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Marion O, Abravanel F, Del Bello A, Esposito L, Lhomme S, Puissant-Lubrano B, Alric L, Faguer S, Izopet J, Kamar N. Hepatitis E virus-associated cryoglobulinemia in solid-organ-transplant recipients. Liver Int 2018; 38:2178-2189. [PMID: 29845733 DOI: 10.1111/liv.13894] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/18/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS An association between hepatitis E virus (HEV) infection and cryoglobulinemia has been suggested. The aims of this study were to assess the prevalence of cryoglobulinemia during HEV infection in solid-organ-transplant (SOT) recipients, to describe its outcomes under ribavirin therapy and to evaluate its effects on kidney function and histology. METHODS Between November 2005 and June 2016, 128 cases of HEV infection were diagnosed among SOT recipients followed in our institution. Cryoglobulinemia data obtained from 66 patients during acute-phase HEV and 51 patients during chronic-phase HEV were compared to a historical control group of 89 SOT recipients without HEV markers. Cryoglobulins were also monitored in a group of 43 patients treated by ribavirin. RESULTS The prevalence of cryoglobulinemia was increased in HEV-infected SOT patients during a chronic phase (52.9%) compared to HEV-infected SOT patients at acute phase (36.4%) (P = .1) and to HEV-negative SOT patients (23.6%) (P < .001). HEV infection was identified as an independent predictive factor for cryoglobulinemia (OR 2.3, CI 95%: 1.17-4.55, P = .02). After ribavirin therapy and HEV clearance, the prevalence of cryoglobulin was significantly decreased from 53.5% to 20.9% (P = .003). Kidney function was significantly worse and proteinuria tended to be higher in chronically HEV-infected patients with cryoglobulinemia compared to those without cryoglobulinemia. Membranoproliferative glomerulonephritis was diagnosed in 2 patients, of which 1 had detectable cryoglobulinemia. CONCLUSIONS In conclusion, a relationship between HEV and cryoglobulin formation seems to exist. However, the clinical impact of cryoglobulinemia in SOT patients infected with HEV has to be confirmed.
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Affiliation(s)
- Olivier Marion
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Centre de Physiopathologie de Toulouse Purpan, Inserm UMR1043, Toulouse, France
| | - Florence Abravanel
- Centre de Physiopathologie de Toulouse Purpan, Inserm UMR1043, Toulouse, France.,Laboratory of Virology, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Sebastien Lhomme
- Centre de Physiopathologie de Toulouse Purpan, Inserm UMR1043, Toulouse, France.,Laboratory of Virology, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | | | - Laurent Alric
- Université Paul Sabatier, Toulouse, France.,Internal Medicine-Digestive Department, CHU Purpan, Toulouse, France
| | - Stanislas Faguer
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Jacques Izopet
- Centre de Physiopathologie de Toulouse Purpan, Inserm UMR1043, Toulouse, France.,Laboratory of Virology, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Centre de Physiopathologie de Toulouse Purpan, Inserm UMR1043, Toulouse, France.,Université Paul Sabatier, Toulouse, France
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Kasagi T, Nobata H, Ikeda K, Banno S, Ito Y. Successful renal transplantation to a recipient with type II cryoglobulinemia: a case report. BMC Nephrol 2018; 19:170. [PMID: 29986657 PMCID: PMC6038236 DOI: 10.1186/s12882-018-0966-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/26/2018] [Indexed: 11/20/2022] Open
Abstract
Background Recurrence of glomerulonephritis is an important risk factor for renal graft dysfunction. Cryoglobulinemia is known as a relatively rare cause of renal failure, and doctors are usually hesitant to perform transplantation on a recipient with cryoglobulinemia because of the risk for graft loss. We present a case of renal transplantation on a patient with organ manifestations of type II cryoglobulinemia. Case presentation At the age of 44 years, the patient developed acute kidney injury and purpura on the lower extremities with type II cryoglobulinemia after interferon therapy for hepatitis C virus. Cryoglobulinemic glomerulonephritis was suspected; however, despite immunosuppressive therapy combined with plasmapheresis, she eventually needed hemodialysis treatment. She was referred to us at the age of 49 years for renal transplantation. Cryocrit was 14% and the organ manifestations persisted, including the lower extremity purpura and neurologic symptoms. After monitoring and confirming sufficient suppression of cryoglobulin concentration by immunosuppressive treatment with prednisolone, cyclophosphamide, and rituximab combined with plasmapheresis, the operation was performed. After transplantation, the cryoglobulin concentration was continuously monitored, and plasmapheresis and rituximab infusion were performed as appropriate. Her graft function has remained stable for 2 years and 6 months. Conclusion Our case suggested that a patient with cryoglobulinemia and persistent organ manifestations can receive a renal graft if the cryoglobulin concentration is sufficiently controlled by pretransplant treatment.
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Affiliation(s)
- Tomomichi Kasagi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi, 480-1195, Japan.
| | - Hironobu Nobata
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi, 480-1195, Japan
| | - Kaori Ikeda
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi, 480-1195, Japan
| | - Shogo Banno
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi, 480-1195, Japan
| | - Yasuhiko Ito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi, 480-1195, Japan
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Mosca T, Arcuri SS, Miorin LA, Cristiano ADO, Sens YADS, Forte WCN. Reduction in the presence of cryoglobulins over time in the hemodialysis treatment. Ren Fail 2017; 39:570-574. [PMID: 28741977 PMCID: PMC6446174 DOI: 10.1080/0886022x.2017.1349676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 01/26/2017] [Accepted: 06/25/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The presence of cryoglobulins in patients with chronic kidney disease (CKD) on hemodialysis is well described. However, the generation of cryoglobulins during the dialysis treatment has yet to be established. The aim of the present study was to determine the presence of serum cryoglobulins over time in the dialysis treatment in patients with CKD not infected with hepatitis C virus (HCV). METHOD Peripheral blood samples were collected at the beginning of dialysis treatment and at 30, 60, 90 and 120 days afterwards. Cryoglobulins were defined by the presence of immunocomplexes that precipitated in vitro with exposure to cold and resolubilized when rewarmed. The components of the cryoprecipitate were analyzed by radial immunodiffusion. RESULTS In this study, 14 patients were included: 11 male and three female, aged 28-88 years, with mean time on hemodialysis of 57 ± 36 days at baseline. The presence of cryoglobulin, constituted by IgM, IgA, IgG and the C3 and C4 components of the complement, was observed in the serum of all patients at the beginning of hemodialysis. Sequence analyses showed that the amount of cryoprecipitate decreased during the dialysis treatment. CONCLUSION There was a high prevalence of mixed cryoglobulins in CKD patients at the beginning of hemodialysis, and the amount of cryoprecipitate decreased during the treatment.
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Affiliation(s)
- Tainá Mosca
- Department of Pathological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Simone Sanches Arcuri
- Department of Pathological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Luiz Antônio Miorin
- