Pediatric Nephrotic Syndrome: From the Simple to the Complex

Jerome C. Lane, MD,* and Frederick J. Kaskel, MD, PhD

Summary: Remarkable advances have been made in the past decade in understanding the pathophysiology of idiopathic nephrotic syndrome. Although the initiating events leading to the onset of proteinuria still are not well dened, it has become increasingly clear that many glomerular diseases can be classied as podocytopathies, with injury to the podocyte playing a major role in the development and progression of disease. A complex interaction of immune system mediators, slit diaphragm signal transduction, podocyte injury and conformational change, and mediators of apoptosis and brosis determine the extent and nature of proteinuria and progression of glomerulosclerosis. New insights into the pathogenesis of idiopathic nephrotic syndrome likely will lead to innovative therapies and new approaches to management and prevention. Semin Nephrol 29:389-398 2009 Elsevier Inc. All rights reserved. Keywords: Nephrotic syndrome, minimal change disease, focal segmental glomerulosclerosis, podocyte, nephrin, podocin

n the 10 years since the rst version1 of this article, there has been remarkable progress in the understanding of the pathophysiology of idiopathic nephrotic syndrome (INS). In particular, elucidation of the genetic causes of congenital NS and familial focal segmental glomerulosclerosis (FSGS), as well as new insights regarding podocyte biology, have led to novel ways of thinking about NS, its pathogenesis, and, perhaps most importantly, its management and treatment. An ever-evolving and increasingly complex web of pathways involved in the development of INS and progression of glomerulosclerosis continues to be investigated. The purpose of this article is to present these new understandings of the pathophysiology of INS, in particular with regards to FSGS and minimal change nephrotic syndrome (MCNS).

PODOCYTE BIOLOGY AND GENETIC MECHANISMS OF NS

Nephrin and the Slit Diaphragm

Perhaps the most exciting development in recent years in understanding the pathophysiology of NS has occurred in the area of podocyte biology and the structure of the slit diaphragm (SD). The glomerular ltration barrier consists of the fenestrated capillary endothelium, the extracellular basement membrane, and the intercalated podocyte foot processes, connected by 35- to 45-nm slit diaphragms. NS is associated with the biopsy nding of effacement of podocyte foot processes. Effacement is characterized by attening of the podocyte, retraction of foot processes, and reduction in the number of SDs.2 This effacement of the podocytes long was thought to be a secondary phenomenon of NS. Recent thinking, however, has shifted toward the podocyte as playing a primary role in the development of proteinuria and progression of glomerulosclerosis. It is now clear that, far from being a simple passive lter, the numerous components of the SD act as a complex signaling platform and play an important role in podocyte function. Similarly, it increasingly is being recognized that MCNS and FSGS can be
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*Division of Kidney Diseases, Department of Pediatrics, Childrens Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, IL. Division of Pediatric Nephrology, Childrens Hospital at Monteore, Bronx, NY. Address reprint requests to Jerome C. Lane, MD, Childrens Memorial Hospital 2300 Childrens Plaza, Box 37, Chicago, IL 60614. E-mail: j-lane@ northwestern.edu 0270-9295/09/$ - see front matter 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.semnephrol.2009.03.015

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classied as podocytopathies, in which disruption of SD and normal podocyte function can lead to proteinuria and glomerular disease. A breakthrough in the understanding of podocytes and the SD came in 1998 with the discovery of nephrin and its associated gene, NPHS1, while investigating the genetic cause of Finnish-type congenital nephrotic syndrome (FNS). FNS is an autosomal-recessive disease characterized by development in the neonatal period of massive proteinuria, edema, and eventual end-stage kidney failure. FNS is caused by mutations in the NPHS1 gene on chromosome 19. The protein product of NPHS1 is nephrin.3 Mutations in NPHS1 lead to absence of nephrin in the SD, disrupting this component of the glomerular ltration barrier and leading to proteinuria. Although more than 70 mutations in NPHS1 have been identied with FNS, a few also have been found that are associated with a milder form of FNS as well as with FSGS.4 Nephrin is a transmembrane protein with a short intracellular and long extracellular domain. Nephrin molecules interact with each other across the space between podocyte foot processes, joining to form a zipper-like structure with pores on either side of the center seam and thereby forming the ltering structure of the SD. Besides forming the skeleton of the SD lter, nephrin also acts as a signal transducer. The intracellular portion of nephrin can be phosphorylated, which, in turn, leads to changes in interaction with the podocyte actin cytoskeleton, inducing conformational changes in the podocyte that may play a role in proteinuric diseases.5 Investigations regarding familial forms of FSGS have led to the discovery of other key components of the SD. Mutations in the NPHS2 gene on chromosome 1 are the cause of a familial, autosomal-recessive form of FSGS. The protein product of NPHS2 is podocin, another component of the SD. Mutations in -actinin-4, encoded by the gene ACTN4 on chromosome 19, and mutations in TRPC6 on chromosome 11, are associated with autosomal-dominant forms of FSGS. Podocin, -actinin-4, and TRPC6 all are podocyte proteins essential to the functioning of the SD and maintenance of the ltration barrier to protein loss.4 Heterozygous mu-

