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Ferrari HM, Kale-Pradhan P, Konja J, Dierker M, Martirosov AL. Systemic-Sclerosis-Related Interstitial Lung Disease: A Review of the Literature and Recommended Approach for Clinical Pharmacists. Ann Pharmacother 2023:10600280231213672. [PMID: 38095621 DOI: 10.1177/10600280231213672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVE To describe the efficacy, safety, and clinical utility of pharmacologic agents in the treatment of systemic sclerosis-related interstitial lung disease (SSc-ILD). DATA SOURCES A review of the literature was performed using the terms lung diseases, (interstitial/therapy) AND (scleroderma, systemic/therapy) OR (scleroderma, systemic) AND (lung diseases, interstitial/therapy) in PubMed, Ovid MEDLINE, CINAHL, and Web of Science. ClinicalTrials.gov was also searched to identify ongoing studies. The initial search was performed in October 2022, with follow-up searches performed in October 2023. STUDY SELECTION AND DATA ABSTRACTION Articles reviewed were limited to those written in the English language, human studies, and adult populations. DATA SYNTHESIS A variety of therapeutic agents, including mycophenolate, azathioprine, cyclophosphamide (CYC), rituximab (RTX), nintedanib, and tocilizumab (TCZ) have slowed the rate of decline in forced vital capacity (FVC) and disease progression. Only nintedanib and TCZ have a labeled indication for SSc-ILD. Two agents, belimumab and pirfenidone, have shown encouraging results in smaller phase II and phase III studies, but have yet to be approved by the Food and Drug Administration. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Patients with pulmonary manifestations of SSc-ILD have worse outcomes and lower survival rates compared with those without. It is imperative that disease management be individualized to achieve optimal patient-centered care. Pharmacists are uniquely suited to support this individualized management. CONCLUSION Numerous pharmacologic agents have been studied and repurposed in the treatment of SSc-ILD, with nintedanib and TCZ gaining approval to slow the rate of decline in pulmonary function in SSc-ILD. Other agents, including belimumab and pirfenidone, are on the horizon as potential treatment options; but further studies are needed to compare their efficacy and safety with the current standard of care.
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Affiliation(s)
- Hannah Marie Ferrari
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and and Henry Ford Hospital, Detroit, MI, USA
| | - Pramodini Kale-Pradhan
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Ascension St. John Hospital, Detroit, MI, USA
| | - Jewel Konja
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and and Henry Ford Hospital, Detroit, MI, USA
| | - Michelle Dierker
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and and Henry Ford Hospital, Detroit, MI, USA
| | - Amber Lanae Martirosov
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and and Henry Ford Hospital, Detroit, MI, USA
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Hughes M, Herrick AL, Hudson M. Treatment of Vascular Complications in Systemic Sclerosis: What Is the Best Approach to Diagnosis and Management of Renal Crisis and Digital Ulcers? Rheum Dis Clin North Am 2023; 49:263-277. [PMID: 37028834 DOI: 10.1016/j.rdc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Vasculopathy as exemplified by scleroderma renal crisis (SRC) and digital ulcers (DUs) is a cardinal feature of systemic sclerosis (SSc) and is associated with significant morbidity, including in patients with early disease. Prompt recognition and management is required to alleviate potentially irreversible damage from SSc-associated vasculopathy. Both SRC and DUs share many etiopathogenic drivers which inform the therapeutic strategy. The aim of our review was to describe the diagnosis and management of SRC and DUs in SSc, and to discuss unmet needs for future research.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK.
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK; Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Marie Hudson
- Department of Medicine, McGill University, Canada; Division of Rheumatology, Jewish General Hospital, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
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3
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Foocharoen C, Tonsawan P, Pongkulkiat P, Anutrakulchai S, Mahakkanukrauh A, Suwannaroj S. Management review of scleroderma renal crisis: An update with practical pointers. Mod Rheumatol 2023; 33:12-20. [PMID: 35349704 DOI: 10.1093/mr/roac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/20/2022] [Accepted: 03/14/2022] [Indexed: 01/05/2023]
Abstract
Scleroderma renal crisis (SRC) represents severe, fatal internal organ involvement brought on by systemic sclerosis. A high rate of renal replacement therapy and mortality persists despite various treatments. Depending on the stage of SRC, a vasodilator called angiotensin-converting enzyme inhibitor is the treatment of choice. The efficacy of various other vasodilators (i.e. endothelin-1 receptor antagonist) and complement cascade blocker for SRC have been investigated; however, no randomized control trial has been conducted. A new approach has been proposed for the management of SRC, categorized by specific clinical features of narrowly defined SRC and systemic sclerosis-thrombotic microangiopathy. SRC prophylaxis using angiotensin-converting enzyme inhibitor might be harmful, leading to a poor renal outcome, so the pathogenesis of SRC needs to be clarified in order to identify other possible preventions or therapies.
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Affiliation(s)
- Chingching Foocharoen
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pantipa Tonsawan
- Department of Medicine, Division of Nephrology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Patnarin Pongkulkiat
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sirirat Anutrakulchai
- Department of Medicine, Division of Nephrology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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4
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Kidney Involvement in Systemic Sclerosis. J Pers Med 2022; 12:jpm12071123. [PMID: 35887620 PMCID: PMC9324204 DOI: 10.3390/jpm12071123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Systemic sclerosis is a chronic multisystem autoimmune disease, characterized by diffuse fibrosis and abnormalities of microcirculation and small arterioles in the skin, joints and visceral organs. Material and Methods: We searched for the relevant articles on systemic sclerosis and kidney involvement in systemic sclerosis in the NIH library of medicine, transplant, rheumatologic and nephrological journals. Results: Half of patients with systemic sclerosis have clinical evidence of kidney involvement. Scleroderma renal crisis represents the most specific and serious renal event associated with this condition. It is characterized by an abrupt onset of moderate to marked hypertension and kidney failure. Early and aggressive treatment is mandatory to prevent irreversible organ damage and death. The advent of ACE-inhibitors revolutionized the management of scleroderma renal crisis. However, the outcomes of this serious complication are still poor, and between 20 to 50% of patients progress to end stage renal disease. Conclusions: Scleroderma renal crisis still represents a serious and life-threatening event. Thus, further studies on its prevention and on new therapeutic strategies should be encouraged.
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Cole A, Ong VH, Denton CP. Renal Disease and Systemic Sclerosis: an Update on Scleroderma Renal Crisis. Clin Rev Allergy Immunol 2022; 64:378-391. [PMID: 35648373 PMCID: PMC10167155 DOI: 10.1007/s12016-022-08945-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 12/16/2022]
Abstract
Scleroderma renal crisis (SRC) is a life-threatening complication of systemic sclerosis (SSc) with a mortality of 20% at 6 months. Once the leading cause of mortality in scleroderma (SSc), it remains a serious complication, often necessitating level three care for patients affected. Whilst renal outcomes have significantly improved following the advent of angiotensin-converting enzyme inhibitor (ACEi) therapy, SRC remains a precarious challenge for clinicians, due to lack of preventative measures and the fact that patients can rapidly decline despite best medical management. Large cohort studies spanning decades have allowed clear identification of phenotypes particularly at risk of developing SRC thus allowing enhanced monitoring and early identification in those individuals. Novel urinary biomarkers for renal disease in SSc may offer a new window for early identification of SRC patients and response to treatment. Multiple studies have demonstrated increased activity of complement pathways in SRC with some anecdotal cases exhibiting serological response to treatment with eculizumab where ACEi and therapeutic plasma exchange (TPE) were not successful. Endothelin-1 blockade, a therapeutic strategy in other SSc vasculopathies, has shown potential as a target but clinical trials are yet to show a clear treatment benefit. Clear guidelines for the management of SRC are in place to standardise care and facilitate early collaboration between rheumatology and renal physicians. Outcomes following renal transplant have improved but the mortality of SRC remains high, indicating the need for continued exploration of the mechanisms precipitating and exacerbating SRC in order to develop novel therapies.
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Affiliation(s)
- Alice Cole
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Voon H Ong
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Christopher P Denton
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
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Herrick AL, Assassi S, Denton CP. Skin involvement in early diffuse cutaneous systemic sclerosis: an unmet clinical need. Nat Rev Rheumatol 2022; 18:276-285. [PMID: 35292731 PMCID: PMC8922394 DOI: 10.1038/s41584-022-00765-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 12/23/2022]
Abstract
Diffuse cutaneous systemic sclerosis (dcSSc) is associated with high mortality resulting from early internal-organ involvement. Clinicians therefore tend to focus on early diagnosis and treatment of potentially life-threatening cardiorespiratory and renal disease. However, the rapidly progressive painful, itchy skin tightening that characterizes dcSSc is the symptom that has the greatest effect on patients' quality of life, and there is currently no effective disease-modifying treatment for it. Considerable advances have been made in predicting the extent and rate of skin-disease progression (which vary between patients), including the development of techniques such as molecular analysis of skin biopsy samples. Risk stratification for progressive skin disease is especially relevant now that haematopoietic stem-cell transplantation is a treatment option, because stratification will inform the balance of risk versus benefit for each patient. Measurement of skin disease is a major challenge. Results from clinical trials have highlighted limitations of the modified Rodnan skin score (the current gold standard). Alternative patient-reported and other potential outcome measures have been and are being developed. Patients with early dcSSc should be referred to specialist centres to ensure best-practice management, including the management of their skin disease, and to maximize opportunities for inclusion in clinical trials.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Shervin Assassi
- McGovern Medical School, The University of Texas, Houston, TX, USA
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Xiong A, Cao Y, Xiang Q, Song Z, Zhang Y, Zhou S, Qiang Y, Chen H, Hu Z, Cui H, Luo J, Wang Y, Yang Y, Yang M, Shuai S. Angiotensin-converting enzyme inhibitors prior to scleroderma renal crisis in systemic sclerosis: A systematic review and meta-analysis. J Clin Pharm Ther 2022; 47:722-731. [PMID: 35233779 DOI: 10.1111/jcpt.13621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Angiotensin-converting enzyme inhibitors (ACEIs) are widely used in the treatment of scleroderma renal crisis (SRC), and their use prior to the onset of SRC in patients with systemic sclerosis (SSc) has received wide attention in recent years. We undertook an evidence-based approach to identify whether the use of ACEIs prior to the onset of SRC is beneficial for patients with SSc. METHODS We searched PubMed and Embase for any published studies produced between database inception and 22 October 2021. Articles obtained after using appropriate keywords were selected independently by two reviewers according to the established inclusion and exclusion criteria. RESULTS Nine studies were included. Pooled results indicated that using ACEIs prior to SRC was associated with a higher incidence of SRC than no ACEIs prior to SRC (RR 2.05, 95% confidence interval 1.08-3.91, p = 0.03). Compared with patients who did not use ACEIs prior to the onset of SRC, a higher proportion of patients with SRC who used ACEIs prior to its onset had a poorer prognosis (RR 1.46, 95% confidence interval 1.20-1.78, p < 0.01). The difference in mortality between patients who used ACEIs prior to SRC onset and those who did not was not statistically significant (RR 1.12, 95% confidence interval 0.76-1.65, p = 0.57). WHAT IS NEW AND CONCLUSIONS We recommend against using ACEIs prior to SRC in SSc patients. The use of ACEIs prior to SRC is associated with a higher incidence of SRC and poorer prognosis, especially in patients with progressive SSc or SSc-related renal vasculopathy (SSc-related hypertension and proteinuria).
