Article

ATLANTA —Jacqueline Lee, MD, a reproductive endocrinologist at Emory School of Medicine, frequently treats patients with cancer. Recently, she treated 4 women in their 30s with histories of colon cancer, acute lymphoblastic leukemia, lymphoma, and breast cancer. A young man in his 20s sought her care, to discuss his case of lymphoma.

All these patients sought guidance from Lee because they want to protect their ability to have children. At the annual meeting of the Association of VA Hematology/Oncology, Lee explained that plenty of patients are finding themselves in similar straits due in part to recent trends.

Cancer rates in the US have been rising among people aged 15 to 39 years, who now account for 4.2% of all cancer cases. An estimated 84,100 people in this age group are expected to be diagnosed with cancer this year. Meanwhile, women are having children later in life-birth rates are up among those aged 25 to 49 years-making it more likely that they have histories of cancer.

Although it's difficult to predict how cancer will affect fertility, Lee emphasized that many chemotherapy medications, including cisplatin and carboplatin, are cytotoxic. "It's hard to always predict what someone's arc of care is going to be," she said, "so I really have a low threshold for recommending fertility preservation in patients who have a strong desire to have future childbearing."

For women with cancer, egg preservation isn't the only strategy. Clinicians can also try to protect ovarian tissue from pelvic radiation through surgical reposition of the ovaries, Lee noted. In addition goserelin, a hormone-suppressing therapy, may protect the ovaries from chemotherapy, though its effectiveness in boosting pregnancy rates is still unclear.

"When I mentioned this option, it's usually for patients who can't preserve fertility via egg or embryo preservation, or we don't have the luxury of that kind of time," Lee said. "I say that if helps at all, it might help you resume menses after treatment. But infertility is still very common."

For some patients, freezing eggs is an easy decision. "They don't have a reproductive partner they're ready to make embryos with, so we proceed with egg preservation. It's no longer considered experimental and comes with lower upfront costs since the costs of actually making embryos are deferred until the future."

In addition, she said, freezing eggs also avoids the touchy topic of disposing of embryos. Lee cautions patients that retrieving eggs is a 2-week process that requires any initiation of cancer care to be delayed. However, the retrieval process can be adjusted in patients with special needs due to the type of cancer they have.

For prepubertal girls with cancer, ovarian tissue can be removed and frozen as a fertility preservation option. However, this is not considered standard of care. "We don't do it," she said. "We refer out if needed. Hopefully we'll develop a program in the future."

As for the 5 patients that Lee mentioned, with details changed to protect their privacy, their outcomes were as follows:

• The woman with colon cancer, who had undergone a hemicolectomy, chose to defer fertility preservation.
• The woman with acute lymphoblastic leukemia, who was taking depo-Lupron, had undetectable anti-Müllerian hormone (AMH) levels. Lee discussed the possibility of IVF with a donor egg.
• The woman with breast cancer, who was newly diagnosed, deferred fertility preservation.
• The man with lymphoma (Hodgkin's), who was awaiting chemotherapy, had his sperm frozen.
• The woman with lymphoma (new diagnosis) had 27 eggs frozen.

Lee had no disclosures to report.

ATLANTA —Jacqueline Lee, MD, a reproductive endocrinologist at Emory School of Medicine, frequently treats patients with cancer. Recently, she treated 4 women in their 30s with histories of colon cancer, acute lymphoblastic leukemia, lymphoma, and breast cancer. A young man in his 20s sought her care, to discuss his case of lymphoma.

All these patients sought guidance from Lee because they want to protect their ability to have children. At the annual meeting of the Association of VA Hematology/Oncology, Lee explained that plenty of patients are finding themselves in similar straits due in part to recent trends.

Cancer rates in the US have been rising among people aged 15 to 39 years, who now account for 4.2% of all cancer cases. An estimated 84,100 people in this age group are expected to be diagnosed with cancer this year. Meanwhile, women are having children later in life-birth rates are up among those aged 25 to 49 years-making it more likely that they have histories of cancer.

Although it's difficult to predict how cancer will affect fertility, Lee emphasized that many chemotherapy medications, including cisplatin and carboplatin, are cytotoxic. "It's hard to always predict what someone's arc of care is going to be," she said, "so I really have a low threshold for recommending fertility preservation in patients who have a strong desire to have future childbearing."

For women with cancer, egg preservation isn't the only strategy. Clinicians can also try to protect ovarian tissue from pelvic radiation through surgical reposition of the ovaries, Lee noted. In addition goserelin, a hormone-suppressing therapy, may protect the ovaries from chemotherapy, though its effectiveness in boosting pregnancy rates is still unclear.

"When I mentioned this option, it's usually for patients who can't preserve fertility via egg or embryo preservation, or we don't have the luxury of that kind of time," Lee said. "I say that if helps at all, it might help you resume menses after treatment. But infertility is still very common."

For some patients, freezing eggs is an easy decision. "They don't have a reproductive partner they're ready to make embryos with, so we proceed with egg preservation. It's no longer considered experimental and comes with lower upfront costs since the costs of actually making embryos are deferred until the future."

In addition, she said, freezing eggs also avoids the touchy topic of disposing of embryos. Lee cautions patients that retrieving eggs is a 2-week process that requires any initiation of cancer care to be delayed. However, the retrieval process can be adjusted in patients with special needs due to the type of cancer they have.

For prepubertal girls with cancer, ovarian tissue can be removed and frozen as a fertility preservation option. However, this is not considered standard of care. "We don't do it," she said. "We refer out if needed. Hopefully we'll develop a program in the future."

As for the 5 patients that Lee mentioned, with details changed to protect their privacy, their outcomes were as follows:

• The woman with colon cancer, who had undergone a hemicolectomy, chose to defer fertility preservation.
• The woman with acute lymphoblastic leukemia, who was taking depo-Lupron, had undetectable anti-Müllerian hormone (AMH) levels. Lee discussed the possibility of IVF with a donor egg.
• The woman with breast cancer, who was newly diagnosed, deferred fertility preservation.
• The man with lymphoma (Hodgkin's), who was awaiting chemotherapy, had his sperm frozen.
• The woman with lymphoma (new diagnosis) had 27 eggs frozen.

Lee had no disclosures to report.

ATLANTA —Jacqueline Lee, MD, a reproductive endocrinologist at Emory School of Medicine, frequently treats patients with cancer. Recently, she treated 4 women in their 30s with histories of colon cancer, acute lymphoblastic leukemia, lymphoma, and breast cancer. A young man in his 20s sought her care, to discuss his case of lymphoma.

All these patients sought guidance from Lee because they want to protect their ability to have children. At the annual meeting of the Association of VA Hematology/Oncology, Lee explained that plenty of patients are finding themselves in similar straits due in part to recent trends.

Cancer rates in the US have been rising among people aged 15 to 39 years, who now account for 4.2% of all cancer cases. An estimated 84,100 people in this age group are expected to be diagnosed with cancer this year. Meanwhile, women are having children later in life-birth rates are up among those aged 25 to 49 years-making it more likely that they have histories of cancer.

Although it's difficult to predict how cancer will affect fertility, Lee emphasized that many chemotherapy medications, including cisplatin and carboplatin, are cytotoxic. "It's hard to always predict what someone's arc of care is going to be," she said, "so I really have a low threshold for recommending fertility preservation in patients who have a strong desire to have future childbearing."

For women with cancer, egg preservation isn't the only strategy. Clinicians can also try to protect ovarian tissue from pelvic radiation through surgical reposition of the ovaries, Lee noted. In addition goserelin, a hormone-suppressing therapy, may protect the ovaries from chemotherapy, though its effectiveness in boosting pregnancy rates is still unclear.

"When I mentioned this option, it's usually for patients who can't preserve fertility via egg or embryo preservation, or we don't have the luxury of that kind of time," Lee said. "I say that if helps at all, it might help you resume menses after treatment. But infertility is still very common."

For some patients, freezing eggs is an easy decision. "They don't have a reproductive partner they're ready to make embryos with, so we proceed with egg preservation. It's no longer considered experimental and comes with lower upfront costs since the costs of actually making embryos are deferred until the future."

In addition, she said, freezing eggs also avoids the touchy topic of disposing of embryos. Lee cautions patients that retrieving eggs is a 2-week process that requires any initiation of cancer care to be delayed. However, the retrieval process can be adjusted in patients with special needs due to the type of cancer they have.

For prepubertal girls with cancer, ovarian tissue can be removed and frozen as a fertility preservation option. However, this is not considered standard of care. "We don't do it," she said. "We refer out if needed. Hopefully we'll develop a program in the future."

As for the 5 patients that Lee mentioned, with details changed to protect their privacy, their outcomes were as follows:

• The woman with colon cancer, who had undergone a hemicolectomy, chose to defer fertility preservation.
• The woman with acute lymphoblastic leukemia, who was taking depo-Lupron, had undetectable anti-Müllerian hormone (AMH) levels. Lee discussed the possibility of IVF with a donor egg.
• The woman with breast cancer, who was newly diagnosed, deferred fertility preservation.
• The man with lymphoma (Hodgkin's), who was awaiting chemotherapy, had his sperm frozen.
• The woman with lymphoma (new diagnosis) had 27 eggs frozen.

Lee had no disclosures to report.

In the United States, 1 in 4 veterans lives with type 2 diabetes mellitus (T2DM), double the rate of the general population.¹ Medications are important for the treatment of T2DM and preventing complications that may develop if not properly managed. Common classes of medications for diabetes include biguanides, sodiumglucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, sulfonylureas, and insulin. The selection of treatment depends on patient-specific factors including hemoglobin A_1c (HbA_1c) goal, potential effects on weight, risk of hypoglycemia, and comorbidities such as atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease.²

HbA_1c level reflects the mean blood glucose over the previous 3 months and serves as an indication of diabetes control. In patients with diabetes, it is recommended that HbA_1c is checked ≥ 2 times annually for those meeting treatment goals, or more often if the patient needs to adjust medications to reach their HbA_1c goal. The goal HbA_1c level for most adults with diabetes is < 7%.³ This target can be adjusted based on age, comorbidities, or other patient factors. It is generally recommended that frequent glucose monitoring is not needed for patients with T2DM who are only taking oral agents and/or noninsulin injectables. However, for those on insulin regimens, it is advised to monitor glucose closely, with even more frequent testing for those with an intensive insulin regimen.³

Most patients with diabetes use fingerstick testing to self-monitor their blood glucose. However, continuous glucose monitors (CGMs) are becoming widely available and offer a solution to those who do not have the ability to check their glucose multiple times a day and throughout the night. The American Diabetes Association recommends that the frequency and timing of blood glucose monitoring, or the consideration of CGM use, should be based on the specific needs and goals of each patient.³ Guidelines also encourage those on intensive insulin regimens to check glucose levels when fasting, before and after meals, prior to exercise, and when hypoglycemia or hyperglycemia is suspected. Frequent testing can become a burden for patients, whereas once a CGM sensor is placed, it can be worn for 10 to 14 days. CGMs are also capable of transmitting glucose readings every 1 to 15 minutes to a receiver or mobile phone, allowing for further adaptability to a patient’s lifestyle.³

CGMs work by measuring the interstitial glucose with a small filament sensor and have demonstrated accuracy when compared to blood glucose readings. The ability of a CGM to accurately reflect HbA_1c levels is a potential benefit, reducing the need for frequent testing to determine whether patients have achieved glycemic control.⁴ Another benefit of a CGM is the ease of sharing data; patient accounts can be linked with a health care site, allowing clinicians to access glucose data even if the patient is not able to be seen in clinic. This allows health care practitioners (HCPs) to more efficiently tailor medications and optimize regimens based on patient-specific data that was not available by fingerstick testing alone.

