Glomerulonephritis in Childhood

**35**

**Chapter 3**

**Abstract**

*Samuel N. Uwaezuoke*

syndrome as a podocytopathy.

**1. Introduction**

glomerulonephritides, podocyte injury

**Keywords:** idiopathic nephrotic syndrome, glomerular disease,

subtype hitherto thought to be more common in adult patients.

Nephrotic syndrome is the commonest manifestation of glomerular disease which is characterized by massive proteinuria, hypoalbuminemia, generalized edema, and hyperlipidemia [1]. In children, primary or idiopathic nephrotic syndrome (INS) may be caused by any of these glomerulonephritides: minimal change nephropathy (MCN), focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), mesangial proliferative glomerulonephritis (MesPGN), and membranous nephropathy (MN). MCN appears to be the most common histopathologic type, followed by FSGS and MPGN in that order [2–4]. However, recent reports from different parts of the world suggest a change in the pattern of the predominant histopathologic types in childhood INS. For instance, there has been a rise in the prevalence rates of FSGS documented among children in the West African subregion [5–7]. This trend also applies to MPGN [8], a histological

In the pathogenesis of INS, there is now a paradigm shift from the concept of an immune-dysregulated disease of the glomerular basement membrane to that of a podocytopathy [9, 10]. In fact, it is now assumed that podocyte abnormalities account

Childhood Idiopathic Nephrotic

Idiopathic nephrotic syndrome is the commonest manifestation of glomerular disease in children. The syndrome is characterized by massive proteinuria, hypoalbuminemia, generalized edema, and hyperlipidemia. Although genetic or congenital forms are now well recognized, nephrotic syndrome is largely acquired. The latter form can be idiopathic or primary (the causes are unknown) and secondary (the causes are known renal or non-renal diseases). Idiopathic nephrotic syndrome consists of the following glomerulonephritides: minimal change nephropathy (MCN), focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), mesangial proliferative glomerulonephritis (MesPGN), and membranous nephritis (MN). The etiopathogenesis of nephrotic syndrome has evolved through several hypotheses ranging from immune dysregulation theory and increased glomerular permeability theory to the current concept of podocytopathy. Podocyte injury is now thought to be the basic pathology in the syndrome. The book chapter aims to highlight the mechanisms underlying the pathogenesis of nephrotic

Syndrome as a Podocytopathy

#### **Chapter 3**

## Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy

*Samuel N. Uwaezuoke*

#### **Abstract**

Idiopathic nephrotic syndrome is the commonest manifestation of glomerular disease in children. The syndrome is characterized by massive proteinuria, hypoalbuminemia, generalized edema, and hyperlipidemia. Although genetic or congenital forms are now well recognized, nephrotic syndrome is largely acquired. The latter form can be idiopathic or primary (the causes are unknown) and secondary (the causes are known renal or non-renal diseases). Idiopathic nephrotic syndrome consists of the following glomerulonephritides: minimal change nephropathy (MCN), focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), mesangial proliferative glomerulonephritis (MesPGN), and membranous nephritis (MN). The etiopathogenesis of nephrotic syndrome has evolved through several hypotheses ranging from immune dysregulation theory and increased glomerular permeability theory to the current concept of podocytopathy. Podocyte injury is now thought to be the basic pathology in the syndrome. The book chapter aims to highlight the mechanisms underlying the pathogenesis of nephrotic syndrome as a podocytopathy.

**Keywords:** idiopathic nephrotic syndrome, glomerular disease, glomerulonephritides, podocyte injury

#### **1. Introduction**

Nephrotic syndrome is the commonest manifestation of glomerular disease which is characterized by massive proteinuria, hypoalbuminemia, generalized edema, and hyperlipidemia [1]. In children, primary or idiopathic nephrotic syndrome (INS) may be caused by any of these glomerulonephritides: minimal change nephropathy (MCN), focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), mesangial proliferative glomerulonephritis (MesPGN), and membranous nephropathy (MN). MCN appears to be the most common histopathologic type, followed by FSGS and MPGN in that order [2–4]. However, recent reports from different parts of the world suggest a change in the pattern of the predominant histopathologic types in childhood INS. For instance, there has been a rise in the prevalence rates of FSGS documented among children in the West African subregion [5–7]. This trend also applies to MPGN [8], a histological subtype hitherto thought to be more common in adult patients.

In the pathogenesis of INS, there is now a paradigm shift from the concept of an immune-dysregulated disease of the glomerular basement membrane to that of a podocytopathy [9, 10]. In fact, it is now assumed that podocyte abnormalities account for all forms of nephrotic syndrome. Basically, the podocyte is involved in maintaining the structural integrity of the glomerular filtration barrier. Thus, podocyte injury and loss result in significant proteinuria as well as progressive glomerulosclerosis [11]. Podocytopathy can occur in immunologic and non-immunologic diseases of the kidney. Acquired podocytopathies such as MCN and FSGS are considered to have immunologic basis [12]. Interestingly, immunosuppressive therapy has been noted to directly affect the podocyte through the regulation of interleukin-4 (IL-4) and interleukin-13 (IL-13) and several signaling pathways involved with the stabilization of the actin cytoskeleton and the distribution of the slit diaphragm components [11]. This book chapter aims to discuss the mechanisms underpinning the pathogenesis of childhood INS as a podocytopathy.

