrome

Abstract Background and Aims Pathogenesis of Idiopathic Nephrotic Syndrome (INS) is still largely unknown. Recently, circulating anti-NEPHRIN antibodies have been proposed as responsible of disarrangement of the slit diaphragm architecture upon glomerular deposition. However, previous experience referred to limited cases and controls with different ELISA assays for antibodies detection. We compared the performance of three different ELISA assays quantifying circulating anti-NEPHRIN antibodies and we developed ELISA assays to quantify circulating antibodies against two proteins homologous of NEPHRIN, the KIRREL.1 and KIRREL-2. Method We compared the performance of three different ELISA assays, two against the extracellular (aa 1-1055NEPHRIN-A and aa 23-1029 NEPHRIN-B) and one against the intracytoplasmic (aa 1160-1241 NEPHRIN-C) domain of NEPHRIN. We tested a large cohort of 166 patients (396 serum samples) with INS, 32 focal segmental glomerulosclerosis kidney transplant recipients, 143 healthy controls and 40 lupus nephritis and membranous nephropathy, respectively. Furthermore, to investigate sensitivity and specificity of circulating anti-NEPHRIN antibodies, we developed ELISA assays to quantify circulating antibodies against two proteins homologous of NEPHRIN, the KIRREL-1 and KIRREL-2. We tested NEPHRIN and KIRREL-2 gene expression among glomeruli in kidney biopsies from 4 FSGS patient and 4 controls. Results Serum levels of anti-NEPHRIN antibodies against the two extracellular domains were highly correlated, but differed significantly to the levels detected using the intracytoplasmic domain of NEPHRIN. Neither the circulating anti-NEPHRIN targeting the extracellular nor the intracellular domains of the protein could differentiate INS patients overall from healthy controls (Fig. 1A). However, after age stratification, we found that circulating anti-NEPHRIN antibodies against the extracellular domain were significatively higher in INS than in healthy controls >6 years old (Fig. 1B).Circulating anti-NEPHRIN antibodies against extracellular domain appeared more specific for INS than anti-NEPHRIN antibodies against cytoplasmic domain. Circulating anti-NEPHRIN antibodies did not correlate with disease activity nor FSGS recurrence after kidney transplant (Fig. 1C). Of note, circulating anti-KIRREL-2 antibodies could differentiate INS and healthy controls more effectively than anti-NEPHRIN antibodies (Fig. 1D). We than confirmed that KIRREL-2 is transcript in glomeruli (Fig. 1E) and, in line with circulating anti-KIRREL-2 antibodies, spatial transcriptomic analyses showed that KIRREL-2 is increased in FSGS than in controls. Conclusion In a large cohort of patients, we showed that circulating anti-NEPHRIN antibodies are positive in a subset of INS and FSGS recurrence. However, they are not associated with disease activity and the circulating levels appeared as age related. Circulating anti-KIRREL-2 antibodies are more strongly associated with INS. Therefore, based on our findings, several podocyte antigens may be supposed target for specific autoantibodies in INS.

Is There a Place for Apheresis in the Management of Idiopathic Membranous Nephropathy? A Report of Three Cases and Literature Review.

Membranous nephropathy constitutes approximately 20% of adult nephrotic syndrome cases. In approximately 80% of cases, membranous nephropathy is primary, mediated by IgG autoantibodies primarily targeting podocyte antigens (PLA2R, THSD7A, etc.). The treatment involves a combination of corticosteroids and cyclophosphamide or anti-CD20-based therapies, e.g., rituximab. In the event of significant proteinuria and in order to avoid the urinary elimination of rituximab, therapeutic apheresis, in particular semi-specific immunoadsorption, may be an option allowing for a reduction in proteinuria and autoantibodies before initiating treatment with rituximab. We present the preliminary experience of three patients treated with semi-specific immunoadsorption for primary membranous nephropathy between January 2021 and March 2023. Two patients were anti-PLA2R-autoantibody-positive and one was seronegative. The average age was 59 ± 17 years. Semi-specific immunoadsorption did not reduce albuminuria, but it, nevertheless, led to an increase in serum albumin, contributing to the regression of edema. It effectively eliminated anti-PLA2R autoantibodies in the two anti-PLA2R-positive patients. Consequently, apheresis may not induce a rapid reduction in proteinuria, but could contribute to a more accelerated remission when combined with the anti-CD20 treatment.

