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IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide with a very severe prognosis, causing kidney failure in up to 50 % of patients in a period of 30 years. For the diagnosis of IgAN it is necessary to perform a renal biopsy, this is an invasive examination that carries number of risks for the patients (the most common is bleeding and others). The aim of our work was to identify markers that could facilitate diagnosis and might help in determining the disease activity with an estimate of prognosis and consequently optimal use of effective therapy. In the pilot project on 19 patients with different types of glomerulonephritides (IgAN, diabetic nephropathy, membranous glomerulonephritis, lupus nephritis, ANCA associated vasculitis) and 19 healthy subjects we demonstrated a panel of 7 biomarkers (8-hydroxyguanosine, dodecanal, leukotriene C4, alpha1-antitrypsin, heparan sulfate , IgA-uromodulin, Gd-IgA1) that were able to completely differentiate patients with IgAN from other types of glomerulonephritides or healthy controls. In a group of 93 Czech patients with IgAN we confirmed the influence of clinical factors (PU, HT, eGFR) on the progression of renal function. Using LDA and logistic regression modelling we found that serum Gd-IgA1 (native without pre-treatment with...

IgA nephropathy is the world's most common primary glomerulonephropathy. Recent evidence in a rat model implicated excessive production of oxygen-free radicals in the pathogenesis and suggested that vitamin E-treatment ameliorated progression. We studied this antioxidant therapy on the glomerular filtration rate (GFR), proteinuria and hematuria in biopsy-proven IgA nephropathy in children. The duration of treatment or placebo was 2 years, with vitamin E treatment consisting of 400 IU/day in children weighing <30 kg, and twice that dose for those >30 kg. We measured GFR at entry, midpoint and exit. At baseline and at 4-month intervals after randomization, urinary protein/creatinine ratios and urinalysis were examined. The mixed model procedure with log transformation was used in data analysis to test treatment difference as well as the potential time effect. Fifty-five patients were randomized and 38 completed at least 1 year of follow-up. At entry, the clinical characteristics were not different between the treatment and placebo groups. There was a trend toward better preservation of GFR in vitamin E-treated versus placebo patients, 127±50 vs. 112±31 ml/min/1.73 m2, respectively (P=0.09). The urinary protein/creatinine ratio was significantly lower in the vitamin E-treated group vs. placebo; 0.24±0.38 vs. 0.61±1.37 (P<0.013). However, there was no difference in the prevalence of hematuria between the groups. Vitamin E treatment in our study patients was associated with significantly lower proteinuria, but no effect on hematuria. While there was a trend toward stabilization of GFR in the vitamin E-treated patients, longterm treatment and follow-up are needed to determine whether antioxidant therapy is associated with preservation of renal function in IgA nephropathy.

Background Glomerulonephritis is a major cause of end-stage kidney disease (ESRD) in Africa. There is scanty data on the clinico-pathological characteristics and outcome of the mesangioproliferative glomerulonephritides in Africa, despite the non-IgA subtype being reported as a common cause of nephrotic syndrome. This study will assess the outcome of patients with biopsy proven mesangioproliferative glomerulonephritis (MesPGN) from a single centre in Cape Town, South Africa. Methods The study is designed as 10-year retrospective analysis of patients with biopsy proven MesPGN. The MesPGN patterns were divided into non-IgA MesPGN and IgA nephropathy (IgAN), depending on the predominant type of immune deposit. Univariate cox regression analysis was used to determine factors associated with ESRD. Results Data of 109 patients with renal biopsy-proven MesPGN were included for the period between 2005-2014. The mean age at biopsy was 33.8 ±14.9 years, 53.2% were males, and 39.4% were black Africans. Clinically, 58.7% presented with nephrotic syndrome. On histology 79.8% had non-IgA MesPGN, and 20.2% had IgAN. Compared to the non-IgA group, most patients with IgAN were not treated with immunosuppression (72.7% vs. 40.2%; p=0.006). At the last visit, 10.1% reached ESRD (40.9% vs. 2.3%; p<0.0001) and 30.2% achieved complete remission (9.1% vs. 35.7%; p=0.015) for IgAN and non-IgA MesPGN respectively. The 5-year renal survival for IgAN and non-IgA MesPGN respectively, were: 63.3% vs. 97.6%, log rank p=0.001. Overall, hypertension (p=0.019), not receiving immunosuppression (p=0.046) and having IgAN (p=0.007) were independent predictors of progression to ESRD. Conclusion There is a significantly higher ESRD-free survival of patients with biopsy proven non-IgA MesPGN than IgAN. Whether this is related to the limited use of immunosuppressive therapy in IgAN patients or represents a true nature of the disease still requires further research.

