Urinary excretion of low and high molecular weight Urinary excretion - - PowerPoint PPT Presentation

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May 6th – 7th 2011 y Mario Negri Institute for Pharmacological Research Clinical Research Centre for Rare Diseases Ald C l D ò Aldo e Cele Daccò

Urinary excretion of low and high molecular weight Urinary excretion of low and high molecular weight proteins as predictors of response to rituximab in proteins as predictors of response to rituximab in p p p p p p patients with membranous nephropathy: patients with membranous nephropathy:

Fernando C. Fervenza, MD, Ph.D Fernando C. Fervenza, MD, Ph.D Division of Nephrology and Hypertension Division of Nephrology and Hypertension Division of Nephrology and Hypertension Division of Nephrology and Hypertension Mayo Clinic College of Medicine Mayo Clinic College of Medicine Rochester, MN Rochester, MN

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Conflict of Interest Conflict of Interest

• Studies supported by unrestricted

Studies supported by unrestricted research grants from Genentech Inc research grants from Genentech Inc research grants from Genentech Inc, research grants from Genentech Inc, the Fulk Foundation and the Mayo the Fulk Foundation and the Mayo Foundation Foundation Foundation. Foundation.

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Rituximab in Membranous Nephropathy Rituximab in Membranous Nephropathy p p y p p y

12 6 8 10 4 5 6 8 3 4

Proteinuria (g/24 hr) Proteinuria (g/24 hr) Serum creatinine (mg/dL) Serum creatinine (mg/dL) * * * * *

2 4 1 2

(g ) (g ) (mg/dL) (mg/dL) *

2 1

• 6

3 6 9 12 * P<0.01 vs months -6 and 0 * P<0.01 vs months -6 and 0 6 3 6 9 12

Months Months

CP1125840-1

P 0.01 vs months 6 and 0 Ruggenenti et al: JASN 14:851, 2003 P 0.01 vs months 6 and 0 Ruggenenti et al: JASN 14:851, 2003

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Main Clinical and Laboratory Characteristics Main Clinical and Laboratory Characteristics at Study Entry in Patients with IMN at Study Entry in Patients with IMN

Characteristic Characteristic No. No. % % Mean Mean SD SD Min Min Max Max Gender Gender Male Male 17 17 85.0 85.0 Female Female 3 3 15.0 15.0 A ( ) A ( ) 48 6 48 6 12 9 12 9 29 29 80 80 Age (years) Age (years) 48.6 48.6 12.9 12.9 29 29 80 80 Disease duration (mo) Disease duration (mo) 29.7 29.7 39.7 39.7 3 3 144 144 Failed prior immunosuppressive therapy Failed prior immunosuppressive therapy 11 11 55.0 55.0 Histology stage Histology stage Histology stage Histology stage I 2 2 10.0 10.0 I-

• II

II 3 3 15.0 15.0 II II 4 20 0 20 0 II II 4 20.0 20.0 II II-

• III

III 8 8 40.0 40.0 III III 1 1 5.0 5.0 III III-IV IV 2 10.0 10.0 III III IV IV 2 10.0 10.0 Urinary protein excretion (g/24 hr) Urinary protein excretion (g/24 hr) 11.9 11.9 4.9 4.9 5.7 5.7 26.5 26.5 Serum creatinine (mg/dL) Serum creatinine (mg/dL) 1.5 1.5 0.5 0.5 0.8 0.8 2.3 2.3 Creatinine clearance (mL/min/1.73 m Creatinine clearance (mL/min/1.73 m2) 72.4 72.4 33.2 33.2 30 30 156 156 ( )

Fervenza, Abraham, …Cattran. CJASN 2010 Fervenza, Abraham, …Cattran. CJASN 2010

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100.00 10.00

4 hr) 4 hr)

NR NR n=2 n=2 LR LR

1 00 10.00

in (g/24 in (g/24

3.50

LR LR n=1 n=1 PR PR 12 12

0 10 1.00

e prote e prote

0.30

n=12 n=12 CR CR n=5 n=5

0 01 0.10

Urine Urine

0.01

• 4

Months Months Baseline 28 3 6 9 18 Days Days Months Months 12 24

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y Fervenza, Abraham, …Cattran. CJASN 2010 Fervenza, Abraham, …Cattran. CJASN 2010

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Can we predict response Can we predict response to therapy? to therapy?