The application of podocyte antigen PLA2R and anti-PLA2R antibody in the diagnosis and treatment of membranous nephropathy

Background The application of podocyte antigen M-type phospholipase A2 receptor (PLA2R, GAg) and serum anti-PLA2R antibody (SAb) in predicting the prognosis of membrane nephropathy (MN) was controversial. Method 328 biopsy-proven MN patients were divided into three phenotypes, 182 MN patients with GAg+/SAb+, 118 MN patients with GAg+/SAb-, and 28 MN patients with GAg-/SAb-. The baseline clinicopathological characteristics, therapy response, and prognosis were compared among the three groups. Cox regression analysis was performed to assess predictors of remission. Anti-PLA2R antibody was analyzed by receiver operating characteristic curve to find the optimal titer for MN diagnosis. Result Lower eGFR (p = 0.009), higher UPCR (p < 0.001), and lower serum albumin (p < 0.001) were observed in GAg+/SAb+ MN patients, compared to GAg+/SAb- MN patients. More GAg+/SAb+ MN patients received cyclophosphamide (CTX) combined with glucocorticoids and calcineurin inhibitors (CNI) based therapy than the other two groups (p = 0.015 and p = 0.023, respectively). No significant difference was observed among the three groups in terms of complete remission, relapse, and developing ESRD. SAb+ status was an independent predictor for no remission (hazard ratio 1.378, 95% confidence interval 1.023 to 1.855; p = 0.035). The optimal cutoff value for anti-PLA2R antibody to predict MN was 2.055 RU/mL (sensibility 0.802, specificity 0.970). Conclusion GAg+/SAb+ MN patients were related to more severe clinical manifestations and more requisition of immunosuppressive treatment. Positive anti-PLA2R antibody was an independent predictor for no remission. An anti-PLA2R antibody above 2.055 RU/mL can be a suggestive indicator of MN diagnosis in patients with proteinuria.

Metalloporphyrins Reduce Proteinuria in Podocyte Immune Injury: The Role of Metal and Porphyrin Moieties.

Depending on their central metal atom, metalloporphyrins (MPs) can attenuate or exacerbate the severity of immune-mediated kidney injury, and this has been attributed to the induction or inhibition of heme oxygenase (HO) activity, particularly the inducible isoform (HO-1) of this enzyme. The role of central metal or porphyrin moieties in determining the efficacy of MPs to attenuate injury, as well as mechanisms underlying this effect, have not been assessed. Using an antibody-mediated complement-dependent model of injury directed against rat visceral glomerular epithelial cells (podocytes) and two MPs (FePPIX, CoPPIX) that induce both HO-1 expression and HO enzymatic activity in vivo but differ in their chelated metal, we assessed their efficacy in reducing albuminuria. Podocyte injury was induced using rabbit immune serum raised against the rat podocyte antigen, Fx1A, and containing an anti-Fx1A antibody that activates complement at sites of binding. FePPIX or CoPPIX were injected intraperitoneally (5 mg/kg) 24 h before administration of the anti-Fx1A serum and on days 1, 3, 6, and 10 thereafter. Upon completion of urine collection on day 14, the kidney cortex was obtained for histopathology and isolation of glomeruli, from which total protein extracts were obtained. Target proteins were analyzed by capillary-based separation and immunodetection (Western blot analysis). Both MPs had comparable efficacy in reducing albuminuria in males, but the efficacy of CoPPIX was superior in female rats. The metal-free protoporphyrin, PPIX, had minimal or no effect on urine albumin excretion. CoPPIX was also the most potent MP in inducing glomerular HO-1, reducing complement deposition, and preserving the expression of the complement regulatory protein (CRP) CD55 but not that of CD59, the expression of which was reduced by both MPs. These observations demonstrate that the metal moiety of HO-1-inducing MPs plays an important role in reducing proteinuria via mechanisms involving reduced complement deposition and independently of an effect on CRPs.

Novel Antigens and Clinical Updates in Membranous Nephropathy.

Membranous nephropathy (MN), an autoimmune kidney disease and leading cause of nephrotic syndrome, leads to kidney failure in up to one-third of affected individuals. Most MN cases are due to an autoimmune reaction against the phospholipase A2 receptor (PLA2R) located on kidney podocytes. Serum PLA2R antibody quantification is now part of routine clinical practice because antibody titers correlate with disease activity and treatment response. Recent advances in target antigen detection have led to the discovery of more than 20 other podocyte antigens, yet the clinical impact of additional antigen detection remains unknown and is under active investigation. Here we review recent findings and hypothesize how current research will inform future care of patients with MN.