tations in the protein CD2AP have been found in 2 patients with primary FSGS,6 and, more recently, a homozygous mutation in this protein has been implicated in a patient with FSGS (although the parents had heterozygous mutations and no proteinuria).7 CD2AP interacts with nephrin and appears to be involved in anchoring nephrin to the actin cytoskeleton of the podocyte.5

The SD, Podocyte Proteins, and Signal Transduction

A growing number of SD proteins continue to be found and their role in the complex signaling pathways of the podocyte elucidated in normal and proteinuric states. Indeed, signal transduction through the SD appears to play a critical role in regulating the podocyte cell cycle, polarity, cytoskeleton, and apoptosis.8 It is beyond the scope of this review to present in depth the multiplicity of signaling pathways in the podocyte and SD and their complex interactions (the reader is referred to several excellent recent reviews on the subject).2,9,10 However, a few of these pathways are described in the following paragraphs. During formation of the SDs, the interaction of the extracellular domains of nephrin leads to transient activation of Fyn, a member of the Src tyrosine kinase family. Activation of Fyn, in turn, leads to phosphorylation of tyrosine residues in the intracellular tail of nephrin. Phosphorylation of nephrin leads to recruitment of the adaptor proteins Nck 1 and 2, which induce actin polymerization and stabilization of the SD complex by attachment to the podocyte cytoskeleton. After SD formation is complete, nephrin is dephosphorylated and anchored to the actin cytoskeleton through CD2AP and podocin. During podocyte injury, the podocyte cytoskeleton and SD framework is disrupted, leading to podocyte foot process effacement and proteinuria. During the healing phase, nephrin molecules again interact to form the SD framework and become phosphorylated, thereby recruiting Nck 1 and 2 and inducing regeneration of actin laments and restoration of normal podocyte architecture.5 Phosphorylation of nephrin also leads to activation of phosphoinositide 3-OH kinase

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External Factors

Fyn

NEPHRIN ILK Dend Pod PI3K

Nck

-act-4

Syn

CD2AP
Akt

Actin Polymerization

Apoptosis
TGF- AII

Figure 1. Signal transduction in the SD. P, phosphate; Dend, dendrin; Akt, serine-threonine kinase Akt; AII, angiotensin II; Pod, podocin; CD2AP, CD2-associated protein; Syn, synaptopodin; -act-4, -actinin-4; Nck, adaptor proteins Nck1 and Nck2; Fyn, tyrosine kinase Fyn.

(PI3K), which recognizes the phosphorylated nephrin-CD2AP complex. Activation of PI3K leads to eventual inactivation of the apoptosis factor Bad, thereby protecting the podocyte from apoptosis.11 Interestingly, another recently described SD protein, dendrin, also appears to participate in apoptotic signaling pathways. Dendrin binds to nephrin and CD2AP. In experimental models, podocyte injury leads to migration of dendrin to the nucleus of the podocyte, where it potentiates pro-apoptotic signals from transforming growth factor (TGF-) and other mediators.8 SD signaling also appears to be linked to adhesion of the basal membrane of the podocyte to the basement membrane, primarily through the integrin 31. Integrin-linked kinase (ILK) mediates integrin signaling within the podocyte.8 In the mouse, selective disruption of ILK leads to foot process effacement, proteinuria, apoptosis, and detachment of po-

docytes and FSGS.12 ILK also binds to nephrin and -actinin-4. In the absence of ILK, nephrin loses its attachments at the SD and relocates throughout the podocyte cell membrane.8 Figure 1 illustrates some of the signal transduction pathways occurring in the SD. New pathways and interactions between known pathways continue to be discovered, and Figure 1 is meant to be illustrative rather than comprehensive. External mediators can lead to phosphorylation of nephrin by Fyn. Phosphorylated nephrin induces actin polymerization through Nck1 and 2. CD2AP, synaptopodin, ILK, and -actinin-4 anchor the SD to the actin cytoskeleton, and disruption of these proteins, perhaps induced by changes in nephrin or other signal transducers, can lead to cytoskeletal changes and alterations in podocyte architecture. Nephrin also can protect the podocyte from apoptosis through the PI3K/Akt pathway, or induce apoptosis by releasing dendrin to migrate to the

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nucleus and amplify TGF-mediated apoptosis.

