primary & secondary glomerular disease john...
TRANSCRIPT
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Primary & Secondary Glomerular Disease
John Feehally
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GLOMERULONEPHRITIS
Immune disease which mainly affects glomeruli
Renal biopsy required to make the diagnosis
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ISSUES IN GLOMERULONEPHRITIS
Terminology
Classification
Aetiology
Natural History
Treatment
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ISSUES IN GLOMERULONEPHRITIS
Terminology
Classification
Aetiology
Natural history
Treatment
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TERMINOLOGY IN GLOMERULONEPHRITIS
Glomerulonephritis
or
Glomerular disease
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TERMINOLOGY IN GLOMERULONEPHRITIS
Primary ?
Secondary ?
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TERMINOLOGY IN GLOMERULONEPHRITIS
Different names for the same thing…..
Minimal change nephrotic syndrome_______
Minimal change disease
Lipoid nephrosis
Idiopathic nephrotic syndrome
Minimal change glomerulonephritis
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ISSUES IN GLOMERULONEPHRITIS
Terminology
Classification
Aetiology
Natural History
Treatment
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Clinical Immune
mechanisms
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
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ClinicalImmune
mechanisms
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
Patterns established on light microscopy
Membranous
Mesangiocapillary
Focal segmental glomerulosclerosis
etc……
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ClinicalImmune
mechanisms
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
Patterns established on light microscopy
Membranous
Mesangiocapillary
Focal segmental glomerulosclerosis
etc……‘Patterns’ not ‘diseases’
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Light microscopic appearancee.g.
MEMBRANOUS NEPHROPATHY
Type of immune depositse.g.
IgA NEPHROPATHY
PATHOLOGICAL CLASSIFICATION OF GLOMERULONEPHRITIS
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ISSUES IN GLOMERULONEPHRITIS
Terminology
Classification
Aetiology
Natural History
Treatment
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AETIOLOGY OF GN
INFECTION
- the dominant aetiological agent for GN in
the developing world
Bacterial
Viral
Parasitic
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POST-STREPTOCOCCAL GLOMERULONEPHRITIS
PSGN
NephritogenicStreptococci
EpidemicStreptoccal
infection
Impaired host response
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MEMBRANOUS NEPHROPATHY
DEVELOPING WORLD
HBV
Leprosy
Syphilis
Hydatid disease
Malaria
Schistosomiasis
DEVELOPED WORLD
Idiopathic
Drugs
Malignancy
Lupus
…….
Infections
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CHRONIC INFECTION AND GN
Commonest histological pattern Mesangiocapillary [membranoproliferative] GN type 1
Pattern of GN associated with a wide range of chronic infections
• Infective endocarditis
• ‘Shunt’ nephritis
• Schistosomiasis
…..
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CHANGING PREVALENCE OF MCGN
Hurtado A, Johnson RJ. KI 2005; Suppl 97: S62-S67
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CHRONIC INFECTION AND GN
Commonest histological pattern Mesangiocapillary [membranoproliferative] GN type 1
DEVELOPED WORLD
Incidence falling
Emergence of HCV as a causative agent
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AETIOLOGY OF GN
INFECTION
Dominant aetiological agent for GN in the developin g world
VARIED HOST RESPONSE
Same infection different patterns of GN
Same pattern of GN different infection
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AETIOLOGY OF GN
The developed world
Are the common patterns of GN caused by infections we have not yet identified ?
Are other enviromental antigens involved ?
Do changing patterns of GN reflect changing pattern sof host immunity in urbanised culture ?
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AETIOLOGY OF GN
Infection
Other identifiable environmental antigens
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AETIOLOGY OF GN
Infection
Other identifiable environmental antigens
Auto-immunity
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GOODPASTURE’S DISEASE – ANTI-GBM DISEASE
The circulating anti-GBM IgG antibody is directly pa thogenic
Transfer experiments
Depletion of antibody is therapeutic
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LUPUS NEPHRITIS
The archetypal ‘immune complex’ disease
…. although the antigens involved in the complexes remain incompletely defined
Highly variable expression of renal disease
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AETIOLOGY OF GN
Infection
Other identifiable environmental antigens
Auto-immunity
Other
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Hingeregion
IgA1IgA1
ALTERED IgA1 O-GLYCOSYLATION IN IgA NEPHROPATHY
A plausible site for a pathogenic abnormality
Hinge has unusual O-glycosylation
Hinge O-glycosylation abnormal in:
Serum IgA1 & mesangial IgA1 in IgAN
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AETIOLOGY OF GN
Infection
Other identifiable environmental antigens
Auto-immunity
Other
Genetics
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DISEASE MECHANISMS IN GLOMERULONEPHRITIS
Immune injury
Infection Auto-immunity Unknown
Genetics
Inflammation
Resolution
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PATHOGENESIS OF GN
Evidence from renal transplantation
Some patterns of GN have always recurred despite innovative anti-rejection therapy
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ISSUES IN GLOMERULONEPHRITIS
Terminology
Classification
Aetiology
Natural History
Treatment
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INTERPRETING NATURAL HISTORY STUDIES & TREATMENT TRIALS IN GLOMERULONEPHRITIS
Patterns or diseases ?
Changing incidences ?
Worldwide variations ?
Inclusion criteria ?
Disease onset ?
Therapeutic effects ?
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INTERPRETING NATURAL HISTORY STUDIES IN GLOMERULONEPHRITIS
Patterns or diseases ?
Changing incidences ?
Worldwide variations ?
Inclusion criteria ?
Disease onset ?
Therapeutic effects ?
Moranne O et al. Quart J Med 2008; 101: 215
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GENDER & OUTCOME IN PRIMARY GN
Benefit of female gender
…mostly explained by
lower proteinuria & BP
throughout follow up
Cattran D et al. NDT 2008; 23: 2247
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ISSUES IN GLOMERULONEPHRITIS
Terminology
Classification
Aetiology
Natural History
Treatment
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ?
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ? X
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ? X
Antibiotics ?
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ? X
Antibiotics ? X
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ? X
Antibiotics ? X
Public health ?
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ? X
Antibiotics ? X
Public health ? YES
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WHY IS POST-STREPTOCOCCAL GNNOW SO UNCOMMON IN THE DEVELOPED WORLD ?
The progress of immunology ? X
Antibiotics ? X
Public health ? YES
Spontaneous changes in streptococcal types ? ?