#### **2. The molecular structure and function of the podocyte**

The glomerular filtration barrier is essentially a trilaminate structure which consists of the podocyte on the outer surface, the glomerular basement membrane (GBM) in the middle, and the fenestrated endothelium on the inner surface (**Figure 1**). The podocyte (also known as the visceral glomerular epithelial cell) constitutes the last barrier to protein loss, given its unique structure and location as a terminally differentiated cell which lines the outer surface of the GBM. Each podocyte comprises the foot processes which are separated by a filtration slit (or the slit diaphragm). The foot process comprises components such as actin, myosin-II, α-actinin-4, talin, and vinculin which all constitute a contractile structure [13]. The filament bundles which make up actin are disposed together as arches between contiguous podocyte foot processes [14] and are connected to the GBM at specific points through an adhesion molecule (α-3β-1 integrin complex) [15, 16]. Similarly, the linkage of the podocyte foot processes to the GBM is made possible through both α-3β-1 integrin and dystroglycans [17]. Adjacent foot processes are linked by the slit diaphragm, which forms the main size-selective filter barrier in the glomerular architecture [18, 19]. The filtration slit is composed of multiple protein molecules such as nephrin, P-cadherin, CD2AP, ZO-1, FAT, podocin, and possibly

#### **Figure 1.**

*Schematic representation of the molecular structure of the glomerular filtration barrier (Courtesy: Flickr photos).*

**37**

*Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy*

**2.1 The molecular mechanisms in podocytopathy**

Neph1 [20–22]. In addition, synaptopodin is closely related to the actin filaments located within the podocyte foot processes [23] and interacts with the tight junction protein, MAGI-1, in the same way as α-actinin-4 MAGI-1 being expressed in podocytes as well [24]. The functional integrity of the podocytes depends on the actin cytoskeleton. This is critical in preserving the intact glomerular filtration barrier, as

Among the fundamental biologic events in INS, a molecular disruption of the filtration slit or GBM results in proteinuria, while rearrangement of podocyte cytoskeleton accounts for foot process effacement. In fact, the basic role played by the podocyte actin cytoskeleton (the skeletal structure of the foot processes) in the pathogenesis of INS is predicated on the disruption of actin-related proteins with the GBM, resulting in effacement of the podocyte foot processes [25]. Still at the molecular level, focal adhesion kinase (FAK) plays an essential role in this foot process effacement, usually observed in podocytopathies [26]. Furthermore, alterations in podocyte proteins such as nephrin and Neph1 (nephrin homologue), CD2-associated protein (CD2AP), and podocin all contribute to the pathogenesis of INS as podocytopathies [27–29]. Nephrin represents an essential constituent of the slit diaphragm and also serves as an efficient mobilizer of other proteins such as podocin and CD2AP (**Figure 1**) [30]. It has been proposed that a vital interaction exists between the actin cytoskeleton and the molecules that make up the filtration slit such as podocin, nephrin, and CD2AP [31, 32]. Thus, nephrotic-range proteinuria occurs as a result of structural disruptions in the podocytes which present as foot process effacement, as well as changes in the actin cytoskeleton and molecular alteration of the filtration slit [33]. Again, the component molecules of the actin cytoskeleton include actin, α-actinin, and synaptopodin [34, 35]. Interestingly, the upregulation of α-actinin results in the reorganization of the cytoskeleton in some nephrotic syndromes [36], while the expression of synaptopodin is generally preserved in MCN, but diminished in FSGS [37]. Podocalyxin is a molecule presumed to mediate the stability of the foot processes [38] and has also been found to be raised in nephrotic syndromes [39]. Finally, the fundamental role of adhesion molecules such as integrins and focal adhesion proteins has been shown in genetically based animal experiments which end up in nephrotic syndrome [40, 41]. Specifically, α3β1 (the main integrin heterodimer in the podocyte), when destroyed in the podocytes of experimental mice, gave rise to nephrotic-range proteinuria and foot process effacement. In addition, αvβ3 integrin (also expressed in podocytes) can be activated by uroplasminogen type I activator receptor (uPAR) (in podocytes) [42] or its soluble form, suPAR (from the circulation) [43]. Its activation notably leads to foot process effacement through the rearrangement of the podocyte

a healthy podocyte is essential for the maintenance of this barrier.

actin cytoskeleton: a characteristic event in podocytopathy [44].

Interventions targeting molecular pathways which regulate the actin cytoskeleton can potentially play an important role in the treatment of proteinuric kidney diseases, such as nephrotic syndrome. There are three major molecular frameworks which modulate the actin cytoskeleton and prevent podocyte detachment from GBM, namely, Rho-GTPases, cell-matrix adhesion proteins, and endocytic proteins. For instance, the podocyte-expressed RhoA, Rac1, and Cdc42 regulate signal transduction pathways which affect many aspects of cell behavior, including alterations

**3. Treatment targets in the podocytopathy model**

*DOI: http://dx.doi.org/10.5772/intechopen.85994*

*Glomerulonephritis and Nephrotic Syndrome*

childhood INS as a podocytopathy.

for all forms of nephrotic syndrome. Basically, the podocyte is involved in maintaining the structural integrity of the glomerular filtration barrier. Thus, podocyte injury and loss result in significant proteinuria as well as progressive glomerulosclerosis [11]. Podocytopathy can occur in immunologic and non-immunologic diseases of the kidney. Acquired podocytopathies such as MCN and FSGS are considered to have immunologic basis [12]. Interestingly, immunosuppressive therapy has been noted to directly affect the podocyte through the regulation of interleukin-4 (IL-4) and interleukin-13 (IL-13) and several signaling pathways involved with the stabilization of the actin cytoskeleton and the distribution of the slit diaphragm components [11]. This book chapter aims to discuss the mechanisms underpinning the pathogenesis of

The glomerular filtration barrier is essentially a trilaminate structure which consists of the podocyte on the outer surface, the glomerular basement membrane (GBM) in the middle, and the fenestrated endothelium on the inner surface (**Figure 1**). The podocyte (also known as the visceral glomerular epithelial cell) constitutes the last barrier to protein loss, given its unique structure and location as a terminally differentiated cell which lines the outer surface of the GBM. Each podocyte comprises the foot processes which are separated by a filtration slit (or the slit diaphragm). The foot process comprises components such as actin, myosin-II, α-actinin-4, talin, and vinculin which all constitute a contractile structure [13]. The filament bundles which make up actin are disposed together as arches between contiguous podocyte foot processes [14] and are connected to the GBM at specific points through an adhesion molecule (α-3β-1 integrin complex) [15, 16]. Similarly, the linkage of the podocyte foot processes to the GBM is made possible through both α-3β-1 integrin and dystroglycans [17]. Adjacent foot processes are linked by the slit diaphragm, which forms the main size-selective filter barrier in the glomerular architecture [18, 19]. The filtration slit is composed of multiple protein molecules such as nephrin, P-cadherin, CD2AP, ZO-1, FAT, podocin, and possibly

*Schematic representation of the molecular structure of the glomerular filtration barrier (Courtesy: Flickr* 

**2. The molecular structure and function of the podocyte**

**36**

**Figure 1.**

*photos).*

Neph1 [20–22]. In addition, synaptopodin is closely related to the actin filaments located within the podocyte foot processes [23] and interacts with the tight junction protein, MAGI-1, in the same way as α-actinin-4 MAGI-1 being expressed in podocytes as well [24]. The functional integrity of the podocytes depends on the actin cytoskeleton. This is critical in preserving the intact glomerular filtration barrier, as a healthy podocyte is essential for the maintenance of this barrier.

#### **2.1 The molecular mechanisms in podocytopathy**

Among the fundamental biologic events in INS, a molecular disruption of the filtration slit or GBM results in proteinuria, while rearrangement of podocyte cytoskeleton accounts for foot process effacement. In fact, the basic role played by the podocyte actin cytoskeleton (the skeletal structure of the foot processes) in the pathogenesis of INS is predicated on the disruption of actin-related proteins with the GBM, resulting in effacement of the podocyte foot processes [25]. Still at the molecular level, focal adhesion kinase (FAK) plays an essential role in this foot process effacement, usually observed in podocytopathies [26]. Furthermore, alterations in podocyte proteins such as nephrin and Neph1 (nephrin homologue), CD2-associated protein (CD2AP), and podocin all contribute to the pathogenesis of INS as podocytopathies [27–29]. Nephrin represents an essential constituent of the slit diaphragm and also serves as an efficient mobilizer of other proteins such as podocin and CD2AP (**Figure 1**) [30]. It has been proposed that a vital interaction exists between the actin cytoskeleton and the molecules that make up the filtration slit such as podocin, nephrin, and CD2AP [31, 32]. Thus, nephrotic-range proteinuria occurs as a result of structural disruptions in the podocytes which present as foot process effacement, as well as changes in the actin cytoskeleton and molecular alteration of the filtration slit [33]. Again, the component molecules of the actin cytoskeleton include actin, α-actinin, and synaptopodin [34, 35]. Interestingly, the upregulation of α-actinin results in the reorganization of the cytoskeleton in some nephrotic syndromes [36], while the expression of synaptopodin is generally preserved in MCN, but diminished in FSGS [37]. Podocalyxin is a molecule presumed to mediate the stability of the foot processes [38] and has also been found to be raised in nephrotic syndromes [39]. Finally, the fundamental role of adhesion molecules such as integrins and focal adhesion proteins has been shown in genetically based animal experiments which end up in nephrotic syndrome [40, 41]. Specifically, α3β1 (the main integrin heterodimer in the podocyte), when destroyed in the podocytes of experimental mice, gave rise to nephrotic-range proteinuria and foot process effacement. In addition, αvβ3 integrin (also expressed in podocytes) can be activated by uroplasminogen type I activator receptor (uPAR) (in podocytes) [42] or its soluble form, suPAR (from the circulation) [43]. Its activation notably leads to foot process effacement through the rearrangement of the podocyte actin cytoskeleton: a characteristic event in podocytopathy [44].

### **3. Treatment targets in the podocytopathy model**

Interventions targeting molecular pathways which regulate the actin cytoskeleton can potentially play an important role in the treatment of proteinuric kidney diseases, such as nephrotic syndrome. There are three major molecular frameworks which modulate the actin cytoskeleton and prevent podocyte detachment from GBM, namely, Rho-GTPases, cell-matrix adhesion proteins, and endocytic proteins. For instance, the podocyte-expressed RhoA, Rac1, and Cdc42 regulate signal transduction pathways which affect many aspects of cell behavior, including alterations

in the actin cytoskeleton [45, 46]. The regulatory ability of these protein molecules on the actin cytoskeleton points to their fundamental role in the pathogenesis of nephrotic syndrome and as possible treatment targets [25]. For instance, the inhibition of RhoA and Rac1 could potentially reduce proteinuria and optimize renal function and ameliorate glomerulopathy [47–50], given that elevated RhoA activity has been noted to induce foot process effacement and subsequent proteinuria [51].

Furthermore, blocking αvβ3 integrin with an anti-β3 antibody or cilengitide (the small molecule inhibitor) was noted to have ameliorated uPAR-induced proteinuria, underscoring the importance of this integrin as another potential therapeutic target [42, 43]. Also, targeted pharmacologic inhibition of integrin α2β1 in murine models also reduced proteinuria [52], while inhibition of major focal adhesion proteins, such as FAK and Crk1/Crk2, reduced both podocyte foot process effacement and proteinuria [26, 53]. In addition, one important therapeutic target in proteinuria is the regulating activation of integrin β1 via abatacept (CTLA-4-Ig) or integrin αv inhibitor, cilengitide, or integrin α2β1 [42, 43, 52, 54].