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, Sichuan, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zhuoyao Song
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yan Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shifeng Zhou
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yiying Qiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Huini Chen
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ziyi Hu
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Hongxu Cui
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jie Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ye Wang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yuan Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Min Yang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, Sichuan, China
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8
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Herrick AL. Advances in the Treatment of Systemic Sclerosis. Rheumatology (Oxford) 2022. [DOI: 10.17925/rmd.2022.1.2.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Although systemic sclerosis (SSc) is currently incurable, there have been recent advances in treatment. This review article begins by providing a brief background to SSc in terms of disease subtyping and autoantibodies, because both predict disease trajectory and help clinicians to select appropriate monitoring and treatment protocols. Broad principles of management are then described: ‘disease-modifying’ therapies and therapies directed at reducing disease burden and/or progression of SSc-related digital vascular disease and of internal organ involvement. Next, advances in the management of digital vasculopathy, pulmonary arterial hypertension (PAH), interstitial lung disease (ILD) and early diffuse cutaneous SSc are discussed in turn, for example: (a) increased use of phosphodiesterase inhibitors and endothelin receptor antagonists for digital vasculopathy; (b) early recognition and treatment of PAH, including with combination therapies; (c) increased use of mycophenolate mofetil and of nintedanib in ILD; and (d) immunosuppression now as standard practice in early diffuse cutaneous SSc, and autologous haematopoietic stem cell transplantation for highly selected patients with progressive diffuse disease. Finally, future challenges are discussed, including ensuring that all patients with SSc are monitored and treated according to best practice guidelines, and whenever possible giving patients the opportunity to participate in clinical trials.
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Simon M, Lücht C, Hosp I, Zhao H, Wu D, Heidecke H, Witowski J, Budde K, Riemekasten G, Catar R. Autoantibodies from Patients with Scleroderma Renal Crisis Promote PAR-1 Receptor Activation and IL-6 Production in Endothelial Cells. Int J Mol Sci 2021; 22:11793. [PMID: 34769227 PMCID: PMC8584031 DOI: 10.3390/ijms222111793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Scleroderma renal crisis (SRC) is a life-threatening complication of systemic sclerosis (SSc). Autoantibodies (Abs) against endothelial cell antigens have been implicated in SSc and SRC. However, their detailed roles remain poorly defined. Pro-inflammatory cytokine interleukin-6 (IL-6) has been found to be increased in SSc, but its role in SRC is unclear. Here, we aimed to determine how the autoantibodies from patients with SSc and SRC affect IL-6 secretion by micro-vascular endothelial cells (HMECs). METHODS Serum IgG fractions were isolated from either SSc patients with SRC (n = 4) or healthy individuals (n = 4) and then each experiment with HMECs was performed with SSc-IgG from a separate patient or separate healthy control. IL-6 expression and release by HMECs was assessed by quantitative reverse transcription and quantitative PCR (RT-qPCR) and immunoassays, respectively. The mechanisms underlying the production of IL-6 were analyzed by transient HMEC transfections with IL-6 promoter constructs, electrophoretic mobility shift assays, Western blots and flow cytometry. RESULTS Exposure of HMECs to IgG from SSc patients, but not from healthy controls, resulted in a time- and dose-dependent increase in IL-6 secretion, which was associated with increased AKT, p70S6K, and ERK1/2 signalling, as well as increased c-FOS/AP-1 transcriptional activity. All these effects could be reduced by the blockade of the endothelial PAR-1 receptor and/or c-FOS/AP-1silencing. CONCLUSIONS Autoantibodies against PAR-1 found in patients with SSc and SRC induce IL-6 production by endothelial cells through signalling pathways controlled by the AP-1 transcription factor. These observations offer a greater understanding of adverse endothelial cell responses to autoantibodies present in patients with SRC.
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Affiliation(s)
- Michèle Simon
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
| | - Christian Lücht
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
| | - Isa Hosp
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
| | - Hongfan Zhao
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
| | - Dashan Wu
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
| | | | - Janusz Witowski
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
- Department of Pathophysiology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Klemens Budde
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
| | - Gabriela Riemekasten
- Clinic for Rheumatology and Clinical Immunology, Universitätsklinikum Schleswig-Holstein, 23538 Lübeck, Germany;
| | - Rusan Catar
- Department of Nephrology and Internal Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (M.S.); (C.L.); (I.H.); (H.Z.); (D.W.); (J.W.); (K.B.)
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Abbas F, El Kossi M, Shaheen IS, Sharma A, Halawa A. Journey of a patient with scleroderma from renal failure up to kidney transplantation. World J Transplant 2021; 11:372-387. [PMID: 34631469 PMCID: PMC8465513 DOI: 10.5500/wjt.v11.i9.372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/10/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
The increased awareness of systemic sclerosis (SS) and its pathogenetic background made the management of this disease more amenable than previously thought. However, scleroderma renal crisis (SRC) is a rarely seen as an associated disorder that may involve 2%-15% of SS patients. Patients presented with earlier, rapidly progressing, diffuse cutaneous SS disease, mostly in the first 3-5 years after non-Raynaud clinical manifestations, are more vulnerable to develop SRC. SRC comprises a collection of acute, mostly symptomatic rise in blood pressure, elevation in serum creatinine concentrations, oliguria and thrombotic microangiopathy in almost 50% of cases. The advent of the antihypertensive angiotensin converting enzyme inhibitors in 1980 was associated with significant improvement in SRC prognosis. In a scleroderma patient maintained on regular dialysis; every effort should be exerted to declare any possible evidence of renal recovery. A given period of almost two years has been suggested prior to proceeding in a kidney transplant (KTx). Of note, SS patients on dialysis have the highest opportunity of renal recovery and withdrawal from dialysis as compared to other causes of end-stage renal disease (ESRD). KTx that is the best well-known therapeutic option for ESRD patients can also be offered to SS patients. Compared to other primary renal diseases, SS-related ESRD was considered for a long period of poor patient and allograft survivals. Pulmonary involvement in an SS patient is considered a strong post-transplant independent risk factor of death. Recurrence of SRC after transplantation has been observed in some patients. However, an excellent post-transplant patient and graft outcome have been recently reported. Consequently, the absence of extrarenal manifestations in an SS-induced ESRD patient can be accepted as a robust indicator for a successful KTx.
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Affiliation(s)
- Fedaey Abbas
- Department of Nephrology, Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Doncaster Renal Unit, Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Ihab Sakr Shaheen
- Department of Paediatric Nephrology, St James’s University Hospital, Glasgow G51 4TF, United Kingdom
| | - Ajay Sharma
- Department of Transplant Surgery, Royal Liverpool University Hospital, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Department of Transplant Surgery, Sheffield Teaching Hospital, Sheffield S5 7AU, United Kingdom
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Ramalingam S, Shah A. Stem Cell Therapy as a Treatment for Autoimmune Disease-Updates in Lupus, Scleroderma, and Multiple Sclerosis. Curr Allergy Asthma Rep 2021; 21:22. [PMID: 33759038 DOI: 10.1007/s11882-021-00996-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Evidence for hematopoietic stem cell transplantation (HCT) in autoimmune disease has been building since the 1990s; however, many clinicians may not yet be aware of its applications to autoimmune disease. We review the basic tenets of HCT and evidence for autologous HCT in multiple sclerosis (MS), systemic sclerosis (SSc), and lupus with an emphasis on recent advanced phase trials. RECENT FINDINGS In MS, the phase 3 randomized MIST trial and the phase 2 randomized ASTIMS trial demonstrated the efficacy of autologous HCT in refractory MS over disease-modifying therapies and mitoxantrone, respectively. In SSc, the phase 3 randomized ASTIS trial and the phase 2 randomized SCOT trial demonstrated the efficacy of autologous HCT in advanced SSc compared to cyclophosphamide. The evidence for HCT in autoimmune diseases continues to grow, particularly in MS and SSc. In lupus, large, comparative trials are still needed. Across autoimmune diseases, questions that still remain to be answered include optimizing patient selection to limit TRM, the appropriate use of MAC, and the necessity for graft manipulation. Furthermore, collaboration between disease-specific and transplant physicians is imperative to expand the appropriate use of HCT in routine clinical practice.
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Affiliation(s)
- Sendhilnathan Ramalingam
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, NC, USA
| | - Ankoor Shah
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3874, Durham, NC, 27710, USA.
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12
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Hudson M, Ghossein C, Steen V. Scleroderma renal crisis. Presse Med 2021; 50:104063. [PMID: 33548376 DOI: 10.1016/j.lpm.2021.104063] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 01/17/2023] Open
Abstract
Scleroderma renal crisis (SRC) is a rare but life-threatening complication of systemic sclerosis (SSc) characterized by malignant hypertension and acute kidney injury. Historically, SRC was the leading cause of death in SSc. However, with the advent of angiotensin converting enzyme (ACE) inhibitors, mortality rates have decreased significantly. Nevertheless, one-year outcomes remain poor, with over 30% mortality and 25% of patients remaining dialysis-dependent. There is an urgent need to improve early recognition and treatment, and to identify novel treatments to improve outcomes of SRC. In this chapter, the clinical features, classification, pathophysiology, differential diagnosis, management and outcomes of SRC are presented. Specific issues relating to pregnancy, prophylactic ACE inhibition and management of essential hypertension are also discussed.
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Affiliation(s)
- Marie Hudson
- Jewish General Hospital, Lady Davis Institute, McGill University, Montreal, Canada
| | - Cybele Ghossein
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Virginia Steen
- Georgetown University Medical Center, Washington (DC), USA
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Scleroderma Renal Crisis in a Case of Mixed Connective Tissue Disease Treated Successfully with Angiotensin-Converting Enzyme Inhibitors. Case Rep Nephrol 2021; 2021:8862405. [PMID: 33505743 PMCID: PMC7808802 DOI: 10.1155/2021/8862405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/10/2020] [Accepted: 12/23/2020] [Indexed: 11/17/2022] Open
Abstract
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome with overlapping features of scleroderma, systemic lupus erythematosus, and polymyositis. An extremely rare but serious complication that can occur in MCTD is scleroderma renal crisis (SRC). There have been different approaches to the treatment of SRC associated with MCTD. We present a case of MCTD with chronic features of Raynaud's phenomenon, dermatomyositis, and thrombocytopenia complicated with acute SRC which showed a great response to ACE inhibitors. Here, we advise the early and aggressive use of ACE inhibitors as soon as SRC is suspected.
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14
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Herrick AL, Shukla R, Watson REB. Frontiers in translational systemic sclerosis research: A focus on the unmet 'cutaneous' clinical needs (Viewpoint). Exp Dermatol 2020; 29:1144-1153. [DOI: 10.1111/exd.14179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Ariane L. Herrick
- Division of Musculoskeletal and Dermatological Sciences Salford Royal NHS Foundation Trust Manchester Academic Health Science Centre The University of Manchester Manchester UK
| | | | - Rachel E. B. Watson
- Division of Musculoskeletal and Dermatological Sciences Salford Royal NHS Foundation Trust Manchester Academic Health Science Centre The University of Manchester Manchester UK
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15
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Nevskaya T, Zheng B, Baxter CA, Ramey DR, Pope JE, Baron M. Skin improvement is a surrogate for favourable changes in other organ systems in early diffuse cutaneous systemic sclerosis. Rheumatology (Oxford) 2020; 59:1715-1724. [PMID: 31774531 DOI: 10.1093/rheumatology/kez529] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/26/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Skin improvement in diffuse cutaneous SSc (dcSSc), measured with modified Rodnan skin score (mRSS), is frequently used as a primary outcome in clinical trials, but it is uncertain whether mRSS changes reflect changes in other organ systems. This aim of this study was to explore if skin changes in early dcSSc over 1 and 2 years are associated with changes in severity of other organ involvement. METHODS Canadian Scleroderma Research Group database patients with dcSSc, disease duration of ≤5 years, no evidence of initial end-stage organ damage and/or significant comorbidity who had 1 year (n = 154) and 2 years (n = 128) of follow-up data were included. mRSS changes of 25% and/or ≥5 points were considered significant. Organ involvement was assessed by Medsger Disease Severity Score and Canadian Scleroderma Research Group definitions using bivariate, chi-square, ANOVA, adjusted regression and longitudinal mixed effect model analyses. RESULTS Improvement in mRSS was found in 41% of patients at 1 year and in 50% at 2 years. Improved patients showed less forced vital capacity decline (P = 0.012) and less frequent new cardiac involvement (P = 0.02) over 1 year, as well as better lung (by both Disease Severity Score, P = 0.006, and Δforced vital capacity%, P = 0.026), peripheral vascular (P = 0.006) and joint/tendon (P = 0.002) involvement over 2 years. mRSS worsening was consistently linked to less favourable lung outcomes at both 1- and 2-year follow-up visits, and more severe gastrointestinal disease at 2 years. CONCLUSION Changes in lung function in early dcSSc closely parallel skin changes. mRSS improvement reflects better prognosis for visceral disease and may be a reliable outcome measure in clinical trials.
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Affiliation(s)
| | - Boyang Zheng
- Division of Rheumatology, McGill University, Montreal, QC, Canada
| | | | | | | | - Murray Baron
- Division of Rheumatology, McGill University, Montreal, QC, Canada.,Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
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16
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Herrick AL, Griffiths-Jones DJ, Ryder WD, Mason JC, Denton CP. Clinical trial protocol: PRednisolone in early diffuse cutaneous Systemic Sclerosis (PRedSS). JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 6:146-153. [PMID: 34222671 PMCID: PMC8216311 DOI: 10.1177/2397198320957552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/16/2020] [Indexed: 11/17/2022]
Abstract
Background: Many of the painful, disabling features of early diffuse cutaneous systemic
sclerosis have an inflammatory component and are potentially treatable with
corticosteroid therapy. These features include painful and itchy skin,
fatigue and musculoskeletal involvement. Yet many clinicians are
understandably reluctant to prescribe corticosteroids because of the concern
that these are a risk factor for scleroderma renal crisis. The aim of PRedSS
(PRednisolone in early diffuse cutaneous Systemic Sclerosis) is to evaluate
the efficacy and safety of moderate dose prednisolone in patients with early
diffuse cutaneous systemic sclerosis, specifically whether moderate dose
prednisolone is (a) effective in terms of reducing pain and disability, and
improving skin score and (b) safe, with particular reference to renal
function. Methods: PRedSS is a Phase II, multicentre, double-blind randomised controlled trial
which aims to recruit 72 patients with early diffuse cutaneous systemic
sclerosis. Patients are randomised to receive either prednisolone (dosage
approximately 0.3 mg/kg) or placebo therapy for 6 months. The two co-primary
outcome measures are the difference in mean Health Assessment Questionnaire
Disability Index at 3 months and the difference in modified Rodnan skin
score at 3 months. Secondary outcome measures include patient reported
outcome measures of itch, hand function, anxiety and depression, and
helplessness. Results: Recruitment commenced in December 2017 and after a slow start (due to delays
in opening centres) 25 patients have now been recruited. Conclusion: PRedSS should help to answer the question as to whether clinicians should or
should not prescribe prednisolone in early diffuse cutaneous systemic
sclerosis.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and
Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic
Health Science Centre, The University of Manchester, Manchester, UK
- Ariane L Herrick, Clinical Sciences
Building, Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK.
| | - Deborah J Griffiths-Jones
- Division of Musculoskeletal and
Dermatological Sciences, Salford Royal NHS Foundation Trust, Manchester Academic
Health Science Centre, The University of Manchester, Manchester, UK
| | - W David Ryder
- Manchester Clinical Trials Unit, Jean
McFarlane Building, The University of Manchester, Manchester, UK
| | - Justin C Mason
- National Heart and Lung Institute,
Imperial College London, Hammersmith Hospital, London, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective
Tissue Diseases, University College London Division of Medicine, Royal Free Campus,
London, UK
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17
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Simms RW. Expert Perspectives On Clinical Challenges: Expert Perspectives: Challenges in Scleroderma. Arthritis Rheumatol 2020; 72:1415-1426. [PMID: 32562363 DOI: 10.1002/art.41406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/12/2020] [Indexed: 11/11/2022]
Abstract
You are consulted to evaluate a 56-year-old woman with known Raynaud's phenomenon, finger swelling of several; months' duration, and new hypertension with a blood pressure of 160/100 mm/Hg. She also reports progressive shortness of breath. Physical examination reveals telangiectasias, sclerodactyly, and proximal skin sclerosis (thick shiny skin on the chest and upper arms), and bibasilar crackles are found on chest examination. Laboratory tests reveal evidence of microangiopathic hemolytic anemia, thrombocytopenia, and elevation of the serum creatinine level (previously normal), and chest computed tomography shows evidence of ground-glass opacification in both lower lung fields.
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Affiliation(s)
- Robert W Simms
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire
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18
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Chrabaszcz M, Małyszko J, Sikora M, Alda-Malicka R, Stochmal A, Matuszkiewicz-Rowinska J, Rudnicka L. Renal Involvement in Systemic Sclerosis: An Update. Kidney Blood Press Res 2020; 45:532-548. [PMID: 32521536 DOI: 10.1159/000507886] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/14/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Systemic sclerosis is an immune-mediated rheumatic disease characterized by vascular abnormalities, tissue fibrosis and autoimmune phenomena. SUMMARY Renal disease occurring in patients with systemic sclerosis may have a variable clinicopathological picture. The most specific renal condition associated with systemic sclerosis is scleroderma renal crisis, characterized by acute onset of renal failure and severe hypertension. Although the management of scleroderma renal crisis was revolutionized by the introduction of angiotensin-converting enzyme inhibitors, there is still a significant proportion of patients with poor outcomes. Therefore, research on establishing disease markers (clinical, ultrasonographical and serological) and clear diagnostic criteria, which could limit the risk of developing scleroderma renal crisis and facilitate diagnosis of this complication, is ongoing. Other forms of renal involvement in systemic sclerosis include vasculitis, an isolated reduced glomerular filtration rate in systemic sclerosis, antiphospholipid-associated nephropathy, high intrarenal arterial stiffness and proteinuria. Key Messages: Scleroderma renal crisis is the most specific and life-threatening renal presentation of systemic sclerosis, albeit with declining prevalence. In patients with scleroderma renal crisis, it is mandatory to control blood pressure early with increasing doses of angiotensin-converting enzyme inhibitors, along with other antihypertensive drugs if necessary. There is a strong association between renal involvement and patients' outcomes in systemic sclerosis; consequently, it becomes mandatory to find markers that may be used to identify patients with an especially high risk of scleroderma renal crisis.