Vigersky and colleagues provided one of the few studies on the long-term effects of CGM in patients managing T2DM through diet and exercise alone, oral medications, or basal insulin and found significant improvement in HbA_1c after only 3 months of CGM use.⁵

An important aspect of CGM use is the ability to alert the patient to low blood glucose readings, which can be dangerous for those unaware of hypoglycemia. Many studies have investigated the association between CGM use and acute metabolic events, demonstrating the potential for CGMs to prevent these emergencies. Karter and colleagues found a reduction in emergency department visits and hospitalizations for hypoglycemia associated with the use of CGMs in patients with type 1 DM (T1DM) and T2DM.⁶

There have been few studies on the use of CGM in veterans. Langford and colleagues found a reduction of HbA_1c among veterans with T2DM using CGMs. However, > 50% of the patients in the study were not receiving insulin therapy, which currently is a US Department of Veterans Affairs (VA) CGM criteria for use.⁷ While current studies provide evidence that supports improvement in HbA_1c levels with the use of CGMs, data are lacking for veterans with T2DM taking insulin. There is also minimal research that indicates which patients should be offered a CGM. The objective of this study was to evaluate glycemic control in veterans with T2DM on insulin using a CGM who were previously monitoring blood glucose with fingerstick testing. Secondary endpoints were explored to identify subgroups that may benefit from a CGM and other potential advantages of CGMs.

Methods

This was a retrospective study of veterans who transitioned from fingerstick testing to CGM for glucose monitoring. Each veteran served as their own control to limit confounding variables when comparing HbA_1c levels. Veterans with an active or suspended CGM order were identified by reviewing outpatient prescription data. All data collection and analysis were done within the Veterans Affairs Sioux Falls Health Care System.

The primary objective of this study was to assess glycemic control from the use of a CGM by evaluating the change in HbA_1c after transitioning to a CGM compared to the change in HbA_1c with standard fingerstick monitoring. Three HbA_1c values were collected for each veteran: before starting CGM, at initiation, and following CGM initiation (Figure 1). CGM start date was the date the CGM prescription order was placed. The pre-CGM HbA_1c level was ≥ 1 year prior to the CGM start date or the HbA_1c closest to 1 year. The start CGM HbA_1c level was within 3 months before or 1 month after the CGM start date. The post-CGM HbA_1c level was the most recent time of data collection and at least 6 months after CGM initiation. The change in HbA_1c from fingerstick glucose monitoring was the difference between the pre-CGM and start CGM values. The change in HbA_1c from use of a CGM was the difference between start CGM and post-CGM values, which were compared to determine HbA_1c reduction from CGM use.

This study also explored secondary outcomes including changes in HbA_1c by prescriber type, differences in HbA_1c reduction based on age, and changes in diabetes medications, including total daily insulin doses. For secondary outcomes, diabetes medication information and the total daily dose of insulin were gathered at the start of CGM use and at the time of data collection. The most recent CGM order prescribed was also collected.

Veterans were included if they were aged ≥ 18 years, had an active order for a CGM, T2DM diagnosis, an insulin prescription, and previously used test strips for glucose monitoring. Patients with T1DM, those who accessed CGMs or care in the community, and patients without HbA_1c values pre-CGM, were excluded.

Statistical Analysis

The primary endpoint of change in HbA_1c level before and after CGM use was compared using a paired t test. A 0.5% change in HbA_1c was considered clinically significant, as suggested in other studies.^8,9P < .05 was considered statistically significant. Analysis for continuous baseline characteristics, including age and total daily insulin, were reported as mean values. Nominal characteristics including sex, race, diabetes medications, and prescriber type are reported as percentages.

Results

A total of 402 veterans were identified with an active CGM at the time of initial data collection in January 2024 and 175 met inclusion criteria. Sixty patients were excluded due to diabetes managed through a community HCP, 38 had T1DM, and 129 lacked HbA_1c within all specified time periods. The 175 veterans were randomized, and 150 were selected to perform a chart review for data collection. The mean age was 70 years, most were male and identified as White (Table 1). The majority of patients were managed by endocrinology (53.3%), followed by primary care (24.0%), and pharmacy (22.7%) (Table 2). The mean baseline HbA_1c was 8.6%.

The difference in HbA_1c before and after use of CGM was -0.97% (P = .0001). Prior to use of a CGM the change in HbA_1c was minimal, with an increase of 0.003% with the use of selfmonitoring glucose. After use of a CGM, HbA_1c decreased by 0.971%. This reduction in HbA_1c would also be considered clinically significant as the change was > 0.5%. The mean pre-, at start, and post-CGM HbA_1c levels were 8.6%, 8.6%, and 7.6%, respectively (Figure 2). Pharmacy prescribers had a 0.7% reduction in HbA_1c post-CGM, the least of all prescribers. While most age groups saw a reduction in HbA_1c, those aged ≥ 80 years had an increase of 0.18% (Table 3). There was an overall mean reduction in insulin of 22 units, which was similar between all prescribers.

Discussion

The primary endpoint of difference in change of HbA_1c before and after CGM use was found to be statistically and clinically significant, with a nearly 1% reduction in HbA_1c, which was similar to the reduction found by Vigersky and colleagues. ⁵ Across all prescribers, post-CGM HbA_1c levels were similar; however, patients with CGM prescribed by pharmacists had the smallest change in HbA_1c. VA pharmacists primarily assess veterans taking insulin who have HbA_1c levels that are below the goal with the aim of decreasing insulin to reduce the risk of hypoglycemia, which could result in increased HbA1c levels. This may also explain the observed increase in post-CGM HbA_1c levels in patients aged ≥ 80 years. Patients under the care of pharmacists also had baseline mean HbA1c levels that were lower than primary care and endocrinology prescribers and were closer to their HbA_1c goal at baseline, which likely was reflected in the smaller reduction in post-CGM HbA_1c level.

While there was a decrease in HbA_1c levels with CGM use, there were also changes to medications during this timeframe that also may have impacted HbA_1c levels. The most common diabetes medications started during CGM use were GLP-1 agonists and SGLT2-inhibitors. Additionally, there was a reduction in the total daily dose of insulin in the study population. These results demonstrate the potential benefits of CGMs for prescribers who take advantage of the CGM glucose data available to assist with medication adjustments. Another consideration for differences in changes of HbA_1c among prescriber types is the opportunity for more frequent follow- up visits with pharmacy or endocrinology compared with primary care. If veterans are followed more closely, it may be associated with improved HbA_1c control. Further research investigating changes in HbA_1c levels based on followup frequency may be useful.

Strengths and Limitations

The crossover design was a strength of this study. This design reduced confounding variables by having veterans serve as their own controls. In addition, the collection of multiple secondary outcomes adds to the knowledge base for future studies. This study focused on a unique population of veterans with T2DM who were taking insulin, an area that previously had very little data available to determine the benefits of CGM use.

Although the use of a CGM showed statistical significance in lowering HbA_1c, many veterans were started on new diabetes medication during the period of CGM use, which also likely contributed to the reduction in HbA_1c and may have confounded the results. The study was limited by its small population size due to time constraints of chart reviews and the limited generalizability of results outside of the VA system. The majority of patients were from a single site, male and identified as White, which may not be reflective of other VA and community health care systems. It was also noted that the time from the initiation of CGM use to the most recent HbA_1c level varied from 6 months to several years. Additionally, veterans managed by community-based HCPs with complex diabetes cases were excluded.

Conclusions

This study demonstrated a clinically and statistically significant reduction in HbA_1c with the use of a CGM compared to fingerstick monitoring in veterans with T2DM who were being treated with insulin. The change in post-CGM HbA_1c levels across prescribers was similar. In the subgroup analysis of change in HbA_1c among age groups, there was a lower HbA_1c reduction in individuals aged ≥ 80 years. The results from this study support the idea that CGM use may be beneficial for patients who require a reduction in HbA_1c by allowing more precise adjustments to medications and optimization of therapy, as well as the potential to reduce insulin requirements, which is especially valuable in the older adult veteran population.

In the United States, 1 in 4 veterans lives with type 2 diabetes mellitus (T2DM), double the rate of the general population.¹ Medications are important for the treatment of T2DM and preventing complications that may develop if not properly managed. Common classes of medications for diabetes include biguanides, sodiumglucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, sulfonylureas, and insulin. The selection of treatment depends on patient-specific factors including hemoglobin A_1c (HbA_1c) goal, potential effects on weight, risk of hypoglycemia, and comorbidities such as atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease.²

HbA_1c level reflects the mean blood glucose over the previous 3 months and serves as an indication of diabetes control. In patients with diabetes, it is recommended that HbA_1c is checked ≥ 2 times annually for those meeting treatment goals, or more often if the patient needs to adjust medications to reach their HbA_1c goal. The goal HbA_1c level for most adults with diabetes is < 7%.³ This target can be adjusted based on age, comorbidities, or other patient factors. It is generally recommended that frequent glucose monitoring is not needed for patients with T2DM who are only taking oral agents and/or noninsulin injectables. However, for those on insulin regimens, it is advised to monitor glucose closely, with even more frequent testing for those with an intensive insulin regimen.³

Most patients with diabetes use fingerstick testing to self-monitor their blood glucose. However, continuous glucose monitors (CGMs) are becoming widely available and offer a solution to those who do not have the ability to check their glucose multiple times a day and throughout the night. The American Diabetes Association recommends that the frequency and timing of blood glucose monitoring, or the consideration of CGM use, should be based on the specific needs and goals of each patient.³ Guidelines also encourage those on intensive insulin regimens to check glucose levels when fasting, before and after meals, prior to exercise, and when hypoglycemia or hyperglycemia is suspected. Frequent testing can become a burden for patients, whereas once a CGM sensor is placed, it can be worn for 10 to 14 days. CGMs are also capable of transmitting glucose readings every 1 to 15 minutes to a receiver or mobile phone, allowing for further adaptability to a patient’s lifestyle.³

CGMs work by measuring the interstitial glucose with a small filament sensor and have demonstrated accuracy when compared to blood glucose readings. The ability of a CGM to accurately reflect HbA_1c levels is a potential benefit, reducing the need for frequent testing to determine whether patients have achieved glycemic control.⁴ Another benefit of a CGM is the ease of sharing data; patient accounts can be linked with a health care site, allowing clinicians to access glucose data even if the patient is not able to be seen in clinic. This allows health care practitioners (HCPs) to more efficiently tailor medications and optimize regimens based on patient-specific data that was not available by fingerstick testing alone.