The link between transient receptor potential cation channels (TRPCs) and the actin cytoskeleton has also been well reported [25]. TRPCs are nonselective cationic channels with affinity for calcium ions, which contribute significantly in the pathogenesis of renal and cardiovascular diseases [55]. In podocytes, many


*† Protects synaptopodin from cathepsin L-mediated degradation (stabilizes actin cytoskeleton). ‡ Potentially ameliorates proteinuria.*

*\* Reduces uroplasminogen type 1 activator receptor-induced proteinuria/also inhibits angiogenesis.*

*\*\*Protects against liposaccharide-induced proteinuria and foot process effacement (adapted from Ref. [68]).*

*SRNS, steroid-resistant nephrotic syndrome; CKD, chronic kidney disease; FK 506, nitrogen mustard and tacrolimus; FSGS, focal segmental glomerulosclerosis; TRPC, transient receptor potential cation channel*

#### **Table 1.**

*Summary of current and future treatment targets and the potential drugs for idiopathic nephrotic syndrome.*

**39**

*Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy*

TRPCs are reportedly expressed, namely, TRPC1, TRPC3, TRPC4, TRPC5, and TRPC6 [56–60]. A striking therapeutic application is the ability of TRPC5 inhibitor (ML204) to protect against lipopolysaccharide (LPS)-induced proteinuria, as well

Regarding the supportive function of synaptopodin on the actin cytoskeleton, this protein molecule not only constitutes a linkage to the actin cytoskeleton but remains vital for stress fiber synthesis in podocytes [62, 63]. Despite the previously presumed usefulness of calcineurin inhibitors, like cyclosporine A (CsA) and FK506 in the treatment of INS given their immunosuppressive effects on T cells, the mediatory role of calcineurin on synaptopodin degradation via induction of protease cathepsin L is well established; interestingly, CsA shields synaptopodin from cathepsin L-mediated breakdown, thereby maintaining the integrity of the

Finally, the regulatory activity of endocytic proteins in the actin cytoskeleton is confirmed by recent findings of possible therapeutic benefits of Bis-T-23-induced dynamin oligomerization and actin polymerization for nephrotic syndrome [65]. In fact, some researchers have shown that the GTPase dynamin is important for podocyte physiology [66]. In proteinuric kidney disease, induction of cytoplasmic cathepsin L results in degradation of dynamin, ending up with disruption of the actin cytoskeleton and proteinuria. Again, the modulating effect of dynamin on the actin cytoskeleton is related to the stabilization of the glomerulus. Thus, based on the beneficial activity of Bis-T-23 to kidney health in various models of chronic kidney disease (CKD) through the formation of actin-dependent oligomers of dynamin and polymers of actin, dynamin has been regarded as a possible therapeutic target for the management of CKD [67]. Better still, the recognition of dynamin as one of the vital and autonomous regulators of focal adhesion maturation suggests a molecular mechanism which underpins the beneficial effect of Bis-T-23 on podocyte physiology [67]. The efficacy of some of the therapeutic agents currently used in clinical practice and in experimental animal models is summarized in **Table 1**.

Significant progress has now been made in unraveling the complex molecular mechanisms and pathways responsible for maintaining podocyte health and thus the structural and functional integrity of the glomerular filtration barrier. Podocyte injury is now believed to be the basic pathology in childhood INS. As a podocytopathy, disruption of the podocyte architecture eventually results in the massive proteinuria seen in the syndrome. Consequently, several novel therapeutic targets have been proposed and successfully demonstrated, raising hopes for novel phar-

macologic agents which could be useful in treating the disorder.

as protamine sulfate- and LPS-triggered foot process effacement [61].

*DOI: http://dx.doi.org/10.5772/intechopen.85994*

actin cytoskeleton [64].

**4. Conclusion**

*Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy DOI: http://dx.doi.org/10.5772/intechopen.85994*

*Glomerulonephritis and Nephrotic Syndrome*

inhibitor, cilengitide, or integrin α2β1 [42, 43, 52, 54].

**Treatment targets in podocytopathy**

Downregulation of synaptopodin

Small Rho-GTPases (Rho A,

Blockage of αvβ3 integrin

activation of integrin β1

oligomerization and actin polymerization

*Protects synaptopodin from cathepsin L-mediated degradation (stabilizes actin cytoskeleton).*

*FSGS, focal segmental glomerulosclerosis; TRPC, transient receptor potential cation channel*

*Reduces uroplasminogen type 1 activator receptor-induced proteinuria/also inhibits angiogenesis. \*\*Protects against liposaccharide-induced proteinuria and foot process effacement (adapted from Ref. [68]). SRNS, steroid-resistant nephrotic syndrome; CKD, chronic kidney disease; FK 506, nitrogen mustard and tacrolimus;* 

*Summary of current and future treatment targets and the potential drugs for idiopathic nephrotic syndrome.*

Rac 1)

**Potential pharmacologic agents**

Cyclosporine A† (a major calcineurin inhibitor. Another example is FK 506)

Inhibitors of small Rho-GTPases‡

Cilengitide/anti-β3 antibody\*

Inhibitors of TRPC 5\*\*

Abatacept Modulating

Bis-T-23 Dynamin

*Potentially ameliorates proteinuria.*

in the actin cytoskeleton [45, 46]. The regulatory ability of these protein molecules on the actin cytoskeleton points to their fundamental role in the pathogenesis of nephrotic syndrome and as possible treatment targets [25]. For instance, the inhibition of RhoA and Rac1 could potentially reduce proteinuria and optimize renal function and ameliorate glomerulopathy [47–50], given that elevated RhoA activity has been noted to induce foot process effacement and subsequent proteinuria [51]. Furthermore, blocking αvβ3 integrin with an anti-β3 antibody or cilengitide (the small molecule inhibitor) was noted to have ameliorated uPAR-induced proteinuria, underscoring the importance of this integrin as another potential therapeutic target [42, 43]. Also, targeted pharmacologic inhibition of integrin α2β1 in murine models also reduced proteinuria [52], while inhibition of major focal adhesion proteins, such as FAK and Crk1/Crk2, reduced both podocyte foot process effacement and proteinuria [26, 53]. In addition, one important therapeutic target in proteinuria is the regulating activation of integrin β1 via abatacept (CTLA-4-Ig) or integrin αv

The link between transient receptor potential cation channels (TRPCs) and the actin cytoskeleton has also been well reported [25]. TRPCs are nonselective cationic channels with affinity for calcium ions, which contribute significantly in the pathogenesis of renal and cardiovascular diseases [55]. In podocytes, many

> Clinical use in SRNS and in renal transplantation

Still under trial (nephrotic syndrome)

Still under trial (nephrotic syndrome) Clinical use in glioblastoma

Still under trial/ clinical use in FSGS

TRPC 5 Still under trial – –

Still under trial l (proteinuric kidney diseases, CKD)

**Indications Efficacy Side effects**

Induces remission in SRNS

– –

– –

– –

– –

Major side effects in humans: tremors, hypertension, nephrotoxicity, hirsutism, and gum hypertrophy

**38**

**Table 1.**

*†*

*‡*

*\**

TRPCs are reportedly expressed, namely, TRPC1, TRPC3, TRPC4, TRPC5, and TRPC6 [56–60]. A striking therapeutic application is the ability of TRPC5 inhibitor (ML204) to protect against lipopolysaccharide (LPS)-induced proteinuria, as well as protamine sulfate- and LPS-triggered foot process effacement [61].

