Experimental studies of nephrotoxic nephritis in animals have demonstrated many of the underlying pathogenetic mechanisms involved in human glomerulonephritis. The first part of this thesis reviews the literature with regard to the factors and mechanisms responsible for the causation of glomerulonephritis and those factors which determine severity and allow for its persistence. In order to study these mechanisms, a reproducible model of nephrotoxic nephritis (NTN) in rabbits was established. This disease is produced by the intravenous injection of nephrotoxic serum, raised in sheep, containing antibodies to rabbit glomerular basement membrane. In a second group of experiments, the induction of an acute phase response in rabbits by the subcutaneous injection of a local irritant was studied. It was characterised by changes in C-reactive protein (CRP), the third component of complement (C3), fibrinogen and polymorphonuclear leucocytes (PMN' s), however renal function and renal histology were not affected in any way. When the so called heterologous phase of NTN in rabbits was induced during maximal acute phase stimulation, it did not result in enhancement of injury when compared to unstimulated rabbits. A similar situation was found during 7 the autologous phase, where a superimposed acute phase stimulus again did not cause enhancement of injury. Despite the fact that CRP has been shown to localize in injured tissue under certain circumstances, it did not fix in the kidneys of rabbits with induced NTN, nor in human kidneys affected by a variety of glomerulonephritides. The reasons for the variation in severity of disease during the autologous phase were analysed. Rabbits which developed severe glomerulonephritis during· the autologous phase of NTN characteristically produced high titres of rabbit anti-sheep antibody early in the disease when compared to those which did not develop injury, even though they might ultimately have developed the same titre of antibodies. One of the major determinants of injury appears to have been the rate at which antibody bound to the glomerular basement membrane (GBM). Studies during the heterologous phase confirmed this impression when it was shown that nephrotoxic globulin (NTG) given slowly, produced less injury than when the same amount was infused fast. This observation also suggested that the effector function of immunoglobulin decays much more rapidly than was previously thought. Finally, a mechanism of "protection" from injury by circulating antibody was shown by the phenomenon of "saturation" of available antibody binding sites on the 8 glomerular basement membrane which appeared to limit the deposition of further circulating antibody thus preventing further damage. These studies have advanced the understanding of human glomerulonephritis by illustrating how variation in immune responsiveness may contribute to the development of disease. They suggest that something inherent in infections, other than merely an acute phase response, is responsible for infection induced relapse in certain cases of allergic renal disease. By demonstrating a mechanism of “protection" from the effect of circulating antibodies, these studies suggest that therapy directed towards blocking of available antigenic sites on the human glomerular basement membrane, may become a therapeutic reality.

Résumé : Objectifs : La vancomycine est un antibiotique néphrotoxique couramment utilisé chez les enfants gravement malades. L'objectif de l’étude était de mesurer l'association entre la vancomycine sérique (Vs) et l'insuffisance rénale aiguë (IRA) chez les enfants en unité de soins intensifs pédiatriques (USIP). Méthode : Notre cohorte comprend les admissions à l’USIP entre 2017 et 2022, ayant reçu de la vancomycine pendant ≥48 heures, avec les Vs mesurées selon la norme de soins clinique. La Vs la plus élevée dans les sept jours suivant la vancomycine a été considérée comme l'exposition et catégorisée en deux groupes : ≤20 mg/L and >20 mg/L. L’issue principale était le développement de l’IRA stade 1(augmentation de créatinine >50%) et l’issue secondaire était le changement de créatinine sérique entre avant et après le début de la vancomycine (24 heures à sept jours). Nous avons utilisé des modèles de régression logistique et linéaire ajustés en fonction de l'âge, du diagnostic, du score de gravité clinique des patients, des médicaments concomitants et de la durée du séjour en USIP. Résultats : Nous avons inclus 161 admissions chez 149 patients, dont 18 (11.18 %) ont développé une IRA dans les sept jours après la vancomycine. Le rapport de cotes ajusté pour l'association entre l’IRA et un niveau de Vs de >20 mg/L était de 5.86 [95% CI : 1.70-22.65]. Conclusion : Une mesure de vancomycine sérique >20 mg/L était associé à un risque accru d’IRA et justifie une surveillance de la Vs chez les enfants gravement malade. Mots-clés : Antibiotiques néphrotoxiques, Vancomycine, Insuffisance rénale aiguë, Enfants gravement malades, Unité de soins intensifs pédiatriques. / Abstract: Objectives: Vancomycin is a nephrotoxic antibiotic commonly used in critically ill children. The objective of the study was to measure the association between serum vancomycin (Vs) and acute kidney injury (AKI) in children in the pediatric intensive care unit (PICU). Method: Our cohort included PICU admissions between 2017 and 2022, having received vancomycin for ≥48 hours, with Vs measured according to clinical care standards. The highest Vs within seven days following vancomycin administration was considered as the exposure and categorized into two groups: ≤20 mg/L and >20 mg/L. The primary outcome was the development of stage 1 AKI (creatinine increase >50%) and the secondary outcome was the change in serum creatinine between before and after the start of vancomycin (24 hours to seven days). We used logistic and linear regression models adjusted for age, diagnosis, patient clinical severity score, concomitant medications, and length of stay in the PICU. Results: We included 161 admissions of 149 patients, of whom 18 (11.18%) developed AKI within seven days after vancomycin. The adjusted odds ratio for the association between AKI and a Vs level of >20 mg/L was 5.86 [95% CI: 1.70-22.65]. Conclusion: A serum vancomycin measurement of >20 mg/L was associated with an increased risk of AKI, justifying the monitoring of Vs in critically ill children. Keywords: Nephrotoxic antibiotics, Vancomycin, Acute Kidney Injury, Critically ill children, Pediatric Intensive Care Unit.

Non-resolving inflammation plays a critical role during the transition from renal injury towards end-stage renal disease. The glucocorticoid-inducible protein annexin A1 has been shown to function as key regulator in the resolution phase of inflammation, but its role in immune-mediated crescentic glomerulonephritis has not been studied so far. Methods: Acute crescentic glomerulonephritis was induced in annexin A1-deficient and wildtype mice using a sheep serum against rat glomerular basement membrane constituents. Animals were sacrificed at d5 and d10 after nephritis induction. Renal leukocyte abundance was studied by immunofluorescence and flow cytometry. Alterations in gene expression were determined by RNA-Seq and gene ontology analysis. Renal levels of eicosanoids and related lipid products were measured using lipid mass spectrometry. Results: Histological analysis revealed an increased number of sclerotic glomeruli and aggravated tubulointerstitial damage in the kidneys of annexin A1-deficient mice compared to the wildtype controls. Flow cytometry analysis confirmed an increased number of CD45+ leukocytes and neutrophil granulocytes in the absence of annexin A1. Lipid mass spectrometry showed elevated levels of prostaglandins PGE2 and PGD2 and reduced levels of antiinflammatory epoxydocosapentaenoic acid regioisomers. RNA-Seq with subsequent gene ontology analysis revealed induction of gene products related to leukocyte activation and chemotaxis as well as regulation of cytokine production and secretion. Conclusion: Intrinsic annexin A1 reduces proinflammatory signals and infiltration of neutrophil granulocytes and thereby protects the kidney during crescentic glomerulonephritis. The annexin A1 signaling cascade may therefore provide novel targets for the treatment of inflammatory kidney disease.