Faculty Bibliography

Hemophagocytic lymphohistiocytosis is a hyperinflammatory disorder resulting from primary or secondary immune dysfunction. AKI is frequent in severe hemophagocytic lymphohistiocytosis and has been attributed to multiorgan failure or the use of nephrotoxic drugs, but AKI is rarely considered a direct consequence of the disease process. We describe a child with familial hemophagocytic lymphohistiocytosis type 3 who developed AKI requiring prolonged renal replacement therapy because of severe renal inflammation. There was massive infiltration of the renal parenchyma by activated macrophages and cytotoxic T cells, and acute tubular injury. The patient responded to high-dose intravenous methylprednisolone, which resulted in improvement of renal function and discontinuation of renal replacement therapy. This case confirms the occurrence of reversible AKI due to hemophagocytic lymphohistiocytosis-induced activated macrophage infiltration of the renal parenchyma and inflammation.

Focal segmental glomerulosclerosis (FSGS) is a rare but important cause of end-stage kidney disease in children and adults. Current therapy, consisting of corticosteroids and calcineurin inhibitors, fails to achieve a sustained remission in most patients. Therefore, there is a pressing need to develop new treatments for this glomerulopathy. Traditional approaches have focused on agents that modulate the immune system. In this review, we summarize preclinical and clinical data with newer agents that may ameliorate FSGS. We focus on drugs that inhibit immune injury or inflammation, such as abatacept, rituximab, adalimumab, and stem cells. The potential of agents that block the glomerular action of circulating permeability factors such as soluble urokinase receptor is reviewed. Finally, because fibrosis represents the final common pathway of glomerular damage in FSGS, the experience with a wide range of antifibrotic agents is presented. Despite extensive research on the podocyte dysfunction in the pathogenesis of FSGS, there are few agents that directly target podocyte structure or viability. We conclude that FSGS is a heterogeneous disorder and that intensified translational research is vital to improve our understanding of distinct subtypes that have a defined prognosis and predictable response to targeted therapeutic interventions.

BACKGROUND Recent progress in the identification of Magnesium (Mg) transporters and channels has advanced our understanding of Mg homeostasis. The TRPM6 gene, which encodes an ion channel, contributes to the understanding transepithelial Mg transport. An association was identified between hypomagnesemia with secondary hypocalcemia and the TRPM6 gene. Recently a missense mutation in TRPM6 gene was reported (1). Several othergenes have also been reported in hereditary renal Mg loss. No definite phenotype-genotype correlation has been established. Paracellular transport of magnesium was clarified by the claudin 16-19 mutations. Claudins are tight junctions proteins located in the kidney; mutations in these key proteins are responsible for the condition called familial hypomagnesemia with hypercalciuria and nephrocalcinosis (2). Hypomagnesemia occurs in malabsorption, vitamin D deficiency and hypoparathyroidism. The syndrome of hypomagnesemia with secondary hypocalcemia is a rare disorder characterized by a defect in renal or intestinal Mg absorption, which can result in brain damage if not recognized early. We report a newborn who presented with convulsions, profound hypomagnesemia with hypocalcemia. CASE REPORT A full term male, born to Yemenite parents with no parental consanguinity nor any significant family history, presented at 12 days of life with new onset generalized convulsions. Initial studies showed: Mg <0.6 mg/dL (1.6-2.3 mg/dL), calcium 6.4mg/dl (8.3-10.3 mg/dL), phosphorus 10.3 mg/dl (2.7-4.5 mg/dL), glucose 81mg/dl. Genetic investigation is in progress. The baby was initially treated with anticonvulsants and calcium gluconate. Despite this treatment, seizures persisted. IV Mg boluses (50mg/kg)and Ca (100mg/kg) were then administered. Within 24 hrs serum Ca normalized, but Mg remained below normal. The baby was transitioned to PO Mg and Ca supplements. Serum 25 hydroxy vitamin D was <13ng/mL ergocalciferol 2000 unitswere supplemented. Fractional Mg excretion (FEMg) was elevated at 15% (1-8%) with a low serum Mg 1 mg/dL suggestive of renal loss of Mg. Renal ultrasound was normal. After 24 hrs of IV Ca and Mg, the seizures ceased. However, Mg levels remained suboptimal (highest 1.5mg/dl) despite high PO doses of Mg. The baby was discharged on high doses of Mg (100 mg q 6 hrs), Ca and Vit D supplementation. During follow up calcium and vitamin D were tapered then stopped. Supplemental Mg was increased to200mg q 6hrs to maintain Mg levels at least >1.0 mg/dl. CONCLUSION Primary hypomagnesemia can occur with other electrolyte abnormalities and may be life threatening. The diagnosis can be a challenge, and a high index of suspicion is needed. An inherited disorder should be suspected, and genetic studies are recommended. Despite high doses of Mg levels may remain subnormal. Early diagnosis and appropriate treatment are important to avoid irreversible neurologic damage

Steroid-resistant nephrotic syndrome has a poor prognosis and often leads to end-stage renal disease development. In this issue of the JCI, Ashraf and colleagues used exome sequencing to identify mutations in the aarF domain containing kinase 4 (ADCK4) gene that cause steroid-resistant nephrotic syndrome. Patients with ADCK4 mutations had lower coenzyme Q10 levels, and coenzyme Q10 supplementation ameliorated renal disease in a patient with this particular mutation, suggesting a potential therapy for patients with steroid-resistant nephrotic syndrome with ADCK4 mutations.