Vigersky and colleagues provided one of the few studies on the long-term effects of CGM in patients managing T2DM through diet and exercise alone, oral medications, or basal insulin and found significant improvement in HbA_1c after only 3 months of CGM use.⁵

An important aspect of CGM use is the ability to alert the patient to low blood glucose readings, which can be dangerous for those unaware of hypoglycemia. Many studies have investigated the association between CGM use and acute metabolic events, demonstrating the potential for CGMs to prevent these emergencies. Karter and colleagues found a reduction in emergency department visits and hospitalizations for hypoglycemia associated with the use of CGMs in patients with type 1 DM (T1DM) and T2DM.⁶

There have been few studies on the use of CGM in veterans. Langford and colleagues found a reduction of HbA_1c among veterans with T2DM using CGMs. However, > 50% of the patients in the study were not receiving insulin therapy, which currently is a US Department of Veterans Affairs (VA) CGM criteria for use.⁷ While current studies provide evidence that supports improvement in HbA_1c levels with the use of CGMs, data are lacking for veterans with T2DM taking insulin. There is also minimal research that indicates which patients should be offered a CGM. The objective of this study was to evaluate glycemic control in veterans with T2DM on insulin using a CGM who were previously monitoring blood glucose with fingerstick testing. Secondary endpoints were explored to identify subgroups that may benefit from a CGM and other potential advantages of CGMs.

Methods

This was a retrospective study of veterans who transitioned from fingerstick testing to CGM for glucose monitoring. Each veteran served as their own control to limit confounding variables when comparing HbA_1c levels. Veterans with an active or suspended CGM order were identified by reviewing outpatient prescription data. All data collection and analysis were done within the Veterans Affairs Sioux Falls Health Care System.

The primary objective of this study was to assess glycemic control from the use of a CGM by evaluating the change in HbA_1c after transitioning to a CGM compared to the change in HbA_1c with standard fingerstick monitoring. Three HbA_1c values were collected for each veteran: before starting CGM, at initiation, and following CGM initiation (Figure 1). CGM start date was the date the CGM prescription order was placed. The pre-CGM HbA_1c level was ≥ 1 year prior to the CGM start date or the HbA_1c closest to 1 year. The start CGM HbA_1c level was within 3 months before or 1 month after the CGM start date. The post-CGM HbA_1c level was the most recent time of data collection and at least 6 months after CGM initiation. The change in HbA_1c from fingerstick glucose monitoring was the difference between the pre-CGM and start CGM values. The change in HbA_1c from use of a CGM was the difference between start CGM and post-CGM values, which were compared to determine HbA_1c reduction from CGM use.

This study also explored secondary outcomes including changes in HbA_1c by prescriber type, differences in HbA_1c reduction based on age, and changes in diabetes medications, including total daily insulin doses. For secondary outcomes, diabetes medication information and the total daily dose of insulin were gathered at the start of CGM use and at the time of data collection. The most recent CGM order prescribed was also collected.

Veterans were included if they were aged ≥ 18 years, had an active order for a CGM, T2DM diagnosis, an insulin prescription, and previously used test strips for glucose monitoring. Patients with T1DM, those who accessed CGMs or care in the community, and patients without HbA_1c values pre-CGM, were excluded.

Statistical Analysis

The primary endpoint of change in HbA_1c level before and after CGM use was compared using a paired t test. A 0.5% change in HbA_1c was considered clinically significant, as suggested in other studies.^8,9P < .05 was considered statistically significant. Analysis for continuous baseline characteristics, including age and total daily insulin, were reported as mean values. Nominal characteristics including sex, race, diabetes medications, and prescriber type are reported as percentages.

Results

A total of 402 veterans were identified with an active CGM at the time of initial data collection in January 2024 and 175 met inclusion criteria. Sixty patients were excluded due to diabetes managed through a community HCP, 38 had T1DM, and 129 lacked HbA_1c within all specified time periods. The 175 veterans were randomized, and 150 were selected to perform a chart review for data collection. The mean age was 70 years, most were male and identified as White (Table 1). The majority of patients were managed by endocrinology (53.3%), followed by primary care (24.0%), and pharmacy (22.7%) (Table 2). The mean baseline HbA_1c was 8.6%.

The difference in HbA_1c before and after use of CGM was -0.97% (P = .0001). Prior to use of a CGM the change in HbA_1c was minimal, with an increase of 0.003% with the use of selfmonitoring glucose. After use of a CGM, HbA_1c decreased by 0.971%. This reduction in HbA_1c would also be considered clinically significant as the change was > 0.5%. The mean pre-, at start, and post-CGM HbA_1c levels were 8.6%, 8.6%, and 7.6%, respectively (Figure 2). Pharmacy prescribers had a 0.7% reduction in HbA_1c post-CGM, the least of all prescribers. While most age groups saw a reduction in HbA_1c, those aged ≥ 80 years had an increase of 0.18% (Table 3). There was an overall mean reduction in insulin of 22 units, which was similar between all prescribers.

Discussion

The primary endpoint of difference in change of HbA_1c before and after CGM use was found to be statistically and clinically significant, with a nearly 1% reduction in HbA_1c, which was similar to the reduction found by Vigersky and colleagues. ⁵ Across all prescribers, post-CGM HbA_1c levels were similar; however, patients with CGM prescribed by pharmacists had the smallest change in HbA_1c. VA pharmacists primarily assess veterans taking insulin who have HbA_1c levels that are below the goal with the aim of decreasing insulin to reduce the risk of hypoglycemia, which could result in increased HbA1c levels. This may also explain the observed increase in post-CGM HbA_1c levels in patients aged ≥ 80 years. Patients under the care of pharmacists also had baseline mean HbA1c levels that were lower than primary care and endocrinology prescribers and were closer to their HbA_1c goal at baseline, which likely was reflected in the smaller reduction in post-CGM HbA_1c level.

While there was a decrease in HbA_1c levels with CGM use, there were also changes to medications during this timeframe that also may have impacted HbA_1c levels. The most common diabetes medications started during CGM use were GLP-1 agonists and SGLT2-inhibitors. Additionally, there was a reduction in the total daily dose of insulin in the study population. These results demonstrate the potential benefits of CGMs for prescribers who take advantage of the CGM glucose data available to assist with medication adjustments. Another consideration for differences in changes of HbA_1c among prescriber types is the opportunity for more frequent follow- up visits with pharmacy or endocrinology compared with primary care. If veterans are followed more closely, it may be associated with improved HbA_1c control. Further research investigating changes in HbA_1c levels based on followup frequency may be useful.

Strengths and Limitations

The crossover design was a strength of this study. This design reduced confounding variables by having veterans serve as their own controls. In addition, the collection of multiple secondary outcomes adds to the knowledge base for future studies. This study focused on a unique population of veterans with T2DM who were taking insulin, an area that previously had very little data available to determine the benefits of CGM use.

Although the use of a CGM showed statistical significance in lowering HbA_1c, many veterans were started on new diabetes medication during the period of CGM use, which also likely contributed to the reduction in HbA_1c and may have confounded the results. The study was limited by its small population size due to time constraints of chart reviews and the limited generalizability of results outside of the VA system. The majority of patients were from a single site, male and identified as White, which may not be reflective of other VA and community health care systems. It was also noted that the time from the initiation of CGM use to the most recent HbA_1c level varied from 6 months to several years. Additionally, veterans managed by community-based HCPs with complex diabetes cases were excluded.

Conclusions

This study demonstrated a clinically and statistically significant reduction in HbA_1c with the use of a CGM compared to fingerstick monitoring in veterans with T2DM who were being treated with insulin. The change in post-CGM HbA_1c levels across prescribers was similar. In the subgroup analysis of change in HbA_1c among age groups, there was a lower HbA_1c reduction in individuals aged ≥ 80 years. The results from this study support the idea that CGM use may be beneficial for patients who require a reduction in HbA_1c by allowing more precise adjustments to medications and optimization of therapy, as well as the potential to reduce insulin requirements, which is especially valuable in the older adult veteran population.

In the United States, 1 in 4 veterans lives with type 2 diabetes mellitus (T2DM), double the rate of the general population.¹ Medications are important for the treatment of T2DM and preventing complications that may develop if not properly managed. Common classes of medications for diabetes include biguanides, sodiumglucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, sulfonylureas, and insulin. The selection of treatment depends on patient-specific factors including hemoglobin A_1c (HbA_1c) goal, potential effects on weight, risk of hypoglycemia, and comorbidities such as atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease.²

HbA_1c level reflects the mean blood glucose over the previous 3 months and serves as an indication of diabetes control. In patients with diabetes, it is recommended that HbA_1c is checked ≥ 2 times annually for those meeting treatment goals, or more often if the patient needs to adjust medications to reach their HbA_1c goal. The goal HbA_1c level for most adults with diabetes is < 7%.³ This target can be adjusted based on age, comorbidities, or other patient factors. It is generally recommended that frequent glucose monitoring is not needed for patients with T2DM who are only taking oral agents and/or noninsulin injectables. However, for those on insulin regimens, it is advised to monitor glucose closely, with even more frequent testing for those with an intensive insulin regimen.³

Most patients with diabetes use fingerstick testing to self-monitor their blood glucose. However, continuous glucose monitors (CGMs) are becoming widely available and offer a solution to those who do not have the ability to check their glucose multiple times a day and throughout the night. The American Diabetes Association recommends that the frequency and timing of blood glucose monitoring, or the consideration of CGM use, should be based on the specific needs and goals of each patient.³ Guidelines also encourage those on intensive insulin regimens to check glucose levels when fasting, before and after meals, prior to exercise, and when hypoglycemia or hyperglycemia is suspected. Frequent testing can become a burden for patients, whereas once a CGM sensor is placed, it can be worn for 10 to 14 days. CGMs are also capable of transmitting glucose readings every 1 to 15 minutes to a receiver or mobile phone, allowing for further adaptability to a patient’s lifestyle.³

CGMs work by measuring the interstitial glucose with a small filament sensor and have demonstrated accuracy when compared to blood glucose readings. The ability of a CGM to accurately reflect HbA_1c levels is a potential benefit, reducing the need for frequent testing to determine whether patients have achieved glycemic control.⁴ Another benefit of a CGM is the ease of sharing data; patient accounts can be linked with a health care site, allowing clinicians to access glucose data even if the patient is not able to be seen in clinic. This allows health care practitioners (HCPs) to more efficiently tailor medications and optimize regimens based on patient-specific data that was not available by fingerstick testing alone.