Other Podocyte Proteins

Other proteins outside the SD also appear to participate in podocyte architecture and maintenance of the normal glomerular ltration barrier. Cathepsin L, a lysosomal cysteine protease, has been shown to play a role in foot process effacement in mouse models of MCNS. Cathepsin L cleaves the actin-associated protein dynamin, which binds the regulatory proteins cortactin and Arp2/3 complex, leading to actin assembly in the podocyte foot processes. Increased levels of cathepsin L have been found in diabetic nephropathy, MCNS, and FSGS. It is possible that marked increases in protein trafcking and processing by lysosomes during heavy proteinuria could lead to increases in cathepsin L, which in turn would promote podocyte cytoskeleton alteration and foot process effacement.8 A mutation in the enzyme phospholipase C epsilon 1 (PLCE1) has been described in rare cases of familial FSGS and diffuse mesangial sclerosis. PLCE1 is an intracellular podocyte enzyme not located in the foot process. Interestingly, children with this mutation may improve with steroid or cyclosporine treatment, unlike other genetic causes of INS.13 PLCE1 mediates G-proteinreceptor signaling through downstream second messengers such as diacylglycerol and inositol triphosphate and therefore likely plays a role in many crucial podocyte functions.8 Synaptopodin, a unique podocyte protein, plays a role in cytoskeleton regulation by protecting the guanosine triphosphatase RhoA from ubiquitination and degradation. This allows stress ber formation and may play a role in cytoskeletal alterations in response to podocyte injury.14 Synaptopodin also regulates -actinin-4 function and thereby plays a role in maintaining normal podocyte architecture through its effects on the actin cytoskeleton.2 The apical membrane of the podocyte contains the negatively charged proteins podocalyxin, podoplanin, and podoendin. These anionic charges provide another glomerular barrier to ltration of negatively charged pro-

teins such as albumin. In addition, anionic apical proteins are important in maintaining normal podocyte structure by maintaining separation between adjacent podocytes. Podocalyxin is linked to the actin cytoskeleton and is necessary for normal foot process structure.2

Podocyte Genes and Proteins in NonFamilial Nephrotic Syndrome

Mutations in NPHS2 (podocin) and the Wilms tumor suppressor gene (WT1) have been identied in approximately 30% and 7% of cases of nonfamilial steroid-resistant NS, respectively.15 Mutations in podocin and WT1 do not appear to play a role in MCNS.16,17 Although heterozygous mutations in NPHS1 and NPHS2 have been proposed as risk factors for steroid-dependent nephrotic syndrome and frequently relapsing nephrotic syndrome, a recent study found no heterozygous mutations in patients with steroid-dependent nephrotic syndrome or frequently relapsing nephrotic syndrome.15 Acquired alterations in SD architecture and podocyte proteins might play a role in INS apart from actual mutations in the genes encoding these proteins. Podocin appears to be expressed normally in MCNS, but is decreased in FSGS. Various investigators have reported changes in expression and distribution of nephrin in MCNS. Coward et al18 showed that nephrotic plasma induces translocation of the SD proteins nephrin, podocin, and CD2AP away from the plasma membrane into the cytoplasm of the podocyte. They also showed that normal plasma might contain factors that maintain the integrity of SD architecture and that the lack of certain factors (rather than the presence of an abnormal circulating factor) might be responsible for alterations in the podocyte architecture and the development of INS.18 A recent study showed decreased phosphorylation of nephrin in children with MCNS, although total amounts of nephrin and podocin were normal.19 Thus, it is possible that factors external or intrinsic to the podocyte result in changes in nephrin phosphorylation, triggering a myriad of signaling pathways resulting in alteration in podocyte cytoskeletal organization and other functions, thereby leading to proteinuria and, in the case of FSGS, progression of disease.

