Prospective Cohort Study of Felzartamab in Rituximab-Resistant Primary Membranous Nephropathy Matias Trillini, Federica Casiraghi, Alessia Gennarini, Valentina Portalupi, Maddalena Marasà, Manuel Alfredo Podestà, Silvia Prandini, Silvia Nozza, Marta Todeschini, Francesco Pecoraro, Marilena Mister, Fabiola Carrara, Nadia Stucchi, Tobia Peracchi, Diego Fidone, Alessandro Villa, Nadia Rubis, Olimpia Diadei, Davide Martinetti, Giuseppe Remuzzi, Piero Ruggenenti Kidney International Reports, 2026 Introduction.Approximately 30% of patients with primary membranous nephropathy (MN) and nephrotic syndrome (NS) fail rituximab treatment through mechanisms that could be overcome by the human IgG1 monoclonal anti-CD38 antibody felzartamab. Methods.In this prospective, single-arm, single-center, open-label trial, ten consenting Caucasian adult patients with MN, rituximab-resistant NS and eGFR >30 ml/min/1.73m 2 received a five-month, nine-dose course of 16 mg/kg felzartamab infusions at the Nephrology Unit of Bergamo Hospital (Italy) between November 9 th 2021 and February 1 th 2023 and were followed-up for 24-months.Clinical and laboratory parameters were evaluated at baseline, 1, 2, 5, 6, 9, 18 and 24 months, whereas GFR and albumin and IgG fractional clearances were measured at baseline and at 6, 9, 12, 18, and 24 months post-treatment.The primary outcome was 24-hour proteinuria (median of three consecutive measurements) at 12 months.Results.Twelve-month 24-hour proteinuria was similar to baseline.Linear-mixed-model analyses showed no significant time-dependent changes in 24-hour proteinuria and albuminuria; serum totalprotein, albumin, creatinine and lipid levels, GFR and albumin fractional clearances.Circulating anti-PLA2R antibodies transiently decreased but were never depleted.All considered immunoglobulins transiently decreased up to month 12, and recovered to baseline thereafter.Felzartamab deeply and persistently decreased NK B-cell and antigen-inexperienced transitional B-cells, whereas did not affect CD20-expressing memory B-cells, plasmablasts and plasma cells.Treatment was safe and well tolerated.Conclusions.One course of felzartamab was safe and well tolerated, but ineffective in patients with MN and rituximab-resistant NS, possibly because of inability to persistently deplete nephritogenic autoantibody producing CD38-expressing B-cells.
Prospective Cohort Study of Obinutuzumab in Rituximab-Resistant Primary Membranous Nephropathy Matias Trillini, Valentina Portalupi, Alessia Gennarini, Livia Surdi, Annachiara Currado, Maddalena Marasà, Manuel Alfredo Podestà, Alessandro Villa, Tobia Peracchi, Diego Fidone, Nadia Rubis, Olimpia Diadei, Chiara Guarinoni, Federica Casiraghi, Marta Todeschini, Daniela Cugini, Fabiola Carrara, Davide Martinetti, Paola Rizzo, Giuseppe Remuzzi, Piero Ruggenenti Kidney International Reports, 2026 Introduction: Approximately 30% of patients with primary membranous nephropathy (MN) and persistent nephrotic syndrome (NS) fail rituximab therapy through mechanisms that could be overcome by obinutuzumab. Methods: In this prospective, single-arm, single-center, open-label trial, 20 consenting adults with MN and rituximab-resistant NS received three 1000 mg obinutuzumab infusions at the Bergamo Nephrology Unit (Italy) between March 2022 and February 2024 and were monitored for ≤ 12 months. The primary outcome was a composite end point of normo-albuminemia and complete (proteinuria < 0.3 g/d) or partial (proteinuria < 3.5 g/d with ≥ 50% reduction from baseline) NS remission at 12-month follow-up. Twenty-four-hour proteinuria and glomerular filtration rate (GFR) were evaluated at baseline and at 3, 6, 9, 12, 18, and 24 months posttreatment. Results: R antibodies and proteinuria, or relapses. Treatment was safe and well-tolerated. Conclusion: Obinutuzumab treatment is extremely effective and safe in patients with MN and rituximab-resistant NS and can achieve persistent remission in this population.