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PREVENTION OF INFECTION-RELATED GN
Progress with infection control
Schistosomiasis
Malaria
HBV
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PREVENTION OF INFECTION-RELATED GN
Progress with infection control
Schistosomiasis
Malaria
HBV
DURBAN, SOUTH AFRICA
HBV childhood immunisation from 1995 – incomplete co verage
Incidence of HBV-associated MN reduced by 80%After 1998: no child age < 4 years
Bhimma R et al. 2003
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Why are we still treating these diseases with immunosuppressive drugs
introduced into clinical practice..
..while I was still at school ?
TREATMENT OF GN
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Why are we still treating these diseases with immunosuppressive drugs
introduced into clinical practice..
..while I was still at school ?
… and which can be toxic ?
TREATMENT OF GN
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Why are we still treating these diseases with immunosuppressive drugs
introduced into clinical practice..
..while I was still at school ?
… and which can be toxic ?
CORTICOSTEROIDS
CYCLOPHOSPHAMIDE
AZATHIOPRINE
TREATMENT OF GN
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IMMUNE TREATMENT FOR GLOMERULONEPHRITIS
SIDE EFFECTS OF TREATMENT
Cushingism
Opportunistic infection
Infertility
Osteopenia
Secondary neoplasia
IMPLICATIONS OF RENAL FAILURE
Cardiovascular morbidity
Infertility
Transplant recurrence
Quality of life
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PROGRESS IN TREATMENT OF GN
Lack of
Transience of initiating events
Failure to learn lessons from recurrence after transplantation
Broad effects of existing immune therapy
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PROGRESS IN TREATMENT OF GN
Lack of
Newer immunosuppressives have been developed for transplantation
Focus on suppressing T cell driven alloimmunity
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PROGRESS IN TREATMENT OF GN
Lack of
Complexity and redundancy of inflammatory and anti-inflammatory pathways
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NEW TREATMENTS OF GLOMERULONEPHRITIS
POTENTIAL TARGETS
T cells
Macrophages
Cytokines
Adhesion molecules
Chemokines
Profibrotic growth factors
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NEW TREATMENTS OF GLOMERULONEPHRITIS
POTENTIAL TARGETS
T cells
Macrophages
Cytokines
Adhesion molecules
Chemokines
Profibrotic growth factors
PROBLEMS
Development costs
Timing
Kidney-specific delivery
Need multiple interventions
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PROGRESS IN TREATMENT OF GN
Lack of
Why have there been so few RCT’s in this field ?
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PROGRESS IN TREATMENT OF GN
Lack of
Why have there been so few RCT’s in this field ?
Uncommon
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PROGRESS IN TREATMENT OF GN
Lack of
Why have there been so few RCT’s in this field ?
Uncommon
Slowly progressive
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PROGRESS IN TREATMENT OF GN
Lack of
Why have there been so few RCT’s in this field ?
Uncommon
Slowly progressive
Opinion
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PROGRESS IN TREATMENT OF GN
Lack of
Why have there been so few RCT’s in this field ?
Uncommon
Slowly progressive
Opinion
‘Precious patients’
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TREATMENT OF GLOMERULONEPHRITIS
Active treatment does not only mean immunosuppression
Symptoms can be relieved
and
renal failure may be delayed
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TREATMENT OF GLOMERULONEPHRITIS
No steroids or immunosuppressives does not = no treatment
Blood pressure
Oedema
Proteinuria
Cholesterol
Smoking
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GLOMERULAR DISEASE
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
Thrombotic microangiopathy
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
Amyloid, MIDD & fibrillary GN
Thrombotic microangiopathy
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
Diabetic nephropathy
Amyloid, MIDD & fibrillary GN
Thrombotic microangiopathy
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
HEREDITARY
AlportFabry
Nail-patellaLCAT deficiency
etc ..
Diabetic nephropathy
Amyloid, MIDD & fibrillary GN
Thrombotic microangiopathy
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
HEREDITARY
AlportFabry
Nail-patellaLCAT deficiency
etc ..
Diabetic nephropathy
Amyloid, MIDD & fibrillary GN
Thrombotic microangiopathy
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GLOMERULAR DISEASE
Minimal change/FSGS
Membranous
MCGN
IgA nephropathy
Post-infectious GN
Lupus
Vasculitis
Henoch-Schönlein nephritis
Cryoglobulinaemia
Anti-GBM nephritis
HEREDITARY
AlportFabry
Nail-patellaLCAT deficiency
etc ..
Diabetic nephropathy
Amyloid, MIDD & fibrillary GN
Thrombotic microangiopathy
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MINIMALCHANGE DISEASEIN ADULTS
• 10-20% of adults with nephrotic syndrome (cf children 90%)
• Spontaneous remission occurs in 5-10% of cases within 2 months
• Non-nephrotic proteinuria does not respond well to immunosuppression
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MINIMALCHANGE DISEASEIN ADULTS
• 10-20% of adults with nephrotic syndrome (cf children 90%)
• Spontaneous remission occurs in 5-10% of cases within 2 months
• Non-nephrotic proteinuria does not respond well to immunosuppression
Is this the same disease ?
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TREATMENT OF MINIMAL CHANGE DISEASE IN ADULTS
SPECIFIC THERAPY• Few controlled trial in adults
• Guidelines extrapolated from studies in children and cohort studies
• Controversies in corticosteroid therapy– Time to response – Dosage & duration of corticosteroids
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CORTICOSTEROIDS for MINIMAL CHANGE DISEASE TIME TO REMISSION IN ADULTS AND CHILDREN
WHY SUCH VARIANCE ?
Steroid dosing ?
Identifying FSGS?
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MINIMALCHANGE DISEASE IN ADULTSCourse after steroid treatment
• ~50% will have at least one relapse
• 10-25% frequently relapse
• 25-30% are steroid dependent
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MINIMALCHANGE DISEASE IN ADULTSSecond line therapy for frequent relapsing/ steroid dependence
Corticosteroids– Low dose alternate day regimens
Cyclophosphamide– 12weeks - 2mg/kg/day(cumulative ‘safe’ dose of 150-250mg/kg)– Ideally commence following induction of remission
Cyclosporin– 3-5mg/kg/day (trough level 50-150ng/ml)– May be first choice in younger patients– Response within 3 months– If effective try to withdraw after 1 year
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International Study of Kidney Disease in Children
FSGS first described by Habib and others
…correlating histology findings with response to corticosteroids
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CAUSES OF ADULT NEPHROTIC SYNDROME
CHICAGO 1976-9 1995-7
White Black White Black
Membranous 38% 34% 38% 18%
Minimal change 22% 19% 16% 12%
FSGSFSGS 9%9% 30%30% 25%25% 56%56%
IgAN 4% 0% 14% 1%
MCGN 8% 0% 2% 1%
Haas AJKD 1997; 30: 621
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FSGS IN WEST AFRICA
Abdou N et al. Saudi J Kidney Dis Transpl 2003; 14: 21 2
SENEGAL115 biopsies 1993-98
Two thirds - nephrotic syndrome
……….Primary GN
47% FSGS
12.5% Membranous
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FOCAL SEGMENTAL GLOMERULOSCLEROSIS
An histological pattern …… . not a diagnosis
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PATHOLOGICAL CLASSIFICATION OF FSGS
Classic FSGS
Perihilar variant
Cellular variant
Collapsing variant
Tip variant
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Does steroid responsiveness define a ‘disease’ ?