Vigersky and colleagues provided one of the few studies on the long-term effects of CGM in patients managing T2DM through diet and exercise alone, oral medications, or basal insulin and found significant improvement in HbA_1c after only 3 months of CGM use.⁵

An important aspect of CGM use is the ability to alert the patient to low blood glucose readings, which can be dangerous for those unaware of hypoglycemia. Many studies have investigated the association between CGM use and acute metabolic events, demonstrating the potential for CGMs to prevent these emergencies. Karter and colleagues found a reduction in emergency department visits and hospitalizations for hypoglycemia associated with the use of CGMs in patients with type 1 DM (T1DM) and T2DM.⁶

There have been few studies on the use of CGM in veterans. Langford and colleagues found a reduction of HbA_1c among veterans with T2DM using CGMs. However, > 50% of the patients in the study were not receiving insulin therapy, which currently is a US Department of Veterans Affairs (VA) CGM criteria for use.⁷ While current studies provide evidence that supports improvement in HbA_1c levels with the use of CGMs, data are lacking for veterans with T2DM taking insulin. There is also minimal research that indicates which patients should be offered a CGM. The objective of this study was to evaluate glycemic control in veterans with T2DM on insulin using a CGM who were previously monitoring blood glucose with fingerstick testing. Secondary endpoints were explored to identify subgroups that may benefit from a CGM and other potential advantages of CGMs.

Methods

This was a retrospective study of veterans who transitioned from fingerstick testing to CGM for glucose monitoring. Each veteran served as their own control to limit confounding variables when comparing HbA_1c levels. Veterans with an active or suspended CGM order were identified by reviewing outpatient prescription data. All data collection and analysis were done within the Veterans Affairs Sioux Falls Health Care System.

The primary objective of this study was to assess glycemic control from the use of a CGM by evaluating the change in HbA_1c after transitioning to a CGM compared to the change in HbA_1c with standard fingerstick monitoring. Three HbA_1c values were collected for each veteran: before starting CGM, at initiation, and following CGM initiation (Figure 1). CGM start date was the date the CGM prescription order was placed. The pre-CGM HbA_1c level was ≥ 1 year prior to the CGM start date or the HbA_1c closest to 1 year. The start CGM HbA_1c level was within 3 months before or 1 month after the CGM start date. The post-CGM HbA_1c level was the most recent time of data collection and at least 6 months after CGM initiation. The change in HbA_1c from fingerstick glucose monitoring was the difference between the pre-CGM and start CGM values. The change in HbA_1c from use of a CGM was the difference between start CGM and post-CGM values, which were compared to determine HbA_1c reduction from CGM use.

This study also explored secondary outcomes including changes in HbA_1c by prescriber type, differences in HbA_1c reduction based on age, and changes in diabetes medications, including total daily insulin doses. For secondary outcomes, diabetes medication information and the total daily dose of insulin were gathered at the start of CGM use and at the time of data collection. The most recent CGM order prescribed was also collected.

Veterans were included if they were aged ≥ 18 years, had an active order for a CGM, T2DM diagnosis, an insulin prescription, and previously used test strips for glucose monitoring. Patients with T1DM, those who accessed CGMs or care in the community, and patients without HbA_1c values pre-CGM, were excluded.

Statistical Analysis

The primary endpoint of change in HbA_1c level before and after CGM use was compared using a paired t test. A 0.5% change in HbA_1c was considered clinically significant, as suggested in other studies.^8,9P < .05 was considered statistically significant. Analysis for continuous baseline characteristics, including age and total daily insulin, were reported as mean values. Nominal characteristics including sex, race, diabetes medications, and prescriber type are reported as percentages.

Results

A total of 402 veterans were identified with an active CGM at the time of initial data collection in January 2024 and 175 met inclusion criteria. Sixty patients were excluded due to diabetes managed through a community HCP, 38 had T1DM, and 129 lacked HbA_1c within all specified time periods. The 175 veterans were randomized, and 150 were selected to perform a chart review for data collection. The mean age was 70 years, most were male and identified as White (Table 1). The majority of patients were managed by endocrinology (53.3%), followed by primary care (24.0%), and pharmacy (22.7%) (Table 2). The mean baseline HbA_1c was 8.6%.

The difference in HbA_1c before and after use of CGM was -0.97% (P = .0001). Prior to use of a CGM the change in HbA_1c was minimal, with an increase of 0.003% with the use of selfmonitoring glucose. After use of a CGM, HbA_1c decreased by 0.971%. This reduction in HbA_1c would also be considered clinically significant as the change was > 0.5%. The mean pre-, at start, and post-CGM HbA_1c levels were 8.6%, 8.6%, and 7.6%, respectively (Figure 2). Pharmacy prescribers had a 0.7% reduction in HbA_1c post-CGM, the least of all prescribers. While most age groups saw a reduction in HbA_1c, those aged ≥ 80 years had an increase of 0.18% (Table 3). There was an overall mean reduction in insulin of 22 units, which was similar between all prescribers.

Discussion

The primary endpoint of difference in change of HbA_1c before and after CGM use was found to be statistically and clinically significant, with a nearly 1% reduction in HbA_1c, which was similar to the reduction found by Vigersky and colleagues. ⁵ Across all prescribers, post-CGM HbA_1c levels were similar; however, patients with CGM prescribed by pharmacists had the smallest change in HbA_1c. VA pharmacists primarily assess veterans taking insulin who have HbA_1c levels that are below the goal with the aim of decreasing insulin to reduce the risk of hypoglycemia, which could result in increased HbA1c levels. This may also explain the observed increase in post-CGM HbA_1c levels in patients aged ≥ 80 years. Patients under the care of pharmacists also had baseline mean HbA1c levels that were lower than primary care and endocrinology prescribers and were closer to their HbA_1c goal at baseline, which likely was reflected in the smaller reduction in post-CGM HbA_1c level.

While there was a decrease in HbA_1c levels with CGM use, there were also changes to medications during this timeframe that also may have impacted HbA_1c levels. The most common diabetes medications started during CGM use were GLP-1 agonists and SGLT2-inhibitors. Additionally, there was a reduction in the total daily dose of insulin in the study population. These results demonstrate the potential benefits of CGMs for prescribers who take advantage of the CGM glucose data available to assist with medication adjustments. Another consideration for differences in changes of HbA_1c among prescriber types is the opportunity for more frequent follow- up visits with pharmacy or endocrinology compared with primary care. If veterans are followed more closely, it may be associated with improved HbA_1c control. Further research investigating changes in HbA_1c levels based on followup frequency may be useful.

Strengths and Limitations

The crossover design was a strength of this study. This design reduced confounding variables by having veterans serve as their own controls. In addition, the collection of multiple secondary outcomes adds to the knowledge base for future studies. This study focused on a unique population of veterans with T2DM who were taking insulin, an area that previously had very little data available to determine the benefits of CGM use.

Although the use of a CGM showed statistical significance in lowering HbA_1c, many veterans were started on new diabetes medication during the period of CGM use, which also likely contributed to the reduction in HbA_1c and may have confounded the results. The study was limited by its small population size due to time constraints of chart reviews and the limited generalizability of results outside of the VA system. The majority of patients were from a single site, male and identified as White, which may not be reflective of other VA and community health care systems. It was also noted that the time from the initiation of CGM use to the most recent HbA_1c level varied from 6 months to several years. Additionally, veterans managed by community-based HCPs with complex diabetes cases were excluded.

Conclusions

This study demonstrated a clinically and statistically significant reduction in HbA_1c with the use of a CGM compared to fingerstick monitoring in veterans with T2DM who were being treated with insulin. The change in post-CGM HbA_1c levels across prescribers was similar. In the subgroup analysis of change in HbA_1c among age groups, there was a lower HbA_1c reduction in individuals aged ≥ 80 years. The results from this study support the idea that CGM use may be beneficial for patients who require a reduction in HbA_1c by allowing more precise adjustments to medications and optimization of therapy, as well as the potential to reduce insulin requirements, which is especially valuable in the older adult veteran population.

Background

Cancer clinical trials (CCTs) are central to improving cancer care. However, generalizability of findings from CCTs is difficult due to the lack of diversity in most United States CCTs. Clinical trial accrual of underrepresented groups, is low throughout the United States and is approximately 4-5% in most CCTs. Reasons for low accrual in this population are multifactorial. Despite numerous factors related to accruing racial and ethnic underrepresented groups, many institutions have sought to address these barriers. We conducted a scoping review to identify evidence-based approaches to increase participation in cancer treatment clinical trials.

Methods

We reviewed the Salisbury VA Medical Center Oncology clinical trial database from October 2019 to June 2024. The participants in these clinical trials required consent. These clinical trials included treatment interventional as well as non-treatment interventional. Fifteen studies were included and over 260 Veterans participated.

Results

Key themes emerged that included a focus on patient education, cultural competency, and building capacity in the clinics to care for the Veteran population at three separate sites in the Salisbury VA system. The Black Veteran accrual rate of 29% was achieved. This accrual rate is representative of our VA catchment population of 33% for Black Veterans, and is five times the national average.

Conclusions

The research team’s success in enrolling Black Veterans in clinical trials is attributed to several factors. The demographic composition of Veterans served by the Salisbury, Charlotte, and Kernersville VA provided a diverse population that included a 33% Black group. The type of clinical trials focused on patients who were most impacted by the disease. The VA did afford less barriers to access to health care.

Background

Cancer clinical trials (CCTs) are central to improving cancer care. However, generalizability of findings from CCTs is difficult due to the lack of diversity in most United States CCTs. Clinical trial accrual of underrepresented groups, is low throughout the United States and is approximately 4-5% in most CCTs. Reasons for low accrual in this population are multifactorial. Despite numerous factors related to accruing racial and ethnic underrepresented groups, many institutions have sought to address these barriers. We conducted a scoping review to identify evidence-based approaches to increase participation in cancer treatment clinical trials.

Methods

We reviewed the Salisbury VA Medical Center Oncology clinical trial database from October 2019 to June 2024. The participants in these clinical trials required consent. These clinical trials included treatment interventional as well as non-treatment interventional. Fifteen studies were included and over 260 Veterans participated.

Results

Key themes emerged that included a focus on patient education, cultural competency, and building capacity in the clinics to care for the Veteran population at three separate sites in the Salisbury VA system. The Black Veteran accrual rate of 29% was achieved. This accrual rate is representative of our VA catchment population of 33% for Black Veterans, and is five times the national average.

Conclusions

The research team’s success in enrolling Black Veterans in clinical trials is attributed to several factors. The demographic composition of Veterans served by the Salisbury, Charlotte, and Kernersville VA provided a diverse population that included a 33% Black group. The type of clinical trials focused on patients who were most impacted by the disease. The VA did afford less barriers to access to health care.

Background

Cancer clinical trials (CCTs) are central to improving cancer care. However, generalizability of findings from CCTs is difficult due to the lack of diversity in most United States CCTs. Clinical trial accrual of underrepresented groups, is low throughout the United States and is approximately 4-5% in most CCTs. Reasons for low accrual in this population are multifactorial. Despite numerous factors related to accruing racial and ethnic underrepresented groups, many institutions have sought to address these barriers. We conducted a scoping review to identify evidence-based approaches to increase participation in cancer treatment clinical trials.