Regarding the supportive function of synaptopodin on the actin cytoskeleton, this protein molecule not only constitutes a linkage to the actin cytoskeleton but remains vital for stress fiber synthesis in podocytes [62, 63]. Despite the previously presumed usefulness of calcineurin inhibitors, like cyclosporine A (CsA) and FK506 in the treatment of INS given their immunosuppressive effects on T cells, the mediatory role of calcineurin on synaptopodin degradation via induction of protease cathepsin L is well established; interestingly, CsA shields synaptopodin from cathepsin L-mediated breakdown, thereby maintaining the integrity of the actin cytoskeleton [64].

Finally, the regulatory activity of endocytic proteins in the actin cytoskeleton is confirmed by recent findings of possible therapeutic benefits of Bis-T-23-induced dynamin oligomerization and actin polymerization for nephrotic syndrome [65]. In fact, some researchers have shown that the GTPase dynamin is important for podocyte physiology [66]. In proteinuric kidney disease, induction of cytoplasmic cathepsin L results in degradation of dynamin, ending up with disruption of the actin cytoskeleton and proteinuria. Again, the modulating effect of dynamin on the actin cytoskeleton is related to the stabilization of the glomerulus. Thus, based on the beneficial activity of Bis-T-23 to kidney health in various models of chronic kidney disease (CKD) through the formation of actin-dependent oligomers of dynamin and polymers of actin, dynamin has been regarded as a possible therapeutic target for the management of CKD [67]. Better still, the recognition of dynamin as one of the vital and autonomous regulators of focal adhesion maturation suggests a molecular mechanism which underpins the beneficial effect of Bis-T-23 on podocyte physiology [67]. The efficacy of some of the therapeutic agents currently used in clinical practice and in experimental animal models is summarized in **Table 1**.

#### **4. Conclusion**

Significant progress has now been made in unraveling the complex molecular mechanisms and pathways responsible for maintaining podocyte health and thus the structural and functional integrity of the glomerular filtration barrier. Podocyte injury is now believed to be the basic pathology in childhood INS. As a podocytopathy, disruption of the podocyte architecture eventually results in the massive proteinuria seen in the syndrome. Consequently, several novel therapeutic targets have been proposed and successfully demonstrated, raising hopes for novel pharmacologic agents which could be useful in treating the disorder.

*Glomerulonephritis and Nephrotic Syndrome*

### **Author details**

Samuel N. Uwaezuoke1,2

1 College of Medicine, University of Nigeria, Ituku-Ozalla Enugu Campus, Nigeria

2 Pediatric Nephrology Firm, University of Nigeria Teaching Hospital, Enugu, Nigeria

\*Address all correspondence to: snuwaezuoke@yahoo.com; samuel.uwaezuoke@unn.edu.ng

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**41**

*Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy*

glomerulonephritis in childhood nephrotic syndrome in Ibadan. West African Journal of Medicine.

[9] Kaneko K, Tsuji S, Kimata T, et al. Pathogenesis of childhood idiopathic nephrotic syndrome: A paradigm shift from T-cells to podocytes. World Journal of Pediatrics. 2015;**11**:21-28. DOI: 10.1007/s12519-015-0003-9

[10] Uwaezuoke SN. Pathogenesis of idiopathic nephrotic syndrome in children: Molecular mechanisms and therapeutic implications. Integrative Molecular Medicine. 2015;**3**:484-487.

[11] Schönenberger E, Ehrich JH, Haller H, Schiffer M. The podocyte as a direct target of immunosuppressive agents. Nephrology, Dialysis, Transplantation. 2011;**26**:18-24. DOI: 10.1093/ndt/gfq617

[12] Uwaezuoke SN. Steroid-sensitive nephrotic syndrome in children: Triggers of relapse and evolving hypotheses on pathogenesis. Italian Journal of Pediatrics. 2015;**41**:19. DOI:

10.1186/s13052-015-0123-9

1988;**59**:673-682

1995;**192**:385-397

[13] Drenckhahn D, Franke RP. Ultrastructural organization of contractile and cytoskeletal proteins in glomerular podocytes of chicken, rat and man. Laboratory Investigation.

[14] Mundel P, Kriz W. Structure and function of podocytes: An update. Anatomy and Embryology.

[15] Adler S. Characterization of glomerular epithelial cell matrix receptors. The American Journal of

[16] Kriedberg JA, Donovan MJ, Goldstein SL, Rennke H, Shepherd K,

Pathology. 1992;**141**:571-578

DOI: 10.15761/IMM.1000192

1999;**18**:203-206

*DOI: http://dx.doi.org/10.5772/intechopen.85994*

[1] Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet.

[2] Churg J, Habib R, White RH.

Lancet. 1970;**760**:1299-1302

[3] Doe JY, Funk M, Mengel M, Doehring E, Ehrich JHH. Nephrotic syndrome in African children: Lack of evidence for 'tropical nephrotic syndrome'. Nephrology, Dialysis, Transplantation. 2006;**21**:672-676. DOI:

[4] Satgé P, Habib R, Quenum C, Boisson ME, Niang I. Particularité. du syndrome ne'phrotique chez l'enfant au Senegal. Ann Pe'diat. 1970;**17**:382-393

[5] Asinobi AO, Ademola AD, Okolo CA, Yaria JO. Trends in the histopathology of childhood nephrotic syndrome in Ibadan Nigeria: Preponderance of idiopathic focal segmental glomerulosclerosis. BMC Nephrology. 2015;**16**:213. DOI: 10.1186/

[6] Obiagwu PN, Aliyu A, Atanda AT. Nephrotic syndrome among children in Kano: A clinicopathological study. Nigerian Journal of Clinical Practice. 2014;**17**:370-374. DOI: 10.4103/1119-3077.130247

[7] Uwaezuoke SN, Okafor HU, Eneh CI, Odetunde OI. The triggers and patterns of relapse in childhood idiopathic nephrotic syndrome: A retrospective,

descriptive study in a tertiary hospital, south-east Nigeria. Journal of Clinical Nephrology and Research.

[8] Asinobi AO, Gbadegesin RA, Adeyemo AA. The predominance of membrano-proliferative

2016;**3**(1):1032

Pathology of the nephrotic syndrome in children a report for the International Study of Kidney Disease in children.

**References**

2003;**362**:629-639

10.1093/ndt/gfi297

s12882-015-0208-0

*Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy DOI: http://dx.doi.org/10.5772/intechopen.85994*

#### **References**

*Glomerulonephritis and Nephrotic Syndrome*

**40**

**Author details**

Nigeria

Samuel N. Uwaezuoke1,2

provided the original work is properly cited.

samuel.uwaezuoke@unn.edu.ng

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 College of Medicine, University of Nigeria, Ituku-Ozalla Enugu Campus, Nigeria

2 Pediatric Nephrology Firm, University of Nigeria Teaching Hospital, Enugu,

\*Address all correspondence to: snuwaezuoke@yahoo.com;

[1] Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet. 2003;**362**:629-639

[2] Churg J, Habib R, White RH. Pathology of the nephrotic syndrome in children a report for the International Study of Kidney Disease in children. Lancet. 1970;**760**:1299-1302

[3] Doe JY, Funk M, Mengel M, Doehring E, Ehrich JHH. Nephrotic syndrome in African children: Lack of evidence for 'tropical nephrotic syndrome'. Nephrology, Dialysis, Transplantation. 2006;**21**:672-676. DOI: 10.1093/ndt/gfi297

[4] Satgé P, Habib R, Quenum C, Boisson ME, Niang I. Particularité. du syndrome ne'phrotique chez l'enfant au Senegal. Ann Pe'diat. 1970;**17**:382-393

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ajprenal.00290.2001

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2001;**10**:19-22

2002;**277**:30183-30190

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1996;**122**:3537-3547

S0002-9440(10)65046-8

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10.1172/JCI12849

2001;**59**:1003-1012

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[20] Holzman LB, St John PL, Kovari IA, et al. Nephrin localizes to the slit pore of the glomerular epithelial cell. Kidney International. 1999;**56**:1481-1491

[21] Schwarz K, Simons M, Reiser J, et al. Podocin, a raft-associated component of the glomerular slit diaphragm, interacts with CD2AP and nephrin. The Journal of Clinical Investigation. 2001;**108**:1621-1629. DOI:

[22] Inoue T, Yaoita E, Kurihara H, et al. FAT is a component of glomerular slit diaphragms. Kidney International.

[24] Patrie KM, Drescher AJ, Welihinda A, Mundel P, Margolis B. Interaction of two actin-binding proteins, synaptopodin and alpha-actinin-4, with the tight junction protein MAGI-1.

[23] Mundel P, Gilbert P, Kriz W. Podocytes in glomerulus of rat kidney express a characteristic 44KD protein. The Journal of Histochemistry and Cytochemistry. 1991;**39**:1047-1056

**42**

[33] Somlo S, Mundel P. Getting a foothold in nephrotic syndrome. Nature Genetics. 2000;**24**:333-335. DOI: 10.1038/74139

[34] Andrews PM. Investigations of cytoplasmic contractile and cytoskeletal elements in the kidney glomerulus. Kidney International. 1981;**20**:549-562

[35] Mundel P, Heid HW, Mundel TM, et al. Synaptopodin: An actin-associated protein in telencephalic dendrites and renal podocytes. The Journal of Cell Biology. 1997;**139**:193-204

[36] Smoyer WE, Mundel P, Gupta A, Welsh MJ. Podocyte alpha-actinin induction precedes foot process effacement in experimental nephrotic syndrome. The American Journal of Physiology. 1997;**273**:F150-F157

[37] Srivastava T, Garola RE, Whiting JM, Alon US. Synaptopodin expression in idiopathic nephrotic syndrome of childhood. Kidney International. 2001;**59**:118-125. DOI: 10.1046/j.1523-1755.2001.00472.x

[38] Kerjaschki D, Sharkey DJ, Farquhar MG. Identification and characterization of podocalyxin—The major sialoprotein of the renal glomerular epithelial cell. The Journal of Cell Biology. 1984;**98**:1591-1596

[39] Kavoura E, Gakiopoulou H, Paraskevakou H, et al. Immunohistochemical evaluation of podocalyxin expression in glomerulopathies associated with nephrotic syndrome. Human Pathology. 2011;**42**:227-235. DOI: 10.1016/j. humpath.2010.05.028

[40] Pozzi A, Jarad G, Moeckel GW, et al. Beta1 integrin expression by podocytes

is required to maintain glomerular structural integrity. Developmental Biology. 2008;**316**:288-301. DOI: 10.1016/j.ydbio.2008.01.022

[41] Kanasaki K, Kanda Y, Palmsten K, et al. Integrin beta1-mediated matrix assembly and signaling are critical for the normal development and function of the kidney glomerulus. Developmental Biology. 2008;**313**:584-593

[42] Wei C, Möller CC, Altintas MM, et al. Modification of kidney barrier function by the urokinase receptor. Nature Medicine. 2008;**14**:55-63. DOI: 10.1038/nm1696