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Observed Serum Rituxan Concentrations from IMN (Study U4086s) vs. PK Observed Serum Rituxan Concentrations from IMN (Study U4086s) vs. PK profile Simulated* Using model derived from Rituxan RA Study (375mg/m profile Simulated* Using model derived from Rituxan RA Study (375mg/m2 x 4) x 4) x 4) x 4)

1,000,000

• Red Symbols represent the original observations

100,000

(ng/mL)

• Black solid line represents the median of the simulated data
• Black dashed lines represent the lines 5th and 95th percentiles
• f the simulated data.

10,000

• ncentration

1 000

m Rituxan Co

1,000

Seru *Simulations were based on the estimated PK parameters and inter- and intra- individual variability for RA patients

100 28 56 84 112 140

Time (days)

Observed serum concentrations (red symbols) from study in IMN are lower than the PK data simulated using PK model from adult RA population.

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Do baseline T and B cell Do baseline T and B cell subsets predict response subsets predict response subsets predict response subsets predict response to therapy? to therapy?

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B cell subsets B cell subsets

• CD19+ B Cells

B Cells

• CD19+ B Cells

B Cells

• CD19+CD27+

Total Memory B Cells

• CD19+CD27+IGM+IGD-

IgM Memory B Cells

• CD19+CD27+

Total Memory B Cells

• CD19+CD27+IGM+IGD-

IgM Memory B Cells

• CD19+CD27+IGM+IGD+

Non-Switched Memory B Cells

• CD19+CD27+IGM-IGD-

Switched Memory B Cells

• CD19+CD27+IGM+IGD+

Non-Switched Memory B Cells

• CD19+CD27+IGM-IGD-

Switched Memory B Cells CD19+CD27+IGM IGD Switched Memory B Cells

• CD19+IGM+ B CELLS

IgM B Cells

• CD38+IGM+CD19+

T iti l B C ll CD19+CD27+IGM IGD Switched Memory B Cells

• CD19+IGM+ B CELLS

IgM B Cells

• CD38+IGM+CD19+

T iti l B C ll

• CD38+IGM+CD19+

Transitional B Cells

• CD38+IGM-CD19+

Plasmablasts

• CD38+IGM+CD19+

Transitional B Cells

• CD38+IGM-CD19+

Plasmablasts

• CD19+CD21+

Mature B Cells

• CD19+CD21-

Immature B Cells

• CD19+CD21+

Mature B Cells

• CD19+CD21-

Immature B Cells

• CD45+CD20+

Pan-lymphocyte marker

• CD45+CD20+

Pan-lymphocyte marker

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T cell subsets T cell subsets

• CD4+CD45RA+ naïve T-cells
• CD4+CD62L+CD27+ naïve (n) T-cells
• CD4+CD45RA+ naïve T-cells
• CD4+CD62L+CD27+ naïve (n) T-cells

CD4 CD62L CD27 naïve (n) T cells

• CD8+CD45RA+ naïve T-cells
• CD8+CD62L+CD27+naïve (n) T-cells

CD4 CD62L CD27 naïve (n) T cells

• CD8+CD45RA+ naïve T-cells
• CD8+CD62L+CD27+naïve (n) T-cells

CD8+CD62L+CD27+naïve (n) T cells

• CD4+CD45RO+ memory T-cells
• CD4+CD62L+CD27+CD45RO+ (Tcm)

CD8+CD62L+CD27+naïve (n) T cells

• CD4+CD45RO+ memory T-cells
• CD4+CD62L+CD27+CD45RO+ (Tcm)
• CD4+CD62L+CD27+CD45RO+ (Tcm)
• CD4+CD62L-CD27-CD45RO+ (Tem)
• CD8+CD45RO+