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IMMUNE DYSREGULATION IN INS It has long been postulated that MCNS and FSGS are the consequence of immune factors, specically, a disorder in T-cell regulation. Evidence of a possible immune-mediated nature of INS is shown by the fact that immunosuppressive agents such as corticosteroids, cyclosporine, and alkylating agents can result in remission of NS. NS has been known to remit during infection with the measles virus, which suppresses cell-mediated immunity.20 A kidney taken from a donor with MCNS will no longer show proteinuria when transplanted into a patient without nephrosis and, conversely, FSGS can reoccur in a patient with FSGS who has received a kidney transplant.21 Furthermore, when FSGS has recurred in a kidney transplant, proteinuria sometimes can be reversed successfully by plasmapheresis, presumably by the removal of soluble factor(s) responsible for the induction of proteinuria.22,23 MCNS has been associated with Hodgkin lymphoma, thymoma, and T-cell lymphoma, and resolves with treatment of these malignancies.24 All of the above have been taken as strong evidence of the role of the immune system in the development of INS. However, the precise nature of the immune process leading to proteinuria has yet to be dened and conicting evidence exists. Immunosuppressive agents such as steroids and cyclosporine can affect cells other than the immune system, and it is possible that their benecial effect in nephrosis is due to effects on other cells such as podocytes. In addition, it is possible that the various and conicting alterations in cytokine responses and T-cell subset alterations reported in INS are a consequence, rather than a cause, of nephrosis.20 The association of allergic responses with NS also illustrates the role of the immune system in INS. NS has been reported to occur after allergic reactions to bee stings, fungi, poison ivy, ragweed, house dust, jellysh stings, and cat fur. Food allergy might play a role in relapses of INS; a reduced-antigenic diet was associated with improved proteinuria and complete remission in one study.25 Atopy also occurs at a higher rate in patients with MCNS (17%-40% of nephrotic patients versus 10%-23% of nonnephrotic peers). Atopy and allergic responses are

characterized by high IgE levels.24 INS also is associated with high IgE levels, which persists even after remission of proteinuria and cessation of immunosuppressive medications, suggesting the increased IgE is not merely a consequence of proteinuria and nephrosis but might be a component of the pathogenetic mechanisms of INS.20 Atopy and INS also are characterized by a type 2 cytokine response. Type 1 cytokines, produced by T helper 1 (Th1) lymphocytes, are typied by interferon-, tumor necrosis factor (TNF)-, and interleukin-2 (IL-2), and are involved in cytotoxic and inammatory responses. Type 2 cytokines, produced by Th2 lymphocytes and mast cells, are involved in antibody and allergic responses and are exemplied by cytokines such as IL-4, IL-5, IL-9, IL10, and IL-13.24 Although the data regarding cytokine proles in INS are conicting, there does seem to be a predominance of type 2 over type 1 cytokines in INS. The increased IgE levels, association with atopy, and increased production of type 2 cytokines all seem to indicate a role for T cells, especially Th2 lymphocytes, in the pathophysiology of INS.20 However, the fact that not all patients with atopy and allergic reactions develop NS indicates that disturbances in T-cell regulation and cytokine production alone are not sufcient to explain the pathogenesis of INS.24 The holy grail of research into the causes of INS has been the identication of a permeability factora presumed circulating factor that can alter the glomerular ltration barrier and induce proteinuria. The identication of such a factor(s) could link the observations of immune dysregulation and podocyte dysfunction. A permeability factor, perhaps a cytokine or other mediator, produced by an abnormal lymphocyte response, could induce podocyte damage, allowing the development of proteinuria. Various permeability factors have been proposed. Savin et al have identied and partially puried a permeability factor in patients with FSGS. The presence of this FSGS factor correlates with an increased risk of recurrence of FSGS in kidney transplant recipients. Injection of this factor into rats induces proteinuria as well.26-29

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It also is possible that cytokines act as permeability factors in INS, perhaps by mediating alterations in podocytes. Podocytes possess receptors for the type 2 cytokines IL-4, IL-10, IL-14, and TNF-.24,30-32 IL-4 and IL-13 induce changes in protein sorting, ion transport, and lysosome enzymes such as cathepsin L and heparanase in cultured podocytes.24,30,33 IL-1 and TNF- also have been shown to alter nephrin expression and cytoskeleton structure in podocytes.24,34,35 PODOCYTE INJURY IN MCNS AND FSGS

