Pathogenesis of Glomerulosclerosis

The present protocol seeks to advance our understanding of sclerosing glomerular and
tubulointerstitial kidney diseases, including but not limited to variants of focal segmental
glomerulosclerosis (FSGS) and chronic kidney disease of unknown etiology (CKDu). This
protocol will encompass studies of the natural history, pathogenesis and treatment of these
chronic kidney disorders. It will also allow us to: (1) provide second opinions to referring
physicians about management of subjects with these relatively rare kidney diseases; (2)
collect research samples (e.g., blood), urine, and kidney tissue obtained from
clinically-indicated or from research renal biopsies); (3) and treat these subjects with
standard or other approved therapies; or (4) invite selected subjects patients to participate
in limited pilot studies of novel combinations of standard therapeutic agents, such as
rituximab and cyclosporine. (5) Agricultural worker chronic kidney disease of undetermined
etiology (CKDu) is a growing problem in tropical countries in the Americas and Asia,
including Sri Lanka where collaborators are located. We will receive kidney tissue from 25
CKDu cases for pathologic examination and transcriptional profiling and blood, plasma, serum,
urine for metabolomic and genetic analysis from 50 cases and controls. Subjects were
consented and samples were collected under a protocol approved by the University of Colombo
IRB. These studies may provide the opportunity to generate new hypotheses regarding
pathogenesis and treatment that would be candidates for testing in other research protocols.

Subjects with known or suspected forms of sclerosing glomerular or chronic, fibrosing
tubulointerstitial kidney diseases will undergo routine medical evaluation, laboratory
testing, imaging procedures and kidney biopsies as medically indicated. Selected subjects
will be invited to provide informed consent to undergo a kidney biopsy for research purposes.
Blood, urine, and tissue samples will be evaluated both for standard diagnostic purposes and
for research purposes using specialized molecular methods that may provide insights into
specific disease pathogenesis. Subjects may elect to receive the results of their kidney
disease evaluation, NIH treatment recommendations, and return to the care of their referring
physicians. Other subjects may be treated with either conventional or approved agents, or
(with separate consent) with a novel combination of conventional therapies (rituximab and
cyclosporine) as part of pilot studies that would involve long-term follow-up care at the
NIH.

- EVALUATION AND TREATMENT OF GLOMERULOSCLEROSIS

- INCLUSION CRITERIA:

---An unlimited number of subjects with known or suspected glomerular or
tubulointerstitial disease will be eligible for study. No sex, race or ethnic
selection will be applied. It is anticipated the African-Americans will predominate,
given the increased risk of FSGS (focal segmental glomerulosclerosis) in this
population.

- EXCLUSION CRITERIA:

-WHOLE EXOME/GENOME SEQUENCING

- ELIGIBLITY FOR WHOLE EXOME/GENOME SEQUENCING:

- Subjects with kidney disease

- Unexplained kidney disease, family history of kidney disease, or other
kidney disease suggestive of a genetic origin, excluding FSGS

- Age greater than or equal to 2 years

- Subjects without kidney disease

- Family member with unexplained kidney disease, family history of kidney
disease, or other kidney disease suggestive of a genetic origin, excluding
FSGS

- Age greater than or equal to 18 years

- Able to provide informed consent

- RITUXIMAB AND CYCLOSPORINE. (CLOSED FOR SUBJECT RECRUITMENT.)

- INCLUSION CRITERIA FOR ADULT PATIENTS PARTICIPATING IN PILOT STUDY OF COMBINATION
RITUXIMAB AND CYCLOSPORINE:

- First void urine protein to creatinine ratio > 2g/g despite optimal use of an ACE
inhibitor or ARB (or possibly both), last dose increase at least 4 weeks before
qualifying proteinuria determination

- Women must use reliable birth control method to avoid pregnancy while
participating in the study.

- Subjects who have failed to respond with a complete remission or partial
remission after at least 8 weeks of prednisone at a dose of at least 60 mg or are
steroid dependent or relapse off steroids.

- Subjects who have compelling contraindications to the use of glucocorticoids,
such as morbid obesity, defined as BMI >35 or diabetes mellitus

- Subjects with idiopathic FSGS or collapsing glomerulopathy

- Subjects with eGFR greater than or equal to 50 mL/min/1.73 m^2 at screening or at
some time in preceding 6 months.

- INCLUSION CRITERIA FOR MINORS (BETWEEN AGES 4 AND 18 YEARS):

- Estimated average protein to creatinine ratio >2.0 g/g despite use of an ACE
inhibitor or ARB. At least one-first void urine will be obtained and must have a
urine protein/creatinine ratio >2.0 g/g to exclude the diagnosis of orthostatic
proteinuria

- Girls who are going through puberty and/or have menstrual periods must use
reliable birth control method to avoid pregnancy while participating in the study

- Failed to respond with a complete remission or partial remission after at least 8
weeks of prednisone at a dose of at least 1 mg/kg or are steroid dependent or
relapse off steroids.

- Compelling contraindications to the use of glucocorticoids, such as morbid
obesity, defined as 99th percentile for age and sex, or diabetes mellitus

- Subjects with idiopathic FSGS or collapsing glomerulopathy

- Subjects with eGFR greater than or equal to 50 mL/min/1.73 m^2 at screening or at
some time in preceding 6 months.