[43] Wei C, El Hindi S, Li J, et al. Circulating urokinase receptor as a cause of focal segmental glomerulosclerosis. Nature Medicine. 2011;**17**:952-960. DOI: 10.1038/nm.2411

[44] Lin Y, Rao J, Zha XL, Xu H. Angiopoietin-like 3 induces podocyte F-actin rearrangement through integrin α (V) β₃/FAK/PI3K pathwaymediated Rac1 activation. BioMed Research International. vol 2013; Article ID 135608, 8 pages. DOI: 10.1155/2013/135608

[45] Pertz O, Hodgson L, Klemke RL, Hahn KM. Spatiotemporal dynamics of RhoA activity in migrating cells. Nature. 2006;**440**:1069-1072. DOI: 10.1038/ nature04665

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[47] Babelova A, Jansen F, Sander K, et al. Activation of Rac-1 and RhoA contributes to podocyte injury in chronic kidney disease. PLoS One. 2013;**8**:(11):e80328. DOI: 10.1371/ journal.pone.0080328

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[49] Shikawa Y, Nishikimi T, Akimoto K, et al. Long-term administration of rho-kinase inhibitor ameliorates renal damage in malignant hypertensive rats. Hypertension. 2006;**47**:1075-1083. DOI: 10.1161/01.HYP.0000221605.94532.71

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[51] Wang L, Ellis MJ, Gomez JA, et al. Mechanisms of the proteinuria induced by Rho GTPases. Kidney International. 2012;**81**:1075-1085. DOI: 10.1038/ ki.2011.472

[52] Borza CM, Su Y, Chen X, et al. Inhibition of integrin α2β1 ameliorates glomerular injury. Journal of the American Society of Nephrology. 2012;**23**:1027-1038

[53] George B, Verma R, Soofi AA, Garg P, Zhang J, Park TJ, et al. Crk1/2 dependent signaling is necessary for podocyte foot process spreading in mouse models of glomerular disease. The Journal of Clinical Investigation. 2012;**122**:674-692. DOI: 10.1172/ JCI60070

[54] Yu CC, Fornoni A, Weins A, et al. Abatacept in B7-1-positive proteinuric kidney disease. The New England Journal of Medicine. 2013;**369**:2416-2423. DOI: 10.1056/NEJMoa1304572

[55] Abramowitz J, Birnbaumer L. Physiology and pathophysiology of canonical transient receptor potential channels. The FASEB Journal.

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[56] Goel M, Sinkins WG, Zuo CD, Estacion M, Schilling WP. Identification and localization of TRPC channels in the rat kidney. American Journal of Physiology. Renal Physiology. 2006;**290**:F1241-F1252. DOI: 10.1152/ ajprenal.00376.2005

[57] Dryer SE, Reiser J. TRPC6 channels and their binding partners in podocytes: Role in glomerular filtration and pathophysiology. American Journal of Physiology. Renal Physiology. 2010;**299**:689-701. DOI: 10.1152/ ajprenal. 00298.2010

[58] Kalwa H, Storch U, Demleitner J, et al. Phospholipase C epsilon (PLCε) induced TRPC6 activation: A common but redundant mechanism in primary podocytes. Journal of Cellular Physiology. 2015;**230**:1389-1399. DOI: 10.1002/jcp.24883

[59] Ilatovskaya DV, Levchenko V, Ryan RP, Cowley AW Jr, Staruschenko A. NSAIDs acutely inhibit TRPC channels in freshly isolated rat glomeruli. Biochemical and Biophysical Research Communications. 2011;**408**:242-247. DOI: 10.1016/j. bbrc.2011.04.005

[60] Kim EY, Alvarez-Baron CP, Dryer SE. Canonical transient receptor potential channel (TRPC) 3 and TRPC6 associate with large-conductance Ca2+-activated K+ (BKCa) channels: Role in BKCa trafficking to the surface of cultured podocytes. Molecular Pharmacology. 2009;**75**:466-477. DOI: 10.1124/mol.108.051912

[61] Schaldecker T, Kim S, Tarabanis C, et al. Inhibition of the TRPC5 ion channel protects the kidney filter. The Journal of Clinical Investigation. 2013;**123**:5298-5309. DOI: 10.1172/ JCI71165

**45**

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*DOI: http://dx.doi.org/10.5772/intechopen.85994*

[62] Asanuma K, Kim K, Oh J, et al. Synaptopodin regulates the actinbundling activity of alpha-actinin in an isoform-specific manner. The Journal of Clinical Investigation. 2005;**115**:1188-1198. DOI: 10.1172/

[63] Asanuma K, Yanagida-Asanuma E, Faul C, et al. Synaptopodin orchestrates actin organization and cell motility via regulation of RhoA signaling. Nature Cell Biology. 2006;**8**:485-491. DOI:

[64] Faul C, Donnelly M, Merscher-Gomez S, et al. The actin cytoskeleton of kidney podocytes is a direct target of the antiproteinuric effect of cyclosporine A. Nature Medicine. 2008;**14**:931-938.

[65] Schiffer M, Teng B, Gu C, et al. Pharmacological targeting of actindependent dynamin oligomerization ameliorates chronic kidney disease in diverse animal models. Nature Medicine. 2015;**21**:601-609. DOI:

[66] Sever S, Altintas MM, Nankoe SR, et al. Proteolytic processing of dynamin by cytoplasmic cathepsin L is a mechanism for proteinuric kidney disease. The Journal of Clinical Investigation. 2007;**117**:2095-2104. DOI:

[67] Gu C, Lee HW, Garborcauskas G, Reiser J, Gupta V, Sever S. Dynamin autonomously regulates podocyte focal adhesion maturation. Journal of the American Society of Nephrology. 2017;**28**:446-451. DOI: 10.1681/

[68] Uwaezuoke SN. Childhood idiopathic nephrotic syndrome as a podocytopathy: Potential therapeutic targets. Journal of Clinical Nephrology

and Research. 2017;**4**(4):1071

JCI23371

10.1038/ncb1400

DOI: 10.1038/nm.1857

10.1038/nm.3843

10.1172/JCI32022

ASN.2016010008

*Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy DOI: http://dx.doi.org/10.5772/intechopen.85994*

