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Accapezzato D, Caccavale R, Paroli MP, Gioia C, Nguyen BL, Spadea L, Paroli M. Advances in the Pathogenesis and Treatment of Systemic Lupus Erythematosus. Int J Mol Sci 2023; 24:ijms24076578. [PMID: 37047548 PMCID: PMC10095030 DOI: 10.3390/ijms24076578] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a genetically predisposed, female-predominant disease, characterized by multiple organ damage, that in its most severe forms can be life-threatening. The pathogenesis of SLE is complex and involves cells of both innate and adaptive immunity. The distinguishing feature of SLE is the production of autoantibodies, with the formation of immune complexes that precipitate at the vascular level, causing organ damage. Although progress in understanding the pathogenesis of SLE has been slower than in other rheumatic diseases, new knowledge has recently led to the development of effective targeted therapies, that hold out hope for personalized therapy. However, the new drugs available to date are still an adjunct to conventional therapy, which is known to be toxic in the short and long term. The purpose of this review is to summarize recent advances in understanding the pathogenesis of the disease and discuss the results obtained from the use of new targeted drugs, with a look at future therapies that may be used in the absence of the current standard of care or may even cure this serious systemic autoimmune disease.
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Affiliation(s)
- Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Rosalba Caccavale
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Maria Pia Paroli
- Eye Clinic, Department of Sense Organs, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Bich Lien Nguyen
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Luca Spadea
- Post Graduate School of Public Health, University of Siena, 53100 Siena, Italy
| | - Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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2
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Kim JW, Suh CH. The Safety of Medications During Pregnancy and Lactation in Patients with Inflammatory Rheumatic Diseases. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/21-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The advances in treatments, including disease-modifying anti-rheumatic drugs and biologic agents, have significantly improved the management of inflammatory rheumatic diseases, allowing females with severe disease to become pregnant and lactate, previously considered as prohibited. Maintaining low disease activity with medications known to be safe from pre-conception to post-partum is a key point in reducing adverse pregnancy outcomes. Numerous observational and case studies have provided a growing amount of evidence on the use of safe anti-rheumatic medications in patients during pregnancy and lactation. Based on this information, this review discusses the safety of medications for patients with inflammatory rheumatic diseases during pregnancy and lactation. Among these, hydroxychloroquine, sulfasalazine, azathioprine, low-dose glucocorticoids, and low-dose aspirin are considered compatible with pregnancy, while methotrexate, cyclophosphamide, mycophenolate mofetil, and leflunomide are contraindicated. Non-steroidal anti-inflammatory drugs are only recommended for use early in pregnancy, as they are reported to cause rare but serious kidney problems in the fetus after 20 weeks or later. Cyclosporin, tacrolimus, and anti-TNF agents can be continued throughout pregnancy if the benefit is greater than the potential risk for the individual patient. Physicians should carefully weigh the risks and benefits of medications in patients with inflammatory rheumatic diseases considering pregnancy.
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Affiliation(s)
- Ji-Won Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Li X, Shopit A, Wang J. Biochemical and clinical predictors in pregnant women with antiphospholipid syndrome and systemic lupus erythematosus: comprehensive update. Arch Gynecol Obstet 2021; 304:1153-1160. [PMID: 34390384 DOI: 10.1007/s00404-021-06178-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Autoimmune diseases as antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) could cause many maternal complications. The most common maternal complications of autoimmune diseases are lupus flare, hypertension, nephritis, preeclampsia (PE), eclampsia, and poor pregnancy outcomes which including preterm delivery and pregnancy loss. Only the lupus anticoagulant in the greatest prospective multicenter study has been associated with adverse pregnancy outcomes of the APS. PURPOSE This review aims to provide a comprehensive update for predictors in pregnant women with APS/SLE. METHODS These data have been collected from clinical and pathological studies, systematic reviews, and meta-analysis. RESULTS In recent years the SLE and APS demonstrated to have different and valuable clinical and biomarker predictors for the pregnancy outcome. Treatment of pregnant women with APS is low molecular weight heparin (LMWH) and aspirin; however, around 75% of this management is considered successful. CONCLUSION This review summarizes recent research that focuses on biochemical and clinical predictors of adverse pregnancy outcomes (APOs) of pregnant women with SLE and APS. Furthermore, we have collected more evidence that confirms the safety and efficacy of hydroxychloroquine (HCQ) preventing APOs.
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Affiliation(s)
- Xiaodong Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116044, China
| | - Abdullah Shopit
- Department of Pharmacology, Academic Integrated Medicine and College of Pharmacy, Dalian Medical University, Dalian, 116044, China
| | - Jingmin Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116044, China.
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Singampalli KL, Jui E, Shani K, Ning Y, Connell JP, Birla RK, Bollyky PL, Caldarone CA, Keswani SG, Grande-Allen KJ. Congenital Heart Disease: An Immunological Perspective. Front Cardiovasc Med 2021; 8:701375. [PMID: 34434978 PMCID: PMC8380780 DOI: 10.3389/fcvm.2021.701375] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/13/2021] [Indexed: 12/28/2022] Open
Abstract
Congenital heart disease (CHD) poses a significant global health and economic burden-despite advances in treating CHD reducing the mortality risk, globally CHD accounts for approximately 300,000 deaths yearly. Children with CHD experience both acute and chronic cardiac complications, and though treatment options have improved, some remain extremely invasive. A challenge in addressing these morbidity and mortality risks is that little is known regarding the cause of many CHDs and current evidence suggests a multifactorial etiology. Some studies implicate an immune contribution to CHD development; however, the role of the immune system is not well-understood. Defining the role of the immune and inflammatory responses in CHD therefore holds promise in elucidating mechanisms underlying these disorders and improving upon current diagnostic and treatment options. In this review, we address the current knowledge coinciding CHDs with immune and inflammatory associations, emphasizing conditions where this understanding would provide clinical benefit, and challenges in studying these mechanisms.