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Affiliation(s)
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland,
| | - Mariusz Sikora
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | | | - Anna Stochmal
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | | | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
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Abstract
PURPOSE OF REVIEW Scleroderma renal crisis (SRC) is a life-threatening manifestation in systemic sclerosis (SSc) and is usually presented by an acute onset of severe hypertension together with an acute kidney injury. We can conceptualize SRC as a systemic syndrome with features that extend beyond the involvement of the kidney. The goal of this review is to inform clinicians about the risk factors for SRC in patients with SSc and to emphasize the importance of early identification and initiation of treatment. RECENT FINDINGS For the past 3 decades, the use of angiotensin-converting enzyme inhibitors (ACE-I) to treat SRC, has been rightfully synonymized with a good outcome, and has changed the trajectory of mortality in SRC. Despite this, SRC still figures in one of the top four causes of mortality in patients with SSc. There is a need for additional therapeutic agents to treat SRC that is refractory to ACE-I. There has been a recent interest in combining ACE-I with endothelin receptor blockers and agents targeting the complement component 5. There is no role for using ACE-I prophylactically in high-risk patients. SUMMARY Early diagnosis of SRC is the key, and early initiation of ACE-I is life-saving and associated with a better prognosis. We should consider renal transplantation in selected patients, especially those on long-term dialysis.
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20
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Cao XY, Liu H, Xu D, Li MT, Wang Q, Jiang L, Hou Y, Zhu LX, Zeng XF. Patterns of renal pathology in Chinese patients with systemic sclerosis undergoing renal biopsy at a tertiary medical center. J Int Med Res 2020; 48:300060519894456. [PMID: 31878823 PMCID: PMC7783277 DOI: 10.1177/0300060519894456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/21/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE We investigated renal injury characteristics in Chinese patients with systemic sclerosis (SSc) who had undergone renal biopsy. METHODS We searched the medical records of patients with SSc who were hospitalized at Peking Union Medical College Hospital between January 1990 and August 2019. We analyzed the clinical characteristics and pathological results of these patients. RESULTS We identified 25 patients who had undergone renal biopsy. Of these patients, 10 had scleroderma renal crisis (SRC); one underwent renal biopsy twice (for diffuse mesangial proliferative glomerulonephritis and for SRC); two had antineutrophil cytoplasmic antibody-associated glomerulonephritis; one had immunoglobulin M nephropathy; one had minimal change nephropathy; seven had lupus nephritis; one had scleroderma renal crisis with comorbid lupus nephritis; and two had drug-related kidney injury (caused by aristolochic acid in one and D-penicillamine in the other). Acute tubular necrosis was observed in the patient taking oral aristolochic acid, while minimal change nephropathy was observed in the patient with D-penicillamine-induced renal injury. CONCLUSIONS SRC was the most commonly encountered renal damage in patients with SSc. We recommend biopsy for patients undergoing treatment for SRC who have persistent renal injury with proteinuria, regardless of hematuria. Rheumatologists in Eastern countries should be aware of aristolochic acid nephropathy.
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Affiliation(s)
- Xiao-yu Cao
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
| | - He Liu
- Department of Ultrasound, Peking
Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking
Union Medical College, Beijing, China
| | - Dong Xu
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
| | - Meng-tao Li
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
| | - Qian Wang
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
| | - Li Jiang
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
| | - Yong Hou
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
| | - Li-xiu Zhu
- Department of Rheumatology, Ningde
Hospital Affiliated to Fujian Medical University, Ningde, Fujian Province,
China
| | - Xiao-feng Zeng
- Department of Rheumatology and
Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Graduate School of Peking
Union Medical College, Beijing, China
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21
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Suga K, Yamashita H, Takahashi Y, Katagiri D, Hinoshita F, Kaneko H. Therapeutic efficacy of combined glucocorticoid, intravenous cyclophosphamide, and double-filtration plasmapheresis for skin sclerosis in diffuse systemic sclerosis. Medicine (Baltimore) 2020; 99:e19301. [PMID: 32150064 PMCID: PMC7478820 DOI: 10.1097/md.0000000000019301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We treated skin sclerosis with triple therapy consisting of a glucocorticoid, intravenous cyclophosphamide, and double-filtration plasmapheresis. The objective of this study was to analyze its effectiveness in a case series of patients who received triple therapy.We enrolled 8 patients with diffuse cutaneous systemic sclerosis (dcSSc) who received triple therapy at our hospital from 2008 to 2016. We analyzed the mean change in the modified Rodnan skin score (mRSS), percentage of the predicted forced vital capacity (%FVC), percentage of the predicted carbon monoxide diffusing capacity (%DLCO), and serum KL-6 levels from baseline to follow-up.All patients were treated with an intermediate dose of oral prednisolone (30.6 ± 2.1 mg/day) initially. The mean cumulative dose of intravenous cyclophosphamide was 1.4 ± 0.2 g. The mean mRSS decreased significantly at follow-up compared with that at baseline (27.0 ± 3.3 vs 15.8 ± 3.5; P = .03). At the end of the treatment, the mean %FVC and %DLCO were improved moderately, although the differences were not significant. The serum KL-6 levels decreased from 578.9 ± 146.5 to 205.3 ± 43.1 U/ml (P = .02). No significant correlation was found between the change in mRSS or disease duration and the initial skin score severity.Triple therapy may improve skin sclerosis, with effectiveness equal or superior to other reported treatments. This preliminary case series demonstrates the potential of triple therapy for treating dcSSc. However, prospective studies with long-term follow-up should be performed to assess its role.
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Affiliation(s)
| | | | | | - Daisuke Katagiri
- Division of Nephrology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Fumihiko Hinoshita
- Division of Nephrology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
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22
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Khanna D, Tashkin DP, Denton CP, Lubell MW, Vazquez-Mateo C, Wax S. Ongoing clinical trials and treatment options for patients with systemic sclerosis-associated interstitial lung disease. Rheumatology (Oxford) 2020; 58:567-579. [PMID: 29893938 PMCID: PMC6434373 DOI: 10.1093/rheumatology/key151] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/24/2018] [Indexed: 01/20/2023] Open
Abstract
SSc is a rare CTD that affects multiple organ systems, resulting in substantial morbidity and mortality. Evidence of interstitial lung disease (ILD) is seen in ∼80% of patients with SSc. Currently there is no approved disease-modifying treatment for ILD and few effective treatment options are available. CYC is included in treatment guidelines, but it has limited efficacy and is associated with toxicity. MMF is becoming the most commonly used medication in clinical practice in North America and the UK, but its use is not universal. Newer agents targeting the pathogenic mechanisms underlying SSc-ILD, including fibrotic and inflammatory pathways, lymphocytes, cell-cell and cell-extracellular membrane interactions, hold promise for better treatment outcomes, including improved lung function, patient-related outcomes and quality of life. Here we review ongoing trials of established and novel agents that are currently recruiting patients with SSc-ILD.
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Affiliation(s)
- Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Donald P Tashkin
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Christopher P Denton
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Martin W Lubell
- Global Clinical Development, EMD Serono Inc., Billerica, MA, USA
| | | | - Stephen Wax
- Global Clinical Development, EMD Serono Inc., Billerica, MA, USA
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23
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Acute Heart Failure in Scleroderma Renal Crisis: A Case Study for Review of Cardiac Disease in Systemic Sclerosis. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:1-7. [PMID: 31773058 PMCID: PMC6878899 DOI: 10.12691/ajmcr-8-1-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight recent data regarding feasibility and outcomes following lung transplantation for patients with systemic sclerosis related pulmonary disease as well as to emphasize areas of uncertainly in need of further study. We include a description of our centre's approach to lung transplant evaluation and posttransplant management in this complex patient population. RECENT FINDINGS Historical data have demonstrated that patients with scleroderma have an increased risk of complications following lung transplantation owing to the multisystem nature of disease, particularly concurrent gastrointestinal, cardiac and renal involvement. Emerging data support the safety of lung transplant in appropriately selected patients with scleroderma-related interstitial lung disease and pulmonary arterial hypertension. SUMMARY Accumulating evidence validates that a diagnosis of scleroderma is not a priori a contraindication to lung transplant. In the carefully selected patient, both short-term and long-term outcomes following lung transplantation are comparable to counterparts with fibrotic lung disease or pulmonary arterial hypertension. However, further prospective study to detail how these patients should be evaluated and managed posttransplant is definitely needed. Cardiac disease is an emerging cause of morbidity and mortality in the scleroderma population and deserves particular attention during the pre and posttransplant period.