Podocyte Injury in MCNS

Podocyte number is not reduced in MCNS and podocytes are not lost in the urine. However, podocytes do change their phenotype, as shown by effacement of foot processes and microvillus transformation. As discussed previously, podocyte transformation likely results from changes in cytoskeletal structure, perhaps initiated by immune factors such as cytokines and/or permeability factors, and mediated by a wide variety of podocyte processes, including signal transduction through the SD, increased lysosomal proteases, loss of cell polarity, and loss of negatively charged proteins. The alteration in podocyte structure results in proteinuria and nephrosis. Because there is no podocyte loss, these changes are potentially reversible, as seen in corticosteroid treatment.36

Podocyte Injury in FSGS

Regardless of the initiating mechanism (genetic, immune, or other), it appears that podocyte injury is the nal common pathway in many forms of glomerular disease. Podocytes respond to injury by a variety of processes, including hypertrophy, apoptosis, dedifferentiation, and detachment.36,37 Loss of podocyte number, for example, through detachment or apoptosis, has been linked to progression of proteinuria and glomerulosclerosis. Depletion of podocytes leads to denudation of the glomerular basement membrane (GBM). In addition, loss of the supportive structure podocytes provide the glomerular capillary loops permits these loops to bulge outward, exposing the bare GBM to the parietal epithelium of Bow-

mans capsule.2 This results in attachment of the capillary tuft to Bowmans capsule (synechia), segmental and global sclerosis, and leakage of glomerular ltrate into the interstitial space. The misdirection of glomerular ltrate leads to recruitment of broblasts, interstitial injury, and eventual brosis.36 The remaining podocytes, in response to depletion in number, compensate by undergoing hypertrophy, which causes podocyte stress and increases the vulnerability of these cells to further loss.10 Podocytes are particularly vulnerable to reduction in number because of their limited capacity for proliferation and replacement of lost cells. Cellular proliferation is dependent on binding of cyclins to their corresponding cyclin-dependent kinases (CDKs). However, in FSGS (noncollapsing histology) and MCNS, proliferation is prevented by the CDK inhibitors p21, p27, and p57.2 In addition to its probrotic effects in kidney tubular cells, TGF- promotes apoptosis in the podocyte, a process that requires p21, the same CDK inhibitor that prevents podocyte proliferation.2 Angiotensin II also promotes podocyte apoptosis through the angiotensin II receptor type 1 (AT1).38 Nephrin and CD2AP protect the podocyte from apoptosis. As mentioned previously, both proteins bind dendrin and, during podocyte injury, dendrin is free to migrate to the nucleus and potentiate pro-apoptotic mediators. Nephrin and CD2AP also increase the anti-apoptotic phosphoinositide 3-kinase/Akt pathway. Thus, disruptions in nephrin and CD2AP can promote podocyte apoptosis.2 A recent study has shown that, similar to renal tubular cells, podocytes also can undergo epithelial-to-mesenchymal transition (EMT) under the inuence of TGF-.37 Thus, besides decreased podocyte number, EMT might be another mechanism for the development of proteinuria and glomerulosclerosis. Another mechanism whereby injured podocytes might contribute to the progression of sclerosis is the release of proteinases and oxidants. Oxidants have a variety of effects, including degradation of GBM, promotion of foot process effacement, disruption of integrinmediated podocyte adhesion to the GBM, injury to adjacent podocytes by oxidative stress, DNA

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damage, and induction of apoptosis. Podocytes also might release proteinases, such as cathepsin L, metalloproteinase-2, and metalloproteinase-9, which ordinarily play a role in podocyte maintenance of the GBM. Activity of these proteinases is augmented by TGF-.2 PROGRESSION OF FIBROSIS Great advances have been made over the past decade in the understanding of interstitial brosis and progression to end-stage kidney failure. Especially important have been new insights into the induction of brosis by TGF- through Smad signaling. A detailed discussion of these advances is beyond the scope of this review and the reader is referred to the article on Progression of Glomerular and Tubular Disease (by Woroniecki and Schnaper, p. 412) for more information. It is interesting to note that many of the mechanisms involved in brosis and EMT of renal tubule cells also participate in mechanisms of podocyte injury. Therefore, there are likely multiple and complex pathways linking podocyte injury and brosis in the progression of glomerulosclerosis. IMPLICATIONS FOR TREATMENT Recent advancements in our understanding of podocyte biology, progression of renal disease, and the pathogenesis of MCNS and FSGS offer tantalizing new possibilities in treatment. Angiotensin II has multiple effects on the podocyte, including induction of apoptosis, changes in cytoskeletal structure, increased TGF-, and reduced nephrin and zonula occludens-1 (ZO-1) (another component of the slit diaphragm). Thus, apart from the benecial effects angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) have on intrarenal hemodynamics, blood pressure, proteinuria, and brosis, ACEI and ARB treatment may have a direct benecial effect on podocytes in the mitigation of nephrosis and the progression of glomerulosclerosis.2 Protection of podocytes from apoptosis might provide another avenue of therapy. Traditional corticosteroid therapy, in addition to its other effects, directly reduces podocyte apoptosis by increasing anti-apoptotic factors, re-