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Affiliation(s)
- Kavya L. Singampalli
- Department of Bioengineering, Rice University, Houston, TX, United States
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, United States
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Elysa Jui
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Kevin Shani
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, United States
| | - Yao Ning
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | | | - Ravi K. Birla
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
- Division of Congenital Heart Surgery, Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Paul L. Bollyky
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Christopher A. Caldarone
- Division of Congenital Heart Surgery, Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Sundeep G. Keswani
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
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5
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Canny SP, Jackson SW. B Cells in Systemic Lupus Erythematosus: From Disease Mechanisms to Targeted Therapies. Rheum Dis Clin North Am 2021; 47:395-413. [PMID: 34215370 PMCID: PMC8357318 DOI: 10.1016/j.rdc.2021.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
B cells exert a prominent contribution to the pathogenesis of systemic lupus erythematosus (SLE). Here, we review the immune mechanisms underlying autoreactive B cell activation in SLE, focusing on how B cell receptor and Toll-like receptor signals integrate to drive breaks in tolerance to nuclear antigens. In addition, we discuss autoantibody-dependent and autoantibody-independent B cell effector functions during lupus pathogenesis. Finally, we address efforts to target B cells therapeutically in human SLE. Despite initial disappointing clinical trials testing B cell depletion in lupus, more recent studies show promise, emphasizing how greater understanding of underlying immune mechanisms can yield clinical benefits.
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Affiliation(s)
- Susan P Canny
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Benaroya Research Institute, 1201 Ninth Avenue, Seattle, WA 98101, USA
| | - Shaun W Jackson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA.
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Abstract
PURPOSE OF REVIEW This review summarizes recent research in the field of systemic lupus erythematosus (SLE) and pregnancy with focus on clinical and biochemical predictors of adverse pregnancy outcomes (APOs), accumulating evidence for the safety and efficacy of hydroxychloroquine (HCQ) in pregnancy, and the importance of preconception counseling. RECENT FINDINGS Ongoing research from PROMISSE investigators (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) adds to the understanding of risk factors for APOs in SLE pregnancies, including aberrant complement activation, incomplete downregulation of lupus-associated transcription factors, and lower socioeconomic status. Evidence supporting numerous advantages for continuing HCQ in pregnancy, as well as support for low-dose aspirin in preeclampsia prevention is reviewed. Practice gaps exist among rheumatologists in ensuring effective contraception when women of childbearing age are undergoing therapy with potentially fetotoxic medications. The publication of organizational guidelines provides evidence-based recommendations on lupus pregnancy management. SUMMARY Outcomes of lupus pregnancies continue to improve with understanding of risk factors that predict APOs as well as improvements in disease management. Rheumatologists caring for women with SLE should be familiar with the most up-to-date research in order to optimize pregnancy outcomes in this population.
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Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, Marder W, Guyatt G, Branch DW, Buyon J, Christopher-Stine L, Crow-Hercher R, Cush J, Druzin M, Kavanaugh A, Laskin CA, Plante L, Salmon J, Simard J, Somers EC, Steen V, Tedeschi SK, Vinet E, White CW, Yazdany J, Barbhaiya M, Bettendorf B, Eudy A, Jayatilleke A, Shah AA, Sullivan N, Tarter LL, Birru Talabi M, Turgunbaev M, Turner A, D'Anci KE. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken) 2020; 72:461-488. [PMID: 32090466 DOI: 10.1002/acr.24130] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). METHODS We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary. RESULTS This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD. CONCLUSION This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.
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Affiliation(s)
- Lisa R Sammaritano
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Michael D Lockshin
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | - Wendy Marder
- University of Michigan School of Medicine, Ann Arbor
| | | | | | - Jill Buyon
- New York University School of Medicine, New York, New York
| | | | | | - John Cush
- Baylor Research Institute, Dallas, Texas
| | | | | | | | - Lauren Plante
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane Salmon
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Evelyne Vinet
- McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Medha Barbhaiya
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | - Amanda Eudy
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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8
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Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, Marder W, Guyatt G, Branch DW, Buyon J, Christopher‐Stine L, Crow‐Hercher R, Cush J, Druzin M, Kavanaugh A, Laskin CA, Plante L, Salmon J, Simard J, Somers EC, Steen V, Tedeschi SK, Vinet E, White CW, Yazdany J, Barbhaiya M, Bettendorf B, Eudy A, Jayatilleke A, Shah AA, Sullivan N, Tarter LL, Birru Talabi M, Turgunbaev M, Turner A, D'Anci KE. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2020; 72:529-556. [DOI: 10.1002/art.41191] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | | | | | | | - Wendy Marder
- University of Michigan School of Medicine Ann Arbor
| | | | | | - Jill Buyon
- New York University School of Medicine New York New York
| | | | | | - John Cush
- Baylor Research Institute Dallas Texas
| | | | | | | | - Lauren Plante
- Drexel University College of Medicine Philadelphia Pennsylvania
| | - Jane Salmon
- Weill Cornell MedicineHospital for Special Surgery New York New York
| | | | | | | | | | - Evelyne Vinet
- McGill University Health Center Montreal Quebec Canada
| | | | | | - Medha Barbhaiya
- Weill Cornell MedicineHospital for Special Surgery New York New York
| | | | - Amanda Eudy
- Duke University Medical Center Durham North Carolina
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology Atlanta Georgia
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9
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Abstract
Lupus nephritis (LN) is a form of glomerulonephritis that constitutes one of the most severe organ manifestations of the autoimmune disease systemic lupus erythematosus (SLE). Most patients with SLE who develop LN do so within 5 years of an SLE diagnosis and, in many cases, LN is the presenting manifestation resulting in the diagnosis of SLE. Understanding of the genetic and pathogenetic basis of LN has improved substantially over the past few decades. Treatment of LN usually involves immunosuppressive therapy, typically with mycophenolate mofetil or cyclophosphamide and with glucocorticoids, although these treatments are not uniformly effective. Despite increased knowledge of disease pathogenesis and improved treatment options, LN remains a substantial cause of morbidity and death among patients with SLE. Within 10 years of an initial SLE diagnosis, 5-20% of patients with LN develop end-stage kidney disease, and the multiple comorbidities associated with immunosuppressive treatment, including infections, osteoporosis and cardiovascular and reproductive effects, remain a concern. Clearly, early and accurate diagnosis of LN and prompt initiation of therapy are of vital importance to improve outcomes in patients with SLE.