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Gordon SM, Hughes JB, Nee R, Stitt RS, Bailey WT, Little DJ, Edison JD, Olson SW. Systemic sclerosis medications and risk of scleroderma renal crisis. BMC Nephrol 2019; 20:279. [PMID: 31345158 PMCID: PMC6659266 DOI: 10.1186/s12882-019-1467-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/17/2019] [Indexed: 01/13/2023] Open
Abstract
Background Scleroderma Renal Crisis (SRC) is associated with significant morbidity and mortality. While prednisone is strongly associated with SRC, there are no previous large cohort studies that have evaluated ace inhibitor (ACEi) calcium channel blocker (CCB), angiotensin receptor blocker (ARB), endothelin receptor blocker (ERB), non-steroidal anti-inflammatory drug (NSAID), fluticasone, or mycophenolate mofetil (MMF) use in systemic sclerosis (SSc) and the risk of SRC. Methods In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the use of ACEi, ARB, CCB, NSAID, ERB, fluticasone, and MMF after SSc diagnosis for 31 cases who subsequently developed SRC to 322 SSc without SRC disease controls. Results ACEi was associated with an increased risk for SRC adjusted for age, race, and prednisone use [odds ratio (OR) 4.1, 95% confidence interval (CI) 1.6–10.2, P = 0.003]. On stratified analyses, ACEi was only associated with SRC in the presence [OR 5.3, 95% CI 1.1–29.2, p = 0.03], and not the absence of proteinuria. In addition, a doubling of ACEi dose [61% vs. 12%, p < 0.001) and achieving maximum ACEi dose [45% vs. 4%, p < 0.001] after SSc diagnosis was associated with future SRC. CCB, ARB, NSAIDs, ERB, fluticasone, and MMF use were not significantly associated with SRC. Conclusion ACEi use at SSC diagnosis was associated with an increased risk for SRC. Results suggest that it may be a passive marker of known SRC risk factors, such as proteinuria, or evolving disease. SSC patients that require ACEi should be more closely monitored for SRC.
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Affiliation(s)
- S M Gordon
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - J B Hughes
- Department of Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - R Nee
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - R S Stitt
- Rheumatology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - W T Bailey
- Rheumatology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - D J Little
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - J D Edison
- Rheumatology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - S W Olson
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA.
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Stifano G, Sornasse T, Rice LM, Na L, Chen-Harris H, Khanna D, Jahreis A, Zhang Y, Siegel J, Lafyatis R. Skin Gene Expression Is Prognostic for the Trajectory of Skin Disease in Patients With Diffuse Cutaneous Systemic Sclerosis. Arthritis Rheumatol 2019; 70:912-919. [PMID: 29858547 DOI: 10.1002/art.40455] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/08/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE At present, there are no clinical or laboratory measures that accurately forecast the progression of skin fibrosis and organ involvement in patients with systemic sclerosis (SSc). The goal of this study was to identify skin biomarkers that could be prognostic for the progression of skin fibrosis in patients with early diffuse cutaneous SSc (dcSSc). METHODS We analyzed clinical data and gene expression in skin biopsy samples from 38 placebo-treated patients, part of the Roche Safety and Efficacy of Subcutaneous Tocilizumab in Adults with Systemic Sclerosis (FASSCINATE) phase II study of tocilizumab in SSc. RNA samples were analyzed using nCounter. A trajectory model based on a modified Rodnan skin thickness score was used to describe 3 skin disease trajectories over time. We examined the association of skin gene expression with skin score trajectory groups, by chi-square test. Logistic regression was used to examine the prognostic power of each gene identified. RESULTS We found that placebo-treated patients with high expression of messenger RNA for CD14, SERPINE1, IL13RA1, CTGF, and OSMR at baseline were more likely to have progressive skin score trajectories. We also found that those genes were prognostic for the risk of skin progression and that IL13RA1, OSMR, and SERPINE1 performed the best. CONCLUSION Skin gene expression of biomarkers associated with macrophages (CD14, IL13RA1) and transforming growth factor β activation (SERPINE1, CTGF, OSMR) are prognostic for progressive skin disease in patients with dcSSc. These biomarkers may provide guidance in decision-making about which patients should be considered for aggressive therapies and/or for clinical trials.
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Affiliation(s)
| | | | - Lisa M Rice
- Boston University School of Medicine, Boston, Massachusetts
| | - Leo Na
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Dinesh Khanna
- University of Michigan Scleroderma Program, Ann Arbor
| | | | - Yuqing Zhang
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Robert Lafyatis
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Montrief T, Koyfman A, Long B. Scleroderma renal crisis: a review for emergency physicians. Intern Emerg Med 2019; 14:561-570. [PMID: 31076978 DOI: 10.1007/s11739-019-02096-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/27/2019] [Indexed: 12/15/2022]
Abstract
Scleroderma renal crisis (SRC) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of SRC. While SRC remains a rare clinical presentation, surveillance data suggest an overall incidence between 4 and 6% of patients with scleroderma. The diagnostic criteria for SRC include a new onset blood pressure > 150/85 mm Hg OR increase ≥ 20 mm Hg from baseline systolic blood pressure, along with a decline in renal function, defined as an increase serum creatinine of ≥ 10% and supportive features. There are many risk factors for SRC, including diffuse and rapidly progressive skin thickening, palpable tendon friction rubs, and new anemia or cardiac events. Critical patients should be evaluated in the resuscitation bay, and consultation with the nephrology team for appropriate patients improves patient outcomes.
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MESH Headings
- Angiotensin-Converting Enzyme Inhibitors/therapeutic use
- Antibodies, Antineutrophil Cytoplasmic/analysis
- Antibodies, Antineutrophil Cytoplasmic/blood
- Emergency Service, Hospital/organization & administration
- Humans
- Kidney Failure, Chronic/drug therapy
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/physiopathology
- Purpura, Thrombotic Thrombocytopenic/blood
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/physiopathology
- Renal Dialysis/methods
- Risk Factors
- Scleroderma, Systemic/blood
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/physiopathology
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Affiliation(s)
- Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Hospital/Miller School of Medicine, University of Miami, 1611 N.W. 12th Avenue, Miami, FL, 33136, USA
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
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de Almeida AR, Dantas AT, Pereira MC, Cordeiro MF, Gonçalves RSG, de Melo Rêgo MJB, da Rocha Pitta I, Duarte ALBP, da Rocha Pitta MG. Dexamethasone inhibits cytokine production in PBMC from systemic sclerosis patients. Inflammopharmacology 2019; 27:723-730. [PMID: 31069604 DOI: 10.1007/s10787-019-00600-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/27/2019] [Indexed: 01/19/2023]
Abstract
Glucocorticoids (GC) are widely used in the treatment of SSc, although there is not much evidence to prove the benefits offered by these drugs in this disease. In this study, we evaluated the effects of a GC on cytokine production in peripheral blood mononuclear cells (PBMC) of SSc patients. The effect of dexamethasone (DEX) was evaluated in PBMC of 21 SSc patients and 10 healthy volunteers after stimulation of cells with anti-CD3 and anti-CD28. Cytokines IL-2, IL-4, IL-6, IL-10, IL-17A, IL-17F, IFN-γ, TNF, and IL-1β were quantified in the culture supernatant by CBA or ELISA. Of the patients evaluated in this study, 8 (38%) were taking corticosteroids, and esophageal dysfunction was more frequent in these patients when compared to those who did not take corticosteroids. DEX (1.000 nM) treatment in PBMC of SSc patients stimulated with anti-CD3 and anti-CD28 promoted a significant reduction in IL-2, IL-4, IL-6, IL-10, IL-17A, IFN-γ, TNF, IL-1β (p < 0.001 for all), and IL-17F (p = 0.023) cytokines levels. We did not observe differences in response to in vitro treatment with DEX between groups of patients taking or not taking corticosteroids. In PBMC from healthy volunteers, we observed that DEX treatment significantly reduced IL-4, IFN-γ (p = 0.003 for both), IL-6, IL-10, IL-17A, and TNF (p = 0.002 for all) cytokines. These results show that DEX treatment in PBMC of SSc patients reduced the production of important cytokines involved in the pathogenesis of the disease, suggesting a possible mechanism of action of the CG in the treatment of SSc.
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Affiliation(s)
- Anderson Rodrigues de Almeida
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil
| | - Andréa Tavares Dantas
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil.,Serviço de Reumatologia, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Michelly Cristiny Pereira
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil
| | - Marina Ferraz Cordeiro
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil
| | - Rafaela Silva Guimarães Gonçalves
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil.,Serviço de Reumatologia, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Moacyr Jesus Barreto de Melo Rêgo
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil
| | - Ivan da Rocha Pitta
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil
| | - Angela Luzia Branco Pinto Duarte
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil.,Serviço de Reumatologia, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Maira Galdino da Rocha Pitta
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil.
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Burbelo PD, Gordon SM, Waldman M, Edison JD, Little DJ, Stitt RS, Bailey WT, Hughes JB, Olson SW. Autoantibodies are present before the clinical diagnosis of systemic sclerosis. PLoS One 2019; 14:e0214202. [PMID: 30913258 PMCID: PMC6435159 DOI: 10.1371/journal.pone.0214202] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 03/08/2019] [Indexed: 02/02/2023] Open
Abstract
Systemic sclerosis (SSc) is a heterogeneous autoimmune disorder associated with vascular dysfunction and fibrotic changes in the skin, vasculature and internal organs. Although serologic abnormalities are an important diagnostic tool for SSc, little is known about whether autoantibodies precede clinical diagnosis. Here we investigated the presence of autoantibodies before SSc diagnosis and assessed whether certain autoantibodies might associate with the future onset of scleroderma renal crisis (SRC), a potentially fatal complication of the disease. Using the Department of Defense Serum Repository, autoantibodies were analyzed from archived, prospectively collected, longitudinal serum samples from sixteen individuals with SRC (SSc/SRC) and thirty cases of SSc without SRC (SSc/no SRC), matched for age, sex, and race. Seventy five percent (12/16) of the SSc/SRC and 40% (12/30) of the SSc/no SRC were seropositive for at least one autoantibody prior to clinical diagnosis (up to 27.1 years earlier, mean = -7.4 years). Although both disease groups demonstrated a heterogeneous immunoreactivity profile against the autoantigen panel, the SSc/SRC subjects showed two enriched clusters with one featuring elevated levels of autoantibodies against Ro52 and/or Ro60 and another with high levels of immunoreactivity against the RNA polymerase complex. Consistent with larger spectrum of immunoreactivity and the elevated levels of autoantibodies in SSc/SRC, the total response against the autoantigen panel from the last time point of the seropositive subjects revealed that the SSc/SRC cohort harbored higher antibody levels (p = 0.02) compared to SSc/no SRC. Overall, our findings demonstrate that relevant seropositive autoantibodies often precede the clinical diagnosis of SSc/no SRC and SSc/SRC.
