Nephrotic Syndrome Study Network
- Conditions
- Membranous NephropathyMinimal Change Disease (MCD)Glomerulosclerosis, Focal Segmental
- Interventions
- Procedure: Kidney Biopsy
- Registration Number
- NCT01209000
- Lead Sponsor
- University of Michigan
- Brief Summary
Minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), and Membranous nephropathy (MN), generate an enormous individual and societal financial burden, accounting for approximately 12% of prevalent end stage renal disease (ESRD) cases (2005) at an annual cost in the US of more than $3 billion. However, the clinical classification of these diseases is widely believed to be inadequate by the scientific community. Given the poor understanding of MCD/FSGS and MN biology, it is not surprising that the available therapies are imperfect. The therapies lack a clear biological basis, and as many families have experienced, they are often not beneficial, and in fact may be significantly toxic. Given these observations, it is essential that research be conducted that address these serious obstacles to effectively caring for patients.
In response to a request for applications by the National Institutes of Health, Office of Rare Diseases (NIH, ORD) for the creation of Rare Disease Clinical Research Consortia, a number of affiliated universities joined together with The NephCure Foundation the NIDDK, the ORDR, and the University of Michigan in collaboration towards the establishment of a Nephrotic Syndrome (NS) Rare Diseases Clinical Research Consortium.
Through this consortium the investigators hope to understand the fundamental biology of these rare diseases and aim to bank long-term observational data and corresponding biological specimens for researchers to access and further enrich.
- Detailed Description
Idiopathic Nephrotic Syndrome (NS) is a rare disease syndrome responsible for approximately 12% of all causes of end-stage kidney disease (ESRD) and up to 20% of ESRD in children. Treatment strategies for Focal and Segmental Glomerulosclerosis (FSGS), Minimal Change Disease (MCD) and Membranous Nephropathy (MN), the major causes of NS, include high dose prolonged steroid therapy, cyclophosphamide, cyclosporine A, tacrolimus, mycophenolate mofetil and other immunosuppressive agents, which all carry significant side effects. Failure to obtain remission using the current treatment approaches frequently results in progression to ESRD with its associated costs, morbidities, and mortality. In the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry, half of the pediatric patients with Steroid Resistant Nephrotic Syndrome required renal replacement therapy within two years of being enrolled in the disease registry. FSGS also has a high recurrence rate following kidney transplantation (30-40%) and is the most common recurrent disease leading to allograft loss.
The prevailing classification of Nephrotic Syndrome categorizes patients into FSGS, MCD, and MN, if in the absence of other underlying causes, glomerular histology shows a specific histological pattern. This classification does not adequately predict the heterogeneous natural history of patients with FSGS, MCD, and MN. Major advances in understanding the pathogenesis of FSGS and MCD have come over the last ten years from the identification of several mutated genes responsible for causing Steroid Resistant Nephrotic Syndrome (SRNS) presenting with FSGS or MCD histopathology in humans and model organisms. These functionally distinct genetic disorders can present with indistinguishable FSGS lesions on histology confirming the presence of heterogeneous pathogenic mechanisms under the current histological diagnoses.
The limited understanding of FSGS, MCD, and MN biology in humans has necessitated a descriptive classification system in which heterogeneous disorders are grouped together. This invariably consigns these heterogeneous patients to the same therapeutic approaches, which use blunt immunosuppressive drugs that lack a clear biological basis, are often not beneficial, and are complicated by significant toxicity. The foregoing shortcomings make a strong case that concerted and innovative investigational strategies combining basic science, translational, and clinical methods should be employed to study FSGS, MCD, and MN. It is for these reasons that the Nephrotic Syndrome Study Network is established to conduct clinical and translational research in patients with FSGS/MCD and MN.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 1200
Patients presenting with an incipient clinical diagnosis for FSGS/MCD or MN or pediatric participants not previously biopsied, with a clinical diagnosis for FSGS/MCD or MN meeting the following inclusion criteria:
- Documented urinary protein excretion ≥1500 mg/24 hours or spot protein: creatinine ratio equivalent at the time of diagnosis or within 3 months of the screening/eligibility visit.