Corrigendum: Bi-specific autoantigen-T cell engagers as targeted immunotherapy for autoreactive B cell depletion in autoimmune diseases (Frontiers in Immunology, (2024), 15, (1335998), 10.3389/fimmu.2024.1335998) Luca Perico, Federica Casiraghi, Fabiane Sônego, Marta Todeschini, Daniela Corna, Domenico Cerullo, Anna Pezzotta, Patricia Isnard-Petit, Silvia Faravelli, Federico Forneris, Kader Thiam, Ariela Benigni, Giuseppe Remuzzi Frontiers in Immunology, 2024 Corrigendum on: Perico L, Casiraghi F, Sônego F, Todeschini M, Corna D, Cerullo D, Pezzotta A, Isnard-Petit P, Faravelli S, Forneris F, Thiam K, Benigni A and Remuzzi G (2024) Bi-specific autoantigen-T cell engagers as targeted immunotherapy for autoreactive B cell depletion in autoimmune diseases. Front. Immunol. 15:1335998. doi: 10.3389/fimmu.2024.1335998 Frontiers Media SA PAGE 1 1MERGEFORMAT 3In the published article, there was an error. Typographical errors have been identified in the Methods section pertaining to the description of targeting vector construction for homologous recombination.A correction has been made to Materials and methods, Construction of targeting vectors for homologous recombination in embryonic stem cells, 4.3. This sentence previously stated:"The homology arms were isolated by cloning from C57BL/6N mouse genomic DNA. Three targeting vectors were generated targeting specifically Cd3γ, Cd3δ and Cd3ε extracellular domains genes in C57BL/6N mouse ES cells. For the Cd3γ targeting vector, the humanizing chimeric CD3γ cDNA was introduced into the murine exon 3 by DNA synthesis. A loxP-flanked puromycin resistance cassette was inserted in 3' of the humanized cassette. For the Cd3δ targeting vector, the humanizing chimeric CD3δ cDNA was introduced into the murine exon 2 by DNA synthesis. An FRT-flanked hygromycin resistance cassette was inserted in 3' of the humanized cassette. For the Cd3ε targeting vector, the humanizing chimeric CD3ε cDNA was introduced into the murine exon 2 by DNA synthesis. A lox2272-flanked neomycin resistance cassette was inserted in 3' of the humanized cassette. The integrity of the targeting vectors was assessed by full sequencing."The corrected sentence appears below:"The homology arms were isolated by cloning from C57BL/6N mouse genomic DNA. Three different targeting vectors were generated to humanize the three different genes, part of the Cd3 locus: a first vector composed of a CD3γ cDNA upstream of a lox2272-flanked neomycin cassette has been inserted in frame with Cd3γ exon 2; a second vector composed of a CD3δ cDNA upstream of an FRT-flanked hygromycin cassette has been inserted in frame with murine Cd3δ exon 2; a third vector composed of a CD3ε complete cDNA upstream of a loxP-flanked puromycin cassette has been inserted in frame with murine Cd3ε exon 3. All targeting were performed in cis. The insertion of the human sequences under the control of the mouse promoters and regularity regions prevents the production of the three endogenous mouse Cd3γ, Cd3δ and Cd3ε proteins. The integrity of the targeting vectors was assessed by full sequencing."The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.