ducing pro-apoptotic factors, and stabilizing the actin cytoskeleton.2 Other medications currently available or yet to be developed also might be useful in protecting the podocyte from apoptosis. For example, podocytes possess receptors for erythropoietin. Administration of darbopoeitin protects podocytes from induction of apoptosis by TGF-. Darbopoetin also seems to protect the podocyte from cytoskeletal changes and preserve nephrin expression. Other agents, such as glial cell line derived neurotrophic factor and pioglitazone, also have been found to protect the podocyte from apoptosis.8 Monoclonal antibody therapy also holds promise in the treatment of INS by addressing the alterations in the immune system discussed previously. Rituximab, an anti-CD20 monoclonal antibody that results in the depletion of CD20-positive B-lymphocytes, in small studies has been reported to induce remission in steroid-dependent NS.39 Although it is used primarily for recurrence of FSGS after kidney transplantation, small reports have shown that plasmapheresis results in improvement in proteinuria in primary FSGS. However, the invasiveness of plasmapheresis and risks of infection, bleeding, and hypocalcemia limit the usefulness of this treatment at this time.40 Currently, the FSGS-Clinical Trial (http://fsgstrial. org) is the largest controlled trial of FSGS in North America and will establish a standard of therapy for corticosteroid-resistant primary FSGS. Additional benets of the trial are the establishment of an infrastructure for the study of FSGS, the creation of a national repository of biospecimens for investigations of the pathogenesis of FSGS and the role of histologic subclassications of FSGS in the response to therapies, and the evaluation of the efcacy of withdrawing immunosuppressive drugs while maintaining ACEIs/ARBs. CONCLUSION: TOWARD A UNIFIED MODEL OF PROTEINURIC GLOMERULAR DISEASE Although the initiating events underlying the pathogenesis of MCNS and FSGS are yet to be determined, a clearer, more robust, yet more complex model of nephrosis and progression to

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External Factors
P21, 27, 57

Proliferation

CDK

Podocyte Injury

Detachment Apoptosis

Hypertrophy

EMT

Foot process effacement

Proteinase Release

podocyte #

Podocyte stress

Proteinuria Irreversible Reversible

Sclerosis

Interstitial filtrate leakage Fibrosis TGF- FSGS

MCNS

Figure 2. Podocyte model of glomerular disease. p21, p27, p57, CDK inhibitors p21, p27 and p57.

end-stage kidney failure is emerging. The model is a complex interaction of humoral mediators, podocyte injury, and progression of sclerosis. Figure 2 presents a schematic diagram of possible pathways to FSGS and MCNS. In response to as yet undened external factors, likely immune-mediated, podocytes respond to injury in a variety of ways. Inhibition of a proliferative response, as well as a decrease in podocyte number through detachment and/or apoptosis, lead to glomerulosclerosis and brosis. The remaining podocytes undergo hypertrophy to compensate for lost cells, leading to podocyte stress, vulnerability to injury, and further podocyte loss. Injured podocytes can release proteinases, which extend the local podocyte injury. Phenotypic changes in podocyte structure, characterized by EMT and/or foot process effacement, lead to loss of function of the SDs and glomerular ltration barrier and thereby lead to proteinuria. If these podocyte changes

are reversible, the result is steroid-sensitive NS, such as MCNS. However, if the podocyte injury and maladaptive responses have progressed far enough, the changes become irreversible and the result is FSGS. As more podocyte proteins are identied, more signaling pathways are discovered, and further mechanisms of disease progression are elucidated, our understanding of INS will continue to become more comprehensive and more complex. Despite the complexity, the identication of new pathways of injury and disease progression likely will offer new strategies for the management, treatment, and, perhaps, prevention of progressive glomerular disease. REFERENCES
1. Eddy AA, Schnaper HW. The nephrotic syndrome: from the simple to the complex. Semin Nephrol. 1998;18:304-16.