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10
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Sammaritano LR. Contraception and preconception counseling in women with autoimmune disease. Best Pract Res Clin Obstet Gynaecol 2019; 64:11-23. [PMID: 31679995 DOI: 10.1016/j.bpobgyn.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
Abstract
Appropriate contraception and preconception counseling are critical for women of reproductive age with systemic autoimmune diseases (AIDs) because clinical diagnosis, rheumatology medications, and disease activity may impact the safety or efficacy of certain contraceptives as well as the risk of adverse pregnancy outcomes. The presence of antiphospholipid (aPL) antibodies (anticardiolipin, anti-β2 glycoprotein I, and lupus anticoagulant) is the most important determinant of contraception choice, as women with these antibodies should not receive estrogen-containing contraceptives because of the increased risk of thrombosis. Prepregnancy counseling generally includes the assessment of preexisting disease-related organ damage, current disease activity, aPL antibodies, anti-Ro/SS-A and anti-La/SS-B antibodies, and medication safety in pregnancy. Quiescent AID for six months on pregnancy-compatible medications optimizes maternal and fetal/neonatal outcomes for most patients.
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Affiliation(s)
- Lisa R Sammaritano
- Hospital for Special Surgery - Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA.
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11
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Arese V, Murabito P, Ribero S, Panzone M, Tonella L, Fierro MT, Papini M, Quaglino P. Autoimmune connective tissue diseases and pregnancy. GIORN ITAL DERMAT V 2019; 154:263-276. [PMID: 30650958 DOI: 10.23736/s0392-0488.18.06252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune connective tissue-diseases are more frequent in women and deserve a multidisciplinary approach in which the dermatologist play a major role together with other physicians. Pregnancy in these patients has to be considered a high-risk situation, because of possible worsening of the mother's disease and increased morbility and mortality for the fetus; also, therapies have to be chosen carefully because some drugs cannot be used during pregnancy. For all these reasons, the decision to become pregnant needs to consider the type of disease, stage of disease, age and clinical condition, and requires a multidisciplinary approach. A correct counselling, a close monitoring, a specific approach based on the risks involved and the use of appropriate therapies are the keys to obtain optimal pregnancy outcomes.
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Affiliation(s)
- Veronica Arese
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Pierangela Murabito
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Michele Panzone
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Luca Tonella
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Maria T Fierro
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Manuela Papini
- Department of Surgical and Biomedical Sciences, Dermatologic Clinic of Terni, University of Perugia, Perugia, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy -
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12
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Abstract
Autoimmune bullous diseases (AIBD), including pemphigus, bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid, and pemphigoid gestationis, pose significant therapeutic challenges, especially in pregnant and post-partum breastfeeding patients or those planning to conceive. Data on the safety and efficacy of therapeutic interventions during the perinatal period are lacking because randomized controlled trials are typically not performed in this setting. However, many of the treatments for AIBD are also used in other diseases, so data can be extrapolated from studies or case reports in these other patient populations. It appears that many of the treatments for AIBD can adversely affect the fetus or neonate, and alterations in immune status caused by pregnancy-associated hormonal changes can negatively impact disease control. This article summarizes and weighs the risks and benefits of the various agents used to treat AIBD during pregnancy. We also present the available information on lactation as well as effects on male fertility.
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Affiliation(s)
- Carolyn J Kushner
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Josef Symon S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Section of Dermatology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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Vanoni F, Lava SAG, Fossali EF, Cavalli R, Simonetti GD, Bianchetti MG, Bozzini MA, Agostoni C, Milani GP. Neonatal Systemic Lupus Erythematosus Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2017; 53:469-476. [DOI: 10.1007/s12016-017-8653-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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14
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Affiliation(s)
- Ian W. Hovis
- Address reprint requests and correspondence: Dr Ian W. Hovis, Division of Cardiology, Children's National Health System, 111 Michigan Ave, NW, Washington, DC 20010.Division of CardiologyChildren's National Health System111 Michigan AveNW, WashingtonDC20010
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15
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with a strong female predilection. Pregnancy remains a commonly encountered but high-risk situation in this setting. Both maternal and fetal mortality and morbidity are still significantly increased despite improvements in outcomes. Maternal morbidity includes higher risk of disease flares, preeclampsia and other pregnancy-related complications. Fetal issues include higher rates of preterm birth, intrauterine growth restriction, and neonatal lupus syndromes. Treatment options during pregnancy are also limited and maternal benefit has to be weighed against fetal risk. A coordinated approach, with close monitoring by a multidisciplinary team, is essential for optimal outcomes.