Bi-specific autoantigen-T cell engagers as targeted immunotherapy for autoreactive B cell depletion in autoimmune diseases Luca Perico, Federica Casiraghi, Fabiane Sônego, Marta Todeschini, Daniela Corna, Domenico Cerullo, Anna Pezzotta, Patricia Isnard-Petit, Silvia Faravelli, Federico Forneris, Kader Thiam, Ariela Benigni, Giuseppe Remuzzi Frontiers in Immunology, 2024 IntroductionIn autoimmune diseases, autoreactive B cells comprise only the 0.1-0.5% of total circulating B cells. However, current first-line treatments rely on non-specific and general suppression of the immune system, exposing patients to severe side effects. For this reason, identification of targeted therapies for autoimmune diseases is an unmet clinical need.MethodsHere, we designed a novel class of immunotherapeutic molecules, Bi-specific AutoAntigen-T cell Engagers (BiAATEs), as a potential approach for targeting the small subset of autoreactive B cells. To test this approach, we focused on a prototype autoimmune disease of the kidney, membranous nephropathy (MN), in which phospholipase A2 receptor (PLA2R) serves as primary nephritogenic antigen. Specifically, we developed a BiAATE consisting of the immunodominant Cysteine-Rich (CysR) domain of PLA2R and the single-chain variable fragment (scFv) of an antibody against the T cell antigen CD3, connected by a small flexible linker.ResultsBiAATE creates an immunological synapse between autoreactive B cells bearing an CysR-specific surface Ig+ and T cells. Ex vivo, the BiAATE successfully induced T cell-dependent depletion of PLA2R-specific B cells isolated form MN patients, sparing normal B cells. Systemic administration of BiAATE to mice transgenic for human CD3 reduced anti-PLA2R antibody levels following active immunization with PLA2R.DiscussionShould this approach be confirmed for other autoimmune diseases, BiAATEs could represent a promising off-the-shelf therapy for precision medicine in virtually all antibody-mediated autoimmune diseases for which the pathogenic autoantigen is known, leading to a paradigm shift in the treatment of these diseases.
Safety and Preliminary Efficacy of Mesenchymal Stromal Cell (ORBCEL-M) Therapy in Diabetic Kidney Disease: A Randomized Clinical Trial (NEPHSTROM) Norberto Perico, Giuseppe Remuzzi, Matthew D. Griffin, Paul Cockwell, Alexander P. Maxwell, Federica Casiraghi, Nadia Rubis, Tobia Peracchi, Alessandro Villa, Marta Todeschini, Fabiola Carrara, Bernadette A. Magee, Piero L. Ruggenenti, Stefano Rota, Laura Cappelletti, Veronica McInerney, Tomás P. Griffin, Md Nahidul Islam, Martino Introna, Olga Pedrini, Josée Golay, Andrew A. Finnerty, Jon Smythe, Willem E. Fibbe, Stephen J. Elliman, Timothy O'Brien, and Journal of the American Society of Nephrology, 2023 Significance Statement Mesenchymal stromal cells (MSCs) may offer a novel therapy for diabetic kidney disease (DKD), although clinical translation of this approach has been limited. The authors present findings from the first, lowest dose cohort of 16 adults with type 2 diabetes and progressive DKD participating in a randomized, placebo-controlled, dose-escalation phase 1b/2a trial of next-generation bone marrow–derived, anti-CD362 antibody–selected allogeneic MSCs (ORBCEL-M). A single intravenous (iv) infusion of 80×106 cells was safe and well-tolerated, with one quickly resolved infusion reaction in the placebo group and no subsequent treatment-related serious adverse events (SAEs). Compared with placebo, the median annual rate of decline in eGFR was significantly lower with ORBCEL-M, although mGFR did not differ. The results support further investigation of ORBCEL-M in this patient population in an appropriately sized phase 2b study. Background Systemic therapy with mesenchymal stromal cells may target maladaptive processes involved in diabetic kidney disease progression. However, clinical translation of this approach has been limited. Methods The Novel Stromal Cell Therapy for Diabetic Kidney Disease (NEPHSTROM) study, a randomized, placebo-controlled phase 1b/2a trial, assesses safety, tolerability, and preliminary efficacy of next-generation bone marrow–derived, anti-CD362–selected, allogeneic mesenchymal stromal cells (ORBCEL-M) in adults with type 2 diabetes and progressive diabetic kidney disease. This first, lowest dose cohort of 16 participants at three European sites was randomized (3:1) to receive intravenous infusion of ORBCEL-M (80×106 cells, n=12) or placebo (n=4) and was followed for 18 months. Results At baseline, all participants were negative for anti-HLA antibodies and the measured GFR (mGFR) and estimated GFR were comparable between groups. The intervention was safe and well-tolerated. One placebo-treated participant had a quickly resolved infusion reaction (bronchospasm), with no subsequent treatment-related serious adverse events. Two ORBCEL-M recipients died during follow-up of causes deemed unrelated to the trial intervention; one recipient developed low-level anti-HLA antibodies. The median annual rate of kidney