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2. Shankland SJ. The podocytes response to injury: role in proteinuria and glomerulosclerosis. Kidney Int. 2006;69:2131-47. 3. Kestila M, Lenkkkeri U, Mannikko M, Lamerdin J, McCready P, Putaala H, et al. Positionally cloned gene for a novel glomerular proteinnephrinis mutated in congenital nephrotic syndrome. Moll Cell. 1998;4: 575-82. 4. Tryggvason K, Patrakka J, Wartiovaara J. Hereditary proteinuria syndromes and mechanisms of proteinuria. N Engl J Med. 2006;354:1387-401. 5. Patrakka J, Tryggvason K. Nephrina unique structural and signaling protein of the kidney lter. Trends Mol Med. 2007;13:396-403. 6. Kim JM, Wu H, Green G, Winkler CA, Kopp JB, Miner JH, et al. CD2-associated protein haploinsufciency is linked to glomerular disease susceptibility. Science. 2003;300:1298-300. 7. Lwik MM, Groenen PJTA, Pronk I, Lilien MR, Goldschmeding R, Dijkman HB, et al. Focal segmental glomerulosclerosis in a patient homozygous for a CD2AP mutation. Kidney Int. 2007;72:1198-203. 8. DAgati VD. The spectrum of focal segmental glomerulosclerosis: new insights. Curr Opin Nephrol Hypertens. 2008;17:271-81. 9. Faul C, Asanuma K, Yanagida-Asanuma E, Kim K, Mundel P. Actin up: regulation of podocyte structure and function by components of the actin cytoskeleton. Trends Cell Biol. 2007;17:428-37. 10. Lehir M, Kriz W. New insights into structural patterns encountered in glomerulosclerosis. Curr Opin Nephrol Hypertens. 2007;16:184-91. 11. Aaltonen P, Holthfer H. The nephrin-based slit diaphragm: new insight into the signaling platform identies targets for therapy. Nephrol Dial Transplant. 2007;22:3408-10. 12. Dai C, Stolz DB, Bastacky SI, St-Arnaud R, Wu C, Dedhar S, et al. Essential role of integrin-linked kinase in podocyte biology: bridging the integrin and slit diaphragm signaling. J Am Soc Nephrol. 2006;17: 2164-75. 13. Hinkes B, Wiggins RC, Gbadegesin R, Vlangos CN, Seelow D, Nurnberg G, et al. Positional cloning uncovers mutations in PLCE1 responsible for a nephrotic syndrome variant that may be reversible. Nat Genet. 2006;38:1397-404. 14. Pollak MR. Focal segmental glomerulosclerosis: recent advances. Curr Opin Nephrol Hypertens. 2008; 17:138-42. 15. Gbadegesin R, Hinkes B, Vlangos C, Mucha B, Liu J, Hopcian J, et al. Mutational analysis of NPHS2 and WT1 in frequently relapsing and steroid-dependent nephrotic syndrome. Pediatr Nephrol. 2007;22:509-13. 16. Ruf RG, Lichtenberger A, Karle SM, Haas JP, Anacleto FE, Schultheiss M, et al. Arbeitsgemeinschaft fr Pdiatrische Nephrologie Study Group. Patients with mutations in NPHS2 (podocin) do not respond to standard steroid treatment of nephrotic syndrome. J Am Soc Nephrol. 2004;15:722-32.