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The mammalian immune system has developed diverse strategies to protect the gastrointestinal tract, as this tissue locale represents a huge absorptive surface and is susceptible to microbial breach. Paradoxically, one key aspect of this protective strategy is the maintenance of selected commensal microorganisms. These commensals serve essential roles in digestion, interfere with pathogenic microbial invasion and stimulate development of the host immune system. Therefore, immune responses which deplete these commensal populations are detrimental to the host. One effective intestinal immune response which selectively promotes the survival of commensals is production of antibodies of the IgA isotype which bind to bacteria without triggering inflammatory cytokines. Proteins of the tumor necrosis factor (TNF) family such as Lymphotoxin and BAFF contribute to the induction of IgA responses. Lymphotoxin is required for generation and organization of most organized lymphoid tissues, where B cell differentiation occurs, while BAFF is necessary for B cell survival and induces B cells to produce IgA. In this thesis, I describe work I have done in examining the roles of the TNF family members Lymphotoxin, BAFF and two related TNF family member cytokines, LIGHT and APRIL, in the regulation of IgA production in mice and in humans. Specifically, LIGHT over-expression drives immense production of IgA, leading to renal deposition of immune complexes in mice. Similar to LIGHT, BAFF over-expression drives increases in IgA production in the intestine, however I have shown that the effects of the BAFF pathway on IgA hyper-production are independent of LIGHT activity. Secondly, examining the phenotype of BAFF-over-expressing mice, I have shown that this phenotype resembles human IgA nephropathy (IgAN) and is dependent on intestinal commensals. Finally, I have described a lymphotoxin-dependent chemokine system in the intestinal lamina propria that could be responsible for organizing cells for the development of IgA responses in this mucosal site.