function decline after ORBCEL-M therapy compared with placebo did not differ by mGFR, but was significantly lower by eGFR estimated by the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease equations. Immunologic profiling provided evidence of preservation of circulating regulatory T cells, lower natural killer T cells, and stabilization of inflammatory monocyte subsets in those receiving the cell therapy compared with placebo. Conclusions Findings indicate safety and tolerability of intravenous ORBCEL-M cell therapy in the trial's lowest dose cohort. The rate of decline in eGFR (but not mGFR) over 18 months was significantly lower among those receiving cell therapy compared with placebo. Further studies will be needed to determine the therapy's effect on CKD progression. Clinical Trial registration number ClinicalTrial.gov NCT02585622. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_10_10_JASN0000000000000189.mp3
Hypoimmunogenic Human Pluripotent Stem Cells as a Powerful Tool for Liver Regenerative Medicine Piera Trionfini, Elena Romano, Marco Varinelli, Lorena Longaretti, Paola Rizzo, Roberta Giampietro, Annalina Caroli, Sistiana Aiello, Marta Todeschini, Federica Casiraghi, Giuseppe Remuzzi, Ariela Benigni, Susanna Tomasoni International Journal of Molecular Sciences, 2023 Induced pluripotent stem cells (iPSC) have huge potential as cell therapy for various diseases, given their potential for unlimited self-renewal and capability to differentiate into a wide range of cell types. Although autologous iPSCs represents the ideal source for patient-tailored regenerative medicine, the high costs of the extensive and time-consuming production process and the impracticability for treating acute conditions hinder their use for broad applications. An allogeneic iPSC-based strategy may overcome these issues, but it carries the risk of triggering an immune response. So far, several approaches based on genome-editing techniques to silence human leukocyte antigen class I (HLA-I) or II (HLA-II) expression have been explored to overcome the immune rejection of allogeneic iPSCs. In this study, we employed the CRISPR/Cas9 (clustered regularly interspaced short palindromic repeats/CRISPR associated protein 9) system to delete the β2-Microglobulin (B2M) and the Class II Major Histocompatibility Complex Transactivator (CIITA) genes, essential for the correct surface expression of HLA-I and HLA-II proteins. The resulting hypoimmunogenic iPSC line has a normal karyotype, expresses the pluripotency stem cell markers, and is capable of differentiating into the three embryonic germ layers. Furthermore, we showed that it specifically retains the ability to differentiate towards different liver cells, such as endothelial-like cells, hepatocyte-like cells, and hepatic stellate-like cells. Our results indicate that hypoimmunogenic iPSCs could give a new cost-effective and off-the-shelf opportunity for cell therapy in liver diseases.
Immunophenotypic Alterations in Adult Patients with Steroid-Dependent and Frequently Relapsing Nephrotic Syndrome Federica Casiraghi, Marta Todeschini, Manuel Alfredo Podestà, Marilena Mister, Barbara Ruggiero, Matias Trillini, Camillo Carrara, Olimpia Diadei, Alessandro Villa, Ariela Benigni, Giuseppe Remuzzi International Journal of Molecular Sciences, 2023 Immune dysregulation plays a key role in the pathogenesis of steroid-dependent/frequently relapsing nephrotic syndrome (SDNS/FRNS). However, in contrast with evidence from the pediatric series, no major B- or T-cell alterations have been described for adults. In these patients, treatment with rituximab allows safe discontinuation of steroids, but long-term efficacy is variable, and some patients experience NS relapses after B cell reconstitution. In this study, we aimed to determine disease-associated changes in the B and T cell phenotype of adult patients with SDND/FRNS after steroid-induced remission. We also investigated whether any of these changes in immune cell subsets could discriminate between patients who developed NS relapses after steroid-sparing treatment with rituximab from those who did not. Lymphocyte subsets in SDNS/FRNS patients (n = 18) were compared to those from patients with steroid-resistant NS (SRNS, n = 7) and healthy volunteers (HV, n = 15). Before rituximab, SDND/FRNS patients showed increased frequencies of total and memory B cells, mainly with a CD38-negative phenotype. Within the T-cell compartment, significantly lower levels of FOXP3+ regulatory T cells (Tregs) were found, mostly due to a reduction in CD45RO+ memory Tregs compared to both SRNS and HV. The levels of CD45RO+ Tregs were significantly lower at baseline in patients who relapsed after rituximab (n = 9) compared to patients who did not (n = 9). In conclusion, patients with SDND/FRNS displayed expansion of memory B cells and reduced memory Tregs. Treg levels at baseline may help identify patients who will achieve sustained remission following rituximab infusion from those who will experience NS relapses.
