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  • Review Article
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Hurdles to the introduction of new therapies for immune-mediated kidney diseases

Nature Reviews Nephrology volume 12, pages 205–216 (2016)Cite this article

Subjects

Key Points

  • Disease classifications that define syndromes by their pathogenesis rather than their histopathological appearance or biomarker profile increase the likelihood of identifying effective treatments that will succeed in clinical trials

  • Patients need to be better stratified according to the likelihood that they will respond to certain drugs by combining the concepts of evidence-based and personalized medicine

  • Most immune-mediated kidney diseases are rare, implying that national registries and clinical trial networks will be needed to progress translational research and clinical trials

  • To improve the applicability of findings from preclinical animal studies to human disease not only are better disease models needed, but study designs must more closely reflect those of clinical trials

  • Testing of novel drugs in an add-on design should not be considered unless supported by respective preclinical studies; add-on designs are less suitable for drugs with similar modes-of-action

  • Biomarkers of intrarenal inflammation, nephron injury, and nephron number need to be identified and established as surrogate markers of disease activity and nephron loss

Abstract

Innovative immunotherapies continue to markedly benefit many disciplines in clinical medicine but disappointingly, these benefits have not translated to the treatment of kidney diseases despite encouraging findings from preclinical models of kidney dysfunction. This lack of progress in nephrology might relate to the unique biology of the kidney. More likely, this lack of progress relates to conceptual hurdles in the application of newer therapies to renal disease. In this Review we discuss seven hurdles that must be addressed in order to appropriately assess and introduce immunologic therapies for immune-mediated kidney disease: the use of appropriate criteria to define disease categories; issues relating to the heterogeneity of kidney diseases and how this heterogeneity affects approaches to treatment; issues related to the rarity of most kidney diseases; the paucity of good animal models of human kidney disease; issues relating to trial design; problems with current approaches to the identification and use of appropriate and feasible study end points; and a lack of adequate biomarkers of intrarenal inflammation and parenchymal injury. We suggest that overcoming these hurdles, in addition to searching for better therapeutic targets, will be necessary to progress the treatment of immune-mediated kidney disease into a new age of drug therapy.

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Figure 1: Design of a multicentre randomized controlled trial in rodents.
Figure 2: Considerations in the design of trials for immune-mediated kidney disease.

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Acknowledgements

H.-J.A. would like to thank the Deutsche Forschungsgemeinschaft for research support via GRK1202. D.R.W.J. is supported by the Cambridge Biomedical Research Centre. B.H.R. is supported in part by NIDDK U01 DK096927.

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Authors and Affiliations

  1. Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstrasse 1, München, 80336, Germany

    Hans-Joachim Anders

  2. Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hill's Road, Cambridge, CB2 2QQ, UK

    David R. W. Jayne

  3. Division of Nephrology, Ohio State University Wexner Medical Center, 395 West 12th Avenue, Columbus, 43210, Ohio, USA

    Brad H. Rovin

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All authors contributed equally to researching data for the article, discussing the article's content, writing the article and review/editing of the manuscript before submission.

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Correspondence to Hans-Joachim Anders, David R. W. Jayne or Brad H. Rovin.

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Competing interests

H.-J.A. has received consultancy fees from GlaxoSmithKine, Roche and Bayer. D.R.W.J. has received research grants from Roche/Genentech and Sanofi/Genzyme, consultancy fees from Boehringer-Ingelheim, BIOGEN, Chemocentryx, GlaxoSmithKine and Roche/Genentech, and is a director of Aurinia Pharmaceuticals Inc. B.H.R. has received consultancy fees from Genentech, Biogen, Roche, Boehringer-Ingelheim, Lilly, and Mallinckrodt, and a research grant from Mallinckrodt.

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NEPTUNE

EURenOMICs consortium

EUVAS

Lupus Nephritis Trial Network

NIH Rare Disease Network

European Union Health Technology Schemes

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Anders, HJ., Jayne, D. & Rovin, B. Hurdles to the introduction of new therapies for immune-mediated kidney diseases. Nat Rev Nephrol 12, 205–216 (2016). https://doi.org/10.1038/nrneph.2015.206

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