L’immunoglobuline A (IgA) est l’immunoglobuline la plus abondamment synthétisée chez les mammifères. Ses propriétés ambivalentes l’impliquent non seulement dans des fonctions de protection contre les agents pathogènes mais aussi dans des phénomènes de tolérance immunitaire vis-à-vis des germes commensaux du microbiote. Toutefois, les IgA peuvent développer des propriétés pathogènes. Dans la première partie de mon travail de thèse, nous avons étudié les effets pathogènes de l’IgA. Les dépôts d’IgA sur le mésangium sont la caractéristique de l’IgAN. La physiopathologie de cette maladie est mal connue. L’hypothèse d’un défaut de glycosylation de l’IgA est souvent retenue ; ce défaut peut être la cause de sa polymérisation et de son antigénicité, il peut aussi favoriser le clivage du récepteur CD89. Nous avons analysé l’effet du défaut d’affinité de la région variable des IgA, de la substitution de la chaîne légère ainsi que de l’association des IgA à leur récepteur, le CD89 sur l’induction des lésions et le dysfonctionnement rénal chez quatre modèles murins différents générés au laboratoire et suivis pendant 12 mois. Nous avons également étudié les propriétés physico-chimiques des IgA de 28 patients ayant une dysglobulinémie et de 28 IgA produites par des hybridomes ; la relation entre ces propriétés et la capacité des IgA à se déposer a été observée. Dans une seconde partie, nous avons étudié l’aspect immunomodulateur et les propriétés antiinflammatoires conférées par l’IgA humaine surexprimée chez un modèle murin de lupus systémique (souris MRL/lpr). Dans la dernière partie du travail, nous avons contribué à la caractérisation d’un modèle de souris transgénique exprimant l’IgA de classe 2 et à l’étude de l’effet de signalisation médiée par cette IgA2 sur le développement des populations lymphocytaires. L’ensemble de ces travaux a montré l’effet pathogène des IgA naturelles ayant une faible affinité sur le développement de la néphropathie à IgA ; ainsi les analyses des IgA des patients et des hybridomes montrent que c’est la stabilité moléculaire de préférence au profil de glycosylation qui joue un rôle crucial dans leur capacité de dépôt. L’expression des IgA humaines chez les souris lupiques a considérablement prolongé leur durée de vie et a ralenti la survenue de l’auto-immunité et de l’atteinte rénale ce qui témoigne du rôle anti-inflammatoire des IgA. L’étude du modèle murin exprimant l’IgA2 humaine a montré que la signalisation via l’IgA2 joue un rôle inhibiteur sur le développement précoce de certaines sous-populations de cellules B. L’ensemble de ces résultats montrent la multitude d’effets de l’IgA lui permettant d’intervenir d’une part dans la pathogenèse d’une maladie complexe (l’IgAN) et d’autre part dans la protection de l’auto-immunité, témoignant de la complexité des interactions mises en jeu et du caractère régulateur de cette immunoglobuline. / Immunoglobulin A (IgA) is the most synthetized immunoglobulin in mammals. IgA has ambivalent properties: it is implicated in the mechanisms of defense against pathogens but also in the immune tolerance of commensal microbiota. However, IgA can develop pathogenic properties. In the first part of my thesis, we studied the pathogenic effects of IgA. IgA deposits are the main characteristic of IgA nephropathy (IgAN). IgAN physiopathology is not yet clearly understood. The hypothesis of a glycosylation defect is strongly adapted. This defect can be due to IgA polymerization or antigenicity. It can also induce shedding of CD89 (IgA Fc receptor) or other factors. We studied the effect of variable region altered affinity, the light chain substitution and the association of IgA with CD89 on the development of kidney lesions and impairment of kidney function in four mouse models followed up during 12 months. In addition, we studied the physico-chemical properties of 28 IgA purified from patients with dysglobulinaemia and 28 chimeric IgA produced by hybridomas. The effect of these properties on the propensity of IgA for mesangial deposition was explored. In the second part, we studied the immunomodulatory and anti-inflammatory properties conferred by the overexpression of human IgA in a mouse model with systemic lupus (MRL/lpr model). In the last part, we contributed to the characterization of a transgenic mouse model producing IgA class 2 and to the study of the effect of IgA2-mediated signaling on B lymphocyte development. Altogether, obtained results show the pathogenic effect of low affinity-IgA on the development of IgA nephropathy. In addition, different analyses showed that molecular stability but not glycosylation profile is the determining factor for IgA deposition. On the other hand, IgA expression in lupus-prone mice extended their survival, delayed the onset of auto-immunity and ameliorated kidney functions in these animals which supports IgA anti-inflammatory properties. The study of IgA2-mediated signaling in the transgenic model showed the inhibitory effect of IgA2 on the early development of several B cell sub-populations. All of these results show the multiple effects of IgA which contribute on one hand to the pathogenesis of a complex disease (IgAN) and on the other hand to protection from autoimmunity, demonstrating the complexity of interactions and the regulatory character of this immunoglobulin.

The mammalian immune system has developed diverse strategies to protect the gastrointestinal tract, as this tissue locale represents a huge absorptive surface and is susceptible to microbial breach. Paradoxically, one key aspect of this protective strategy is the maintenance of selected commensal microorganisms. These commensals serve essential roles in digestion, interfere with pathogenic microbial invasion and stimulate development of the host immune system. Therefore, immune responses which deplete these commensal populations are detrimental to the host. One effective intestinal immune response which selectively promotes the survival of commensals is production of antibodies of the IgA isotype which bind to bacteria without triggering inflammatory cytokines. Proteins of the tumor necrosis factor (TNF) family such as Lymphotoxin and BAFF contribute to the induction of IgA responses. Lymphotoxin is required for generation and organization of most organized lymphoid tissues, where B cell differentiation occurs, while BAFF is necessary for B cell survival and induces B cells to produce IgA. In this thesis, I describe work I have done in examining the roles of the TNF family members Lymphotoxin, BAFF and two related TNF family member cytokines, LIGHT and APRIL, in the regulation of IgA production in mice and in humans. Specifically, LIGHT over-expression drives immense production of IgA, leading to renal deposition of immune complexes in mice. Similar to LIGHT, BAFF over-expression drives increases in IgA production in the intestine, however I have shown that the effects of the BAFF pathway on IgA hyper-production are independent of LIGHT activity. Secondly, examining the phenotype of BAFF-over-expressing mice, I have shown that this phenotype resembles human IgA nephropathy (IgAN) and is dependent on intestinal commensals. Finally, I have described a lymphotoxin-dependent chemokine system in the intestinal lamina propria that could be responsible for organizing cells for the development of IgA responses in this mucosal site.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第24536号 / 社医博第128号 / 新制||社医||12(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 近藤 尚己, 教授 西浦 博, 教授 柳田 素子 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

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