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Affiliation(s)
- Peter D. Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States of America
| | - Sarah M. Gordon
- Nephrology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - Meryl Waldman
- Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, and, National Institutes of Health, Bethesda, MD, United States of America
| | - Jess D. Edison
- Rheumatology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - Dustin J. Little
- Nephrology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - Rodger S. Stitt
- Rheumatology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - Wayne T. Bailey
- Rheumatology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - James B. Hughes
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Stephen W. Olson
- Nephrology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
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30
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Lung Transplantation in Connective Tissue Disease-Associated Interstitial Lung Disease (CTD-ILD). CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0207-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Zanatta E, Polito P, Favaro M, Larosa M, Marson P, Cozzi F, Doria A. Therapy of scleroderma renal crisis: State of the art. Autoimmun Rev 2018; 17:882-889. [DOI: 10.1016/j.autrev.2018.03.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/12/2018] [Indexed: 12/12/2022]
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Gordon SM, Stitt RS, Nee R, Bailey WT, Little DJ, Knight KR, Hughes JB, Edison JD, Olson SW. Risk Factors for Future Scleroderma Renal Crisis at Systemic Sclerosis Diagnosis. J Rheumatol 2018; 46:85-92. [PMID: 30008456 DOI: 10.3899/jrheum.171186] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is a disease of autoimmunity, fibrosis, and vasculopathy. Scleroderma renal crisis (SRC) is one of the most severe complications. Corticosteroid exposure, presence of anti-RNA polymerase III antibodies (ARA), skin thickness, and significant tendon friction rubs are among the known risk factors at SSc diagnosis for developing future SRC. Identification of additional clinical characteristics and laboratory findings could expand and improve the risk profile for future SRC at SSc diagnosis. METHODS In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the demographics, clinical characteristics, and laboratory results at SSc diagnosis for 31 cases who developed SRC after SSc diagnosis to 322 SSc without SRC disease controls. RESULTS After adjustment for potential confounding variables, at SSc diagnosis these conditions were all associated with future SRC: proteinuria (p < 0.001; OR 183, 95% CI 19.1-1750), anemia (p = 0.001; OR 9.9, 95% CI 2.7-36.2), hypertension (p < 0.001; OR 13.1, 95% CI 4.7-36.6), chronic kidney disease (p = 0.008; OR 20.7, 95% CI 2.2-190.7), elevated erythrocyte sedimentation rate (p < 0.001; OR 14.3, 95% CI 4.8-43.0), thrombocytopenia (p = 0.03; OR 7.0, 95% CI 1.2-42.7), hypothyroidism (p = 0.01; OR 2.8, 95% CI 1.2-6.7), Anti-Ro antibody seropositivity (p = 0.003; OR 3.9, 95% CI 1.6-9.8), and ARA (p = 0.02; OR 4.1, 95% CI 1.2-13.8). Three or more of these risk factors present at SSc diagnosis was sensitive (77%) and highly specific (97%) for future SRC. No SSc without SRC disease controls had ≥ 4 risk factors. CONCLUSION In this SSc cohort, we present a panel of risk factors for future SRC. These patients may benefit from close observation of blood pressure, proteinuria, and estimated glomerular filtration rate, for earlier SRC identification and intervention. Future prospective therapeutic studies could focus specifically on this high-risk population.
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Affiliation(s)
- Sarah M Gordon
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Rodger S Stitt
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Robert Nee
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Wayne T Bailey
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Dustin J Little
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Kendral R Knight
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - James B Hughes
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Jess D Edison
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center
| | - Stephen W Olson
- From the Nephrology Department, and the Rheumatology Department, Walter Reed National Military Medical Center; the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA. .,S.W. Olson, MD, Nephrology Department, Walter Reed National Military Medical Center; S.M. Gordon, MD, Nephrology Department, Walter Reed National Military Medical Center; R. Nee, MD, Nephrology Department, Walter Reed National Military Medical Center; R.S. Stitt, MD, Rheumatology Department, Walter Reed National Military Medical Center; W.T. Bailey, MD, Rheumatology Department, Walter Reed National Military Medical Center; D.J. Little, MD, Nephrology Department, Walter Reed National Military Medical Center; K.R. Knight, MD, Nephrology Department, Walter Reed National Military Medical Center; J.B. Hughes, Medical Student, Uniformed Services University of the Health Sciences; J.D. Edison, MD, Rheumatology Department, Walter Reed National Military Medical Center.
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Konma J, Kotani T, Shoda T, Suzuka T, Fujiki Y, Nagai K, Hata K, Yoshida S, Takeuchi T, Makino S, Arawaka S. Efficacy and safety of combination therapy with prednisolone and oral tacrolimus for progressive interstitial pneumonia with systemic sclerosis: A retrospective study. Mod Rheumatol 2018; 28:1009-1015. [PMID: 29442534 DOI: 10.1080/14397595.2018.1441658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We retrospectively investigated efficacy and safety of combination therapy with prednisolone (PSL) and tacrolimus (TAC) for progressive interstitial pneumonitis with systemic sclerosis (SSc-PIP). METHODS We studied 11 patients with SSc-PIP who received combination therapy with PSL (0.5 mg/kg/d) and TAC (3 mg/d). RESULTS Baseline Hugh-Jones grades were I, II, III, and IV in 2, 6, 2, and 1 patients, respectively. Krebs von den Lungen-6 (KL-6) values were elevated to 914 (range 300-2614) U/mL. % Diffusing capacity of carbon monoxide (%DLco) remarkably decreased to 47.4 (range 9.7-64.4) %. All patients were alive at 1 year after therapy. In response to treatment, interstitial pneumonia (IP) improved in three patients, stable in seven patients, and deteriorated in one patient. Total ground-glass opacity (GGO) score improved (p = .005). No significant changes occurred in values of KL-6, % forced vital capacity (%FVC), and %DLco. Presently, all seven patients who could be followed up were alive. IP improved in three patients and stable in four patients. Total GGO score improved (p = .016). KL-6, %FVC, and %DLco did not change. Mild cytomegalovirus or herpes zoster infection occurred in two patients. Grade I renal injuries were observed in three and one patient at 1 year and present, respectively. CONCLUSION Combination therapy with PSL and TAC appeared to be well tolerated and effective in suppressing the disease activity of SSc-PIP.
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Affiliation(s)
- Junichi Konma
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Takuya Kotani
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Takeshi Shoda
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Takayasu Suzuka
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Youhei Fujiki
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Koji Nagai
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Kenichiro Hata
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Shuzo Yoshida
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Tohru Takeuchi
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Shigeki Makino
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
| | - Shigeki Arawaka
- a Department of Internal Medicine (IV) , Osaka Medical College , Takatsuki , Osaka , Japan
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Bruni C, Cuomo G, Rossi FW, Praino E, Bellando-Randone S. Kidney involvement in systemic sclerosis: From pathogenesis to treatment. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:43-52. [PMID: 35382123 PMCID: PMC8892882 DOI: 10.1177/2397198318758607] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2018] [Indexed: 11/09/2023]
Abstract
Among all possible systemic sclerosis internal organ complications, kidney involvement is frequently neglected or underestimated, except for the life-threatening scleroderma renal crisis. Fortunately, this severe clinical presentation is nowadays better controlled with available treatments, in particular angiotensin-converting enzyme inhibitors, and this has led to a reduction in its short- and longer-term mortality. Pathogenetic determinants are not well understood and many different other kidney involvements are possible in systemic sclerosis, including proteinuria, albuminuria, reduction of renal filtration, autoantibodies-related glomerulonephritis, and drug-related side effects. Different serological and radiological methods of evaluations are nowadays available, some representing promising diagnostic tool and prognostic outcome measure. Except for angiotensin-converting enzyme inhibitors in scleroderma renal crisis, no other treatment is currently recommended for treatment of kidney involvement in systemic sclerosis. For this reason, further studies are necessary to investigate its prognostic impact, in particular in combination with other systemic sclerosis-related internal organ manifestations. This review summarizes current available literature on kidney involvement in systemic sclerosis.
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Affiliation(s)
- Cosimo Bruni
- Department of Experimental and
Clinical Medicine, Division of Rheumatology, University of Florence,
Florence - Italy
- Department of Geriatric Medicine,
Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero
Universitaria Careggi, Florence - Italy
| | - Giovanna Cuomo
- Department of Clinical and
Experimental Internal Medicine “F. Magrassi,” University of Study of
Campania “Luigi Vanvitelli,” Naples - Italy
| | - Francesca W. Rossi
- Department of Translational
Medical Sciences and Center for Basic and Clinical Immunology Research
(CISI), WAO Center of Excellence, University of Naples Federico II, Naples -
Italy
| | - Emanuela Praino
- Department of Emergency and Organ
Transplantation, Rheumatology Unit, University of Bari, Bari - Italy
| | - Silvia Bellando-Randone
- Department of Experimental and
Clinical Medicine, Division of Rheumatology, University of Florence,
Florence - Italy
- Department of Geriatric Medicine,
Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero
Universitaria Careggi, Florence - Italy
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George PM, Wells AU. Disease staging and sub setting of interstitial lung disease associated with systemic sclerosis: impact on therapy. Expert Rev Clin Immunol 2018; 14:127-135. [DOI: 10.1080/1744666x.2018.1427064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Peter M. George
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
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Determinants of mortality in systemic sclerosis: a focused review. Rheumatol Int 2017; 38:1847-1858. [PMID: 29116439 DOI: 10.1007/s00296-017-3826-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/20/2017] [Indexed: 02/06/2023]
Abstract
Scleroderma (systemic sclerosis) is an autoimmune rheumatic disorder that is characterized by fibrosis, vascular dysfunction, and autoantibody production that involves most visceral organs. It is characterized by a high morbidity and mortality rate, mainly due to disease-related complications. Epidemiological data describing mortality and survival in this population have been based on both population and observational studies. Multiple clinical and non-clinical factors have been found to predict higher likelihood of death among thepatients. Here, we do an extensive review of the available literature, utilizing the PubMed database, to describe scleroderma and non-scleroderma related determinants of mortality in this population. We found that even though the mortality among the general population has declined, scleroderma continues to carry a very high morbidity and mortality rate, however we have made some slow progress in improving the mortality among scleroderma patients over the last few decades.