#6605 A CASE REPORT OF MEMBRANOUS NEPHROPATHY SECONDARY TO SYPHILIS: A STEROID-RESPONSIVE DISEASE?

Abstract Background and Aims Membranous Nephropathy (MN) is among the most common forms of nephrotic syndrome in the adults. MN in adults is most often primary (75-80%) and caused by circulating autoantibodies against podocyte antigens being PLA2R the most important target. In the remaining 20-25% of cases, the MN lesion is associated with various disorders, including infections, autoimmune diseases, thyroiditis, malignancies, and the use of certain drugs. Syphilis is a chronic bacterial infection caused by Treponema Pallidum that can present in the primary, secondary or tertiary forms. Kidneys can be involved during either the secondary or the tertiary phase and the most frequent clinical presentation is nephrotic syndrome underlying membranous nephropathy. Here, we present the case of a 47-year-old man who developed rapidly progressive acute kidney injury, nephrotic syndrome and a blotchy diffuse macular rash secondary to Treponema Pallidum infection. Method Data review and collection of clinical records, kidney biopsy evaluation, treatment and outcomes description. Results A 47-year-old man presented to our hospital complaining about asthenia and dizziness. He reported recent use of both antinflammatory drugs and antibiotics to treat an anal fissure. His past medical history was notable for previous drug abuse and alcohol consumption. Physical examination highlighted peripheral edema and a diffuse macular rash. Serum analysis showed serum creatinine of 2.06 mg/dL, urea 84 mg/dL, haemoglobin 13.8 g/dL, albumin 4 g/dL and protein/creatinine ratio of 17741 mg/g; urinary dipstick was positive for haemoglobinuria and proteinuria. Urine collection revealed 22 g proteins/24h. Kidney ultrasound showed normal kidneys with a preserved cortico-medullary differentiation and thickness. In the next days kidney function worsened (serum creatinine 3 mg/dL and urea 100 mg/dL) and daily proteinuria reached a peak of 35 g/24h. A complete panel of antibodies was searched. IgG4 against PLA2R were negative. ANA, ENA and ANCA were absent, C3 and C4 were in the normal range. Serologic testing for HBV, HCV and HIV were negative. Empiric steroid therapy with prednisone 1 mg/kg/day was started obtaining a rapid improvement in terms of proteinuria and kidney function (Fig. 1), the cutaneous rash fainted. Kidney biopsy was performed and demonstrated a membranous nephropathy. Serologic testing for syphilis revealed positive TPHA (titer, 1:2560; normal value, &amp;lt;1:80) and a positive Venereal Disease Research Laboratory test (VDRL) (titer, 1:32; normal value, &amp;lt;1:2). The presentation suggested the diagnosis of anti-PLA2R negative membranous nephropathy secondary to systemic syphilis. Because of the serious clinical manifestation and the unknown duration of the infection we decided to treat the patient with Benzathine penicillin G 2.4 million units administered as three doses at one week intervals (Schön &amp; Bertsch, 2016). Oral steroid was maintained at a dose of 1mg/kg/body weight and descalation started after 30 days. The proteinuria also improved with a reduction in the 24-hour collection from 30 g to 200 mg and serum creatinine went back to normal. Clinical course according to treatment phases are summarized in Fig. 1. Conclusion As far as we know, this is the first case of PLA2R negative membranous nephropathy secondary to syphilis. Although, antibiotic therapy is pivotal in syphilis treatment, our patient showed a fast improvement of kidney function, proteinuria and fainting of the cutaneous erythema after steroid therapy and before starting antibiotic therapy. This suggested the possible role of steroids in treatment of secondary T. Pallidum infection complicated by anti-PLA2R negative membranous nephropathy. Further researches are needed to better define the possible role of steroids in the context of an infective but immune-complex mediated nephropathy.