Long-term adaptive response in COVID-19 vaccine recipients and the effect of a booster dose Luca Perico, Marta Todeschini, Federica Casiraghi, Marilena Mister, Anna Pezzotta, Tobia Peracchi, Susanna Tomasoni, Piera Trionfini, Ariela Benigni, Giuseppe Remuzzi Frontiers in Immunology, 2023 We examined the immune response in subjects previously infected with SARS-CoV2 and infection-naïve 9 months after primary 2-dose COVID-19 mRNA vaccination and 3 months after the booster dose in a longitudinal cohort of healthcare workers. Nine months after primary vaccination, previously infected subjects exhibited higher residual antibody levels, with significant neutralizing activity against distinct variants compared to infection-naïve subjects. The higher humoral response was associated with higher levels of receptor binding domain (RBD)-specific IgG+ and IgA+ memory B cells. The booster dose increased neither neutralizing activity, nor the B and T cell frequencies. Conversely, infection-naïve subjects needed the booster to achieve comparable levels of neutralizing antibodies as those found in previously infected subjects after primary vaccination. The neutralizing titer correlated with anti-RBD IFNγ producing T cells, in the face of sustained B cell response. Notably, pre-pandemic samples showed high Omicron cross-reactivity. These data show the importance of the booster dose in reinforcing immunological memory and increasing circulating antibodies in infection-naïve subjects.
A phase I study of autologous mesenchymal stromal cells for severe steroid-dependent nephrotic syndrome Marina Vivarelli, Manuela Colucci, Mattia Algeri, Federica Zotta, Francesco Emma, Ines L’Erario, Marco Busutti, Stefano Rota, Chiara Capelli, Martino Introna, Marta Todeschini, Federica Casiraghi, Annalisa Perna, Tobia Peracchi, Andrea De Salvo, Nadia Rubis, Franco Locatelli, Giuseppe Remuzzi, Piero Ruggenenti Jci Insight, 2023 BACKGROUND Severe forms of idiopathic nephrotic syndrome require prolonged immune-suppressive therapies and repeated courses of high-dose glucocorticoids. Mesenchymal stromal cells (MSCs) have promising immunomodulatory properties that may be employed therapeutically to reduce patient exposure to medications and their side effects. METHODS We performed a phase 1 open-label trial assessing safety and feasibility of autologous bone marrow-derived (BM) MESenchymal stromal cells in children and young adults with severe forms of steroid-dependent NEPHrotic syndrome, (MESNEPH). Following autologous BM-MSC preparation and infusion, oral immunosuppression was tapered. Safety, efficacy and immunomodulatory effects in vivo were monitored for 12 months. RESULTS Sixteen patients (10 children, 6 adults) were treated. Adverse events were limited and not related to BM-MSC infusions. All patients relapsed during follow-up, but in the 10 treated children, time to first relapse was delayed (p=0.02) and number of relapses was reduced (p=0.002) after BM-MSC infusion, compared to the previous 12 months. Cumulative prednisone dose was also reduced at 12 months compared to baseline (p<0.05). No treatment benefit was observed in adults.In children, despite tapering of immunosuppression, clinical benefit was mirrored by a significant reduction of total CD19+, mature and memory B cells and an increase of regulatory T cells in vivo up to 3-6 months following BM-MSC infusion. CONCLUSION Treatment with autologous BM-MSC is feasible and safely reduces relapses and immunosuppression at 12 months in children with severe steroid-dependent INS. Immunomodulatory studies suggest that repeating MSC infusions at 3-6 months may sustain benefit. TRIAL REGISTRATION EudraCT 2016-004804-77FUNDING. AIFA Ricerca Indipendente 2016-02364623.