Methods

We reviewed the Salisbury VA Medical Center Oncology clinical trial database from October 2019 to June 2024. The participants in these clinical trials required consent. These clinical trials included treatment interventional as well as non-treatment interventional. Fifteen studies were included and over 260 Veterans participated.

Results

Key themes emerged that included a focus on patient education, cultural competency, and building capacity in the clinics to care for the Veteran population at three separate sites in the Salisbury VA system. The Black Veteran accrual rate of 29% was achieved. This accrual rate is representative of our VA catchment population of 33% for Black Veterans, and is five times the national average.

Conclusions

The research team’s success in enrolling Black Veterans in clinical trials is attributed to several factors. The demographic composition of Veterans served by the Salisbury, Charlotte, and Kernersville VA provided a diverse population that included a 33% Black group. The type of clinical trials focused on patients who were most impacted by the disease. The VA did afford less barriers to access to health care.

Podocytes are terminally differentiated, highly specialized cells located in juxtaposition to the basement membrane over the abluminal surfaces of endothelial cells within the glomerular tuft. This triad structure is the site of the filtration barrier, which forms highly delicate and tightly regulated architecture to carry out the ultrafiltration function of the kidney.¹ The filtration barrier is characterized by foot processes that are connected by specialized junctions called slit diaphragms.

Insults to components of the filtration barrier can initiate cascading events and perpetuate structural alterations that may eventually result in sclerotic changes.² Common causes among children include minimal change disease (MCD) with the collapse of foot processes resulting in proteinuria, Alport syndrome due to mutation of collagen fibers within the basement membrane leading to hematuria and proteinuria, immune complex mediated nephropathy following common infections or autoimmune diseases, and focal segmental glomerulosclerosis (FSGS) that can show variable histopathology toward eventual glomerular scarring.^3,4 These children often clinically have minimal, if any, signs of systemic inflammation.^3-5 This has been a limiting factor for the commitment to immunomodulatory treatment, except for steroids for the treatment of MCD.⁶ Although prolonged steroid treatment may be efficacious, adverse effects are significant in a growing child. Alternative treatments, such as tacrolimus and rituximab have been suggested as second-line steroid-sparing agents.^7,8 Not uncommonly, however, these cases are managed by supportive measures only during the progression of the natural course of the disease, which may eventually lead to renal failure, requiring transplant for survival.^8,9

This case report highlights a child with a variant of uncertain significance (VUS) in genes involved in Alport syndrome and FSGS who developed an abrupt onset of proteinuria and hematuria after a respiratory illness. To our knowledge, he represents the youngest case demonstrating the benefit of targeted treatment against tumor necrosis factor-α (TNF-α) for glomerulopathy using biologic response modifiers.

Case Description

This is currently a 7-year-old male patient who was born at 39 weeks gestation to gravida 3 para 3 following induced labor due to elevated maternal blood pressure. During the first 2 years of life, his growth and development were normal and his immunizations were up to date. The patient's medical history included upper respiratory tract infections (URIs), respiratory syncytial virus, as well as 3 bouts of pneumonia and multiple otitis media that resulted in 18 rounds of antibiotics. The child was also allergic to nuts and milk protein. The patient’s parents are of Northern European and Native American descent. There is no known family history of eye, ear, or kidney diseases.

Renal concerns were first noted at the age of 2 years and 6 months when he presented to an emergency department in Fall 2019 (week 0) for several weeks of intermittent dark-colored urine. His mother reported that the discoloration recently progressed in intensity to cola-colored, along with the onset of persistent vomiting without any fever or diarrhea. On physical examination, the patient had normal vitals: weight 14.8 kg (68th percentile), height 91 cm (24th percentile), and body surface area 0.6 m². There was no edema, rash, or lymphadenopathy, but he appeared pale.
 

The patient’s initial laboratory results included: complete blood count with white blood cells (WBC) 10 x 10³/L (reference range, 4.5-13.5 x 10³/L); differential lymphocytes 69%; neutrophils 21%; hemoglobin 10 g/dL (reference range, 12-16 g/dL); hematocrit, 30%; (reference range, 37%-45%); platelets 437 10³/L (reference range, 150-450 x 10³/L); serum creatinine 0.46 mg/dL (reference range, 0.5-0.9 mg/dL); and albumin 3.1 g/dL (reference range, 3.5-5.2 g/dL). Serum electrolyte levels and liver enzymes were normal. A urine analysis revealed 3+ protein and 3+ blood with dysmorphic red blood cells (RBC) and RBC casts without WBC. The patient's spot urine protein-to-creatinine ratio was 4.3 and his renal ultrasound was normal. The patient was referred to Nephrology.

During the next 2 weeks, his protein-to-creatinine ratio progressed to 5.9 and serum albumin fell to 2.7 g/dL. His urine remained red colored, and a microscopic examination with RBC > 500 and WBC up to 10 on a high powered field. His workup was negative for antinuclear antibodies, antineutrophil cytoplasmic antibody, antistreptolysin-O (ASO) and anti-DNase B. Serum C3 was low at 81 mg/dL (reference range, 90-180 mg/dL), C4 was 13.3 mg/dL (reference range, 10-40 mg/dL), and immunoglobulin G was low at 452 mg/dL (reference range 719-1475 mg/dL). A baseline audiology test revealed normal hearing.

Percutaneous renal biopsy yielded about 12 glomeruli, all exhibiting mild mesangial matrix expansion and hypercellularity (Figure 1). One glomerulus had prominent parietal epithelial cells without endocapillary hypercellularity or crescent formation. There was no interstitial fibrosis or tubular atrophy. Immunofluorescence studies showed no evidence of immune complex deposition with negative staining for immunoglobulin heavy and light chains, C3 and C1q. Staining for α 2 and α 5 units of collagen was normal. Electron microscopy showed patchy areas of severe basement membrane thinning with frequent foci of mild to moderate lamina densa splitting and associated visceral epithelial cell foot process effacement (Figure 2).

These were reported as concerning findings for possible Alport syndrome by 3 independent pathology teams. The genetic testing was submitted at a commercial laboratory to screen 17 mutations, including COL4A3, COL4A4, and COL4A5. Results showed the presence of a heterozygous VUS in the COL4A4 gene (c.1055C > T; p.Pro352Leu; dbSNP ID: rs371717486; PolyPhen-2: Probably Damaging; SIFT: Deleterious) as well as the presence of a heterozygous VUS in TRPC6 gene (c2463A>T; p.Lys821Asn; dbSNP ID: rs199948731; PolyPhen-2: Benign; SIFT: Tolerated). Further genetic investigation by whole exome sequencing on approximately 20,000 genes through MNG Laboratories showed a new heterozygous VUS in the OSGEP gene [c.328T>C; p.Cys110Arg]. Additional studies ruled out mitochondrial disease, CoQ10 deficiency, and metabolic disorders upon normal findings for mitochondrial DNA, urine amino acids, plasma acylcarnitine profile, orotic acid, ammonia, and homocysteine levels.

Figure 3 summarizes the patient’s treatment response during 170 weeks of follow-up (Fall 2019 to Summer 2023). The patient was started on enalapril 0.6 mg/kg daily at week 3, which continued throughout treatment. Following a rheumatology consult at week 30, the patient was started on prednisolone 3 mg/mL to assess the role of inflammation through the treatment response. An initial dose of 2 mg/kg daily (9 mL) for 1 month was followed by every other day treatment that was tapered off by week 48. To control mild but noticeably increasing proteinuria in the interim, subcutaneous anakinra 50 mg (3 mg/kg daily) was added as a steroid-sparing agent at week 39 and increased to 100mg daily by week 41.His urine proteintocreatinineratiodecreasedfrom 1.720 to 0.575, andserumalbuminnormalizedbyweek 53. At that time, due to the patient’s up-trending proteinuria after a URI, as well as concerns for injection site skin reaction and quality of life on daily subcutaneous treatment, anakinra was substituted with subcutaneous adalimumab 20 mg every 2 weeks.

By week 80,the patient’s urineproteintocreatininerationormalized (< 0.2). Thiswasfollowedbynormalizedurine microalbumintocreatinineratio, andbyweek 130 hismicroscopichematuriaresolved. While onadalimumab, heremainedwellandwasabletomountan immune response to viralinfectionsuneventfully,including COVID-19. He tolerated agradual wean of adalimumab to every 3 weeks by week 139 and discontinuation at week 151. At week 204, the patient has normal renal function and urine findings; his growth parameters are at 20.3 percentile for weight and 15.3percentile for height.

DISCUSSION

This case describes a child with rapidly progressive proteinuria and hematuria following a URI who was found to have VUS mutations in 3 different genes associated with chronic kidney disease. Serology tests on the patient were negative for streptococcal antibodies and antinuclear antibodies, ruling out poststreptococcal glomerulonephritis, or systemic lupus erythematosus. His renal biopsy findings were concerning for altered podocytes, mesangial cells, and basement membrane without inflammatory infiltrate, immune complex, complements, immunoglobulin A, or vasculopathy. His blood inflammatory markers, erythrocyte sedimentation rate, C-reactive protein, and ferritin were normal when his care team initiated daily steroids.

Overall, the patient’s clinical presentation and histopathology findings were suggestive of Alport syndrome or thin basement membrane nephropathy with a high potential to progress into FSGS.^10-12 Alport syndrome affects 1 in 5000 to 10,000 children annually due to S-linked inheritance of COL4A5, or autosomal recessive inheritance of COL4A3 or COL4A4 genes. It presents with hematuria and hearing loss.¹⁰ Our patient had a single copy COL4A4 gene mutation that was classified as VUS. He also had 2 additional VUS affecting the TRPC6 and OSGEP genes. TRPC6 gene mutation can be associated with FSGS through autosomal dominant inheritance. Both COL4A4 and TRPC6 gene mutations were paternally inherited. Although the patient’s father not having renal disease argues against the clinical significance of these findings, there is literature on the potential role of heterozygous COL4A4 variant mimicking thin basement membrane nephropathy that can lead to renal impairment upon copresence of superimposed conditions.¹³ The patient’s rapidly progressing hematuria and changes in the basement membrane were worrisome for emerging FSGS. Furthermore, VUS of TRPC6 has been reported in late onset autosomal dominant FSGS and can be associated with early onset steroid-resistant nephrotic syndrome (NS) in children.¹⁴ This concern was voiced by 3 nephrology consultants during the initial evaluation, leading to the consensus that steroid treatment for podocytopathy would not alter the patient’s long-term outcomes (ie, progression to FSGS).