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Controversies on the Use of Steroids in Systemic Sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017. [DOI: 10.5301/jsrd.5000234] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of corticosteroids in patients with systemic sclerosis (SSc) always requires caution (especially because corticosteroids are a risk factor for scleroderma renal crisis [SRC]), and is often controversial. This review focuses on the main area of controversy, that is whether corticosteroids should be prescribed in patients with early diffuse cutaneous SSc (dcSSc). The arguments for and against corticosteroids in this clinical situation are presented, along with two case histories to illustrate the clinical dilemma. In favour of corticosteroids, is that these might suppress the musculoskeletal manifestations and itch that are so disabling in early disease, the argument against is that patients with early dcSSc are those at highest risk of SRC. That current opinion is divided amongst clinicians is evidenced by a roughly even split between patients previously prescribed and those not prescribed corticosteroids in the recent European Scleroderma Observational Study of early dcSSc (43% of 326 patients were on corticosteroids at their baseline visit or had previously been prescribed these). Other clinical situations in which corticosteroids may be considered in patients with SSc (mainly overlap syndromes and pulmonary involvement) are briefly discussed. Finally, some additional concerns relating to corticosteroid use specifically in patients with SSc are highlighted.
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Wangkaew S, Lertthanaphok S, Puntana S, Noppakun K. Risk factors and outcome of Thai patients with scleroderma renal crisis: a disease duration-matched case control study. Int J Rheum Dis 2017; 20:1562-1571. [PMID: 28752678 DOI: 10.1111/1756-185x.13145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Data regarding the prevalence, risk factors and outcome of scleroderma renal crisis (SRC) in Asian patients with systemic sclerosis (SSc) are limited. OBJECTIVE To determine the prevalence, risk factors and outcomes of SRC in Thai SSc patients. METHOD Medical records of all SSc patients seen at the Division of Rheumatology, Chiang Mai University, Thailand, from January 1990 to December 2015 were retrospectively reviewed. For each SRC case, a disease duration (±1 year) matched control (four SSc patient without SRC for each SRC patient) was identified. RESULT Of 608 SSc patients seen during the study period, 19 SRC cases were identified, resulting in an SRC prevalence of 3.13%, with 76 matched controls. Of the 19 cases, mean ± SD age and median (interquartile range 1-3) disease duration was 56.2 ± 13.8 years and 5 (3-22) months, respectively. Seventeen patients (89.5%) had diffuse cutaneous SSc. Twelve patients (63.2%) had hypertensive renal crisis and seven (36.8%) had normotensive renal crisis. Multivariate conditional logistic regression analyses showed that digital gangrene (adjusted odd ratio [AOR] 31.41, 95% CI = 1.16-852.23, P = 0.041), current prednisolone dose ≥ 15 mg/day (AOR 31.22, 95% CI = 1.59-613.85, P = 0.024), serum albumin < 3 mg/dL (AOR 7.97, 95% CI = 1.49-42.56, P = 0.015), and cardiac involvement (AOR = 6.62, 95% CI = 1.08-40.63, P = 0.041) were independent risk factors for SRC. Fifteen SRC patients (78.9%) required dialysis and 10 (52.6%) died. CONCLUSION SRC was an uncommon complication in Thai patients with SSc, but is associated with high mortality. Digital gangrene, current prednisolone dose ≥ 15 mg/day, serum albumin < 3 mg/dL and cardiac involvement were independent risk factors for SRC.
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Affiliation(s)
- Suparaporn Wangkaew
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Supawita Lertthanaphok
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Saowanee Puntana
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kajohnsak Noppakun
- Division of Nephrology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
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Abstract
Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are
leading causes of morbidity and mortality in systemic sclerosis (SSc). As
symptoms are often under-reported in SSc, early screening of ILD and PAH is of
paramount importance, and early treatment may be associated with better clinical
outcomes. Serologies are particularly helpful in identifying patients at risk
for pulmonary involvement. Pulmonary function testing, high-resolution computed
tomography of the chest and echocardiography are important tools in the initial
screening of these patients. Extensive research has also led to an improved
understanding of the mediators involved in the pathogenesis of ILD and PAH. As a
result, there have been significant advances in the development of novel
targeted therapeutics and an increase in the number of early-phase clinical
trials in SSc.
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Affiliation(s)
- Sara R Schoenfeld
- Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Flavia V Castelino
- Division of Rheumatology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 2C-2100, Boston, MA 02114, USA
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Hoa S, Stern EP, Denton CP, Hudson M. Towards developing criteria for scleroderma renal crisis: A scoping review. Autoimmun Rev 2017; 16:407-415. [PMID: 28212921 DOI: 10.1016/j.autrev.2017.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/18/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The absence of a gold standard for scleroderma renal crisis (SRC) has hindered our understanding of this problem. The objective of this scoping review was to identify the criteria used to define SRC in order to guide the development of a consensus definition for SRC. METHODS We conducted a search in three databases: Medline, Embase and non-Ovid Pubmed. Papers were eligible for inclusion if they were full-length articles in English whose main topic was SRC or scleroderma renal disease. Two reviewers independently screened eligible papers for final study selection. Data was extracted using a customized form. A web-based survey of members of the Scleroderma Clinical Trials Consortium was used to identify unpublished definitions of SRC. RESULTS We identified 415 papers that met inclusion criteria. Forty original definitions of SRC were identified from 36 studies, 9 reviews and 2 editorials. There was significant heterogeneity in definitions. As a rule, though, in addition to new-onset hypertension and acute kidney injury, other common items used to define SRC included hypertensive encephalopathy and seizures, microangiopathic hemolytic anemia and characteristic changes on kidney biopsy. The web-based survey identified unpublished definitions of SRC that were largely consistent with the results of the published literature. CONCLUSION SRC was defined in a minority of studies and criteria were heterogeneous. A consensus definition of SRC is urgently needed to standardize data collection on SRC and further our understanding of this serious problem.
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Affiliation(s)
- Sabrina Hoa
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Edward P Stern
- Centre for Rheumatology, Royal Free London and UCL Division of Medicine, London, UK
| | - Christopher P Denton
- Centre for Rheumatology, Royal Free London and UCL Division of Medicine, London, UK
| | - Marie Hudson
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada
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Yanaba K. Strategy for treatment of fibrosis in systemic sclerosis: Present and future. J Dermatol 2017; 43:46-55. [PMID: 26782006 DOI: 10.1111/1346-8138.13026] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/06/2015] [Indexed: 11/30/2022]
Abstract
Systemic sclerosis (SSc) is a generalized connective tissue disorder characterized by microvascular damage, autoimmunity, and excessive fibrosis of the skin and various internal organs. Regardless of the recent progress in medicine, no radical therapy for SSc has been developed, and the risk of mortality remains high. Therefore, diagnosis in the early disease stage, risk stratification for the development of serious organ involvement and therapeutic intervention with disease-modifying drugs can reduce the maximum degree of fibrosis, leading to improved long-term survival. Recently, new criteria for very early diagnosis of SSc have been proposed, which are expected to be useful for regularly following up patients with very early SSc, regardless of the absence of skin sclerosis, and for detecting the development of internal organ involvement as early as possible. At present, several immunosuppressants, including methotrexate, corticosteroids and cyclophosphamide, are being used for the treatment of fibrosis. Furthermore, mycophenolate mofetil, i.v. immunoglobulins, B-cell depletion, anti-interleukin-6 receptor antibody, autologous hematopoietic stem cell transplantation, rapamycin, pirfenidone and imatinib mesylate are potential candidates for the treatment of SSc, although their efficacy has not been validated. Moreover, targeting transforming growth factor-1 and its signaling pathway or modulating the imbalance between T-helper 1 and 2 immune responses are also attractive therapeutic options. This review describes recent advances in the strategy for treatment of fibrosis in SSc and future perspectives.
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Affiliation(s)
- Koichi Yanaba
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
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Iudici M. What should clinicians know about the use of glucocorticoids in systemic sclerosis? Mod Rheumatol 2017; 27:919-923. [DOI: 10.1080/14397595.2016.1270796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Michele Iudici
- Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
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Musculoskeletal Involvement in Systemic Sclerosis: An Unexplored Aspect of the Disease. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016. [DOI: 10.5301/jsrd.5000228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Musculoskeletal (MSK) symptoms in patients with systemic sclerosis (SSc) include articular involvement (arthralgia, synovitis, contractures), which is often an early phenomenon and significantly contributes to the disability. Predominantly the hands are affected. Consensus in outcome measures of articular involvement is missing. Health Assessment Questionnaire Disability Index (HAQ-DI), Cochin Hand Function Scale (CHFS), Hand Mobility Index in Scleroderma (HAMIS), and Disease Activity Score of 28 Joints (DAS28) may be used for the assessment of different aspects of joint involvement. There is an unmet need for therapies confirmed by randomized controlled clinical trials (RCTs) to treat both synovitis and non-inflammatory joint involvement. The few rehabilitation studies that have been conducted have shown some promising efficacy. Muscle involvement may be an early symptom. The presence of clinically meaningful muscle involvement often heralds an unfavourable prognosis. The histology of muscle biopsy shows a variable picture including inflammation and necrosis. Besides, signs of acute neurogenic atrophy have been recently described as a previously underestimated contributor to muscle weakness. Similar to articular involvement, the lack of classification criteria on inflammatory and non-inflammatory SSc-associated myopathies, and the lack of validated core set of outcome measures makes it difficult to perform RCTs. The SSc-specific fibrinous tenosynovitis (tendon-friction rubs /TFRs/) is a frequent finding in SSc. Patients with TFR are at increased risk of developing renal, vascular, cardiac and gastrointestinal involvement and have reduced survival rates. Changes of fibrinous tenosynovitis can be objectively detected by ultrasound and may be used as an outcome measure in the treatment of MSK involvement.