Amnion epithelial cells are an effective source of factor H and prevent kidney complement deposition in factor H-deficient mice Federica Casiraghi, Pamela Yossenaidy Rodriguez Ordonez, Nadia Azzollini, Marta Todeschini, Daniela Rottoli, Roberta Donadelli, Roberto Gramignoli, Ariela Benigni, Marina Noris, Giuseppe Remuzzi Stem Cell Research and Therapy, 2021 Complement factor H (FH) is the main plasma regulator of the alternative pathway of complement. Genetic and acquired abnormalities in FH cause uncontrolled complement activation amplifying, with the consequent accumulation of complement components on the renal glomeruli. This leads to conditions such as C3 glomerulopathy (C3G) and atypical hemolytic uremic syndrome (aHUS). There is no effective therapy for these diseases. Half of the patients progress to end-stage renal disease and the condition recurs frequently in transplanted kidneys. Combined liver/kidney transplantation is a valid option for these patients, but the risks of the procedure and donor organ shortages hamper its clinical application. Therefore, there is an urgent need for alternative strategies for providing a normal FH supply. Human amnion epithelial cells (hAEC) have stem cell characteristics, including the capability to differentiate into hepatocyte-like cells in vivo.Here, we administered hAEC into the livers of newborn Cfh−/− mice, which spontaneously developed glomerular complement deposition and renal lesions resembling human C3G. hAEC engrafted at low levels in the livers of Cfh−/− mice and produced sufficient human FH to prevent complement activation and glomerular C3 and C9 deposition. However, long-term engraftment was not achieved, and eventually hAEC elicited a humoral immune response in immunocompetent Cfh−/− mice.hAEC cell therapy could be a valuable therapeutic option for patients undergoing kidney transplantation in whom post-transplant immunosuppression may protect allogeneic hAEC from rejection, while allogeneic cells provide normal FH to prevent disease recurrence.
Third-party bone marrow–derived mesenchymal stromal cell infusion before liver transplantation: A randomized controlled trial Federica Casiraghi, Norberto Perico, Manuel A. Podestà, Marta Todeschini, Marco Zambelli, Michele Colledan, Stefania Camagni, Stefano Fagiuoli, Antonio D. Pinna, Matteo Cescon, Valentina Bertuzzo, Lorenzo Maroni, Martino Introna, Chiara Capelli, Josee T. Golay, Marina Buzzi, Marilena Mister, Pamela Y.R. Ordonez, Matteo Breno, Caterina Mele, Alessandro Villa, Giuseppe Remuzzi American Journal of Transplantation, 2021
Mutations in FN1 cause glomerulopathy with fibronectin deposits Federica Castelletti, Roberta Donadelli, Federica Banterla, Friedhelm Hildebrandt, Peter F. Zipfel, Elena Bresin, Edgar Otto, Christine Skerka, Alessandra Renieri, Marta Todeschini, Jessica Caprioli, Rosa Maria Caruso, Rosangela Artuso, Giuseppe Remuzzi, Marina Noris Proceedings of the National Academy of Sciences of the United States of America, 2008
Regulatory T cells and T cell depletion: Role of immunosuppressive drugs Marina Noris, Federica Casiraghi, Marta Todeschini, Paolo Cravedi, Daniela Cugini, Giuseppe Monteferrante, Sistiana Aiello, Linda Cassis, Eliana Gotti, Flavio Gaspari, Dario Cattaneo, Norberto Perico, Giuseppe Remuzzi Journal of the American Society of Nephrology, 2007
Nitric oxide synthetic capacity in relation to dialysate temperature Charles H. Beerenhout, Marina Noris, Jeroen P. Kooman, Francesca Porrati, Elena Binda, Marina Morigi, Otto Bekers, Frank M. van der Sande, Marta Todeschini, Daniela Macconi, Karel M.L. Leunissen, Giuseppe Remuzzi Blood Purification, 2004
Erratum: 17β-estradiol corrects hemostasis in uremic rats by limiting vascular expression of nitric oxide synthases (American Journal of Physiology (October 2000) 279 (F626-F635)) American Journal of Physiology Renal Physiology, 2001