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Affiliation(s)
- Aisha Lateef
- Division of Rheumatology, University Medicine Cluster, National University Hospital, National University Health System, 1E, Kent Ridge Road, Singapore 119074
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins Lupus Center, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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16
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Knight CL, Nelson-Piercy C. Management of systemic lupus erythematosus during pregnancy: challenges and solutions. Open Access Rheumatol 2017; 9:37-53. [PMID: 28331377 PMCID: PMC5354538 DOI: 10.2147/oarrr.s87828] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease predominantly affecting women, particularly those of childbearing age. SLE provides challenges in the prepregnancy, antenatal, intrapartum, and postpartum periods for these women, and for the medical, obstetric, and midwifery teams who provide their care. As with many medical conditions in pregnancy, the best maternal and fetal-neonatal outcomes are obtained with a planned pregnancy and a cohesive multidisciplinary approach. Effective prepregnancy risk assessment and counseling includes exploration of factors for poor pregnancy outcome, discussion of risks, and appropriate planning for pregnancy, with consideration of discussion of relative contraindications to pregnancy. In pregnancy, early referral for hospital-coordinated care, involvement of obstetricians and rheumatologists (and other specialists as required), an individual management plan, regular reviews, and early recognition of flares and complications are all important. Women are at risk of lupus flares, worsening renal impairment, onset of or worsening hypertension, preeclampsia, and/or venous thromboembolism, and miscarriage, intrauterine growth restriction, preterm delivery, and/or neonatal lupus syndrome (congenital heart block or neonatal lupus erythematosus). A cesarean section may be required in certain obstetric contexts (such as urgent preterm delivery for maternal and/or fetal well-being), but vaginal birth should be the aim for the majority of women. Postnatally, an ongoing individual management plan remains important, with neonatal management where necessary and rheumatology followup. This article explores the challenges at each stage of pregnancy, discusses the effect of SLE on pregnancy and vice versa, and reviews antirheumatic medications with the latest guidance about their use and safety in pregnancy. Such information is required to effectively and safely manage each stage of pregnancy in women with SLE.
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Affiliation(s)
- Caroline L Knight
- Division of Women’s Health, Women’s Health Academic Centre, King’s College London and King’s Health Partners, St Thomas’ Hospital, London, UK
| | - Catherine Nelson-Piercy
- Division of Women’s Health, Women’s Health Academic Centre, King’s College London and King’s Health Partners, St Thomas’ Hospital, London, UK
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17
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Ruffatti A, Favaro M, Brucato A, Ramoni V, Facchinetti M, Tonello M, Del Ross T, Calligaro A, Hoxha A, Grava C, De Silvestro G. Apheresis in high risk antiphospholipid syndrome pregnancy and autoimmune congenital heart block. Transfus Apher Sci 2015; 53:269-78. [DOI: 10.1016/j.transci.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Autoimmune connective tissue diseases. Best Pract Res Clin Obstet Gynaecol 2015; 29:658-70. [DOI: 10.1016/j.bpobgyn.2015.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 11/17/2022]
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Yun D, Stein SL. Review of the cutaneous manifestations of autoimmune connective tissue diseases in pediatric patients. World J Dermatol 2015; 4:80-94. [DOI: 10.5314/wjd.v4.i2.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 02/25/2015] [Accepted: 04/07/2015] [Indexed: 02/06/2023] Open
Abstract
Autoimmune connective tissue diseases are chronic inflammatory disorders associated with complex genetic and environmental interplay resulting in a variety of cutaneous and systemic manifestations. Pediatric onset of these disorders carries a unique diagnostic pressure for the clinician due to the potential years of disease burden and complications. Mortality and morbidity from these disorders has fallen dramatically over the past fifty years due to increasing awareness of these disease sequelae and utilization of systemic treatment modalities when necessary. This review highlights the clinical features that are unique to pediatric presentations of lupus erythematosus, juvenile idiopathic arthritis, juvenile dermatomyositis, juvenile onset systemic sclerosis and morphea. Each of these disorders has a distinct appearance corresponding to a particular cutaneous and systemic clinical course and prognosis. Awareness of the associated potential systemic complications can also alert the clinician to make astute management decisions when confronted with a probable rheumatologic case. Cutaneous symptoms may predate onset of systemic symptoms and by keeping the rheumatologic differential diagnoses in mind, the dermatologist can play a key role in potentially offsetting autoimmune disease burden in children.
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Chaudhary P, Clowse ME. Systemic lupus erythematosus in the pregnant patient and neonatal lupus. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00137-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Santos-Pardo I, Villuendas R, Salvador-Corres I, Martínez-Morillo M, Olivé A, Bayes-Genis A. Anti-Ro/SSA antibodies and cardiac rhythm disturbances: Present and future perspectives. Int J Cardiol 2014; 184:244-250. [PMID: 25725306 DOI: 10.1016/j.ijcard.2014.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/06/2014] [Accepted: 11/01/2014] [Indexed: 12/17/2022]
Abstract
Several case reports, small case series, and original research papers have recently suggested that the action of certain auto-antibodies related to connective tissue diseases may be responsible for significant cardiac rhythm disturbances in adults. The relationship between anti-Ro/SSA antibodies and congenital complete atrioventricular block is well recognized in the fetal heart. Herein we review the emerging evidences of the link to increased levels of anti-Ro/SSA antibodies with rhythm disorders of unknown origin in the adult. Confirmation of this distinct etiology may eventually be the basis for new therapies.
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Affiliation(s)
- Irene Santos-Pardo
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain
| | - Roger Villuendas
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain
| | - Iñaki Salvador-Corres
- Immunology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), FOCIS-CE, Spain
| | - Melania Martínez-Morillo
- Rheumatology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain
| | - Alejandro Olivé
- Rheumatology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Spain
| | - Antoni Bayes-Genis
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Spain
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Abstract
Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.