Is it more important than presence of FSGS ?
Can minimal change ‘evolve’ into FSGS ?
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CLINICAL PRESENTATIONS OF FSGS
PRIMARY FSGS
Typically ‘like minimal change’:
Sudden onset of nephrotic syndrome
Any age –but commonest in children
and young adults
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CLINICAL PRESENTATIONS OF FSGS
SECONDARY FSGS
More often:
Asymptomatic proteinuria
Normal serum albumin
Any age
PRIMARY FSGS
Typically ‘like minimal change’:
Sudden onset of nephrotic syndrome
Any age –but commonest in children
and young adults
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Secondary FSGS
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Drugs
Intravenous heroinPamidronateInterferon-α
Secondary FSGS
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Viruses
HIVParvovirus B19
Drugs
Intravenous heroinPamidronateInterferon-α
Secondary FSGS
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Viruses
HIVParvovirus B19
Drugs
Intravenous heroinPamidronateInterferon-α
Adaptive responseto
reduced renal mass
Renal agenesis/dysplasiaOligomeganephronia
Surgical renal ablation Reflux nephropathy
Cortical necrosisChronic allograft nephropathy
Any advanced renal disease with reduction in functioning nephrons
Secondary FSGS
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Adaptive responsewith
initially normal renal mass
Obesity Sickle cell nephropathy
Congenital cyanotic heart disease
Viruses
HIVParvovirus B19
Drugs
Intravenous heroinPamidronateInterferon-α
Adaptive responseto
reduced renal mass
Renal agenesis/dysplasiaOligomeganephronia
Surgical renal ablation Reflux nephropathy
Cortical necrosisChronic allograft nephropathy
Any advanced renal disease with reduction in functioning nephrons
Secondary FSGS
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Primary
( Idiopathic )
FSGS
Secondary
FSGS
FSGS
Genetic
FSGS
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Primary
(Idiopathic )
FSGS
Secondary
FSGS
FSGS
Genetic
FSGS
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NPHS2
Autosomal recessive FSGS
Sporadic steroid-resistant FSGSChildren>adults
Autosomal dominant FSGS
Sub-nephrotic proteinuria
Autosomal dominant FSGS
? sporadic FSGS
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PREDICTIONS
FSGS associated with podocyte protein mutations
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PREDICTIONS
FSGS associated with podocyte protein mutations
… will be steroid resistant
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PREDICTIONS
FSGS associated with podocyte protein mutations
… will be steroid resistant
… will not recur in transplants
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PATHOGENESIS OF FSGS
Lessons from transplant recurrence
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PATHOGENESIS OF FSGS
Lessons from transplant recurrence
RECURRENCE is not inevitable
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PATHOGENESIS OF FSGS
Lessons from transplant recurrence
RECURRENCEis not inevitable
CLINICALrecurrent proteinuria may be immediate
……implies ‘circulating factor’
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PATHOGENESIS OF FSGS
Lessons from transplant recurrence
RECURRENCE is not inevitable
CLINICALrecurrent proteinuria may be immediate
……implies ‘circulating factor’
PATHOLOGICALAfter one month of recurrence
there may be foot process effacement …….but no segmental lesions
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PATHOGENESIS OF PRIMARY FSGS
Genetics
Circulating factor[s]
Second [or third] ‘hit’
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PRIMARY FSGS
Can we predict outcome at presentation ?
Does spontaneous remission occur ?
Can we select which patients should receive cortico steroids ?
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PRIMARY FSGS
Can we predict outcome at presentation ?
Histology
Genetics
Clinical
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PRIMARY FSGS
Can we predict outcome at presentation ?
HISTOLOGY
Tip lesion
Collapsing variant
Number of glomeruli with segmental / global sclerosi s ?
Tubular atrophy & interstitial fibrosis
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FSGS – HISTOLOGICAL VARIANTS & OUTCOME
Thomas DB et al . KI 2006; 69: 920
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PRIMARY FSGS
Can we predict outcome at presentation ?
GENETICS
Not yet ……
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PRIMARY FSGS
Can we predict outcome at presentation ?
Non-nephrotic 20% ESRD at 10 years
Nephrotic >50% ESRD at 5-10 years
Nephrotic >10g/day ~100% ESRD at 5-10 years
Malignant FSGS
IMPORTANCE OF PROTEINURIA
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Time to RRT or death(yrs)
1086420
Per
cent
age
Sur
viva
l
1.0
.8
.6
.4
.2
0.0
PRIMARY FSGSSurvival according to remission
Remission
No Remission
5yr survival 94% v 52%
Stirling C et al– QJM 2005; 98: 443
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PROGNOSIS IN NEPHROTIC PRIMARY FSGS
Rydel et al AJKD 1995; 25: 534
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TREATMENT OF
NEPHROTIC PRIMARY FSGS
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TREATMENT OF PRIMARY FSGS
Renin-angiotensin blockadeBP control
Statins
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TREATMENT OF PRIMARY FSGS
Renin-angiotensin blockadeBP control
Statins
IMMUNOSUPPRESSION
CorticosteroidsCyclophosphamide
Cyclosporine
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TREATMENT OF PRIMARY FSGS
Renin-angiotensin blockadeBP control
Statins
IMMUNOSUPPRESSION
CorticosteroidsCyclophosphamide
Cyclosporine
NEWER IMMUNOSUPPRESSIVES
TacrolimusMycophenolate
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TREATMENT OF PRIMARY FSGS
Renin-angiotensin blockadeBP control
Statins
IMMUNOSUPPRESSION
CorticosteroidsCyclophosphamide
Cyclosporine
NEWER IMMUNOSUPPRESSIVES
TacrolimusMycophenolate
Plasma exchange
Plasma adsorption
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CORTICOSTEROIDS IN FSGS
Evidence from randomised controlled trials…
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CORTICOSTEROIDS IN FSGS
1980’s
8 weeks oral prednisolone ~ 1mg/kg/day [based on MC NS in children]
Complete remission ~ 20-30%
No RCTs - retrospective cohort studies
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CORTICOSTEROIDS IN FSGS
1980’s
8 weeks oral prednisolone ~ 1mg/kg/day [based on MC NS in children]
Complete remission ~ 20-30%
1990’s
At least 4 months - prednisolone starting 1-2 mg/kg/d ay
�4 months treatment - complete remission – 50-60%
No RCTs - retrospective cohort studies
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INTERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
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INTERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
Definitions of response
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INTERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
Definitions of response
Are the demographics typical ?