- Scheduled renal biopsy
Cohort B (non-biopsy, cNEPTUNE) Inclusion Criteria:
-
Age <19 years of age
-
Initial presentation with <30 days immunosuppression therapy
-
Proteinuria/nephrotic
- UA>2+ and edema OR
- UA>2+ and serum albumin <3 OR
- UPC > 2g/g and serum albumin <3
Exclusion Criteria (Cohort A&B):
- Prior solid organ transplant
- A clinical diagnosis of glomerulopathy without diagnostic renal biopsy
- Clinical, serological or histological evidence of systemic lupus erythematosus (SLE) as defined by the ARA criteria. Patients with membranous in combination with SLE will be excluded because this entity is well defined within the International Society of Nephrology/Renal Pathology Society categories of lupus nephritis, and frequently overlaps with other classification categories of SLE nephritis (68)
- Clinical or histological evidence of other renal diseases (Alport, Nail Patella, Diabetic Nephropathy, IgA-nephritis, monoclonal gammopathy (multiple myelomas), genito-urinary malformations with vesico-urethral reflux or renal dysplasia)
- Known systemic disease diagnosis at time of enrollment with a life expectancy less than 6 months
- Unwillingness or inability to give a comprehensive informed consent
- Unwillingness to comply with study procedures and visit schedule
- Institutionalized individuals (e.g., prisoners)
Not provided
Study & Design
- Study Type
- OBSERVATIONAL
- Study Design
- Not specified
- Arm && Interventions
Group Intervention Description Other glomerulopathies cohort Kidney Biopsy Participants enrolled in NEPTUNE and determined to not have FSGS/MCD or MN will be followed in a third group. Eligible participants must be scheduled for a clinically indicated renal biopsy. FSGS/MCD Cohort (Cohort A) Kidney Biopsy Focal Segmental Glomerulosclerosis/Minimal Change Disease (FSGS/MCD) Cohort Participants enrolled in NEPTUNE with a biopsy proven histological diagnosis for FSGS or MCD. Eligible participants must be scheduled for a clinically indicated renal biopsy. MN Cohort (Cohort A) Kidney Biopsy Membranous Nephropathy (MN) Cohort Participants enrolled in NEPTUNE with a biopsy proven histological diagnosis for MN. Eligible participants must be scheduled for a clinically indicated renal biopsy.
- Primary Outcome Measures
Name Time Method Rate of change in renal function. 60 months Defined as:
1. 25 mls/min/1.73m2 reduction in follow-up estimated GFR (using the 4-variable MDRD equation for ages ≥18 years and modified Schwartz for ages \<18 years) compared to baseline estimated GFR
2. 50% decline in follow-up estimated GFR compared to baseline measurement
3. End stage renal disease defined as estimated GFR ≤10cc/min, initiation of maintenance dialysis or preemptive kidney transplantation.Event rate of change in urinary protein excretion and renal function. 60 months Defined as remission, partial remission and non-remission
- Secondary Outcome Measures
Name Time Method Thromboembolic Events 60 months Documented diagnosis of one of the following:
1. Embolic cerebrovascular accident
2. Deep venous thrombosis
3. Renal vein thrombosis or
4. Pulmonary embolusAcute Kidney Injury 60 months Documented diagnosis of acute kidney injury as defined by the AKIN (Mehta et al., Critical Care 2007, 11:R31) and/or renal failure requiring renal replacement therapy \<3 months.
Death 60 months 1. Documentation of death that is secondary to infection or sepsis.
2. Cardiovascular/Cerebrovascular-related Death: Sudden death; Myocardial infarction; Congestive heart failure; Primary intractable serious arrhythmia; Peripheral vascular disease; Ischemic cerebrovascular accident; Hemorrhagic cerebrovascular accident; Thromboembolic event
3. Documentation of death secondary to cancer
4. Other Death: Documentation of death that does not fall into the above categories.New Onset Diabetes 60 months Diagnosis of diabetes as indicated by 1 or more of the following not present at NEPTUNE Enrollment:
1. Documented diagnosis of diabetes in medical record
2. Casual (non-fasting) blood glucose \> 200 mg/dL c) Fasting blood glucose \> 126 mg/dL d) 2 hour glucose \> 200 after oral glucose tolerance test e) chronic use (\>6 mos) hypoglycemic therapy outside of pregnancy f) Hemogloblin A1C \>= 6.5%Quality of Life: 60 months Patient-reported outcome will be assessed using Quality of Life questionnaires at regular intervals as stipulated in the visit calendar using the SF-36, PedsQL and the Patient Reported Outcome Measurement Information System (PROMIS) (in the age-appropriate groups).