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Affiliation(s)
- O Ateka-Barrutia
- Lupus Research Unit, Women's Health Division, King's College London, UK
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Satoh M, Chan EKL, Sobel ES, Kimpel DL, Yamasaki Y, Narain S, Mansoor R, Reeves WH. Clinical implication of autoantibodies in patients with systemic rheumatic diseases. Expert Rev Clin Immunol 2014; 3:721-38. [DOI: 10.1586/1744666x.3.5.721] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Xiao Z, Hang H, Dai H, Yan B. A case of neonatal lupus erythematosus with a typical malar rash. Rheumatology (Oxford) 2014; 53:1152-4. [DOI: 10.1093/rheumatology/ket412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Connective tissue diseases (CTD) include a variety of chronic multisystem disorders with a high percentage of autoimmune conditions. Many of these conditions affect women of childbearing age and, therefore, pregnancy poses an important challenge for doctors looking after such women. Knowledge of medication safety, the effect of pregnancy on such diseases and vice versa, together with preconception counselling and multidisciplinary team care, are the basic pillars needed to provide the best obstetric and medical care to these women. In this review, we discuss the management of the most common autoimmune CTD before, during and after pregnancy, along with the most relevant issues regarding appropriate medication.
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Evaluation and management of systemic lupus erythematosus and rheumatoid arthritis during pregnancy. Clin Immunol 2013; 149:225-35. [DOI: 10.1016/j.clim.2013.05.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 05/09/2013] [Accepted: 05/11/2013] [Indexed: 11/19/2022]
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Gleicher N, Elkayam U. Preventing congenital neonatal heart block in offspring of mothers with anti-SSA/Ro and SSB/La antibodies: A review of published literature and registered clinical trials. Autoimmun Rev 2013; 12:1039-45. [DOI: 10.1016/j.autrev.2013.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/11/2013] [Indexed: 12/14/2022]
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Moretti D, Cimaz R, Vannucci G, Marino A, De Martino M, Greco A. Cutaneous neonatal lupus: a case report and review of the literature. Int J Dermatol 2013; 53:1508-12. [DOI: 10.1111/j.1365-4632.2012.05809.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Davide Moretti
- Department of Paediatric Rheumatology; University of Florence; Anna Meyer Children's Hospital; Florence Italy
| | - Rolando Cimaz
- Department of Paediatric Rheumatology; University of Florence; Anna Meyer Children's Hospital; Florence Italy
| | - Gaia Vannucci
- Department of Paediatric Rheumatology; University of Florence; Anna Meyer Children's Hospital; Florence Italy
| | - Achille Marino
- Department of Paediatric Rheumatology; University of Florence; Anna Meyer Children's Hospital; Florence Italy
| | - Maurizio De Martino
- Department of Paediatric Rheumatology; University of Florence; Anna Meyer Children's Hospital; Florence Italy
| | - Antonella Greco
- Department of Paediatric Rheumatology; University of Florence; Anna Meyer Children's Hospital; Florence Italy
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A combination therapy protocol of plasmapheresis, intravenous immunoglobulins and betamethasone to treat anti-Ro/La-related congenital atrioventricular block. A case series and review of the literature. Autoimmun Rev 2013; 12:768-73. [DOI: 10.1016/j.autrev.2013.01.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/28/2012] [Indexed: 01/25/2023]
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Abstract
The treatment of inflammatory rheumatic diseases, such as rheumatoid arthritis, spondylitis ankylosans and systemic lupus erythematosus, is improving continuously. This has lead to an increasing number of young patients with a wish to have children. Greater insight into the course of rheumatic diseases during pregnancy and post partum has enabled optimized support for women with rheumatic diseases wishing to have children. To ensure a favorable outcome, pregnancy should be started during a period of disease stability and should be monitored closely. A careful assessment of possible risks and the justified use of antirheumatic drugs before, during and after pregnancy are key issues for success.
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Ateka-Barrutia O, Nelson-Piercy C. Management of rheumatologic diseases in pregnancy. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.54] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Frey MN, Ioppi AEE, Garbin GC, Furian RD, Bau AEK. Congenital and neonatal lupus erythematosus: two case reports. An Bras Dermatol 2012; 87:625-8. [PMID: 22892781 DOI: 10.1590/s0365-05962012000400019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/30/2011] [Indexed: 11/22/2022] Open
Abstract
Neonatal lupus erythematosus is an autoimmune disease produced by the passage of maternal antinuclear antibodies and extractable nuclear antigen antibodies through the placenta. At the moment of the diagnosis, the mothers are asymptomatic in 40 to 60% of cases. The most common manifestations are cutaneous lesions and congenital heart block. The cutaneous findings are variable and usually begin within the first weeks or months of life. Congenital lupus erythematosus is a congenital variant of neonatal lupus erythematosus. We present one case of congenital lupus erythematosus and one case of neonatal lupus erythematous, showing the variability of this disease.
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Affiliation(s)
- Marcos Noronha Frey
- Dermatology Service, Federal University of Health Sciences, Porto Alegre, RS, Brazil
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Ugarte A, Villar I, Ruiz-Irastorza G. [Management of pregnancy in patients with systemic lupus erythematosus]. Rev Clin Esp 2012; 212:491-8. [PMID: 22245369 DOI: 10.1016/j.rce.2011.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 10/02/2011] [Accepted: 11/07/2011] [Indexed: 11/15/2022]
Abstract
Patients with systemic lupus erythematosus are exposed to a remarkably high number of maternal-fetal complications during pregnancy. Knowledge regarding the reciprocal influence between lupus and pregnancy is the starting point to assure that these patients are correctly monitored. It is also important to carry out comprehensive preconception evaluation to individually evaluate the risk of each patient. The immunological profile, history of nephritis, presence of chronic damage and disease activity are the basic data that will determine the specific individual risk profile. Finally, correct drug management must be assured during this period, based on the safety profile of the different treatments during pregnancy and lactation.