T ll

• CD4+CD62L+CD27+CD45RO+ (Tcm)
• CD4+CD62L-CD27-CD45RO+ (Tem)
• CD8+CD45RO+

T ll

• CD8+CD45RO+ memory T-cells
• CD8+CD62L+CD27+CD45RO+ (Tcm)
• CD8+CD45RO+ memory T-cells
• CD8+CD62L+CD27+CD45RO+ (Tcm)
• CD8+CD62L-CD27- CD45RO+ (Tem)
• Activated CD4 T-cells (4+CD25+)
• CD8+CD62L-CD27- CD45RO+ (Tem)
• Activated CD4 T-cells (4+CD25+)
• CD4+HLA DR+CD28+ T-cells
• CD8+HLA DR+CD28+ T-cells
• CD4+HLA DR+CD28+ T-cells
• CD8+HLA DR+CD28+ T-cells

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Does urinary excretion of low Does urinary excretion of low Does urinary excretion of low Does urinary excretion of low and high molecular weight and high molecular weight proteins predicts response proteins predicts response to therapy? to therapy? to therapy? to therapy?

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High High-

• and Low

and Low-

• Molecular Weight Proteins and Renal Outcome

Molecular Weight Proteins and Renal Outcome

• Reichert LJ, Koene RA, Wetzels JF. Urinary excretion of

Reichert LJ, Koene RA, Wetzels JF. Urinary excretion of β2-

• microglobulin predicts renal outcome in

microglobulin predicts renal outcome in patients with idiopathic MN. JASN 1995; 6:1666 patients with idiopathic MN. JASN 1995; 6:1666-

• 1669

1669

• R i h

t LJ K RA W t l JF U i I G ti ti f t i idi thi MN R i h t LJ K RA W t l JF U i I G ti ti f t i idi thi MN

• Reichert LJ, Koene RA, Wetzels JF. Urinary IgG excretion as a prognostic factor in idiopathic MN.

Reichert LJ, Koene RA, Wetzels JF. Urinary IgG excretion as a prognostic factor in idiopathic MN. Clin Nephrol 1997; 48:79 Clin Nephrol 1997; 48:79-

• 84

84

• Bazzi C, Petrini C, Rizza V, Arrigo G, et al. Urinary excretion of IgG and

Bazzi C, Petrini C, Rizza V, Arrigo G, et al. Urinary excretion of IgG and α1-

• microglobulin predicts

microglobulin predicts clinical course better than extent of proteinuria in MN. AJKD 2001; 38:240 clinical course better than extent of proteinuria in MN. AJKD 2001; 38:240-

• 248

248

• Bakoush O, Torffvit O, Rippe B, Tencer J. High proteinuria selectivity index based upon IgM is a

Bakoush O, Torffvit O, Rippe B, Tencer J. High proteinuria selectivity index based upon IgM is a strong predictor of poor renal survival in glomerular diseases. NDT 2001; 16:1357 strong predictor of poor renal survival in glomerular diseases. NDT 2001; 16:1357-

• 63

63

• Bazzi C, Petrini C, Rizza V, Arrigo G, et al. Urinary N

Bazzi C, Petrini C, Rizza V, Arrigo G, et al. Urinary N-

• acetyl

acetyl-

• β

β-glucosaminidase excretion is a marker glucosaminidase excretion is a marker

• f tubular cell dysfunction and a predictor of outcome in primary GN NDT 2002; 17:1890
• f tubular cell dysfunction and a predictor of outcome in primary GN NDT 2002; 17:1890-1896

1896

• f tubular cell dysfunction and a predictor of outcome in primary GN. NDT 2002; 17:1890
• f tubular cell dysfunction and a predictor of outcome in primary GN. NDT 2002; 17:1890-1896

1896

• Bakoush O, Torffvit O, Rippe B, Tencer J. Renal function in proteinuric GN correlates to the changes

Bakoush O, Torffvit O, Rippe B, Tencer J. Renal function in proteinuric GN correlates to the changes in urine IgM excretion but not to the changes in the degree of albuminuria. Clin Nephrol 2003; in urine IgM excretion but not to the changes in the degree of albuminuria. Clin Nephrol 2003; 59:345 59:345-