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INERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
Definitions of response
Are the demographics typical ?
Is the histology defined ?
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INTERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
Definitions of response
Are the demographics typical ?
Is the histology defined ?
Were causes of secondary FSGS excluded ?
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INTERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
Who got the treatment?
The worst nephrotics
Those considered fit enough to have steroids ?
Physician choice/prejudice ?
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INTERPRETING RETROSPECTIVE STUDIES OF TREATMENT IN FSGS
Any immunosuppressive therapy must add benefit to
‘best supportive therapy’…
BP 125/75
ACE inhibitor + ARB
Statin
Were these achieved in retrospective studies ?
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PRIMARY FSGS WITH NEPHROTIC SYNDROME
Does spontaneous remission occur ?
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PRIMARY FSGS WITH NEPHROTIC SYNDROME
Does spontaneous remission occur ?
United States 4-6%
European study 16%
UK 5 centre study 23%
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PRIMARY FSGS
Remission rates
Spontaneous Treatment Benefitremission remission
Conventional view 5% 20-50% 4 – 10 fold
UK 5 centre study 23% 65% < 3 fold
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CORTICOSTEROIDS IN FSGS
There are no RCTs ..we rely on retrospective cohor t studies
Is a ‘response’ to 6 months of corticosteroids just a spontaneous remission?
Half of all patients with FSGS will receive 6 months of futile corticosteroids
What is acceptable toxicity ?
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PREDICTING RESPONSE TO CORTICOSTEROIDS IN FSGS
Genetics
• More steroid resistance in Blacks
• Familial FSGS – usually steroid resistant
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PREDICTING RESPONSE TO CORTICOSTEROIDS IN FSGS
Histology
Tip lesion – steroid responsive
Collapsing variant – steroid resistant
Number of glomeruli with segmental / global sclerosi s
Tubulo-interstitial fibrosis
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CYCLOPHOSPHAMIDE IN FSGS
Evidence from randomised controlled trials…
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CYCLOSPORINE IN FSGS
ONE
randomised controlled trial
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IMMUNOSUPPRESSION IN PRIMARY FSGS
Korbet S et al. KI 2002; 62: 2301
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IMMUNOSUPPRESSION IN PRIMARY FSGS
Korbet S et al. KI 2002; 62: 2301
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1996 97 98 99 2000 01 02 03 04 05
Proteinuriag/day
5
4
3
2
1
0
Serum albuming/l40
30
20
10
GFRml/min
100
Female, born 1955 – Primary FSGS
Pred
CyA
ACE inhibitor
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TACROLIMUS IN PRIMARY FSGS
Anecdotal evidence only
MYCOPHENOLATE IN PRIMARY FSGS
Anecdotal evidence only
SIROLIMUS IN PRIMARY FSGS
Anecdotal evidence only
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PLASMA EXCHANGE IN FSGS
PRIMARY FSGS
Evidence base is small
~ 20 patients - < 50% have some response
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PLASMA EXCHANGE IN FSGS
PRIMARY FSGS
Evidence base is small
~ 20 patients - < 50% have some response
TRANSPLANT RECURRENCE OF PRIMARY FSGS
~ 50% respond. Often completely
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TREATMENT OF MEMBRANOUS NEPHROPATHY
Idiopathic Secondary
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TREATMENT OF MEMBRANOUS NEPHROPATHY
Idiopathic Secondary
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TREATMENT OF MEMBRANOUS NEPHROPATHY
Idiopathic Secondary
Nephrotic Non-nephroticproteinuria
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TREATMENT OF MEMBRANOUS NEPHROPATHY
Idiopathic Secondary
Nephrotic Non-nephroticproteinuria
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TREATMENT GOALS IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
Complete or partial remission of proteinuria
Avoid ESRD
Avoid death
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Troyanov S et al. KI 2004; 66: 1199
VALUE OF PARTIAL REMISSION IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
TORONTO GN REGISTRY - 343 patients
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10 YEAR FOLLOW UP OF ‘PONTICELLI REGIMEN’FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
WITH NEPHROTIC SYNDROME
Ponticelli C et al . KI 1995; 48: 1600
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10 YEAR FOLLOW UP OF ‘PONTICELLI REGIMEN’FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
WITH NEPHROTIC SYNDROME
Ponticelli C et al . KI 1995; 48: 1600
In 6 months the patient receives:
9 grams MethylprednisoloneAnd oral Prednisolone 0.4mg/kg/alt day for 3 months
plus
Chlorambucil 0.2 mg/kg/day for 3 monthsor
Cyclosphosphamide 2.5 mg/kg/day
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Wetzels J et al : QJM 2004; 97: 353 – NDT 2004; 19: 1142 - NDT 2004 ; 19: 2036
RESTRICTED USE OF IMMUNOSUPPRESSIVE TREATMENT IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
The Nijmegen strategy
Immunosuppression only for deteriorating renal function or intractable nephrot ic syndrome
74% 7 year renal survival [32% in historical controls]
Complete or partial remission 86%
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Hofstra J, Wetzels J et al . NDT 2008 epub 17 July
IMPACT OF IMMUNOSUPPRESSIVE TREATMENT ON ESRD IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
The Nijmegen strategyPrednisolone & cyclophosphamide only for
declining GFR or intractable nephrotic syndrome
Incidence of ESRD due to IMN: 1991 – 2005
70% reduction in Nijmegen
compared to remainder of Netherlands
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Schieppati A et al. www.thecochranelibrary.com
IMMUNOSUPPRESSIVE TREATMENT FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
IN ADULTS WITH NEPHROTIC SYNDROME
Cochrane Review: 18 trials – 1025 patients
CORTICOSTEROIDS
No beneficial effect on any end point
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Schieppati A et al. www.thecochranelibrary.com
IMMUNOSUPPRESSIVE TREATMENT FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
IN ADULTS WITH NEPHROTIC SYNDROME
Cochrane Review: 18 trials – 1025 patients
CYCLOSPORIN
No beneficial effect on any end point
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Schieppati A et al. www.thecochranelibrary.com