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Affiliation(s)
- A Ugarte
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital de Cruces, Barakaldo, Bizkaia, Spain
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[Pregnancy and kidney diseases]. Internist (Berl) 2011; 52:1167-77. [PMID: 21935640 DOI: 10.1007/s00108-011-2824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The prevalence of chronic kidney disease in women of childbearing age reaches approximately 0.2%. Under physiological conditions pregnancy results in important hemodynamic changes on the maternal organism. In the case of chronic kidney disease these adaptations often are only partial. Physiological changes of immune response during pregnancy may contribute to the progress of renal disease. Regardless of the underlying kidney disease, one can assume that the better the glomerular filtration rate and blood pressure are the more favorable the course of pregnancy will be with the chance for a healthy child and stable renal function. To achieve this goal, a close interaction is required between gynecologist, nephrologist, and other specialists in a center with appropriate experience.
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Sim S, Wolin SL. Emerging roles for the Ro 60-kDa autoantigen in noncoding RNA metabolism. WILEY INTERDISCIPLINARY REVIEWS. RNA 2011; 2:686-99. [PMID: 21823229 PMCID: PMC3154076 DOI: 10.1002/wrna.85] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
All cells contain an enormous variety of ribonucleoprotein (RNP) complexes that function in diverse processes. Although the mechanisms by which many of these RNPs contribute to cell metabolism are well understood, the roles of others are only now beginning to be revealed. A member of this latter category, the Ro 60-kDa protein and its associated noncoding Y RNAs, was discovered because the protein component is a frequent target of the autoimmune response in patients with the rheumatic diseases systemic lupus erythematosus and Sjögren's syndrome. Recent studies have shown that Ro is ring shaped, binds the single-stranded ends of misfolded noncoding RNAs in its central cavity, and may function in noncoding RNA quality control. Although Ro is not present in yeast, many bacterial genomes contain potential Ro orthologs. In the radiation-resistant eubacterium Deinococcus radiodurans, the Ro ortholog functions with exoribonucleases during stress-induced changes in RNA metabolism. Moreover, in both D. radiodurans and animal cells, Ro is involved in the response to multiple types of environmental stress. Finally, Y RNAs can influence the subcellular location of Ro, inhibit access of the central cavity to other RNAs, and may also act as binding sites for proteins that influence Ro function. WIREs RNA 2011 2 686-699 DOI: 10.1002/wrna.85 For further resources related to this article, please visit the WIREs website.
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MESH Headings
- Animals
- Autoantigens/chemistry
- Autoantigens/genetics
- Autoantigens/metabolism
- Deinococcus/genetics
- Deinococcus/metabolism
- Embryonic Stem Cells/metabolism
- Female
- Humans
- Mice
- Models, Molecular
- Nucleic Acid Conformation
- Oocytes/metabolism
- Phylogeny
- RNA Stability
- RNA, Bacterial/genetics
- RNA, Bacterial/metabolism
- RNA, Ribosomal, 5S/metabolism
- RNA, Small Cytoplasmic/chemistry
- RNA, Small Cytoplasmic/genetics
- RNA, Small Cytoplasmic/metabolism
- RNA, Small Nuclear/metabolism
- RNA, Untranslated/genetics
- RNA, Untranslated/metabolism
- Ribonucleoproteins/chemistry
- Ribonucleoproteins/genetics
- Ribonucleoproteins/metabolism
- Stress, Physiological
- Xenopus laevis
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Affiliation(s)
- Soyeong Sim
- Department of Cell Biology, Yale University School of Medicine, New Haven, CT, USA
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Abstract
Adequate pregnancy care of women with systemic lupus erythematosus (SLE) rests on three pillars: a coordinated medical-obstetrical care, an agreed and well-defined management protocol and a good neonatal unit. Pregnancy should be planned following a preconceptional visit for counselling. Women with severe active disease or a high degree of irreversible damage, such as those with symptomatic pulmonary hypertension, heart failure, severe restrictive pulmonary disease or severe chronic renal failure should best avoid pregnancy. Treatment is based on hydroxychloroquine, low-dose steroids and azathioprine. Patients with antiphospholipid antibodies/syndrome should receive low-dose aspirin +/- low molecular weight heparin. The addition and the dose of heparin depend on the clinical profile of the patient, i.e. a previous history of miscarriage, foetal loss, placental insufficiency or thrombosis. A close surveillance, with monitoring of blood pressure, proteinuria and placental blood flow by Doppler studies helps the early diagnosis and treatment of complications such as preeclampsia and foetal distress. Postpartum follow-up is important.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Department Of Internal Medicine, Hospital De Cruces, University Of The Basque Country, Bizkaia, Spain
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Lleo A, Shimoda S, Ishibashi H, Gershwin ME. Primary biliary cirrhosis and autoimmune hepatitis: apotopes and epitopes. J Gastroenterol 2011; 46 Suppl 1:29-38. [PMID: 20798971 DOI: 10.1007/s00535-010-0303-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 07/28/2010] [Indexed: 02/04/2023]
Abstract
Autoimmune liver diseases (ALDs) represent a wide spectrum of chronic inflammatory diseases that are characterized by an immune-mediated attack against either hepatocytes (in the case of autoimmune hepatitis types 1 and 2, AIH-1, 2) or cholangiocytes (in primary biliary cirrhosis, PBC). PBC is considered a model autoimmune disease due to the homogeneity of patients, the high specificity of antimitochondrial antibodies (AMAs), and the specificity of biliary epithelial cell (BEC) destruction. It ensues from a multi-lineage loss of tolerance to the E2 component of the pyruvate dehydrogenase complex (PDC-E2). One of the major unanswered questions in the pathogenesis of PBC is the specificity of small intrahepatic bile duct attack while PDC-E2 is present in mitochondria of nucleated cells. Recent findings suggest that the apoptosis of BECs may be of considerable importance for understanding PBC, and that they are more than simply an innocent victim of an immune attack. Rather, they attract immune attack by virtue of the unique biochemical mechanisms by which they handle PDC-E2. The role of apoptotic cells in AIH is not well defined, but advances in the study of autoreactive T cells stem mostly from AIH type 2, where the main autoantigen (CYP2D6) is known, enabling the characterization of antigen-specific immune responses. This review article is intended to provide a critical overview of current evidence on tissue specificity in ALDs, as well as the characteristics of the relevant epitopes and apotopes and their biological and clinical significance.