• 352

352

• Branten AJ, du Buf

Branten AJ, du Buf-

• Vereijken PW, Klasen IS, Bosch FH, et al. Urinary excretion of

Vereijken PW, Klasen IS, Bosch FH, et al. Urinary excretion of β2-

• microglobulin

microglobulin and IgG predict prognosis in idiopathic MN: a validation study. JASN 2005; 16:169 and IgG predict prognosis in idiopathic MN: a validation study. JASN 2005; 16:169-

• 174

174

• Deegens JK, Wetzels JF. Fractional excretion of high

Deegens JK, Wetzels JF. Fractional excretion of high-

• and low

and low-

• molecular weight proteins and

molecular weight proteins and

• utcome in primary FSGS. Clin Nephrol 2007; 68:201
• utcome in primary FSGS. Clin Nephrol 2007; 68:201-
• 208

208 p y p ; p y p ;

• Hofstra JM, Deegens JK, Willems HL, Wetzels JF.

Hofstra JM, Deegens JK, Willems HL, Wetzels JF. β β2-

• microglobulin is superior to N

microglobulin is superior to N-

• acetyl

acetyl-

• β-

glucosaminidase in predicting prognosis in idiopathic MN. NDT 2008; 23:2546 glucosaminidase in predicting prognosis in idiopathic MN. NDT 2008; 23:2546-

• 2551

2551

• McQuarrie EP, Shakerdi L, Jardine AG, Fox JG, et al. Fractional excretions of albumin and IgG are

McQuarrie EP, Shakerdi L, Jardine AG, Fox JG, et al. Fractional excretions of albumin and IgG are th b t di t f i i i GN NDT 2010 O t 4th th b t di t f i i i GN NDT 2010 O t 4th

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the best predictors of progression in primary GN. NDT 2010; Oct 4th the best predictors of progression in primary GN. NDT 2010; Oct 4th

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High High-

• and Low

and Low-

• Molecular Weight Proteins and

Molecular Weight Proteins and R t Th R t Th Response to Therapy Response to Therapy

• Bazzi C, Petrini C, Rizza V, Napodano P, Paparella M, Arrigo G, Pisano L, D'Amico G.

Bazzi C, Petrini C, Rizza V, Napodano P, Paparella M, Arrigo G, Pisano L, D'Amico G. Fractional Fractional excretion of IgG predicts renal outcome and response to therapy in primary FSGS: excretion of IgG predicts renal outcome and response to therapy in primary FSGS: a pilot study. AJKD 2003; 41:328 a pilot study. AJKD 2003; 41:328-

• 335

335

• du Buf

du Buf Vereijken PW Wetzels JF Treatment Vereijken PW Wetzels JF Treatment related changes in urinary excretion of high and related changes in urinary excretion of high and

• du Buf

du Buf-Vereijken PW, Wetzels JF. Treatment Vereijken PW, Wetzels JF. Treatment-related changes in urinary excretion of high and related changes in urinary excretion of high and low molecular weight proteins in patients with idiopathic MN and renal insufficiency. NDT low molecular weight proteins in patients with idiopathic MN and renal insufficiency. NDT 2006; 21:389 2006; 21:389-

• 396

396

• Bazzi C, Rizza V, Paparella M, Casellato D, Napodano P, Olivieri G, D'Amico G.

Bazzi C, Rizza V, Paparella M, Casellato D, Napodano P, Olivieri G, D'Amico G. Fractional Fractional i ti f I G i th t f l di t f t ti b ACE i hibit i i ti f I G i th t f l di t f t ti b ACE i hibit i urinary excretion of IgG is the most powerful predictor of renoprotection by ACE inhibitors in urinary excretion of IgG is the most powerful predictor of renoprotection by ACE inhibitors in IgA nephropathy. J Nephrol 2009; 22:387 IgA nephropathy. J Nephrol 2009; 22:387-

• 396

396

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U IgG vs U U IgG vs U 1M at Baseline 1M at Baseline U IgG vs U U IgG vs U 1M at 12 Months 1M at 12 Months