17. Ruf RG, Schultheiss M, Lichtenberger A, Karle SM, Zalewski I, Mucha B, et al. APN Study Group. Prevalence of WT1 mutations in a large cohort of patients with steroid-resistant and steroid-sensitive nephrotic syndrome. Kidney Int. 2004;66:564-70. 18. Coward RJ, Foster RR, Patton D, Ni L, Lennon R, Bates DO, et al. Nephrotic plasma alters slit diaphragm-dependent signaling and translocates nephrin, Podocin, and CD2 associated protein in cultured human podocytes. J Am Soc Nephrol. 2005; 16:629-37. 19. Uchida K, Suzuki K, Iwamoto M, Kawachi H, Ohno M, Horita S, et al. Decreased tyrosine phosphorylation of nephrin in rat and human nephrosis. Kidney Int. 2008;73:926-32. 20. Mathieson PW. Immune dysregulation in minimal change nephropathy. Nephrol Dial Transplant. 2003; 18 Suppl 6:vi26-9. 21. Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet. 2003;362:629-39. 22. Artero ML, Sharma R, Savin VJ, Vincenti F. Plasmapheresis reduces proteinuria and serum capacity to injure glomeruli in patients with recurrent focal glomerulosclerosis. Am J Kidney Dis. 1994;23:574-81. 23. Andresdottir MB, Ajubi N, Croockewit S, Assmann KJ, Hibrands LB, Wetzels JF. Recurrent focal glomerulosclerosis: natural course and treatment with plasma exchange. Nephrol Dial Transplant. 1999; 14:2650-6. 24. van den Berg JG, Weening JJ. Role of the immune system in the pathogenesis of idiopathic nephrotic syndrome. Clin Sci (Lond). 2004;107:125-36. 25. Niaudet P. Steroid-sensitive idiopathic nephrotic syndrome in children. In: Avner E, Harmon W, Niaudet P, editors. Pediatric nephrology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins; 2004. p. 543-56. 26. Brenchley PEC. Vascular permeability factors in steroid-sensitive nephrotic syndrome and focal segmental glomerulosclerosis. Nephrol Dial Transplant. 2003; 18 Suppl 6:vi21-5. 27. Savin VJ, Sharma R, Lovell HB, Welling DJ. Measurement of albumin reection coefcient with isolated rat glomeruli. J Am Soc Nephrol. 1992;3:1260-9. 28. Savin VJ, Sharma R, Sharma M, McCarthy ET, Swan SK, Ellis E, et al. Circulating factor associated with increased glomerular permeability to albumin in recurrent focal segmental glomerulosclerosis. N Engl J Med. 1996;334:878-83. 29. Sharma M, Sharma R, McCarthy ET, Savin VJ. The FSGS factor: enrichment and in vivo effect of activity from focal segmental glomerulosclerosis plasma. J Am Soc Nephrol. 1999;10:552-61. 30. Van Den Berg JG, Aten J, Chand MA, Claessen N, Dijkink L, Wijdenes J, et al. Interleukin-4 and interleukin-13 act on glomerular visceral epithelial cells. J Am Soc Nephrol. 2000;11:413-22. 31. Parry RG, Gillespie KM, Mathieson PW. Effects of type 2 cytokines on glomerular epithelial cells. Exp Nephrol. 2001;9:275-83.

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J.C. Lane and F.J. Kaskel

32. Aten J, Roos A, Claessen N, Schilder-Tol EJ, Ten Berge IJ, Weening JJ. Strong and selective glomerular localization of CD134 ligand and TNF receptor-1 in proliferative lupus nephritis. J Am Soc Nephrol. 2000;11: 1426-38. 33. van den Berg JG, Aten J, Annink C, Ravesloot JH, Weber E, Weening JJ. Interleukin-4 and -13 promote basolateral secretion of H and cathepsin L by glomerular epithelial cells. Am J Physiol Renal Physiol. 2002;282:F26-33. 34. Huwiler A, Ren S, Holthofer H, Pavenstadt H, Pfeilschifter J. Inammatory cytokines upregulate nephrin expression in human embryonic kidney epithelial cells and podocytes. Biochem Biophys Res Commun. 2003;305:136-42. 35. Koukouritaki SB, Vardaki EA, Papakonstanti EA, Lianos E, Stournaras C, Emmanouel DS. TNF- induces actin cytoskeleton reorganization in glomerular epithelial cells involving tyrosine phosphorylation of

36.

37.

38.

39.

40.

paxillin and focal adhesion kinase. Mol Med. 1999;5:382-92. Wiggins RC. The spectrum of podocytopathies: a unifying view of glomerular diseases. Kidney Int. 2007; 71:1205-14. Li Y, Kang YS, Dai C, Kiss LP, Wen X, Liu Y. Epithelialto-mesenchymal transition is a potential pathway leading to podocyte dysfunction and proteinuria. Am J Pathol. 2008;172:299-308. Ding G, Reddy K, Kapasi AA, Franki N, Gibbons N, Kasinath BS, et al. Angiotensin II induces apoptosis in rat glomerular epithelial cells. Am J Renal Physiol. 2002;283:F173-80. Hodson EM, Alexander SI. Evaluation and management of steroid-sensitive nephrotic syndrome. Curr Opin Pediatr. 2008;20:145-50. Gipson DS, Gibson K, Gipson PE, Watkins S, MoxeyMims M. Therapeutic approach to FSGS in children. Pediatr Nephrol. 2007;22:28-36.