IMMUNOSUPPRESSIVE TREATMENT FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
IN ADULTS WITH NEPHROTIC SYNDROME
Cochrane Review: 18 trials – 1025 patients
ALKYLATING AGENTS
Beneficial effect on complete remission only
Cyclophosphamide – fewer discontinuations for adverse effects than Chlorambucil
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PROGNOSIS OF UNTREATED PATIENTS WITH IDIOPATHIC MEMBRANOUS NEPHROPATHY
100 ‘consecutive’ patients
BP Rx / diuretics as indicated
Some ACE inhibitors
BP defined >160/95
Schieppati A et al. NEJM 1993; 329: 85
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PROGNOSIS OF UNTREATED PATIENTS WITH IDIOPATHIC MEMBRANOUS NEPHROPATHY
Schieppati A et al . NEJM 1993; 329: 85
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Shiiki H et al. Kidney Int 2004; 5: 1400
PROGNOSIS OF IDIOPATHIC MEMBRANOUS NEPHROPATHYIN JAPAN
949 patients followed for 20 yearsNo RCTs
374 corticosteroids257 alkylating agents
157 other immunosuppressives
161 ‘supportive therapy’
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10 YEAR FOLLOW UP OF ‘PONTICELLI REGIMEN’FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
WITH NEPHROTIC SYNDROME
Ponticelli C et al . KI 1995; 48: 1600
Blood pressure defined as > 160/90
Renin-angiotensin blockade ?
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Schieppati A et al. www.thecochranelibrary.com
IMMUNOSUPPRESSIVE TREATMENT FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY
IN ADULTS WITH NEPHROTIC SYNDROME
Cochrane Review: 18 trials – 1025 patients
POSSIBLE CONFOUNDING FACTORS
Use of ACE inhibitors/ARB - ? no effect
BP control – no data
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Tight BP control
125/75
Full renin-angiotensin blockade
Statin
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Tight BP control
125/75
Full renin-angiotensin blockade
Statin
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Tight BP control
125/75
Full renin-angiotensin blockade
Statin
Deteriorating renal function or intractable nephrot ic syndrome
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Tight BP control
125/75
Full renin-angiotensin blockade
Statin
What is the evidence that immunosuppressive regimen sgive additional benefit ?
Deteriorating renal function or intractable nephrot ic syndrome
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MYCOPHENOLATE IN RESISTANT MEMBRANOUS NEPHROPATHY
Miller G et al. AJKD 2000; 36: 250Polenakovic M et al. NDT 2003; 18: 1235Chan TM et al. Nephrology 2007; 12: 576Dussol B et al. AJKD 2008 epub 26 June
4 SMALL ‘PILOT’ STUDIES – total 80 patients
MMF 2g/day for 6-16 months
Proteinuria reduced in 3 of 4 studies
No effect on renal function
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RITUXIMAB
Anti-CD20 monoclonal antibody
Two doses typically depletes peripheral B cells for 4-6 months
? FcγRIII polymorphisms modify B cell response
Safety profile encouraging
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Ruggenenti P et al. JASN 2003; 14: 1851
RITUXIMAB IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
8 patientsProteinuria > 3.5g/day for 6 months before Rx
Rituximab – 4 weekly infusions
BP ‘controlled’
Full dose ACE inhibitor
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Ruggenenti P et al. JASN 2003; 14: 1851
RITUXIMAB IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
8 patientsProteinuria > 3.5g/day for 6 months before Rx
Rituximab – 4 weekly infusions
Repeat biopsy in 7 patients
Partial reabsorption of subepithelial deposits
Increase in slit diaphragms
Reduced IgG4 staining
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Fervenza FC et al. Kidney Int 2008; 73: 117
RITUXIMAB IN IDIOPATHIC MEMBRANOUS NEPHROPATHY
N = 14 - mean proteinuria 10.8 g/day despite BP cont rol & RAS blockade
Rituximab – 1g x 3 over 6 months
2 complete remissions6 partial remissions
Responsiveness notnot predictable
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ECULIZAMAB [C5 COMPLEMENT INHIBITOR] IN MEMBRANOUS NEPHROPATHY
Appel G et al. JASN 2002; 13: 668A
RCT
No effect on proteinuria or renal function
Incomplete complement inhibition
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MEMBRANOPROLIFERATIVE /
MESANGIOCAPILLARY
GLOMERULONEPHRITIS
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MEMBRANOPROLIFERATIVE /
MESANGIOCAPILLARY
GLOMERULONEPHRITIS
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ClinicalImmune
mechanisms
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
Patterns established on light microscopy
Membranous
Mesangiocapillary
Focal segmental glomerulosclerosis
etc……‘Patterns’ not ‘diseases’
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AETIOLOGY OF MESANGIOCAPILLARY GN
Infection_ Hepatitis B & C– Bacterial endocarditis– Infected shunt/abscess– HIV– Hantavirus
Auto-immune disease– Lupus– Sjogren syndrome– Cryoglobulinaemia (HCV)
Malignancy– CLL– Lymphoma
Inherited or acquired complement deficiency
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AETIOLOGY OF MESANGIOCAPILLARY GN
Infection_ Hepatitis B & C– Bacterial endocarditis– Infected shunt/abscess– HIV– Hantavirus
Auto-immune disease– Lupus– Sjogren syndrome– Cryoglobulinaemia (HCV)
Malignancy– CLL– Lymphoma
Inherited or acquired complement deficiency
“ IDIOPATHIC “
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MESANGIOCAPILLARY GN TYPE II
Only identified
as a separate entity
when EM became available
‘Dense deposit disease’
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MESANGIOCAPILLARY GN
53 children presenting 1980 - 2000 Birmingham & Brist ol, UK
Cansick JC et al . NDT 2004; 19: 2769
31 Type 114 Type 22 Type 3
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DENSE DEPOSIT DISEASE
Transplant recurrence 100%
LIGHT MICROSCOPY
Mesangiocapillary 25%
Mesangial proliferative 45%
Crescentic 18%
Characteristic alternative pathwaycomplement activation
Walker P et al. 2007
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COMPLEMENT ACTIVATION IN DENSE DEPOSIT DISEASE
C3 NEPHRITIC FACTOR
A stabilising autoantibody
against C3 convertase
PERSISTENT C3 ACTIVATION
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COMPLEMENT ACTIVATION IN DENSE DEPOSIT DISEASE
C3 NEPHRITIC FACTOR
A stabilising autoantibody
against C3 convertase
PERSISTENT C3 ACTIVATION
Associated with partial lipodystrophy
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COMPLEMENT ACTIVATION IN DENSE DEPOSIT DISEASE
C3 NEPHRITIC FACTOR
A stabilising autoantibody
against C3 convertase
COMPLEMENT FACTOR H
Loss of function mutations
PERSISTENT C3 ACTIVATION
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Stabilised by C3Nef