Immunomodulation

Our rationale for immunomodulatory treatment was based on the abrupt onset of renal concerns following a URI, suggesting the importance of an inflammatory trigger causing altered homeostasis in a genetically susceptible host. Preclinical models show that microbial products such as lipopolysaccharides can lead to podocytopathy by several mechanisms through activation of toll-like receptor signaling. It can directly cause apoptosis by downregulation of the intracellular Akt survival pathway.¹⁵ Lipopolysaccharide can also activate the NF-αB pathway and upregulate the production of interleukin-1 (IL-1) and TNF-α in mesangial cells.^16,17

Both cytokines can promote mesangial cell proliferation.¹⁸ Through autocrine and paracrine mechanisms, proinflammatory cytokines can further perpetuate somatic tissue changes and contribute to the development of podocytopathy. For instance, TNF-α can promote podocyte injury and proteinuria by downregulation of the slit diaphragm protein expression (ie, nephrin, ezrin, or podocin), and disruption of podocyte cytoskeleton.^19,20 TNF-α promotes the influx and activation of macrophages and inflammatory cells. It is actively involved in chronic alterations within the glomeruli by the upregulation of matrix metalloproteases by integrins, as well as activation of myofibroblast progenitors and extracellular matrix deposition in crosstalk with transforming growth factor and other key mediators.^17,21,22

For the patient described in this case report, initial improvement on steroids encouraged the pursuit of additional treatment to downregulate inflammatory pathways within the glomerular milieu. However, within the COVID-19 environment, escalating the patient’s treatment using traditional immunomodulators (ie, calcineurin inhibitors or mycophenolate mofetil) was not favored due to the risk of infection. Initially, anakinra, a recombinant IL-1 receptor antagonist, was preferred as a steroid-sparing agent for its short life and safety profile during the pandemic. At first, the patient responded well to anakinra and was allowed a steroid wean when the dose was titrated up to 6 mg/kg daily. However, anakinra did not prevent the escalation of proteinuria following a URI. After the treatment was changed to adalimumab, a fully humanized monoclonal antibody to TNF-α, the patient continued to improve and reach full remission despite experiencing a cold and the flu in the following months.

Literature Review

There is a paucity of literature on applications of biological response modifiers for idiopathic NS and FSGS.^23,24 Angeletti and colleagues reported that 3 patients with severe long-standing FSGS benefited from anakinra 4 mg/kg daily to reduce proteinuria and improve kidney function. All the patients had positive C3 staining in renal biopsy and treatment response, which supported the role of C3a in inducing podocyte injury through upregulated expression of IL-1 and IL-1R.²³ Trachtman and colleagues reported on the phase II FONT trial that included 14 of 21 patients aged < 18 years with advanced FSGS who were treated with adalimumab 24 mg/m², or ≤ 40 mg every other week.²⁴ Although, during a 6-month period, none of the 7 patients met the endpoint of reduced proteinuria by ≥ 50%, and the authors suggested that careful patient selection may improve the treatment response in future trials.²⁴

A recent study involving transcriptomics on renal tissue samples combined with available pathology (fibrosis), urinary markers, and clinical characteristics on 285 patients with MCD or FSGS from 3 different continents identified 3 distinct clusters. Patients with evidence of activated kidney TNF pathway (n = 72, aged > 18 years) were found to have poor clinical outcomes.²⁵ The study identified 2 urine markers associated with the TNF pathway (ie, tissue inhibitor of metalloproteinases-1 and monocyte chemoattractant protein-1), which aligns with the preclinical findings previously mentioned.²⁵

Conclusions

The patient’s condition in this case illustrates the complex nature of biologically predetermined cascading events in the emergence of glomerular disease upon environmental triggers under the influence of genetic factors. Observations on this child’s treatment response suggest that downregulation of somatic tissue-driven proinflammatory milieu originating from the constituents of glomerular microenvironment can help in recovery from emerging podocytopathy. The prolonged time span and stepwise resolution of proteinuria, followed by microalbuminuria (data not shown), and finally microscopic hematuria, supports the delicate balance and presence of reciprocal feedback loops between the podocytes and mesangial cells. Within this framework, blocking TNF-α, even temporarily, may allow time for the de novo regenerative process to prevail.

Chronic kidney disease affects 7.7% of veterans annually, illustrating the need for new therapeutics.²⁶ Based on our experience and literature review, upregulation of TNF-α is a root cause of glomerulopathy; further studies are warranted to evaluate the efficacy of anti-TNF biologic response modifiers for the treatment of these patients. Long-term postmarketing safety profile and steroid-sparing properties of adalimumab should allow inclusion of pediatric cases in future trials. Results may also contribute to identifying new predictive biomarkers related to the basement membrane when combined with precision nephrology to further advance patient selection and targeted treatment.^25,27

Acknowledgments

The authors thank the patient’s mother for providing consent to allow publication of this case report.

Podocytes are terminally differentiated, highly specialized cells located in juxtaposition to the basement membrane over the abluminal surfaces of endothelial cells within the glomerular tuft. This triad structure is the site of the filtration barrier, which forms highly delicate and tightly regulated architecture to carry out the ultrafiltration function of the kidney.¹ The filtration barrier is characterized by foot processes that are connected by specialized junctions called slit diaphragms.

Insults to components of the filtration barrier can initiate cascading events and perpetuate structural alterations that may eventually result in sclerotic changes.² Common causes among children include minimal change disease (MCD) with the collapse of foot processes resulting in proteinuria, Alport syndrome due to mutation of collagen fibers within the basement membrane leading to hematuria and proteinuria, immune complex mediated nephropathy following common infections or autoimmune diseases, and focal segmental glomerulosclerosis (FSGS) that can show variable histopathology toward eventual glomerular scarring.^3,4 These children often clinically have minimal, if any, signs of systemic inflammation.^3-5 This has been a limiting factor for the commitment to immunomodulatory treatment, except for steroids for the treatment of MCD.⁶ Although prolonged steroid treatment may be efficacious, adverse effects are significant in a growing child. Alternative treatments, such as tacrolimus and rituximab have been suggested as second-line steroid-sparing agents.^7,8 Not uncommonly, however, these cases are managed by supportive measures only during the progression of the natural course of the disease, which may eventually lead to renal failure, requiring transplant for survival.^8,9

This case report highlights a child with a variant of uncertain significance (VUS) in genes involved in Alport syndrome and FSGS who developed an abrupt onset of proteinuria and hematuria after a respiratory illness. To our knowledge, he represents the youngest case demonstrating the benefit of targeted treatment against tumor necrosis factor-α (TNF-α) for glomerulopathy using biologic response modifiers.

Case Description

This is currently a 7-year-old male patient who was born at 39 weeks gestation to gravida 3 para 3 following induced labor due to elevated maternal blood pressure. During the first 2 years of life, his growth and development were normal and his immunizations were up to date. The patient's medical history included upper respiratory tract infections (URIs), respiratory syncytial virus, as well as 3 bouts of pneumonia and multiple otitis media that resulted in 18 rounds of antibiotics. The child was also allergic to nuts and milk protein. The patient’s parents are of Northern European and Native American descent. There is no known family history of eye, ear, or kidney diseases.

Renal concerns were first noted at the age of 2 years and 6 months when he presented to an emergency department in Fall 2019 (week 0) for several weeks of intermittent dark-colored urine. His mother reported that the discoloration recently progressed in intensity to cola-colored, along with the onset of persistent vomiting without any fever or diarrhea. On physical examination, the patient had normal vitals: weight 14.8 kg (68th percentile), height 91 cm (24th percentile), and body surface area 0.6 m². There was no edema, rash, or lymphadenopathy, but he appeared pale.
 

The patient’s initial laboratory results included: complete blood count with white blood cells (WBC) 10 x 10³/L (reference range, 4.5-13.5 x 10³/L); differential lymphocytes 69%; neutrophils 21%; hemoglobin 10 g/dL (reference range, 12-16 g/dL); hematocrit, 30%; (reference range, 37%-45%); platelets 437 10³/L (reference range, 150-450 x 10³/L); serum creatinine 0.46 mg/dL (reference range, 0.5-0.9 mg/dL); and albumin 3.1 g/dL (reference range, 3.5-5.2 g/dL). Serum electrolyte levels and liver enzymes were normal. A urine analysis revealed 3+ protein and 3+ blood with dysmorphic red blood cells (RBC) and RBC casts without WBC. The patient's spot urine protein-to-creatinine ratio was 4.3 and his renal ultrasound was normal. The patient was referred to Nephrology.

During the next 2 weeks, his protein-to-creatinine ratio progressed to 5.9 and serum albumin fell to 2.7 g/dL. His urine remained red colored, and a microscopic examination with RBC > 500 and WBC up to 10 on a high powered field. His workup was negative for antinuclear antibodies, antineutrophil cytoplasmic antibody, antistreptolysin-O (ASO) and anti-DNase B. Serum C3 was low at 81 mg/dL (reference range, 90-180 mg/dL), C4 was 13.3 mg/dL (reference range, 10-40 mg/dL), and immunoglobulin G was low at 452 mg/dL (reference range 719-1475 mg/dL). A baseline audiology test revealed normal hearing.

Percutaneous renal biopsy yielded about 12 glomeruli, all exhibiting mild mesangial matrix expansion and hypercellularity (Figure 1). One glomerulus had prominent parietal epithelial cells without endocapillary hypercellularity or crescent formation. There was no interstitial fibrosis or tubular atrophy. Immunofluorescence studies showed no evidence of immune complex deposition with negative staining for immunoglobulin heavy and light chains, C3 and C1q. Staining for α 2 and α 5 units of collagen was normal. Electron microscopy showed patchy areas of severe basement membrane thinning with frequent foci of mild to moderate lamina densa splitting and associated visceral epithelial cell foot process effacement (Figure 2).

These were reported as concerning findings for possible Alport syndrome by 3 independent pathology teams. The genetic testing was submitted at a commercial laboratory to screen 17 mutations, including COL4A3, COL4A4, and COL4A5. Results showed the presence of a heterozygous VUS in the COL4A4 gene (c.1055C > T; p.Pro352Leu; dbSNP ID: rs371717486; PolyPhen-2: Probably Damaging; SIFT: Deleterious) as well as the presence of a heterozygous VUS in TRPC6 gene (c2463A>T; p.Lys821Asn; dbSNP ID: rs199948731; PolyPhen-2: Benign; SIFT: Tolerated). Further genetic investigation by whole exome sequencing on approximately 20,000 genes through MNG Laboratories showed a new heterozygous VUS in the OSGEP gene [c.328T>C; p.Cys110Arg]. Additional studies ruled out mitochondrial disease, CoQ10 deficiency, and metabolic disorders upon normal findings for mitochondrial DNA, urine amino acids, plasma acylcarnitine profile, orotic acid, ammonia, and homocysteine levels.

Figure 3 summarizes the patient’s treatment response during 170 weeks of follow-up (Fall 2019 to Summer 2023). The patient was started on enalapril 0.6 mg/kg daily at week 3, which continued throughout treatment. Following a rheumatology consult at week 30, the patient was started on prednisolone 3 mg/mL to assess the role of inflammation through the treatment response. An initial dose of 2 mg/kg daily (9 mL) for 1 month was followed by every other day treatment that was tapered off by week 48. To control mild but noticeably increasing proteinuria in the interim, subcutaneous anakinra 50 mg (3 mg/kg daily) was added as a steroid-sparing agent at week 39 and increased to 100mg daily by week 41.His urine proteintocreatinineratiodecreasedfrom 1.720 to 0.575, andserumalbuminnormalizedbyweek 53. At that time, due to the patient’s up-trending proteinuria after a URI, as well as concerns for injection site skin reaction and quality of life on daily subcutaneous treatment, anakinra was substituted with subcutaneous adalimumab 20 mg every 2 weeks.