#4851 MOLECULAR FEATURES OF CIRCULATORY B CELLS AND RENAL CELLS AT THE SINGLE-CELL LEVEL IN AUTOANTIBODY-NEGATIVE PRIMARY MEMBRANOUS NEPHROPATHY PATIENTS

Abstract Background and Aims Primary membranous nephropathy (PMN) is an organ-specific autoimmune disease that is the most common cause of idiopathic nephrotic syndrome in adults. Furthermore, the incidence of PMN is increasing, especially in young adults and children. The landmark discovery of nephritogenic autoantibodies against podocyte antigens such as M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing protein 7A (THSD7A) has provided a paradigm shift in diagnosis and treatment of PMN. However, there are still few patients with negative serum and renal tissue autoantibodies. This study aims to explore the molecular features of antibody-negative PMN. Method We sorted CD19+ cells from the peripheral blood of a pediatric patient with seven nephritogenic autoantibodies-negative PMN (NEG) by flow cytometry and performed single-cell transcriptome sequencing (scRNA-seq) and single-cell B cell receptor sequencing (scBCR-seq). Meanwhile, scRNA-seq was performed on renal biopsy tissues from the same patient. In addition, we included the scRNA-seq data of renal from anti-PLA2R antibody positive patients (POS) and healthy controls (CTRL), and the scBCR-seq data of B cell from CTRL for integrative analysis. Results The NEG patient showed typical nephrotic syndrome and was diagnosed as stage Ⅲ membranous nephropathy by renal biopsy. There was no evidence of anti-PLA2R or anti-THSD7A antibodies in peripheral blood and seven nephritogenic autoantibodies such as anti-PLA2R antibodies in renal tissue. After excluding secondary factors, the patient was diagnosed with PMN. Through scRNA-seq of CD19+ cells, we found that the number, characteristic gene, function and clonotype of naÏve B cells and memory B cells in NEG were significantly changed. Expanded CD38+ naÏve B cells in NEG had the molecular characteristics of CD19+CD24+CD27-CD38+, defined as transitional B cells. This group of cells had distinct function features of cell activation, and its up-regulated genes were involved in multiple aspects of the BCR signaling pathway. Pseudotime trajectory analysis suggested CD38+ naÏve B cells were highly enriched in the beginning of B cell differentiation. There was a preference in the use of VJ gene segments of B cells between NEG and CTRL, especially an increase of the IGHV3-23 and IGLV2-14 in NEG. The stronger pairing frequencies, IGLV2-14/IGLJ3 and IGKV2D-29/IGKJ2, were indicated in NEG. We identified 14 distinct kidney cell types by marker genes. Through re-clustering of glomerular parietal epithelial cells (PECs), the patients were clearly distinct from their control counterparts, indicating a major shift in gene expression for this cell type. PECs in NEG showed significant up-regulation of cellular communication network factor-related genes (CCN1, CCN2), phospholipase A and acyltransferase-related genes (PLAAT4, PLAAT3), and septin protein-related genes (SEPTIN2, SEPTIN7), accompanied by significant down-regulation of podocyte-related genes. In addition, there are clearly distinct cellular functions and pseudotime trajectory in PECs from NEG and POS, and genes such as CCN2, PLAAT4, SEPTIN2 might drive the special trajectory of PECs in NEG. For the podocytes, the genes related with extracellular matrix and cell adhesion were significantly enhanced in NEG, which consistented with the functional enrichment analysis of the differentially expressed genes and gene set-based scores. We calculated the gene set-based scores including genes encoding lumen-to-blood sodium transporters. Results indicated the enhanced expression of sodium transporters in distal nephrons of MN patients. More surprisingly, a group of proximal tubule epithelial cells showed significantly higher expression levels of sodium transporters. Among them, the expression of SLC5A12 encoding SMCT2 increased significantly. Conclusion We have systematic revealed the cell-type specific molecular features of PMN patients from circulation to renal tissue. Our research provides valuable evidence for the molecular diagnosis of PMN in children and insights into pathogenic mechanism of classical nephritogenic autoantibody-negative PMN.