800 1000 1200 1400

g/24 hr) g/24 hr)

r2=0.856; p<0.001 CR + PR CR + PR LR + NR LR + NR 800 1000 1200

g/24 hr) g/24 hr)

r2=0.848; p<0.001 200 400 600 800

U IgG (mg U IgG (mg

200 400 600

U IgG (mg U IgG (mg

50 100 150 200 250

U U U 1M (mg/24 hr) 1M (mg/24 hr)

50 100 150 200

U U U 1M (mg/24 hr) 1M (mg/24 hr)

30 14

U IgM vs U U IgM vs U 1M at Baseline 1M at Baseline U IgM vs U U IgM vs U 1M at 12 Months 1M at 12 Months

15 20 25 30 8 10 12 14

mg/24 hr) mg/24 hr)

r2=0.348; p=0.006

mg/24 hr) mg/24 hr)

r2=0.815; p<0.001 5 10 15 2 4 6

U IgM (m U IgM (m U IgM (m U IgM (m

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50 100 150 200 50 100 150 200 250

U U 1M (mg/24 hr) 1M (mg/24 hr) U U 1M (mg/24 hr) 1M (mg/24 hr)

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Urinary Proteins in Patients with IMN treated with Urinary Proteins in Patients with IMN treated with Rituximab Rituximab Rituximab Rituximab

Parameter Parameter Baseline Baseline Month 3 Month 3 Month 6 Month 6 Month 9 Month 9 Month 12 Month 12 Proteinuria g/24h Proteinuria g/24h 11.85 11.85± ±4.85 4.85 7.34 7.34± ±4.11 4.11a 6.63 6.63± ±5.28 5.28a 4.13 4.13± ±3.44 3.44a 4.22 4.22± ±3.78 3.78a U IgG mg/24 hr U IgG mg/24 hr 442.9 442.9± ±328.4 328.4 337.5 337.5± ±346.4 346.4 207.9 207.9± ±205.5* 205.5* 128.3 128.3± ±117.5* 117.5* 151 151± ±248.9* 248.9* FE I G FE I G 0 122 0 122 0 112 0 112 0 078 0 078 0 11* 0 11* 0 059 0 059 0 102* 0 102* 0 02 0 02 0 02* 0 02* 0 02 0 02 0 05* 0 05* FE IgG FE IgG 0.122 0.122±0.112 0.112 0.078 0.078±0.11* 0.11* 0.059 0.059±0.102* 0.102* 0.02 0.02± ±0.02* 0.02* 0.02 0.02± ±0.05* 0.05* U IgM mg/24 hr U IgM mg/24 hr 3.42 3.42± ±3.45 3.45 3.00 3.00± ±3.77 3.77 2.69 2.69± ±4.33 4.33 1.2 1.2± ±2.1* 2.1* 2.5 2.5± ±6.6 6.6 FE IgM FE IgM 0.005 0.005± ±0.006 0.006 0.005 0.005± ±0.007 0.007 0.004 0.004± ±0.009 0.009 0.001 0.001± ±0.001* 0.001* 0.005 0.005± ±0.01 0.01 U U 1M mg/24 hr 1M mg/24 hr 99.2 99.2± ±63.0 63.0 70.74 70.74± ±48.1* 48.1* 62.7 62.7± ±52.5 52.5 39.4 39.4± ±26.9* 26.9* 44 44± ±45.1* 45.1* RBP mg/24 hr RBP mg/24 hr 12.6 12.6± ±12.7 12.7 6.9 6.9± ±7.5 7.5 6.5 6.5± ±9.9 9.9 2.5 2.5± ±2.7* 2.7* 3.8 3.8± ±6.5* 6.5* MALB mg/24 hr MALB mg/24 hr 7091 8 7091 8±3664 8 3664 8 5429 4 5429 4±3035 9 3035 9 4173 2 4173 2±3043 0* 3043 0* 3134 1 3134 1± ±2522* 2522* 3377 3377± ±2776 9* 2776 9* MALB mg/24 hr MALB mg/24 hr 7091.8 7091.8±3664.8 3664.8 5429.4 5429.4±3035.9 3035.9 4173.2 4173.2±3043.0 3043.0 3134.1 3134.1± ±2522 2522 3377 3377± ±2776.9 2776.9 FE albumin FE albumin 0.262 0.262± ±0.173 0.173 0.194 0.194± ±0.177* 0.177* 0.134 0.134± ±0.01* 0.01* 0.074 0.074± ±0.054* 0.054* 0.071 0.071± ±0.066* 0.066* Mean Mean±SD SD

a P≤0.05 vs month 0

*Mean values at 9 and 12 months are based on 19 patients. Patient #7 was discontinued from study at month 6