By week 80,the patient’s urineproteintocreatininerationormalized (< 0.2). Thiswasfollowedbynormalizedurine microalbumintocreatinineratio, andbyweek 130 hismicroscopichematuriaresolved. While onadalimumab, heremainedwellandwasabletomountan immune response to viralinfectionsuneventfully,including COVID-19. He tolerated agradual wean of adalimumab to every 3 weeks by week 139 and discontinuation at week 151. At week 204, the patient has normal renal function and urine findings; his growth parameters are at 20.3 percentile for weight and 15.3percentile for height.

DISCUSSION

This case describes a child with rapidly progressive proteinuria and hematuria following a URI who was found to have VUS mutations in 3 different genes associated with chronic kidney disease. Serology tests on the patient were negative for streptococcal antibodies and antinuclear antibodies, ruling out poststreptococcal glomerulonephritis, or systemic lupus erythematosus. His renal biopsy findings were concerning for altered podocytes, mesangial cells, and basement membrane without inflammatory infiltrate, immune complex, complements, immunoglobulin A, or vasculopathy. His blood inflammatory markers, erythrocyte sedimentation rate, C-reactive protein, and ferritin were normal when his care team initiated daily steroids.

Overall, the patient’s clinical presentation and histopathology findings were suggestive of Alport syndrome or thin basement membrane nephropathy with a high potential to progress into FSGS.^10-12 Alport syndrome affects 1 in 5000 to 10,000 children annually due to S-linked inheritance of COL4A5, or autosomal recessive inheritance of COL4A3 or COL4A4 genes. It presents with hematuria and hearing loss.¹⁰ Our patient had a single copy COL4A4 gene mutation that was classified as VUS. He also had 2 additional VUS affecting the TRPC6 and OSGEP genes. TRPC6 gene mutation can be associated with FSGS through autosomal dominant inheritance. Both COL4A4 and TRPC6 gene mutations were paternally inherited. Although the patient’s father not having renal disease argues against the clinical significance of these findings, there is literature on the potential role of heterozygous COL4A4 variant mimicking thin basement membrane nephropathy that can lead to renal impairment upon copresence of superimposed conditions.¹³ The patient’s rapidly progressing hematuria and changes in the basement membrane were worrisome for emerging FSGS. Furthermore, VUS of TRPC6 has been reported in late onset autosomal dominant FSGS and can be associated with early onset steroid-resistant nephrotic syndrome (NS) in children.¹⁴ This concern was voiced by 3 nephrology consultants during the initial evaluation, leading to the consensus that steroid treatment for podocytopathy would not alter the patient’s long-term outcomes (ie, progression to FSGS).

Immunomodulation

Our rationale for immunomodulatory treatment was based on the abrupt onset of renal concerns following a URI, suggesting the importance of an inflammatory trigger causing altered homeostasis in a genetically susceptible host. Preclinical models show that microbial products such as lipopolysaccharides can lead to podocytopathy by several mechanisms through activation of toll-like receptor signaling. It can directly cause apoptosis by downregulation of the intracellular Akt survival pathway.¹⁵ Lipopolysaccharide can also activate the NF-αB pathway and upregulate the production of interleukin-1 (IL-1) and TNF-α in mesangial cells.^16,17

Both cytokines can promote mesangial cell proliferation.¹⁸ Through autocrine and paracrine mechanisms, proinflammatory cytokines can further perpetuate somatic tissue changes and contribute to the development of podocytopathy. For instance, TNF-α can promote podocyte injury and proteinuria by downregulation of the slit diaphragm protein expression (ie, nephrin, ezrin, or podocin), and disruption of podocyte cytoskeleton.^19,20 TNF-α promotes the influx and activation of macrophages and inflammatory cells. It is actively involved in chronic alterations within the glomeruli by the upregulation of matrix metalloproteases by integrins, as well as activation of myofibroblast progenitors and extracellular matrix deposition in crosstalk with transforming growth factor and other key mediators.^17,21,22

For the patient described in this case report, initial improvement on steroids encouraged the pursuit of additional treatment to downregulate inflammatory pathways within the glomerular milieu. However, within the COVID-19 environment, escalating the patient’s treatment using traditional immunomodulators (ie, calcineurin inhibitors or mycophenolate mofetil) was not favored due to the risk of infection. Initially, anakinra, a recombinant IL-1 receptor antagonist, was preferred as a steroid-sparing agent for its short life and safety profile during the pandemic. At first, the patient responded well to anakinra and was allowed a steroid wean when the dose was titrated up to 6 mg/kg daily. However, anakinra did not prevent the escalation of proteinuria following a URI. After the treatment was changed to adalimumab, a fully humanized monoclonal antibody to TNF-α, the patient continued to improve and reach full remission despite experiencing a cold and the flu in the following months.

Literature Review

There is a paucity of literature on applications of biological response modifiers for idiopathic NS and FSGS.^23,24 Angeletti and colleagues reported that 3 patients with severe long-standing FSGS benefited from anakinra 4 mg/kg daily to reduce proteinuria and improve kidney function. All the patients had positive C3 staining in renal biopsy and treatment response, which supported the role of C3a in inducing podocyte injury through upregulated expression of IL-1 and IL-1R.²³ Trachtman and colleagues reported on the phase II FONT trial that included 14 of 21 patients aged < 18 years with advanced FSGS who were treated with adalimumab 24 mg/m², or ≤ 40 mg every other week.²⁴ Although, during a 6-month period, none of the 7 patients met the endpoint of reduced proteinuria by ≥ 50%, and the authors suggested that careful patient selection may improve the treatment response in future trials.²⁴

A recent study involving transcriptomics on renal tissue samples combined with available pathology (fibrosis), urinary markers, and clinical characteristics on 285 patients with MCD or FSGS from 3 different continents identified 3 distinct clusters. Patients with evidence of activated kidney TNF pathway (n = 72, aged > 18 years) were found to have poor clinical outcomes.²⁵ The study identified 2 urine markers associated with the TNF pathway (ie, tissue inhibitor of metalloproteinases-1 and monocyte chemoattractant protein-1), which aligns with the preclinical findings previously mentioned.²⁵

Conclusions

The patient’s condition in this case illustrates the complex nature of biologically predetermined cascading events in the emergence of glomerular disease upon environmental triggers under the influence of genetic factors. Observations on this child’s treatment response suggest that downregulation of somatic tissue-driven proinflammatory milieu originating from the constituents of glomerular microenvironment can help in recovery from emerging podocytopathy. The prolonged time span and stepwise resolution of proteinuria, followed by microalbuminuria (data not shown), and finally microscopic hematuria, supports the delicate balance and presence of reciprocal feedback loops between the podocytes and mesangial cells. Within this framework, blocking TNF-α, even temporarily, may allow time for the de novo regenerative process to prevail.

Chronic kidney disease affects 7.7% of veterans annually, illustrating the need for new therapeutics.²⁶ Based on our experience and literature review, upregulation of TNF-α is a root cause of glomerulopathy; further studies are warranted to evaluate the efficacy of anti-TNF biologic response modifiers for the treatment of these patients. Long-term postmarketing safety profile and steroid-sparing properties of adalimumab should allow inclusion of pediatric cases in future trials. Results may also contribute to identifying new predictive biomarkers related to the basement membrane when combined with precision nephrology to further advance patient selection and targeted treatment.^25,27

Acknowledgments

The authors thank the patient’s mother for providing consent to allow publication of this case report.

Podocytes are terminally differentiated, highly specialized cells located in juxtaposition to the basement membrane over the abluminal surfaces of endothelial cells within the glomerular tuft. This triad structure is the site of the filtration barrier, which forms highly delicate and tightly regulated architecture to carry out the ultrafiltration function of the kidney.¹ The filtration barrier is characterized by foot processes that are connected by specialized junctions called slit diaphragms.

Insults to components of the filtration barrier can initiate cascading events and perpetuate structural alterations that may eventually result in sclerotic changes.² Common causes among children include minimal change disease (MCD) with the collapse of foot processes resulting in proteinuria, Alport syndrome due to mutation of collagen fibers within the basement membrane leading to hematuria and proteinuria, immune complex mediated nephropathy following common infections or autoimmune diseases, and focal segmental glomerulosclerosis (FSGS) that can show variable histopathology toward eventual glomerular scarring.^3,4 These children often clinically have minimal, if any, signs of systemic inflammation.^3-5 This has been a limiting factor for the commitment to immunomodulatory treatment, except for steroids for the treatment of MCD.⁶ Although prolonged steroid treatment may be efficacious, adverse effects are significant in a growing child. Alternative treatments, such as tacrolimus and rituximab have been suggested as second-line steroid-sparing agents.^7,8 Not uncommonly, however, these cases are managed by supportive measures only during the progression of the natural course of the disease, which may eventually lead to renal failure, requiring transplant for survival.^8,9

This case report highlights a child with a variant of uncertain significance (VUS) in genes involved in Alport syndrome and FSGS who developed an abrupt onset of proteinuria and hematuria after a respiratory illness. To our knowledge, he represents the youngest case demonstrating the benefit of targeted treatment against tumor necrosis factor-α (TNF-α) for glomerulopathy using biologic response modifiers.

Case Description

This is currently a 7-year-old male patient who was born at 39 weeks gestation to gravida 3 para 3 following induced labor due to elevated maternal blood pressure. During the first 2 years of life, his growth and development were normal and his immunizations were up to date. The patient's medical history included upper respiratory tract infections (URIs), respiratory syncytial virus, as well as 3 bouts of pneumonia and multiple otitis media that resulted in 18 rounds of antibiotics. The child was also allergic to nuts and milk protein. The patient’s parents are of Northern European and Native American descent. There is no known family history of eye, ear, or kidney diseases.

Renal concerns were first noted at the age of 2 years and 6 months when he presented to an emergency department in Fall 2019 (week 0) for several weeks of intermittent dark-colored urine. His mother reported that the discoloration recently progressed in intensity to cola-colored, along with the onset of persistent vomiting without any fever or diarrhea. On physical examination, the patient had normal vitals: weight 14.8 kg (68th percentile), height 91 cm (24th percentile), and body surface area 0.6 m². There was no edema, rash, or lymphadenopathy, but he appeared pale.
 

The patient’s initial laboratory results included: complete blood count with white blood cells (WBC) 10 x 10³/L (reference range, 4.5-13.5 x 10³/L); differential lymphocytes 69%; neutrophils 21%; hemoglobin 10 g/dL (reference range, 12-16 g/dL); hematocrit, 30%; (reference range, 37%-45%); platelets 437 10³/L (reference range, 150-450 x 10³/L); serum creatinine 0.46 mg/dL (reference range, 0.5-0.9 mg/dL); and albumin 3.1 g/dL (reference range, 3.5-5.2 g/dL). Serum electrolyte levels and liver enzymes were normal. A urine analysis revealed 3+ protein and 3+ blood with dysmorphic red blood cells (RBC) and RBC casts without WBC. The patient's spot urine protein-to-creatinine ratio was 4.3 and his renal ultrasound was normal. The patient was referred to Nephrology.