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Affiliation(s)
- Ana Lleo
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis, Davis, CA 95616, USA
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40
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Ruiz-Irastorza G, Khamashta MA. Complicated Pregnancies in Patients with Autoimmune Systemic Diseases. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Gillis JZ, Panopalis P, Schmajuk G, Ramsey-Goldman R, Yazdany J. Systematic review of the literature informing the systemic lupus erythematosus indicators project: Reproductive health care quality indicators. Arthritis Care Res (Hoboken) 2010; 63:17-30. [DOI: 10.1002/acr.20327] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Systemic rheumatic diseases commonly affect women during the childbearing years. Many women with these diseases may be contemplating pregnancy or discover an inadvertent pregnancy, leading to concerns regarding medication use, changes in disease activity during pregnancy, safety of lactation, and future ability to care for a child given the presence of chronic illnesses. There are outstanding reviews that summarize the safety and use of immunosuppressive medications during pregnancy. However, in addition to medication use, providers need to be aware of the available data regarding fertility, pregnancy outcomes, delivery, and lactation issues that may be specific to individual diseases. Optimally, women should plan pregnancies to occur around times of disease quiescence, several months after potentially teratogenic medications have been discontinued. The course of the underlying rheumatic disease during pregnancy is variable, and there are no specific clinical or laboratory variables that consistently predict disease improvement or worsening during pregnancy. Recent data suggest that increased disease activity in women with most autoimmune diseases during pregnancy may lead to increased risk of premature delivery, low-birth-weight infants, and other adverse pregnancy outcomes. Arthritis involving the cervical spine and hips may impact delivery and must be considered by both obstetricians and obstetric anesthesiologists. Data are mixed regarding the impact of breastfeeding on underlying autoimmune diseases; the choice to continue breastfeeding is a personal decision.
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Affiliation(s)
- Amy B Elliott
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Cardiac operations for North American children with rheumatic diseases: 1985-2005. Pediatr Cardiol 2010; 31:66-73. [PMID: 19967351 PMCID: PMC2851105 DOI: 10.1007/s00246-009-9572-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 10/13/2009] [Indexed: 10/20/2022]
Abstract
Certain pediatric rheumatic diseases are known to affect the heart, sometimes requiring surgical intervention. The Pediatric Cardiac Care Consortium database was used to characterize cardiac surgical intervention among children with rheumatic diseases from 1985 to 2005. From this large database, the records for patients younger than 21 years who underwent cardiac surgery for any rheumatic disorder were extracted. The data collected included the type of procedure performed, the age at the time of the procedure, and the year the procedure was performed. The 261 pediatric patients identified underwent 361 cardiac surgical procedures for complications of rheumatic heart disease (RHD; 160 patients), neonatal lupus (NLE; 53 patients), Kawasaki disease (KD; 28 patients), systemic lupus erythematosus (SLE; 13 patients), and juvenile rheumatoid arthritis (JRA; 7 patients). Multiple procedures were performed for 23% of the patients. The most common procedures included pacemaker implantations among infants with NLE, coronary artery bypass grafts for KD primarily in 5- to 15-year-olds, and cardiac valve operations among adolescents with RHD, SLE, and JRA. Six perioperative deaths occurred. The proportion of annual pediatric cardiac surgical volume attributable to rheumatic diseases did not change during the period studied. Despite advances in their medical care, children with rheumatic diseases continue to sustain measurable morbidity and mortality due to the cardiovascular manifestations of their disease.
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Eisen A, Arnson Y, Dovrish Z, Hadary R, Amital H. Arrhythmias and conduction defects in rheumatological diseases--a comprehensive review. Semin Arthritis Rheum 2009; 39:145-56. [PMID: 18585758 DOI: 10.1016/j.semarthrit.2008.05.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Revised: 04/07/2008] [Accepted: 05/04/2008] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To review the clinical aspects of cardiac arrhythmias and conduction disturbances in several common and less encountered adult rheumatic diseases and to underline the importance of prompt diagnosis and management in these patients. METHODS The PubMed database was searched for articles published between the years 1960 and 2008 for keywords referring to autoimmune diseases. All relevant English-written articles were reviewed. Most were uncontrolled series and case reports, due to the lack of prospective studies and randomized trials. RESULTS Rheumatologic conditions may affect the cardiovascular system and increase morbidity and mortality. Rhythm and conduction defects are usually mild but may be life-threatening; in certain diseases, such as in systemic lupus erythematosus they may resolve following therapy with corticosteroids. Conduction defects occur frequently in patients with spondyloarthropathies and in those with various forms of vasculitis. Enhanced variation of the QT interval may be a sensitive marker of a higher arrythmogenic tendency in patients with autoimmune conditions. CONCLUSIONS It is important to identify patients at high risk for cardiac arrhythmias. Treating such patients with arrhythmias should not differ fundamentally from other patients. Nevertheless, appropriate clinical attention and judgment should be applied to exclude the possibility that arrhythmias reflect uncontrolled myocardial inflammation.