Exchanging each of the conserved aromatic residues of the NPxxY(x)(5,6)F sequence (at the boundary of helices 7 and 8) generated variants of the A(1) adenosine receptor that were retained within the cell. The mutations disconnected a link between alpha-helix 7 and cytosolic helix 8, likely destabilizing the structure of the proximal carboxyl terminus. The mutant receptors were rescued by incubation of cells with a pharmacochaperone, a membrane-permeable ligand that homosterically binds to the receptor; pharmacochaperoning restored the density of functional receptors at the plasma membrane. The following observations support the assumption that retention and the site of pharmacochaperone action were within bounds of the endoplasmic reticulum (ER): 1) the retained receptor colocalized with an ER marker; 2) pharmacochaperoning initiated receptor transfer to Golgi stacks; and 3) the inhibitor of glycoprotein synthesis tunicamycin suppressed receptor chaperoning. Our data are consistent with the hypothesis that pharmacochaperoning stabilizes the structure of late folding intermediates and lifts a block on maturation, allowing the receptors to exit from the ER. We suggest that the ER-associated 40-kDa heat shock protein family member D(1) receptor interacting protein 78 (DRiP78; M(r), approximately 78,000) represents a model executor of quality control. Overexpressed DRiP78 interacted physically with the A(1) receptor, inhibited export to the plasma membrane, and in this action was selective for the mutants relative to the wild-type receptor. Both agonist and antagonist were effective chaperone ligands. Thus, occupancy of the binding pocket corrected the mutation-induced disorder, indicating a mutual impingement of the transmembrane domain and the proximal carboxyl terminus in establishing the stable receptor fold.

Low biocompatibility of peritoneal dialysis fluid (PDF) injures mesothelial cells and activates their stress response. In this study, we investigated the role of heat shock proteins (HSP), the main cytoprotective effectors of the stress response, in cytoskeletal stabilization of mesothelial cells in experimental peritoneal dialysis. In cultured human mesothelial cells, cytoskeletal integrity was assessed by detergent extractability of marker proteins following in vitro PDF exposure. Effects of HSP on stabilization of ezrin were evaluated by a conditioning protocol (PDF pretreatment) and repair assay, based on coincubation of cytoskeletal protein fractions with recombinant HSP-72 or HSP-72 antibodies. In the rat model, detachment of mesothelial cells from their peritoneal monolayer during in vivo PDF exposure was assessed with and without overexpression of HSP-72 (by heat conditioning). In vitro, cytoskeletal disruption on sublethal PDF exposure was demonstrated by significantly altered detergent extractability of ezrin and ZO-1. Restoration was associated with significant induction and cytoskeletal redistribution of HSP during recovery. Both the conditioning protocol and in vitro repair assay provided evidence for HSP-72-mediated cytoskeletal stabilization. In the rat model, overexpression of HSP-72 following heat conditioning resulted in significantly reduced detachment of mesothelial cells on in vivo exposure to PDF. Our results establish an essential role of HSP in repair and cytoprotection of cytoskeletal integrity in mesothelial cells following acute in vitro and in vivo exposure to PDF. Repeated exposure to PDF, as is the rule in the clinical setting, may not only cause repeat injury to mesothelial cells but rather represents a kind of inadvertent conditioning treatment.

BACKGROUND: During peritoneal dialysis (PD), epithelial-mesenchymal transition (EMT) is likely involved in aberrant healing and progressive peritoneal fibrosis. Recently, EMT of the kidney was actively reversed into the opposite direction, into mesenchymal-epithelial transition (MET), by treatment with bone morphogenic protein-7 (BMP-7). In this study, the potential for ex vivo interconversion of in vivo transdifferentiation processes was investigated in mesothelial cells. METHODS: In vivo EMT was assessed in mesothelial cell cultures randomly grown from peritoneal effluents of seven patients on chronic PD. Then, ex vivo treatment with modulating factors was performed by incubating cobblestone-like cell cultures with transforming growth factor (TGF- beta1) and fibroblast-like cultures with BMP-7. Effects were assessed by morphological characterization, western analysis and reverse transcription-polymerase chain reaction of marker proteins ezrin and alpha-smooth muscle actin (alpha-SMA). RESULTS: PD caused progressive in vivo EMT with loss of the epithelial phenotype in the majority of mesothelial cell cultures over a 12-month period. EMT was reproducible by ex vivo treatment of cultured cells with TGF-beta1, converting the epithelial to the fibroblast-like phenotype. Ex vivo treatment with BMP-7 reversed in vivo and ex vivo EMT. During rhBMP-7 incubation the fibroblast-like growth pattern reversed into a more epithelial morphology, the expression of ezrin increased and alpha-SMA decreased. CONCLUSION: Our study shows that modulating factors of transdifferentiation, such as BMP-7, may be attractive tools in the balance between normal healing and aberrant profibrotic processes in mesothelial cells during peritoneal dialysis. Peritoneal-effluent-derived mesothelial cells are not mere biomarkers for in vivo EMT in the peritoneal cavity, but also represent an assay to test ex vivo interventions to reverse the profibrotic phenotype.