Its’
that time of the year- Renal fellow
network top 10 nephrology stories of the year . My pick is Chih-Chuan
Yu et al ‘s brief report in NEJM on abatacept in proteinuric kidney diseases.
Just like belatacept
in kidney transplantation, abatacept is an inhibitor of co-stimulatory molecule
CD80 or B7-1 in the T cell signaling. It has been approved for use in RA
for patients that fail TNF alpha inhibition. What the authors did was show several
cases ( mostly post transplant proteinuric diseases) and showed how this agent
helped get rid of proteinuria. Taking a step further, they found that post
transplant, not all proteinuric FSGS stained for B7-1 in the kidney biopsy.
They only treated the B7-1 positive FSGS strain with this agent to show
response.
A table in the NEJM paper shows the 5 patient
characteristics. Four patients were post transplant FSGS and had failed
rituxan. Two of the four responded to just one dose of 10mg/kg of abatacept and
the two remaining needed 2 doses of 10mg/kg.
This is remarkable that just few doses put the disease in remission.
They had 36-48 follow up data on all of them and still in remission. The
patient 5 was a non transplanted primary FSGS case which was B7 positive and
also responded to this agent but required monthly dosages for a year. Given transplant
patients are on other agents that are attacking the immune system, one dose
might be sufficient compared to non transplanted native FSGS.
In addition, the RFN did a nice
post that also discusses the role of this agent in lupus nephritis and diabetic
nephropathy. Take a look at these links
Why do I think that compared to other great stories in
nephrology, this makes the number 1 contender in 2014? Besides
my love for podocyte and glomerular diseases?
1.
The authors have now identified another APOL1 like characteristic
of FSGS- B7 + FSGS( perhaps should become a new category in FSGS- as they will
respond to abatacept)
2.
Novel therapies for FSGS and other glomerular diseases are
lacking. While rituximab, IVIG,
galactose, ACTH have come to the market, nothing has shown this dramatic of a
difference.
3.
The authors took the transplantation literature and applied
it to glomerular diseases. This is what is needed more and more. In addition,
let’s take it to the next level- apply rheumatology and oncology literature and
look for agents that will apply to glomerular diseases.
4.
This excites young minds about nephrology. This is a positive step forward in the “sexiest”
part of the kidney( glomerulus) and hope to excite many residents to take on
the field of nephrology.
Go to Renal Fellow
Network and
vote for your top nephrology story of 2013!
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