#6502 ETIOLOGICAL SPECTRUM OF MEMBRANOUS NEPHROPATHY

Abstract Background and Aims Primary MN includes forms of MN in which there is a humoral autoimmune response to a normal podocyte antigen in the absence of secondary features or etiologies of disease. Antigens implicated in primary MN include PLA2R, thrombospondin type-1 domain-containing 7A (THSD7A), neural epidermal growth factor-like 1 (NELL1), semaphorin 3B (Sema3B), the serine protease high-temperature requirement A1 (HTRA1), protocadherin 7 (PCDH7), and others. PLA2R associated MN is most common MN among primary MN. Nowadays, a significant number of newer antigens implicating MN are being discovered. Research is ongoing for a better understanding of the role of these antigens in pathophysiology, and targeted therapeutic implications in future if possible. We aim to analyze the etiological spectrum associated with different antigens in patients with Membranous Nephropathy. We assessed the renal tissue staining of autoantigens PLA2R, THSD7A, and NELL-1 in patients with biopsy-proven Membranous Nephropathy. Method This was a single center ambispective observational study. The study was performed up till September 2022 for prospective data, and retrospective data from January 2018 to March 2021 was retrieved from the medical records department of the institute. The study included patients with biopsy-proven Membranous Nephropathy (Primary and secondary). The primary outcome was to study the etiological spectrum of Membranous Nephropathy. Results A total of 90 patients were included in the study of membranous nephropathy over the period of 4 years. 72 cases had primary MN whereas 18 cases had secondary MN. The mean age was 42.01 ± 14.6 years. Among 18 cases of Secondary MN, the majority of the cases were of lupus nephritis 14 (78%), while other etiologies of secondary MN were malignancy related (11%), rheumatoid arthritis (5.5%) and HCV (5.5%). PLA2R renal tissue positivity was found in 44 (61.1%) cases of primary MN, whereas in 4 (22.2%) cases of Secondary MN. The THSD7A was found in 4 (5.6%) cases of primary MN. One patient of MN was dual PLA2R and NELL1 positive. Two cases of MN were dual PLA2R and THSD7A positive. Renal tissue staining for NELL-1 was found in 8 (11.1%) cases of primary MN whereas it was found in 1 (5.6%) case of secondary MN. In terms of clinical presentation, proteinuria is the most common clinical finding present in nearly all the patients (80%). Most of the cases with nephrotic syndrome (60%) belonged to primary MN. Conclusion PLA2R is the most common etiology of Primary membranous nephropathy. None of the antigens was exclusive to primary membranous nephropathy.

Utility of serum anti-phospholipase A2 receptor antibody as a biomarker in membranous nephropathy: An experience from a tertiary care center of Eastern India

Membranous nephropathy (MN) is a pattern of glomerular injury. Exact categorization into primary membranous nephropathy (PMN) or secondary membranous nephropathy (SMN) is essential for treatment. An endogenous podocyte antigen, M-type phospholipase A2 receptor (PLA2R) has been discovered to be involved in the pathogenesis of PMN. In this article, we aimed to analyze renal tissue PLA2R and serum anti-PLA2R antibodies in MN cases and determined the diagnostic utility. The study was of prospective type carried out from March 2019 to August 2020. Analysis of cases of MN was performed with PLA2R paraffin immunoflourescence and serum anti-PLA2R antibody ELISA. Overall sensitivity, specificity, PPV, and NPV of serum anti-PLA2R ELISA for PMN was 91.3%, 80%, 75%, and 93.3%, respectively, and of tissue PLA2R staining for PMN was 91.67%, 81.08%, 75.86%, and 93.75%, respectively. There was strong concordance between two methods. In the patients that were followed up, we found baseline serum anti-PLA2R antibody was less in complete remission group than that in non-remission group and the reduction in serum anti-PLA2R antibody was more in complete remission group than that in non-remission group. Routine light and immunofluorescence examination are incapable of giving exact categorical opinion regarding PMN and SMN. Serum anti-PLA2R antibody detection and renal tissue PLA2R analysis are sensitive and specific in detecting PMN. Baseline serum anti-PLA2R antibody and anti-PLA2R antibody quantification trends are related to prognosis of PMN. So they can be incorporated as additional biomarker.

Determination of Anti-Phospholipase A2 and Anti-Thrombospondin Type 1 Domain-Containing Protein 7A in Latin Patients with Membranous Nephropathy