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45
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Pellar RE, Pope JE. Evidence-based management of systemic sclerosis: Navigating recommendations and guidelines. Semin Arthritis Rheum 2016; 46:767-774. [PMID: 28088339 DOI: 10.1016/j.semarthrit.2016.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a rare heterogeneous connective tissue disease. Recommendations addressing the major issues in the management of SSc including screening and treatment of organ complications are needed. METHODS The updated European League Against Rheumatism/European Scleroderma Trial and Research (EULAR/EUSTAR) and the British Society of Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guidelines were compared and contrasted. RESULTS The updated EULAR/EUSTAR guidelines focus specifically on the management of SSc features and include data on newer therapeutic modalities and mention a research agenda. These recommendations are pharmacologic, with few guidelines regarding investigations and non-pharmacologic management. Recommendations from BSR/BHPR are similar to the organ manifestations mentioned in the EULAR/EUSTAR recommendations, and expand on several domains of treatment, including general measures, non-pharmacologic treatment, cardiac involvement, calcinosis, and musculoskeletal features. The guidelines usually agree with one another. Limitations include the lack of guidance for combination or second-line therapy, algorithmic suggestions, the absence of evidence-based recommendations regarding the treatment of specific complications (i.e., gastric antral ectasia and erectile dysfunction). Consensus for when to treat interstitial lung disease in SSc is lacking. There are differences between Europe and North American experts due to access and indications for certain therapies. CONCLUSIONS Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc and future updates of these recommendations. Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc.
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Affiliation(s)
| | - Janet Elizabeth Pope
- Department of Medicine, University of Western Ontario, London, ON, Canada; St Joseph Health Care, London, ON, Canada.
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Kowal-Bielecka O, Fransen J, Avouac J, Becker M, Kulak A, Allanore Y, Distler O, Clements P, Cutolo M, Czirjak L, Damjanov N, Del Galdo F, Denton CP, Distler JHW, Foeldvari I, Figelstone K, Frerix M, Furst DE, Guiducci S, Hunzelmann N, Khanna D, Matucci-Cerinic M, Herrick AL, van den Hoogen F, van Laar JM, Riemekasten G, Silver R, Smith V, Sulli A, Tarner I, Tyndall A, Welling J, Wigley F, Valentini G, Walker UA, Zulian F, Müller-Ladner U. Update of EULAR recommendations for the treatment of systemic sclerosis. Ann Rheum Dis 2016; 76:1327-1339. [PMID: 27941129 DOI: 10.1136/annrheumdis-2016-209909] [Citation(s) in RCA: 636] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/22/2016] [Accepted: 10/09/2016] [Indexed: 12/16/2022]
Abstract
The aim was to update the 2009 European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis (SSc), with attention to new therapeutic questions. Update of the previous treatment recommendations was performed according to EULAR standard operating procedures. The task force consisted of 32 SSc clinical experts from Europe and the USA, 2 patients nominated by the pan-European patient association for SSc (Federation of European Scleroderma Associations (FESCA)), a clinical epidemiologist and 2 research fellows. All centres from the EULAR Scleroderma Trials and Research group were invited to submit and select clinical questions concerning SSc treatment using a Delphi approach. Accordingly, 46 clinical questions addressing 26 different interventions were selected for systematic literature review. The new recommendations were based on the available evidence and developed in a consensus meeting with clinical experts and patients. The procedure resulted in 16 recommendations being developed (instead of 14 in 2009) that address treatment of several SSc-related organ complications: Raynaud's phenomenon (RP), digital ulcers (DUs), pulmonary arterial hypertension (PAH), skin and lung disease, scleroderma renal crisis and gastrointestinal involvement. Compared with the 2009 recommendations, the 2016 recommendations include phosphodiesterase type 5 (PDE-5) inhibitors for the treatment of SSc-related RP and DUs, riociguat, new aspects for endothelin receptor antagonists, prostacyclin analogues and PDE-5 inhibitors for SSc-related PAH. New recommendations regarding the use of fluoxetine for SSc-related RP and haematopoietic stem cell transplantation for selected patients with rapidly progressive SSc were also added. In addition, several comments regarding other treatments addressed in clinical questions and suggestions for the SSc research agenda were formulated. These updated data-derived and consensus-derived recommendations will help rheumatologists to manage patients with SSc in an evidence-based way. These recommendations also give directions for future clinical research in SSc.
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Affiliation(s)
- Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Jaap Fransen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jerome Avouac
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Mike Becker
- University Hospital Charité, Berlin, Germany.,University Hospital Zurich, Zurich, Switzerland
| | - Agnieszka Kulak
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | | | - Philip Clements
- University of California at Los Angeles, Los Angeles, California, USA
| | - Maurizio Cutolo
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
| | - Laszlo Czirjak
- Department of Rheumatology and Immunology, Medical Center, University of Pecs, Pecs, Hungary
| | | | | | | | | | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, Germany
| | | | | | - Daniel E Furst
- University of California at Los Angeles, Los Angeles, California, USA
| | | | | | - Dinesh Khanna
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - Ariane L Herrick
- University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester, UK
| | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Richard Silver
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vanessa Smith
- Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
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[Systemic sclerosis : What is currently available for treatment?]. Internist (Berl) 2016; 57:1155-1163. [PMID: 27796473 DOI: 10.1007/s00108-016-0148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic sclerosis (scleroderma) is a rheumatologic disease characterised not only by inflammation/autoimmunity, but also by tissue fibrosis and vascular lesions. The therapeutic approach to patients is dictated by the organ involvement and includes treatment of vascular and fibrotic disease features beyond mere immunosuppression. Fibrotic features in particular, are still inadequately treated, whereas many drugs have been tested for vascular complications within recent years. In this review, the currently available treatment options for this rare disease are presented. Therapy options in systemic sclerosis have changed over the past 10 years and this trend will also continue in the future.
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48
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Long-term clinical stabilization of scleroderma patients treated with a chronic and intensive IV iloprost regimen. Rheumatol Int 2016; 37:245-249. [PMID: 27796521 PMCID: PMC5258785 DOI: 10.1007/s00296-016-3582-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/19/2016] [Indexed: 12/02/2022]
Abstract
Intravenous iloprost is a first-line option for the treatment of scleroderma-related digital vasculopathy, and some studies have suggested its favourable role on disease progression. The aim of our study is to evaluate the disease progression, specifically in terms of cardiopulmonary function, in a group of consecutive patients chronically treated with intravenous iloprost. Our retrospective study enrolled 68 scleroderma patients (68 F, 54.4 ± 12.3 years) treated with iloprost for 7.1 ± 2.9 years, with a schedule of 5–6 consecutive daily infusions per month (6 h/day, 0.5–2.0 ng/kg/min). In all patients, modified Rodnan skin score (4.7 ± 5.3 vs. 3.7 ± 5.3, p < 0.0001), systolic pulmonary arterial pressure (sPAP) (30.9 ± 6.4 vs. 24.0 ± 3.2 mmHg, p < 0.0001), tricuspid annular plane systolic excursion (22.1 ± 2.4 vs. 23.8 ± 3.5 mm, p = 0.0001), pro-brain natriuretic peptide (97.2 ± 69.3 vs. 65.8 ± 31.7 pg/ml, p = 0.0005) showed statistically significant improvement from baseline. In the subgroup of patients with baseline sPAP ≥36 mmHg (n = 17), a significant sPAP reduction was observed (from 39.5 ± 3.8 to 25.1 ± 4.5 mmHg, p < 0.0001) after 7.6 ± 2.5 years of follow-up. The number of patients with digital ulcers (DUs) at follow-up was reduced from baseline (42.6 vs. 11.8%, p < 0.001), and none of the free-DU patients at baseline presented DUs at follow-up. An intensive and chronic regimen of IV iloprost administration seems to stabilize and potentially improve the long-term development of disease in SSc patients, as suggested by stabilization or significant improvement of cardiopulmonary parameters and vasculopathy.
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Abstract
Scleroderma renal crisis (SRC) is a rare, potentially life-threatening complication that affects 2-15% of patients with systemic sclerosis (SSc, also known as scleroderma). SRC typically presents in patients with early, rapidly progressive, diffuse cutaneous SSc within the first 3-5 years after the onset of a non-Raynaud sign or symptom. SRC is characterized by an acute, usually symptomatic increase in blood pressure, a rise in serum creatinine levels, oliguria and thrombotic microangiopathy in about 50% of patients. The prognosis of SRC substantially improved in the 1980s with the introduction of angiotensin-converting-enzyme inhibitors for rapid blood pressure control, with additional antihypertensive agents as required. However, the survival of patients with SRC can still be improved. Current patient survival is 70-82% at 1 year, but decreases to 50-60% at 5 years despite dialysis support. Patients with SRC who show no signs of renal functional recovery despite timely blood pressure control are candidates for transplantation. In this Review, we discuss progress made in the identification and proactive management of patients at risk of SRC and make recommendations aimed at optimizing management for those who progress to chronic kidney failure.
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50
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Affiliation(s)
- Efua Asamoah-Odei
- Internal Medicine-Nephrology, Christiana Care Health Services, Christiana Care Health System, Newark, Delaware, USA
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