[62] Asanuma K, Kim K, Oh J, et al. Synaptopodin regulates the actinbundling activity of alpha-actinin in an isoform-specific manner. The Journal of Clinical Investigation. 2005;**115**:1188-1198. DOI: 10.1172/ JCI23371

*Glomerulonephritis and Nephrotic Syndrome*

[48] Hidaka T, Suzuki Y, Yamashita M, et al. Amelioration of crescentic glomerulonephritis by RhoA kinase inhibitor, Fasudil, through podocyte protection and prevention of leukocyte migration. The American Journal of

2009;**23**:297-328. DOI: 10.1096/

[56] Goel M, Sinkins WG, Zuo CD, Estacion M, Schilling WP. Identification and localization of TRPC channels in the rat kidney. American Journal of Physiology. Renal Physiology. 2006;**290**:F1241-F1252. DOI: 10.1152/

[57] Dryer SE, Reiser J. TRPC6 channels and their binding partners in podocytes:

Role in glomerular filtration and pathophysiology. American Journal of Physiology. Renal Physiology. 2010;**299**:689-701. DOI: 10.1152/

[58] Kalwa H, Storch U, Demleitner J, et al. Phospholipase C epsilon (PLCε) induced TRPC6 activation: A common but redundant mechanism in primary podocytes. Journal of Cellular Physiology. 2015;**230**:1389-1399. DOI:

[59] Ilatovskaya DV, Levchenko V, Ryan RP, Cowley AW Jr, Staruschenko A. NSAIDs acutely inhibit TRPC channels in freshly isolated rat glomeruli. Biochemical and

Biophysical Research Communications. 2011;**408**:242-247. DOI: 10.1016/j.

[60] Kim EY, Alvarez-Baron CP, Dryer SE. Canonical transient receptor potential channel (TRPC) 3 and TRPC6 associate with large-conductance Ca2+-activated K+ (BKCa) channels: Role in BKCa trafficking to the surface of cultured podocytes. Molecular Pharmacology. 2009;**75**:466-477. DOI:

[61] Schaldecker T, Kim S, Tarabanis C, et al. Inhibition of the TRPC5 ion channel protects the kidney filter. The Journal of Clinical Investigation. 2013;**123**:5298-5309. DOI: 10.1172/

fj.08-119495

ajprenal.00376.2005

ajprenal. 00298.2010

10.1002/jcp.24883

bbrc.2011.04.005

10.1124/mol.108.051912

JCI71165

Pathology. 2008;**172**:603-614

[49] Shikawa Y, Nishikimi T, Akimoto K, et al. Long-term administration of rho-kinase inhibitor ameliorates renal damage in malignant hypertensive rats. Hypertension. 2006;**47**:1075-1083. DOI: 10.1161/01.HYP.0000221605.94532.71

[50] Sun GP, Kohno M, Guo P, et al. Involvements of Rho-kinase and TGF-beta pathways in aldosterone-induced renal injury. Journal of the American Society of Nephrology. 2006;**17**:2193-2201. DOI:

[51] Wang L, Ellis MJ, Gomez JA, et al. Mechanisms of the proteinuria induced by Rho GTPases. Kidney International. 2012;**81**:1075-1085. DOI: 10.1038/

[52] Borza CM, Su Y, Chen X, et al. Inhibition of integrin α2β1 ameliorates glomerular injury. Journal of the American Society of Nephrology.

[53] George B, Verma R, Soofi AA, Garg P, Zhang J, Park TJ, et al. Crk1/2 dependent signaling is necessary for podocyte foot process spreading in mouse models of glomerular disease. The Journal of Clinical Investigation. 2012;**122**:674-692. DOI: 10.1172/

[54] Yu CC, Fornoni A, Weins A, et al. Abatacept in B7-1-positive proteinuric kidney disease. The New England Journal of Medicine. 2013;**369**:2416-2423. DOI:

[55] Abramowitz J, Birnbaumer L. Physiology and pathophysiology of canonical transient receptor potential

channels. The FASEB Journal.

10.1056/NEJMoa1304572

10.1681/ASN. 2005121375

ki.2011.472

JCI60070

2012;**23**:1027-1038

**44**

[63] Asanuma K, Yanagida-Asanuma E, Faul C, et al. Synaptopodin orchestrates actin organization and cell motility via regulation of RhoA signaling. Nature Cell Biology. 2006;**8**:485-491. DOI: 10.1038/ncb1400

[64] Faul C, Donnelly M, Merscher-Gomez S, et al. The actin cytoskeleton of kidney podocytes is a direct target of the antiproteinuric effect of cyclosporine A. Nature Medicine. 2008;**14**:931-938. DOI: 10.1038/nm.1857

[65] Schiffer M, Teng B, Gu C, et al. Pharmacological targeting of actindependent dynamin oligomerization ameliorates chronic kidney disease in diverse animal models. Nature Medicine. 2015;**21**:601-609. DOI: 10.1038/nm.3843

[66] Sever S, Altintas MM, Nankoe SR, et al. Proteolytic processing of dynamin by cytoplasmic cathepsin L is a mechanism for proteinuric kidney disease. The Journal of Clinical Investigation. 2007;**117**:2095-2104. DOI: 10.1172/JCI32022

[67] Gu C, Lee HW, Garborcauskas G, Reiser J, Gupta V, Sever S. Dynamin autonomously regulates podocyte focal adhesion maturation. Journal of the American Society of Nephrology. 2017;**28**:446-451. DOI: 10.1681/ ASN.2016010008

[68] Uwaezuoke SN. Childhood idiopathic nephrotic syndrome as a podocytopathy: Potential therapeutic targets. Journal of Clinical Nephrology and Research. 2017;**4**(4):1071

**47**

Section 3

Membranous Nephropathy

Section 3