Mean Mean±SD SD

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Percentage reduction of Urinary i f RTX h proteins after RTX therapy

100 80 90 100 60 70 80

uction

T l i 40 50 60

age redu

Total protein IgG IgM 20 30 40

Percenta

Alpha 1 microglobulin Albumin 10 20

P

Baseline Month 3 Month 6 Month 9 Month 12

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Correlation between urinary markers at baseline Correlation between urinary markers at baseline d ti t t 12 d 24 th d ti t t 12 d 24 th and patients response at 12 and 24 months and patients response at 12 and 24 months

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Urinary markers at baseline and patient Urinary markers at baseline and patient response at 24 months response at 24 months response at 24 months response at 24 months

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“Neither absolute levels of urinary IgG, β2M or α1M at baseline

• r at 12 months nor the % reduction between baseline and 12

months clearly predicted the occurrence of a remission or a l t h ti t i i ” relapse to nephrotic range proteinuria”

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Cumulative Probability of Cumulative Probability of O ( ) (C) O ( ) (C)

100

Obtaining (P) or (C) Remission Obtaining (P) or (C) Remission

Partial + complete Partial + complete

80 100

Partial + complete remission Partial + complete remission

Methylprednisolone + chlorambucil Methylprednisolone + chlorambucil

60

%

Complete Complete

chlorambucil Methylprednisolone + cyclophosphamide chlorambucil Methylprednisolone + cyclophosphamide

40

%

Complete remission Complete remission

20 6 12 18 24 30 36 42 48 54 60

Months Months

CP1134827-19

Ponticelli et al: JASN 9:444, 1998 Ponticelli et al: JASN 9:444, 1998

Months Months

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Conclusion Conclusion

In patients with idiopathic MN, treatment In patients with idiopathic MN, treatment ith RTX t b ff ti i ith RTX t b ff ti i with RTX appears to be effective in with RTX appears to be effective in inducing CR or PR in a significant number inducing CR or PR in a significant number

• f patients, and significantly improves the
• f patients, and significantly improves the

urinary excretion of a number of selective urinary excretion of a number of selective urinary excretion of a number of selective urinary excretion of a number of selective proteins: α1M, RBP, IgG and albumin. proteins: α1M, RBP, IgG and albumin. However, pre However, pre-

• treatment quantification of

treatment quantification of th i t i did t di t th th i t i did t di t th these urinary proteins did not predict the these urinary proteins did not predict the long long-

• term response to RTX therapy.

term response to RTX therapy.

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Conclusion Conclusion

Our data should be interpreted narrowly: Our data should be interpreted narrowly: a) not study the relationship between these proteins a) not study the relationship between these proteins and disease progression. and disease progression. ) b) and did not vary the therapy. b) and did not vary the therapy. c) does not contradict previous studies indicating to c) does not contradict previous studies indicating to predict disease progression predict disease progression predict disease progression predict disease progression d) does not preclude they could be used to identify d) does not preclude they could be used to identify patients who should receive more patients who should receive more aggressive or aggressive or patients who should receive more patients who should receive more-aggressive or aggressive or less less-

• aggressive therapies.

aggressive therapies. e) can identify patients who are likely to go into e) can identify patients who are likely to go into e) can identify patients who are likely to go into e) can identify patients who are likely to go into spontaneous remission ? spontaneous remission ? Reliable markers capable of predicting response to Reliable markers capable of predicting response to

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p p g p p p g p RTX in patients with MN remained to be defined. RTX in patients with MN remained to be defined.