Primary membranous nephropathy (MN) is caused by antibodies against podocyte antigens, especially the type M receptor of phospholipase A2 (PLA2R) and thrombospondin type-1 domain containing 7 A (THSD7A). This study's aim was the determination of anti-PLA2R, anti-THSD7A serum antibodies, and anti-PLA2R renal tissue staining prevalence in a Latin population with MN, as well as evaluating their role as biomarkers for disease activity. The performance of the two anti-PLA2R serum diagnostic methods-ELISA and indirect immunofluorescence (IFI)-was evaluated for the diagnosis of MN. Fifty-nine patients, including 29 with MN, 18 with lupus membranous nephropathy (LMN) and 12 with focal and segmental glomerulosclerosis (FSGS), were evaluated for serum antibodies. Renal biopsies were also evaluated for the presence of anti-PLA2R staining. Twenty-one patients with MN were followed for 1 year. Patients with LMN and FSGS were negative for both antibodies. All 29 MN patients were negative for anti-THSD7A; 16 MN patients were positive for anti-PLA2R by ELISA and/or IFI, and 3 MN patients were positive for anti-PLA2R only by IFI. Thus, the anti-PLA2R ELISA test demonstrated 45% sensitivity and 97% specificity, while the IFI test showed, respectively, 55% and 100% in our MN patients. Among the 28 MN renal biopsies, 20 presented anti-PLA2R positive staining, corresponding to a 72% sensitivity. Positive correlations were observed between the anti-PLA2R ELISA titer and proteinuria. In conclusion, determination of anti-PLA2R antibodies in the MN Latin population showed similar rates to those reported for other populations. The anti-PLA2R serum levels correlated with MN disease activity.

Membranous nephropathy: Clearer pathology and mechanisms identify potential strategies for treatment.

Primary membranous nephropathy (PMN) is one of the common causes of adult-onset nephrotic syndrome and is characterized by autoantibodies against podocyte antigens causing in situ immune complex deposition. Much of our understanding of the disease mechanisms underpinning this kidney-limited autoimmune disease originally came from studies of Heymann nephritis, a rat model of PMN, where autoantibodies against megalin produced a similar disease phenotype though megalin is not implicated in human disease. In PMN, the major target antigen was identified to be M-type phospholipase A2 receptor 1 (PLA2R) in 2009. Further utilization of mass spectrometry on immunoprecipitated glomerular extracts and laser micro dissected glomeruli has allowed the rapid discovery of other antigens (thrombospondin type-1 domain-containing protein 7A, neural epidermal growth factor-like 1 protein, semaphorin 3B, protocadherin 7, high temperature requirement A serine peptidase 1, netrin G1) targeted by autoantibodies in PMN. Despite these major advances in our understanding of the pathophysiology of PMN, treatments remain non-specific, often ineffective, or toxic. In this review, we summarize our current understanding of the immune mechanisms driving PMN from animal models and clinical studies, and the implications on the development of future targeted therapeutic strategies.

Primary membranous nephropathy: an endless story.

Primary membranous nephropathy (PMN) is an autoimmune disease caused by the attack of autoantibodies against podocyte antigens leading to the in situ production of immune complexes. However, the etiology is unknown and the pathogenesis is still far from being completely elucidated. MN is prevalently idiopathic or primary, but in about 20-30% of cases it is secondary to chronic infections, systemic diseases, exposure to drugs, or malignancy. The differentiation between primary and secondary MN may be difficult, particularly when MN precedes signs and symptoms of the original disease, as in some cases of cancer or systemic lupus erythematosus. The natural course of PMN is variable, but in the long term 40-60% of patients with nephrotic syndrome progress to end-stage renal disease (ESRD) or die from thrombotic or cardiovascular events. PMN is a treatable disease. Patients with asymptomatic proteinuria should receive supportive care. Immunosuppressive treatments should be given to patients with nephrotic syndrome or risk of progression. The most frequently adopted treatments rely on cyclical therapy alternating steroids with a cytotoxic agent every other month, i.e., rituximab at different doses, or calcineurin inhibitors plus low-dose steroids. A good rate of response may be obtained but relapses can occur. Randomized controlled trials, with adequate size, long-term follow-up, and fair definition of endpoints are needed to identify treatment with the best therapeutic index.

Advances in the Management of Primary Membranous Nephropathy and Rituximab-Refractory Membranous Nephropathy.