- EXCLUSION CRITERIA:

- Age < 4 years.

- Prior intolerance of rituximab or other monoclonal antibody therapy, including
severe infusion reaction or hypersensitivity to murine proteins.

- History of cardiac arrhythmias, unless cardiology consult approves the use of
rituximab.

- Treatment with rituximab within the last two years.

- Prior intolerance of cyclosporine.

- Subjects with post-adaptive FSGS (including obesity-associated FSGS, reflux
nephropathy, reduced nephron mass). There is not a strong rationale for the use
of immunologic therapy in this population.

- Subjects with genetic FSGS due to a high penetrance mutation, e.g. NPHS2
mutation. There is not a strong rationale for the use of immunologic therapy in
this population.

- Medication-associated FSGS.

- Recurrent FSGS following renal transplant

- Chronic viral infection, such as HIV-1, hepatitis B, and hepatitis C. The safety
of aggressive immunologic therapy in these diseases is in question.

- Chronic bacterial infection. At baseline, if the patient gives a history of BCG
vaccination or prior positive PPD, we will consult with an infectious disease
clinician before enrolling the patient.

- Active malignancy

- Poorly controlled hypertension is defined as home BP measurements >140/90 or
controlled blood pressure requiring 4 or more medications. The rationale is that
blood pressure elevation is common on cyclosporine therapy.

- Women and girls who are pregnant or trying to become pregnant or are unwilling to
practice birth control. Rituximab is in pregnancy class C: no systematic evidence
of safety. In humans, cyclosporine crosses the placenta. Cyclosporine lacks
genotoxic effects in human and animal studies. However, growth restriction and
prematurity occur in up to 40% of neonates born to mothers with organ transplants
who are treated with cyclosporine, but no congenital abnormalities have been
documented.

- Women and girls who are breastfeeding (possible immune suppression in infants as
well as the unknown effects on growth or association with carcinogenesis.)

- Predicted requirement for live vaccines over the 24 months following enrollment.

- ANALYSIS OF LIPID-CONTAINING PARTICLES CHARACTERISTICS UNDER NUCLEAR
MAGNETIC RESONANCE SPECTROSCOPY (NMR-S) AMONG NEPHROTIC SUBJECTS

- INCLUSION CRITERIA:

- We will enroll adult subjects (greater than or equal to 18 years of age), male or
female, and of all racial backgrounds/ethnicities. In this cohort, we will
include subjects with kidney disease or without kidney disease (healthy
volunteers). We will start with subjects with preserved glomerular filtration
rate (eGFR-Cr greater than or equal to 60 ml/min/1.73m2) but may expand to
include individuals with lower GFR in a later study. We will estimate glomerular
filtration rate (eGFR) using the 2009 CKD-EPI creatinine equation.

- In respect to proteinuria, we will accept both urine protein-to-creatinine ratio
(uPCR) or urine protein excretion rate (PER) per 24 hours as a selection
criteria. We will divide enrolled subjects in 3 groups as shown below:

- Group 1. Subjects with nephrotic range proteinuria (uPCR greater than or equal to
2 g/g or PER greater than or equal to 3 gr/24hs.) and eGFR-Cr greater than or
equal to 60 ml/min/1.73m2, regardless of their albumin levels.

- Group 2. Subjects with sub-nephrotic range proteinuria (uPCR greater than or
equal to 0.2 g/g but < 2 g/g or PER greater than or equal to 300 mg/24hs. but < 3
gr/24hs.) and eGFR-Cr greater than or equal to 60 ml/min/1.73m2, regardless of
their albumin levels.

- Group 3. Volunteers with normal eGFR and normal protein excretion and normal
fasting clinical lipid testing.

- For those subjects undergoing lipid lowering therapies for primary prevention,
including statins, fibrates, niacin, ezetimibe, bile acid resins, fish oil or red
yeast rice, we will stop those treatments at least 4 weeks but no more than 6
weeks prior their admission. Lipid lowering therapy will not be stopped for more
than 8 weeks. We will not enroll subjects who are receiving statins or other
lipid lowering therapies for secondary prevention. Also, we will not enroll
subjects with history of triglycerides levels >1000 mg/dl.

- The blood and urine sample collection and brief interruption of statin treatment
performed in this pilot study to involve no more than minimal risk to individual
subjects, with no prospect of direct benefit to subjects, but likely to yield
generalizable knowledge to further society's understanding of the lipoprotein
profiles of nephrotic and non-nephrotic subjects.

- EXCLUSION CRITERIA:

- We will exclude subjects with any of the following:

- Diabetes mellitus

- Body mass index (BMI) greater than or equal to 40,

- Pregnant or breastfeeding women

- Untreated or uncontrolled thyroid disorder

- Active oncologic condition

- Acute infections

- Chronic infections including HIV

- Subjects receiving lipid lowering medications for secondary prevention (e.g.
coronary artery disease, stroke, heart failure)

- Subjects receiving estrogen therapy or contraceptive therapy

- Subjects receiving cyclosporine, azathioprine or sirolimus

- Subjects who are unable to eat the required meals due to allergy,
intolerance, or dietary preferences

- Subjects with history of pancreatitis

- Subjects with reported history of triglycerides >1000 mg/dl

- Subjects unable or unwilling to give their consent