Loss of function factor H mutations
Persistent complement
activation
Deplete Plasma exchange
Rituximab
Replace Plasma infusion
BlockAnti-C5Ab
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Clinical Immune
mechanisms
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
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TREATMENT OF MESANGIOCAPILLARY GN
Very few RCTs
Most are > 20 years old
Cohorts include MCGN I of many aetiologies
And may include dense deposit disease
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TREATMENT OF GLOMERULAR DISEASE PATTERNS
Do the simple things properly
Minimise adverse effects of treatment
Wait for evidence
Help create the evidence
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TREATMENT OF GN ASSOCIATED WITH EXTRARENAL IMMUNE DISEASE
Goodpasture’s disease
Lupus
Systemic vasculitis
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GOODPASTURE’S DISEASE – ANTI-GBM DISEASE
A rare condition studied in great detail…
Expecting that general principles will emerge
about auto-immunity and self-tolerance
which will improve treatment of all types of GN
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1980
TREATMENT OF GOODPASTURE’S DISEASE
Prednisolone
Cyclophosphamide
Plasma exchange
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2008
Prednisolone
Cyclophosphamide
Plasma exchange
TREATMENT OF GOODPASTURE’S DISEASE
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PROBLEMS IN THE TREATMENT OF
LUPUS NEPHRITIS
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QUESTION:
How do you get ten different opinions
about the treatment of lupus nephritis?
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QUESTION:
How do you get ten different opinions
about the treatment of lupus nephritis?
ANSWER:
Ask nine different nephrologists
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LUPUS NEPHRITIS
The archetypal ‘immune complex’ disease
Glomerular immune deposits
…. although the antigens involved in the complexes remain incompletely defined
Highly variable expression of renal disease
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PROBLEMS IN THE TREATMENT OF LUPUS NEPHRITIS
The evidence base is small
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PROBLEMS IN THE TREATMENT OF LUPUS NEPHRITIS
There are few Randomised Controlled Trials
Nearly all are trials in ‘Proliferative’ (III & IV) lupus nephritis
Most studies use histological entry criteria
Most studies include only previously untreated pati ents
Most studies exclude severely ill patients
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PROBLEMS IN THE TREATMENT OF LUPUS NEPHRITIS
Little evidence about….
Mild disease
Very severe disease
Prolonged relapsing disease
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PROBLEMS IN THE TREATMENT OF LUPUS NEPHRITIS
The ‘precious’ patient
Seeing beyond the kidneys
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THE EVIDENCE BASE FOR TREATMENT OF LUPUS NEPHRITIS
WHO Class I & II No trials
WHO Class III & IV Many reports
but
Fewer RCTs than most people think
… and some are from a different era
WHO Class V One small RCT
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Lupus causes premature mortality
…. even without renal failure
Infection
Cardiovascular disease
including premature atherosclerosis
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TREATMENT DECISIONS IN LUPUS NEPHRITIS
Base a treatment decision on all of the following
Renal histology
Extent of clinical renal disease
Extrarenal lupus
Serology
Previous treatment
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TREATMENT FOR WHO III & IV ‘PROLIFERATIVE’ LUPUS NEPHRITIS
Induction treatment
Maintenance treatment
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
META-ANALYSIS
There is very strong evidence that
corticosteroids plus a cytotoxic agent
gives superior outcome to corticosteroids alone
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
META-ANALYSIS
There is very strong evidence that corticosteroids plus a cytotoxic agent
gives superior outcome to corticosteroids alone
…… but which cytotoxic agent ?
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TREATMENT FOR WHO III & IV LUPUS NEPHRITIS
Induction treatment
Most physicians accept that ….
Cyclophosphamide is more potent and allows more rapid control of severe disease
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TREATMENT FOR WHO III & IV LUPUS NEPHRITIS
Induction treatment
Most physicians accept that ….
Cyclophosphamide is more potent and allows more rapid control of severe disease
But does that mean all patients require cyclophosphamide ?
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is cyclophosphamide better than azathioprine ?
Is IV cyclophosphamide better than oral?
How much cyclophosphamide is required ?
Is mycophenolate good enough ?
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is cyclophosphamide better than azathioprine ?
Is IV cyclophosphamide better than oral?
How much cyclophosphamide is required ?
Is mycophenolate good enough ?
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TREATMENT OF DIFFUSE PROLIFERATIVE LUPUS NEPHRITIS
Meta-analysis – Cochrane methodology
AJKD 2004; 43:197
Cyclophosphamide or azathioprine + steroids vs steroids alone
Risk of ESRD
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NIH DATA ON CYTOTOXIC AGENTS IN PROLIFERATIVE LUPUS NEPHRITIS
Steinberg A et al Arth Rheum 1991; 34: 945
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There has never been
a head-to-head comparison of
Cyclophosphamide and azathioprine
in an RCT
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There has never been
a head-to-head comparison of
Cyclophosphamide and azathioprine
in an RCT
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INDUCTION and MAINTENANCE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
CYCLOPHOSPHAMIDE vs AZATHIOPRINE
RCT n = 87 WHO III & IV
IV cyclophosphamide for 3 years + oral prednisolone
Vs
Oral azathioprine for 3 years + oral prednisolone + initial IV methylprednisolone
Ligtenberg G et al ASN abstract 2002
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INDUCTION and MAINTENANCE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
CYCLOPHOSPHAMIDE vs AZATHIOPRINE
Ligtenberg G et al ASN abstract 2002
RCT n = 87
Interim analysis at 32 months
No difference in renal outcome
Herpes zoster increased with cyclophosphamide
No other differences in adverse events
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is cyclophosphamide better than azathioprine ?