Primary membranous nephropathy (pMN) is an auto-immune disease characterized by auto-antibodies targeting podocyte antigens resulting in activation of complement and damage to the glomerular basement membrane. pMN is the most common cause of nephrotic syndrome in adults without diabetes. Despite a very heterogeneous course of the disease, the treatment of pMN has for many years been based on uniform management of all patients regardless of the severity of the disease. The identification of prognostic markers has radically changed the vision of pMN and allowed KDIGO guidelines to evolve in 2021 towards a more personalized management based on the assessment of the risk of progressive loss of kidney function. The recognition of pMN as an antibody-mediated autoimmune disease has rationalized the use immunosuppressive drugs such as rituximab. Rituximab is now a first line immunosuppressive therapy for patients with pMN with proven safety and efficacy achieving remission in 60-80% of patients. For the remaining 20-40% of patients, several mechanisms may explain rituximab resistance: (i) decreased rituximab bioavailability; (ii) immunization against rituximab; and (iii) chronic glomerular damage. The treatment of patients with rituximab-refractory pMN remains controversial and challenging. In this review, we provide an overview of recent advances in the management of pMN (according to the KDIGO 2021 guidelines), in the understanding of the pathophysiology of rituximab resistance, and in the management of rituximab-refractory pMN. We propose a treatment decision aid based on immunomonitoring to identify failures related to underdosing or immunization against rituximab to overcome treatment resistance.

Membranous nephropathy: new pathogenic mechanisms and their clinical implications.

Membranous nephropathy (MN) is characterized histomorphologically by the presence of immune deposits in the subepithelial space of the glomerular filtration barrier; its clinical hallmarks are nephrotic range proteinuria with oedema. In patients with primary MN, autoimmunity is driven by circulating autoantibodies that bind to one or more antigens on the surface of glomerular podocytes. Compared with other autoimmune kidney diseases, the understanding of the pathogenesis of MN has substantially improved in the past decade, thanks to the discovery of pathogenic circulating autoantibodies against phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type 1 domain-containing protein 7A (THSD7A). The subsequent identification of more proteins associated with MN, some of which are also endogenous podocyte antigens, might further advance the clinical characterization of MN, including its diagnosis, treatment and prognosis. Insights from studies in patients with MN, combined with the development of novel in vivo and in vitro experimental models, have potential to improve the management of patients with MN. Characterizing the interaction between autoimmunity and local glomerular lesions provides an opportunity to develop more specific, pathogenesis-based treatments.

Definition of IgG Subclass-Specific Glycopatterns in Idiopathic Membranous Nephropathy: Aberrant IgG Glycoforms in Blood

The podocyte injury, and consequent proteinuria, that characterize the pathology of idiopathic membranous nephropathy (IMN) is mediated by an autoimmune reaction against podocyte antigens. In particular, the activation of pathways leading to abundant renal deposits of complement is likely to involve the binding of mannose-binding lectin (MBL) to aberrant glycans on immunoglobulins. To obtain a landscape of circulatory IgG Fc glycosylation characterizing this disease, we conducted a systematic N-glycan profiling study of IgG1, 2, and 4 by mass spectrometry. The cohort included 57 IMN patients, a pathological control group with nephrotic syndrome (PN) (n = 20), and 88 healthy control subjects. The effect of sex and age was assessed in all groups and controlled by rigorous matching. Several IgG Fc glycan traits were found to be associated with IMN. Interestingly, among them, only IgG4-related results were specific for IMN and not for PN. Hypo-galactosylation of IgG4, already shown for IMN, was observed to occur in the absence of core fucose, in line with a probable increase of pro-inflammatory IgG. In addition, elevated levels of fucosylated IgG4, along with low levels of hybrid-type glycans, were detected. Some of these IgG4 alterations are likely to be more pronounced in high PLA2R (phospholipase A2 receptor) patients. IgG Fc glycosylation patterns associated with IMN warrant further studies of their role in disease mechanisms and may eventually enrich the diagnostic spectrum regarding patient stratification.

The diagnostic value of immunohistochemical staining of the interstitial vascular C4d complement in membranous nephropathy

Abstract Membranous glomerulonephritis (MGN) is the most common cause of adulthood nephrotic syndrome. Diagnosis of membranous nephritis is based on light electron immunofluorescence microscopy and clinical signs. Immune complex deposition against podocyte antigens such as phospholipase A2 receptor (PLA2R) activates the complement system. Of this, complement Component C4d (C4d) is involved in the classical and lectin pathways. This marker may be used by immunohistochemistry to diagnose MGN when other methods are not available. In this work, C4d expression was monitored by immunohistochemical analysis in the glomerular capillaries of patients with primary MGN (study group, N=33) versus patients with minimal change disease (MCD, control group, N=20) in a cross-sectional evaluation performed based on the diagnosis confirmed by light microscopy and immunofluorescence. There was no significant demographic difference between the two groups except for age (P=0.002). C4d immune-expression was positive in glomerular capillary (2+ to 4+) in most of the MGN patients, while it was negative in the MCD group. The sensitivity and specificity of C4d immunostaining were 95% and 100%, respectively. The Pearson correlation coefficient was 0.74 between C4d (immunohistochemistry) and immunoglobulins (IgG; immunofluorescence) and 0.65 between C4d (immunohistochemistry) and the C3 complement product (immunofluorescence). Immunohistochemical evaluation of C4d is, therefore, a sensitive and specific method that has a high correlation with IgG immunofluorescence.

