The utility of urinary biomarker panel in predicting renal pathology and treatment response in Chinese lupus nephritis patients

Li Liu; Ran Wang; Huihua Ding; Lei Tian; Ting Gao; Chunde Bao

doi:10.1371/journal.pone.0240942

Peer Review History

Original SubmissionJune 24, 2020
21 Jul 2020 Decision Letter - Masataka Kuwana, Editor PONE-D-20-15842 The utility of urinary biomarker panel in predicting renal pathology and treatment response in Chinese lupus nephritis patients PLOS ONE Dear Dr. Bao, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Two reviewers found some interests in this study, but also pointed out a number of issues that require improvement or amendment. I ask the authors to fully respond to all comments made by reviewers in the revised version. Please submit your revised manuscript by Sep 04 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Liu L et al investigated a large number of SLE patients to identify the predictor for renal pathological activity and prognosis by using 10-urinary biomarkers. This study is focusing on the important issue estimating activity of lupus nephritis without pathological confirmation. This manuscript sounds interesting, but I have concerns which authors should address. Major Urinary NGAL was highly correlated with both 24-hours proteinuria and RSLEDAI comparing to other urinary biomarkers (Table 3) and only the urinary biomarker predicting renal response. However, it could not distinguish proliferative LN from membranous LN while uVCAM-1, uCystatinC, and uKim-1 were significantly increased in proliferative LN (Figure 2). Author needs to discuss this discrepancy in discussion section. Previous reports already showed uNGAL was good biomarker for AKI. In this manuscript, authors accepted ACR criteria for renal response using only reduction level of proteinuria. According to the criteria, there was another response criterion based on eGFR change. I suggest authors to create another table comparing baseline clinical features including eGFR in patients with CR, PR and NR. Cumulative CR or PR rate using criterion based on eGFR change also needs to be shown. Minor ROC analysis for predicting proliferative LN using 2-urinary biomarkers needs to be done before using 3 (page15, line 226). Reviewer #2: The authors implemented a retrospective study to show the utility of urinary biomarkers in predicting renal pathology and treatment response after induction therapy in Chinese patients with SLE who presented lupus nephritis (LN). Receiver operating characteristics (ROC) curve analysis showed a difference in biomarkers between proliferative LN and membranous LN. The results are interesting and support the utility of urinary biomarkers in LN patients. However, it is difficult to accept the author's opinion since this manuscript contains serious problems such as imprecision due to the extremely small number of cases, lack of induction therapy for LN according to recommendations by the American College of Radiology (ACR), the European League Against Rheumatism (EULAR), or the Kidney Disease Improving Global Outcomes (KDIGO) in this patient population, and the lack of information regarding levels of conventional laboratory measures and histologic features in the studied subjects. Specific comments: 1. The objective of this analysis was to predict renal pathology in lupus nephritis of SLE patients using urinary biomarkers. The biomarkers shown by Liu L have already been demonstrated to be potential predictors of renal pathology feature not only in lupus nephritis but also in glomerulonephritis including IgA nephropathy and diabetic nephropathy. The current study by Liu requires further optimization and validation in another cohort. 2. Table 1: The authors should show more information regarding levels of conventional laboratory measures and histologic features in the studied subjects. 3. Materials and methods, Disease assessment and follow-up: As for the assessment of urinary protein levels, the urinary protein ranges overlap between the active LN group (0.5g/24h) and the partial response group (urinary protein creatinine ratio: 0.2-2.0). Evaluation of urinary protein in patients with LN should be assessed by decrease in urinary protein levels over time. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). 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Revision 1
3 Oct 2020 Author Response Responses to reviewers’ comments We appreciate the reviewers’ efforts in assessing our manuscript and giving constructive criticism. Base on the reviewers’ comments, we have made major revision to the original manuscript. We believe that the manuscript has been further improved. Reviewer’s Comments Reviewer #1: Liu L et al investigated a large number of SLE patients to identify the predictor for renal pathological activity and prognosis by using 10-urinary biomarkers. This study is focusing on the important issue estimating activity of lupus nephritis without pathological confirmation. This manuscript sounds interesting, but I have concerns which authors should address. Major Urinary NGAL was highly correlated with both 24-hours proteinuria and RSLEDAI comparing to other urinary biomarkers (Table 3) and only the urinary biomarker predicting renal response. However, it could not distinguish proliferative LN from membranous LN while uVCAM-1, uCystatinC, and uKim-1 were significantly increased in proliferative LN (Figure 2). Author needs to discuss this discrepancy in discussion section. Re: We have added the following discussion in the manuscript: Although urinary NGAL level correlated well with 24h urine protein and predicted renal disease activity, it couldn’t differentiate proliferative LN from membranous LN. Previous studies also haven’t validated the correlation ship between urinary NGAL and the histopathological type of LN. Since patients’ baseline character including renal pathological characteristics were not predictors for treatment response [40, 41], it’s not surprising that urinary NGAL could predict treatment response but not renal histopathology type while the biomarkers which could differentiate different pathological types of LN could not predict treatment response. Previous reports already showed uNGAL was good biomarker for AKI. In this manuscript, authors accepted ACR criteria for renal response using only reduction level of proteinuria. According to the criteria, there was another response criterion based on eGFR change. I suggest authors to create another table comparing baseline clinical features including eGFR in patients with CR, PR and NR. Cumulative CR or PR rate using criterion based on eGFR change also needs to be shown. Re: We appreciate the insightful suggestion. We fully agree with the concern that using only proteinuria level as renal response might bias the results. We apologize for not describing the ACR criteria for renal response precisely in the manuscript. It actually included the requirement of eGFR change. It has now been corrected in the manuscript as follows: Complete response (CR): eGFR of >90 ml/minute/1.73m2, urinary protein creatinine ratio (UPCR) <0.2. Partial response (PR): no more than 25% decline in estimated GFR or end-stage renal disease, at least 50% reduction in the UPCR and UPCR is 0.2–2.0. Non-response (NR): not meeting the CR or PR criteria. Based on eGFR and UPCR, the patients were divided into CR, PR and NR groups. We didn’t include urine sediment in the criteria of treatment response due to the poor reproductivity. We have double checked our original data and confirmed that the renal response status was defined base on both proteinuria and eGFR change. We have created another table comparing baseline clinical features of the patients with CR, PR and NR as S1 Table. We also did ANOVA test to check if baseline eGFR levels differed in CR, PR, and NR patients. It turned out that the baseline eGFR levels were not significantly different among the three groups (see the following figure 1’). We didn’t calculate the cumulative CR or PR rate using criterion based on eGFR change due to the following two reasons. Firstly, using only eGFR change to define the treatment response in lupus nephritis is not widely accepted. Secondly, the calculation of cumulative CR or PR rate was not doable since the we only have detailed laboratory data at the 6 months. Figure 1’. Baseline eGFR levels in patients with different treatment responses. (shown in the attached file) Minor ROC analysis for predicting proliferative LN using 2-urinary biomarkers needs to be done before using 3 (page15, line 226). Re: Thanks for the suggestion. We have replotted the ROC curve in Figure 2(D), in which we have added ROC curve for predicting proliferative LN using 2-urinary biomarkers. Reviewer #2: The authors implemented a retrospective study to show the utility of urinary biomarkers in predicting renal pathology and treatment response after induction therapy in Chinese patients with SLE who presented lupus nephritis (LN). Receiver operating characteristics (ROC) curve analysis showed a difference in biomarkers between proliferative LN and membranous LN. The results are interesting and support the utility of urinary biomarkers in LN patients. However, it is difficult to accept the author's opinion since this manuscript contains serious problems such as imprecision due to the extremely small number of cases, lack of induction therapy for LN according to recommendations by the American College of Radiology (ACR), the European League Against Rheumatism (EULAR), or the Kidney Disease Improving Global Outcomes (KDIGO) in this patient population, and the lack of information regarding levels of conventional laboratory measures and histologic features in the studied subjects. Specific comments: 1. The objective of this analysis was to predict renal pathology in lupus nephritis of SLE patients using urinary biomarkers. The biomarkers shown by Liu L have already been demonstrated to be potential predictors of renal pathology feature not only in lupus nephritis but also in glomerulonephritis including IgA nephropathy and diabetic nephropathy. The current study by Liu requires further optimization and validation in another cohort. Re: We fully understand the concern and totally agree with the idea that the biomarkers validated in this study were not specific for LN. We envision the clinical application of these biomarkers in predicting renal pathology features of LN in patients who have already had the diagnosis of SLE base on the classification criteria. In this context, it is less likely that the patients will have another type of nephropathy. However, we do agree that future studies should be designed to include patients with different types of nephropathy to clarify if the urinary biomarkers validated in this study were specific to LN or not. To clarify this, we have added the following discussion in the manuscript: Most of the biomarkers validated in this study, however, are not specific to LN. For instants, urinary KIM-1 and NGAL has been reported as biomarkers of kidney injury in obese children [42]. The current study didn’t include patients with other chronic kidney diseases. We envision the clinical implication of the current study is to use these biomarkers in predicting renal pathology features or treatment response of LN after patients’ diagnosis of SLE base on the classification criteria. 2. Table 1: The authors should show more information regarding levels of conventional laboratory measures and histologic features in the studied subjects. Re: Thanks for the suggestion. We have added more detailed clinical and laboratory data and significantly improved Table 1. Unfortunately, we don’t have more detailed information regarding histological features except for historical type, activity index, and chronicity index of the active LN patients. 3. Materials and methods, Disease assessment and follow-up: As for the assessment of urinary protein levels, the urinary protein ranges overlap between the active LN group (0.5g/24h) and the partial response group (urinary protein creatinine ratio: 0.2-2.0). Evaluation of urinary protein in patients with LN should be assessed by decrease in urinary protein levels over time. Re: We fully agree with the concern and we apologize for not describing our criteria on the treatment response precisely in the manuscript. It has now been corrected as follows in the manuscript: Complete response (CR): eGFR of >90 ml/minute/1.73m2, urinary protein creatinine ratio (UPCR) <0.2. Partial response (PR): no more than 25% decline in estimated GFR or end-stage renal disease, at least 50% reduction in the UPCR and UPCR is 0.2–2.0. Non-response (NR): not meeting the CR or PR criteria. Based on eGFR and UPCR, the patients were divided into CR, PR and NR groups. We didn’t include urine sediment in the criteria of treatment response due to the poor reproductivity. We have also double checked our patients’ response status based on the above criteria and confirmed that the renal response status was defined base on both absolute value of proteinuria as well as improvement of proteinuria, and eGFR change. Attachments Attachment Submitted filename: Response to Reviewer comments_20200930.docx https://doi.org/10.1371/journal.pone.0240942.r002
6 Oct 2020 Decision Letter - Masataka Kuwana, Editor The utility of urinary biomarker panel in predicting renal pathology and treatment response in Chinese lupus nephritis patients PONE-D-20-15842R1 Dear Dr. Bao, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Masataka Kuwana, MD, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0240942.r003
Formally Accepted
19 Oct 2020 Acceptance Letter - Masataka Kuwana, Editor PONE-D-20-15842R1 The utility of urinary biomarker panel in predicting renal pathology and treatment response in Chinese lupus nephritis patients Dear Dr. Bao: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Prof. Masataka Kuwana Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0240942.r004

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