Is IV cyclophosphamide better than oral?
How much cyclophosphamide is required ?
Is mycophenolate good enough ?
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is cyclophosphamide better than azathioprine ?
Is IV cyclophosphamide better than oral?
How much cyclophosphamide is required ?
Is mycophenolate good enough ?
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is IV cyclophosphamide better than oral?
High intermittent dosing may improve therapeutic in dex
May reduce cytopenias and infections
May assist compliance
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is IV cyclophosphamide better than oral?
There are no RCTs
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is cyclophosphamide better than azathioprine ?
Is IV cyclophosphamide better than oral?
How much cyclophosphamide is required ?
Is mycophenolate good enough ?
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CYCLOPHOSPHAMIDE IN PROLIFERATIVE LUPUS NEPHRITIS
NIH Study
Maintenance quarterly IV cyclophosphamide
is superior to short induction treatment
… but this was compared to steroid only maintenance treatment
Boumpas DT et al. Lancet 1992; 340:741
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LOW DOSE VERSUS HIGH DOSE CYCLOPHOSPHAMIDE IN PROLIFERATIVE LUPUS NEPHRITIS
‘Eurolupus Nephritis Trial’- RCT
90 patients – median follow up 41 months
Houssiau et al Arth Rheum 2002; 46: 2121
HIGH DOSE CYCLOPHOSPHAMIDE
6 monthly + 2 quarterly pulses
Initial dose 500mg/m2 Dose increased according to WCC nadir
Mean total dose 8.5 gm
LOW DOSE CYCLOPHOSPHAMIDE
6 monthly pulses of 500mg
Total dose 3 gm
Followed by AZATHIOPRINE 2mg/kg/day for 30 months
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LOW DOSE VERSUS HIGH DOSE CYCLOPHOSPHAMIDE IN PROLIFERATIVE LUPUS NEPHRITIS
Houssiau et al. Arth Rheum 2002; 46: 2121
‘Eurolupus Nephritis Trial’- RCT
NoNo difference between high and low dose cyclophosphamide in:
Achieved renal remission [~80%]
Renal flares during follow up [28%]
Severe infection [2-fold increase with high dose-NS ]
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ETHNICITY & LUPUS NEPHRITIS
Lupus nephritisis more common and more severe in some racial groups including -
African AmericansHispanics
South AsiansSouth East Asians
NIH studies: ~40% African Americans
European studies: White Caucasians
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TREATMENT OF WHO III & IV LUPUS NEPHRITIS
Is cyclophosphamide better than azathioprine ?
Is IV cyclophosphamide better than oral?
How much cyclophosphamide is required ?
Is mycophenolate good enough ?
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MYCOPHENOLATE IN PROLIFERATIVE LUPUS NEPHRITIS
Chan; NEJM 2000; 343: 1156
Mycophenolate2g/day
Cyclophosphamide2.5mg/kg/day
Mycophenolate 1g/day
Azathioprine1.5mg/kg/day
Azathioprine 1.5mg/kg/day
Azathioprine 1.5mg/kg/day
Months
0 6 12 18
Diffuse proliferative lupus nephritisRCT – within 48 hours of biopsy
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MYCOPHENOLATE IN PROLIFERATIVE LUPUS NEPHRITIS
Chan TM et al JASN 2005; 16: 1076
P=0.3
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MYCOPHENOLATE IN PROLIFERATIVE LUPUS NEPHRITIS
Li L et al – Chinese Med J 2002; 115: 705
N = 46 - 6 months – open label prospective trial
Mycophenolate vs ‘pulse’ cyclophosphamide
At 6 months
MYCOPHENOLATE
Greater reduction in proteinuria and haematuria
Greater reduction in anti-dsDNA antibodies
More improvement in glomerular inflammation [repeat biopsies in 30]
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MYCOPHENOLATE IN PROLIFERATIVE LUPUS NEPHRITIS
Ginzler EM et al – Arth Rheum 2003; 48: S647
n = 130 United States
Mycophenolate [up to 3g/day] vs ‘pulse’ cyclophosphamide
At 6 months
MYCOPHENOLATE
Superior response rate 67 vs 47% p=0.007
Cross over to other regimen less common
Fewer serious infections
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MYCOPHENOLATE IN PROLIFERATIVE LUPUS NEPHRITIS
Mycophenolate has mostly been studied as an induction agent
There is some evidence about its use and acceptabil ity as a maintenance agent
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MAINTENANCE IMMUNOSUPPRESSIVE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
RCT n = 59 Miami
Contreras G et al NEJM 2004; 350:971
All received induction therapy with cyclophosphamide
THEN for maintenance therapy..
Randomised
‘Pulse’cyclophosphamide
MycophenolateAzathioprine
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MAINTENANCE IMMUNOSUPPRESSIVE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
Contreras G et al NEJM 2004; 350:971
Patient survival notnot different
ADVERSE EFFECTS
Cyclophosphamide > Azathioprine or mycophenolate
HospitalisationsAmenorrhoea
Infections
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MAINTENANCE IMMUNOSUPPRESSIVE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
Contreras G et al NEJM 2004; 350:971
EVENT FREE SURVIVAL – death or double serum creatini ne
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MAINTENANCE IMMUNOSUPPRESSIVE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
Contreras G et al NEJM 2004; 350:971
RELAPSE FREE SURVIVAL
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MAINTENANCE IMMUNOSUPPRESSIVE THERAPY IN PROLIFERATIVE LUPUS NEPHRITIS
Because of the relative toxicity of cyclophosphamid e
It is only necessary to prove equivalenceequivalence
for azathioprine or mycophenolate
Given the cost
it is only necessary to prove equivalence
between azathioprine and mycophenolate
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OTHER TREATMENTS FOR LUPUS NEPHRITIS
Calcineurin inhibitors
Sirolimus
Total lymphoid irradiation
Anti-CD40 ligand antibody
Rituximab
Abetimus
etc….
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OTHER TREATMENTS FOR LUPUS NEPHRITIS
Calcineurin inhibitors
Sirolimus
Total lymphoid irradiation
Anti-CD40 ligand antibody
Rituximab
Abetimus
etc….
The evidence for all these is anecdotal
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OTHER TREATMENTS FOR LUPUS NEPHRITIS
Calcineurin inhibitors
Sirolimus
Total lymphoid irradiation
Anti-CD40 ligand antibody
Rituximab
Abetimus
etc….