Infections, Serious and Systemic 60 months Infections including one of the following:
1. Documented diagnosis of infection of the skin or subcutaneous tissue (e.g. cellulitis), vascular system, peritoneum, or any vital organ requiring the use of parenteral antibiotics and/or oral antibiotics alone or in combination for a treatment interval of ≥72 hours.
2. Hospitalization for treatment of infectionHospitalization 60 months Documented hospital admission, including observation for ≥24 hours.
Emergency Department/ Observation Unit Visit 60 months Documented visit to an emergency department or observation unit that does not lead to hospitalization and is less than 24 hours.
Malignancies 60 months Any cancer diagnosis of the skin, hematopoietic system, or solid organ after enrollment in NEPTUNE
Trial Locations
- Locations (44)
Johns Hopkins Medical Institute
🇺🇸Baltimore, Maryland, United States
Credit Valley Hospital
🇨🇦Toronto, Ontario, Canada
Lundquist Biomedical Research Institute at Harbor UCLA Medical Center
🇺🇸Torrance, California, United States
Emory University and Children's Healthcare of Atlanta
🇺🇸Atlanta, Georgia, United States
University of Texas-Southwestern
🇺🇸Dallas, Texas, United States
Temple University
🇺🇸Philadelphia, Pennsylvania, United States
University Health Network
🇨🇦Toronto, Ontario, Canada
John Stroger Cook County Hospital
🇺🇸Chicago, Illinois, United States
The Ohio State University Wexner Medical Center
🇺🇸Columbus, Ohio, United States
University Hospital Rainbow Babies & Children's Hospital
🇺🇸Cleveland, Ohio, United States
MetroHealth Hospital at Case Western Medical Center
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic
🇺🇸Cleveland, Ohio, United States
Texas Children's Hospital - Baylor College of Medicine
🇺🇸Houston, Texas, United States
Seattle Children's Hospital
🇺🇸Seattle, Washington, United States
University of Washington
🇺🇸Seattle, Washington, United States
University of Miami Miller School of Medicine
🇺🇸Miami, Florida, United States
University of California San Francisco Benioff Children's Hospitals
🇺🇸San Francisco, California, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
Kidney Disease Section, NIDDK, NIH
🇺🇸Bethesda, Maryland, United States
Children's Hospital Colorado
🇺🇸Aurora, Colorado, United States
University of Colorado Anschutz School of Medicine
🇺🇸Aurora, Colorado, United States
Children's Hospital of Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
New York University Medical Center
🇺🇸New York, New York, United States
New York University Veterans Administration
🇺🇸New York, New York, United States
Stanford University School of Medicine
🇺🇸Palo Alto, California, United States
Bellevue Hospital
🇺🇸New York, New York, United States
Cohen Children's Hospital
🇺🇸New Hyde Park, New York, United States
Washington University - St Louis
🇺🇸Saint Louis, Missouri, United States
Scarborough Hospital
🇨🇦Scarborough, Ontario, Canada
University of Southern California-Children's Hospital
🇺🇸Los Angeles, California, United States
Columbia University Medical Center
🇺🇸New York, New York, United States
Sunnybrook Hospital
🇨🇦Toronto, Ontario, Canada
Providence Medical Research Center
🇺🇸Spokane, Washington, United States
Atrium Health Levine Children's Hospital
🇺🇸Charlotte, North Carolina, United States
University of Pennsylvania
🇺🇸Philadelphia, Pennsylvania, United States
York Central Hospital
🇨🇦Richmond Hill, Ontario, Canada
Wake Forest School of Medicine
🇺🇸Winston-Salem, North Carolina, United States
University of North Carolina at Chapel Hill
🇺🇸Chapel Hill, North Carolina, United States
CS Mott Children's Hospital, University of Michigan
🇺🇸Ann Arbor, Michigan, United States
University of Michigan Medical Center
🇺🇸Ann Arbor, Michigan, United States
Children's Mercy Hospital
🇺🇸Kansas City, Missouri, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
Montefiore Medical Center
🇺🇸Bronx, New York, United States
University of Kansas Medical Center
🇺🇸Kansas City, Kansas, United States