Glomerular Endothelial Cell-Derived microRNA-192 Regulates Nephronectin Expression in Idiopathic Membranous Glomerulonephritis.

Autoantibodies binding to podocyte antigens cause idiopathic membranous glomerulonephritis (iMGN). However, it remains elusive how autoantibodies reach the subepithelial space because the glomerular filtration barrier (GFB) is size selective and almost impermeable for antibodies. Kidney biopsies from patients with iMGN, cell culture, zebrafish, and mouse models were used to investigate the role of nephronectin (NPNT) regulating microRNAs (miRs) for the GFB. Glomerular endothelial cell (GEC)-derived miR-192-5p and podocyte-derived miR-378a-3p are upregulated in urine and glomeruli of patients with iMGN, whereas glomerular NPNT is reduced. Overexpression of miR-192-5p and morpholino-mediated npnt knockdown induced edema, proteinuria, and podocyte effacement similar to podocyte-derived miR-378a-3p in zebrafish. Structural changes of the glomerular basement membrane (GBM) with increased lucidity, splitting, and lamellation, especially of the lamina rara interna, similar to ultrastructural findings seen in advanced stages of iMGN, were found. IgG-size nanoparticles accumulated in lucidity areas of the lamina rara interna and lamina densa of the GBM in npnt-knockdown zebrafish models. Loss of slit diaphragm proteins and severe structural impairment of the GBM were further confirmed in podocyte-specific Npnt knockout mice. GECs downregulate podocyte NPNT by transfer of miR-192-5p-containing exosomes in a paracrine manner. Podocyte NPNT is important for proper glomerular filter function and GBM structure and is regulated by GEC-derived miR-192-5p and podocyte-derived miR-378a-3p. We hypothesize that loss of NPNT in the GBM is an important part of the initial pathophysiology of iMGN and enables autoantigenicity of podocyte antigens and subepithelial immune complex deposition in iMGN.

The role of serum levels of anti-phospholipase A2 receptor antibodies in the diagnosis of primary membranous nephropathy.

Primary membranous nephropathy (PMN) is one of the most common causes of nephrotic syndrome in adults. The disease process is probably initiated by the binding of circulating autoantibodies to target podocyte antigens. In 2009, Beck et al. found that phospholipase A2 receptor (PLA2R1) was expressed on human podocytes in patients with PMN. Recent evidence suggests that PLA2R1 autoantibodies play an important role in the diagnosis of PMN. The aim of the present study was to compare the serum levels of anti-PLA2R1 in patients with PMN, second MN (SMN), other nephropathies (ON), and healthy controls (HC). The study included 52 patients with PMN, 12 patients with SMN, 49 patients with ON, and 50 healthy controls. The serum concentration of anti-PLA2R1 was determined with ELISA kit (Anti-PLA2R ELISA, IgG, EUROIMMUN, Lübeck, Germany) using MR-96A microplate Reader (MINDRAY). Statistical analysis was performed with SPSS v.22.0. There was significant difference in the serum anti-PLA2R1 concentrations between patient groups and HC (p<0.0001). Compared to HC, the median anti-PLA2R1 level in the PMN group was significantly higher (4.8 RU/ml vs. 34.9 RU/ml, p=0.001), in the ON group it was lower (2.1 RU/ml, p=0.002) and did not differ in patients with SMN (2.9 RU/ml, p=0.193). The anti-PLA2R1 serum levels were significantly higher in the PMN group than in the SMN (p=0.015) and ON (p<0.001) groups. Our results showed that anti-PLA2R1 is significantly increased in patients with PMN. We can conclude that the anti-PLA2R1 serum concentration may be used as a beneficial biomarker for distinguishing PMN from other membranous nephropathies.