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RITUXIMAB IN LUPUS NEPHRITIS
6 studies
96 patients [ 64 nephritis]
Some response in all patients
Complete remission ~ 40%
Includes some patients resistant to cyclophosphamid e
Walsh M, Jayne D. Kidney Int 2008; 72: 676
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COURSE OF LUPUS NEPHRITIS AFER RESPONSE TO INDUCTION THERAPY
145 patients received induction treatment
with ‘pulse’ cyclophosphamide and methylprednisolone
Of those with complete or partial response…..
45% had at least one nephritic flare during 10 years fo llow up
9/11 who reached ESRD had severe nephritic flares
Illei G et al Arth Rheum 2002; 46: 995
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COURSE OF LUPUS NEPHRITIS AFER RESPONSE TO INDUCTION THERAPY
Euro-Lupus Nephritis Trial
Remission at 6 months
is the best predictor of long term outcome
Houssiau F et al Arth Rheum 2004; 50: 3934
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DIAGNOSIS OF RENAL FLARES IN LUPUS
Proteinuria persisting or increasing during treatmen t
Activity or chronicity ?
Increase immunosuppression Or
Renin-angiotensin blockade
Or
Both ?
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It is always a pleasure to take credit
for a therapeutic manoeuvre
in a patient with lupus…
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It is always a pleasure to take credit
for a therapeutic manoeuvre
in a patient with lupus…
…when all you are doing
is observing spontaneous improvement
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COMMON THERAPEUTIC ERRORS IN LUPUS NEPHRITIS
Toxicity because high dose induction treatment for too long
Flares because stop maintenance too early
Activity not distinguished from chronicity
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TREATMENT FOR PROLIFERATIVE LUPUS NEPHRITIS
What do I do ?
INDUCTION
Prednisolone + azathioprine unless fulminant disease
If no responseMycophenolate [or cyclophosphamide]
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TREATMENT FOR PROLIFERATIVE LUPUS NEPHRITIS
What do I do ?
MAINTENANCE
Low dose prednisolone + azathioprine
…. for a very very long time
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PERSONAL PRINCIPLES FOR THE MANAGEMENT OF LUPUS NEPHRITIS
‘Never kill the patient to save the kidneys’
People with lupus have the right not to look Cushing oid
Fertility must be respected
Maximise objective evidence about disease activity
Never forget lupus is an unpredictable disease
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GLOMERULONEPHRITIS ASSOCIATED WITH SMALL VESSEL VASCULITIS
‘Pauci-immune’
Is ANCA directly pathogenic ?
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
Treatment is effective
75% 5 year kidney survival
Better outcome if treat earlier
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
Treatment is effective
75% 5 year kidney survival
Better outcome if treat earlier
INDUCTION - Corticosteroids plus Cyclophosphamide
Effective but toxic
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
We have very little evidence about treatment of relapsing disease
Most evidence is about induction and maintenance of first remission
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
Specific therapeutic questions
‘Pulse’ or oral cyclophosphamide ?
Methylprednisolone or plasma exchange for severe dis ease ?
Azathioprine or cyclophosphamide for maintenance ther apy ?
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
Specific therapeutic questions
‘Pulse’ or oral cyclophosphamide ?
Methylprednisolone or plasma exchange for severe dis ease ?
Azathioprine or cyclophosphamide for maintenance ther apy ?
Before the mid-1990’s there were no available RCT’s
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EUVAS
The European Vasculitis Study Group
Founded 1993
First trial started recruiting 1996
First trial published 2003
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
‘Pulse’ or oral cyclophosphamide ?
Azathioprine or cyclophosphamide for maintenance ther apy ?
Methylprednisolone or plasma exchange for severe dis ease ?
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CYCLOPHOSPHAMIDE IN ANCA-POSITIVE VASCULITIS
Oral or IV Pulse ?
de Groot NDT 2001; 17: 2018
Meta-analysis of 3 RCTs [154 patients] and 11 non-RCTs
Limited data……
No difference in ESRD or death
Pulse therapy More remissions
Less leucopenia
Fewer infections
More relapses
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Unpublished data
CYCLOPS – a EUVAS TRIAL
Daily oral versus pulse cyclophosphamide for induction therapy in renal vasculitis
No difference in remission or relapse rates
Total dose halved using pulse regimen
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
‘Pulse’ or oral cyclophosphamide ?
Azathioprine or cyclophosphamide for maintenance ther apy ?
Methylprednisolone or plasma exchange for severe dis ease ?
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European Vasculitis Study Group (EUVAS)
143 patients randomised from 11 countries
Randomised trial of cyclophosphamide versus azathioprine during remission in
ANCA-associated systemic vasculitis
CYCAZAREM
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CYCAZAREM
Remission therapy with azathioprine is equally effective to cyclophosphamide
and probably safer
Adverse-effects are frequent and severe -26%
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TREATMENT OF SMALL VESSEL SYSTEMIC VASCULITIS
‘Pulse’ or oral cyclophosphamide ?
Azathioprine or cyclophosphamide for maintenance ther apy ?
Methylprednisolone or plasma exchange for severe dis ease ?
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Biopsy-proven ANCA-associated necrotizing GNwith creatinine >500µmol/l
151 patients from 9 European countries
7 PE treatments (each of 60ml/kg) within the first two weeksor
3 ‘pulses’ of ivMeP (15mg/kg)
+ oral cyclophosphamide and prednisolone
European Vasculitis Study Group
MEPEX
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MEPEX
Renal outcome at 3 months significantly better with Plasma Exchange
dialysis-free survival (p=0.017)
Difference most marked in patients requiring dialysis at presentation
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RITUXIMAB IN RENAL VASCULITIS
7 published reports62 patients [35 nephritis]
Mostly added to conventional therapy or ‘rescue’
73% complete remission
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RITUXIMAB IN RENAL VASCULITIS
Unanswered questions ….
Dosing regimen ?
Long term adverse effects ?
Effective in induction + conventional Rx ?
Impact on relapse rate ?
Two RCTs of induction therapy
are underway
Walsh M, Jayne D. Kidney Int 2008; 72: 676
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EUVAS
European Vasculitis Study Group
A major success
conducting RCTs which where thought near impossible
Ongoing trials include -
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EUVAS - ONGOING TRIALS
Long-term low dose immunosuppression versus treatment withdrawal
for renal vasculitis
Mycophenolate or azathioprine for remission therapy in renal vasculitis
Rituximab as induction therapy