During the next 2 weeks, his protein-to-creatinine ratio progressed to 5.9 and serum albumin fell to 2.7 g/dL. His urine remained red colored, and a microscopic examination with RBC > 500 and WBC up to 10 on a high powered field. His workup was negative for antinuclear antibodies, antineutrophil cytoplasmic antibody, antistreptolysin-O (ASO) and anti-DNase B. Serum C3 was low at 81 mg/dL (reference range, 90-180 mg/dL), C4 was 13.3 mg/dL (reference range, 10-40 mg/dL), and immunoglobulin G was low at 452 mg/dL (reference range 719-1475 mg/dL). A baseline audiology test revealed normal hearing.

Percutaneous renal biopsy yielded about 12 glomeruli, all exhibiting mild mesangial matrix expansion and hypercellularity (Figure 1). One glomerulus had prominent parietal epithelial cells without endocapillary hypercellularity or crescent formation. There was no interstitial fibrosis or tubular atrophy. Immunofluorescence studies showed no evidence of immune complex deposition with negative staining for immunoglobulin heavy and light chains, C3 and C1q. Staining for α 2 and α 5 units of collagen was normal. Electron microscopy showed patchy areas of severe basement membrane thinning with frequent foci of mild to moderate lamina densa splitting and associated visceral epithelial cell foot process effacement (Figure 2).

These were reported as concerning findings for possible Alport syndrome by 3 independent pathology teams. The genetic testing was submitted at a commercial laboratory to screen 17 mutations, including COL4A3, COL4A4, and COL4A5. Results showed the presence of a heterozygous VUS in the COL4A4 gene (c.1055C > T; p.Pro352Leu; dbSNP ID: rs371717486; PolyPhen-2: Probably Damaging; SIFT: Deleterious) as well as the presence of a heterozygous VUS in TRPC6 gene (c2463A>T; p.Lys821Asn; dbSNP ID: rs199948731; PolyPhen-2: Benign; SIFT: Tolerated). Further genetic investigation by whole exome sequencing on approximately 20,000 genes through MNG Laboratories showed a new heterozygous VUS in the OSGEP gene [c.328T>C; p.Cys110Arg]. Additional studies ruled out mitochondrial disease, CoQ10 deficiency, and metabolic disorders upon normal findings for mitochondrial DNA, urine amino acids, plasma acylcarnitine profile, orotic acid, ammonia, and homocysteine levels.

Figure 3 summarizes the patient’s treatment response during 170 weeks of follow-up (Fall 2019 to Summer 2023). The patient was started on enalapril 0.6 mg/kg daily at week 3, which continued throughout treatment. Following a rheumatology consult at week 30, the patient was started on prednisolone 3 mg/mL to assess the role of inflammation through the treatment response. An initial dose of 2 mg/kg daily (9 mL) for 1 month was followed by every other day treatment that was tapered off by week 48. To control mild but noticeably increasing proteinuria in the interim, subcutaneous anakinra 50 mg (3 mg/kg daily) was added as a steroid-sparing agent at week 39 and increased to 100mg daily by week 41.His urine proteintocreatinineratiodecreasedfrom 1.720 to 0.575, andserumalbuminnormalizedbyweek 53. At that time, due to the patient’s up-trending proteinuria after a URI, as well as concerns for injection site skin reaction and quality of life on daily subcutaneous treatment, anakinra was substituted with subcutaneous adalimumab 20 mg every 2 weeks.

By week 80,the patient’s urineproteintocreatininerationormalized (< 0.2). Thiswasfollowedbynormalizedurine microalbumintocreatinineratio, andbyweek 130 hismicroscopichematuriaresolved. While onadalimumab, heremainedwellandwasabletomountan immune response to viralinfectionsuneventfully,including COVID-19. He tolerated agradual wean of adalimumab to every 3 weeks by week 139 and discontinuation at week 151. At week 204, the patient has normal renal function and urine findings; his growth parameters are at 20.3 percentile for weight and 15.3percentile for height.

DISCUSSION

This case describes a child with rapidly progressive proteinuria and hematuria following a URI who was found to have VUS mutations in 3 different genes associated with chronic kidney disease. Serology tests on the patient were negative for streptococcal antibodies and antinuclear antibodies, ruling out poststreptococcal glomerulonephritis, or systemic lupus erythematosus. His renal biopsy findings were concerning for altered podocytes, mesangial cells, and basement membrane without inflammatory infiltrate, immune complex, complements, immunoglobulin A, or vasculopathy. His blood inflammatory markers, erythrocyte sedimentation rate, C-reactive protein, and ferritin were normal when his care team initiated daily steroids.

Overall, the patient’s clinical presentation and histopathology findings were suggestive of Alport syndrome or thin basement membrane nephropathy with a high potential to progress into FSGS.^10-12 Alport syndrome affects 1 in 5000 to 10,000 children annually due to S-linked inheritance of COL4A5, or autosomal recessive inheritance of COL4A3 or COL4A4 genes. It presents with hematuria and hearing loss.¹⁰ Our patient had a single copy COL4A4 gene mutation that was classified as VUS. He also had 2 additional VUS affecting the TRPC6 and OSGEP genes. TRPC6 gene mutation can be associated with FSGS through autosomal dominant inheritance. Both COL4A4 and TRPC6 gene mutations were paternally inherited. Although the patient’s father not having renal disease argues against the clinical significance of these findings, there is literature on the potential role of heterozygous COL4A4 variant mimicking thin basement membrane nephropathy that can lead to renal impairment upon copresence of superimposed conditions.¹³ The patient’s rapidly progressing hematuria and changes in the basement membrane were worrisome for emerging FSGS. Furthermore, VUS of TRPC6 has been reported in late onset autosomal dominant FSGS and can be associated with early onset steroid-resistant nephrotic syndrome (NS) in children.¹⁴ This concern was voiced by 3 nephrology consultants during the initial evaluation, leading to the consensus that steroid treatment for podocytopathy would not alter the patient’s long-term outcomes (ie, progression to FSGS).

Immunomodulation

Our rationale for immunomodulatory treatment was based on the abrupt onset of renal concerns following a URI, suggesting the importance of an inflammatory trigger causing altered homeostasis in a genetically susceptible host. Preclinical models show that microbial products such as lipopolysaccharides can lead to podocytopathy by several mechanisms through activation of toll-like receptor signaling. It can directly cause apoptosis by downregulation of the intracellular Akt survival pathway.¹⁵ Lipopolysaccharide can also activate the NF-αB pathway and upregulate the production of interleukin-1 (IL-1) and TNF-α in mesangial cells.^16,17

Both cytokines can promote mesangial cell proliferation.¹⁸ Through autocrine and paracrine mechanisms, proinflammatory cytokines can further perpetuate somatic tissue changes and contribute to the development of podocytopathy. For instance, TNF-α can promote podocyte injury and proteinuria by downregulation of the slit diaphragm protein expression (ie, nephrin, ezrin, or podocin), and disruption of podocyte cytoskeleton.^19,20 TNF-α promotes the influx and activation of macrophages and inflammatory cells. It is actively involved in chronic alterations within the glomeruli by the upregulation of matrix metalloproteases by integrins, as well as activation of myofibroblast progenitors and extracellular matrix deposition in crosstalk with transforming growth factor and other key mediators.^17,21,22

For the patient described in this case report, initial improvement on steroids encouraged the pursuit of additional treatment to downregulate inflammatory pathways within the glomerular milieu. However, within the COVID-19 environment, escalating the patient’s treatment using traditional immunomodulators (ie, calcineurin inhibitors or mycophenolate mofetil) was not favored due to the risk of infection. Initially, anakinra, a recombinant IL-1 receptor antagonist, was preferred as a steroid-sparing agent for its short life and safety profile during the pandemic. At first, the patient responded well to anakinra and was allowed a steroid wean when the dose was titrated up to 6 mg/kg daily. However, anakinra did not prevent the escalation of proteinuria following a URI. After the treatment was changed to adalimumab, a fully humanized monoclonal antibody to TNF-α, the patient continued to improve and reach full remission despite experiencing a cold and the flu in the following months.

Literature Review

There is a paucity of literature on applications of biological response modifiers for idiopathic NS and FSGS.^23,24 Angeletti and colleagues reported that 3 patients with severe long-standing FSGS benefited from anakinra 4 mg/kg daily to reduce proteinuria and improve kidney function. All the patients had positive C3 staining in renal biopsy and treatment response, which supported the role of C3a in inducing podocyte injury through upregulated expression of IL-1 and IL-1R.²³ Trachtman and colleagues reported on the phase II FONT trial that included 14 of 21 patients aged < 18 years with advanced FSGS who were treated with adalimumab 24 mg/m², or ≤ 40 mg every other week.²⁴ Although, during a 6-month period, none of the 7 patients met the endpoint of reduced proteinuria by ≥ 50%, and the authors suggested that careful patient selection may improve the treatment response in future trials.²⁴

A recent study involving transcriptomics on renal tissue samples combined with available pathology (fibrosis), urinary markers, and clinical characteristics on 285 patients with MCD or FSGS from 3 different continents identified 3 distinct clusters. Patients with evidence of activated kidney TNF pathway (n = 72, aged > 18 years) were found to have poor clinical outcomes.²⁵ The study identified 2 urine markers associated with the TNF pathway (ie, tissue inhibitor of metalloproteinases-1 and monocyte chemoattractant protein-1), which aligns with the preclinical findings previously mentioned.²⁵

Conclusions

The patient’s condition in this case illustrates the complex nature of biologically predetermined cascading events in the emergence of glomerular disease upon environmental triggers under the influence of genetic factors. Observations on this child’s treatment response suggest that downregulation of somatic tissue-driven proinflammatory milieu originating from the constituents of glomerular microenvironment can help in recovery from emerging podocytopathy. The prolonged time span and stepwise resolution of proteinuria, followed by microalbuminuria (data not shown), and finally microscopic hematuria, supports the delicate balance and presence of reciprocal feedback loops between the podocytes and mesangial cells. Within this framework, blocking TNF-α, even temporarily, may allow time for the de novo regenerative process to prevail.

Chronic kidney disease affects 7.7% of veterans annually, illustrating the need for new therapeutics.²⁶ Based on our experience and literature review, upregulation of TNF-α is a root cause of glomerulopathy; further studies are warranted to evaluate the efficacy of anti-TNF biologic response modifiers for the treatment of these patients. Long-term postmarketing safety profile and steroid-sparing properties of adalimumab should allow inclusion of pediatric cases in future trials. Results may also contribute to identifying new predictive biomarkers related to the basement membrane when combined with precision nephrology to further advance patient selection and targeted treatment.^25,27

Acknowledgments

The authors thank the patient’s mother for providing consent to allow publication of this case report.