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Affiliation(s)
- Alon Eisen
- Department of Medicine D, Meir Medical Center, Kefar-Saba, Israel
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Llanos C, Izmirly PM, Katholi M, Clancy RM, Friedman DM, Kim MY, Buyon JP. Recurrence rates of cardiac manifestations associated with neonatal lupus and maternal/fetal risk factors. ARTHRITIS AND RHEUMATISM 2009; 60:3091-7. [PMID: 19790064 PMCID: PMC2764291 DOI: 10.1002/art.24768] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Identifying the frequency of recurrent cardiac manifestations of neonatal lupus (NL) in a second child is critical to understanding the pathogenesis of anti-SSA/Ro-mediated injury and would improve counseling strategies regarding future pregnancies and power the design of clinical prevention trials. Accordingly, this study was undertaken to address the recurrence rates of cardiac NL and associated risk factors in a large US-based cohort. METHODS Families enrolled in the Research Registry for Neonatal Lupus were evaluated for rates of recurrence of cardiac NL and potential risk factors, with a focus on pregnancies immediately following the birth of an affected child. RESULTS The overall rate of recurrence of cardiac NL in 161 pregnancies of 129 mothers with anti-SSA/Ro antibodies was 17.4% (95% confidence interval 11.1-23.6%). Analysis of the potential risk factors among 129 mothers with a pregnancy immediately following the birth of a child with cardiac NL showed that the maternal diagnosis was not associated with the outcome in a subsequent pregnancy. In this group, 23% of mothers who were either asymptomatic or had an undifferentiated autoimmune syndrome, compared with 14% of mothers with systemic lupus erythematosus or Sjögren's syndrome, had a second child with cardiac NL (P = 0.25). The recurrence rate was not statistically significantly different in mothers who had taken steroids compared with those who had not taken steroids (16% versus 21%; P = 0.78). The antibody status of the mother was not predictive of outcome in subsequent pregnancies. Moreover, death of the first child with cardiac NL was not predictive of recurrence of cardiac NL in a subsequent pregnancy (P = 0.31). The risk of cardiac NL was similar between male and female children (17.2% versus 18.3%; P = 1.0). CONCLUSION In this cohort, the overall recurrence rate for cardiac NL was 17%. The recurrence rate appeared to be unaffected by maternal health, use of steroids, antibody status, severity of cardiac disease in the first affected child, or sex of the subsequent child.
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Affiliation(s)
- Carolina Llanos
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY
| | - Peter M. Izmirly
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY
| | - Margaret Katholi
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY
| | - Robert M. Clancy
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY
| | | | - Mimi Y. Kim
- Albert Einstein College of Medicine, New York, NY
| | - Jill P. Buyon
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY
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Demaestri M, Sciascia S, Kuzenko A, Bergia R, Barberis L, Lanza MG, Bertero MT. Neonatal lupus in triplet pregnancy of a patient with undifferentiated connective tissue disease evolving to systemic lupus erythematosus. Lupus 2009; 18:368-71. [PMID: 19276307 DOI: 10.1177/0961203308097512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy in patients suffering from undifferentiated connective tissue disease (UCTD) represents a risk situation for both the mother and the child. SSA/SSB autoantibodies can determine neonatal lupus (NL) in the foetus, regardless of the maternal disease. Furthermore, pregnancy increases the risk of flares and evolution to differentiated connective tissue disease (CTD). We report an uncommon case in which these complications occurred in a mother and in her foetuses. A 37-year-old woman affected by UCTD developed systemic lupus erythematosus (SLE) after her triplet pregnancy. The only manifestation of neonatal lupus we observed in the three newborns was SSA positivity associated with asymptomatic transient neutropenia.
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Affiliation(s)
- M Demaestri
- Master Malattie Rare, Università degli Studi di Torino, Turin, Italy
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Llanos C, Chan EKL, Li S, Abadal GX, Izmirly P, Byrne C, Clancy RM, Buyon JP. Antibody reactivity to alpha-enolase in mothers of children with congenital heart block. J Rheumatol 2009; 36:565-9. [PMID: 19208599 DOI: 10.3899/jrheum.080860] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the frequency of anti-alpha-enolase antibodies in the sera of mothers whose children have congenital heart block (CHB), given provocative results in which alpha-enolase, a membrane protein, was recognized by monoclonal antibodies reactive with the peptide p200 of 52 kDa Ro/SSA in a neonatal rat heart library. METHODS An ELISA using a recombinant alpha-enolase protein was developed. Sera from 100 anti-Ro52+ CHB mothers in the Research Registry for Neonatal Lupus, 50 patients with systemic lupus erythematosus (SLE; 7 anti-Ro52+), and 48 healthy controls were tested for anti-alpha-enolase reactivity. RESULTS There were no significant differences in the median values obtained from CHB mothers, patients with SLE, or controls at each of the dilutions tested. Only 7 (7%) at 1:100 dilution and 2 (2%) at 1:1000 dilution of 100 CHB sera were 3 standard deviations above the mean value obtained for controls. Preincubation with recombinant Ro52 did not inhibit anti-alpha-enolase reactivity. CONCLUSION The low frequency of anti-alpha-enolase antibodies in the sera of CHB mothers and the absence of apparent cross-reactivity with Ro52 suggest that antibodies to Ro52 are not likely to mediate CHB via binding to alpha-enolase.
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Affiliation(s)
- Carolina Llanos
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
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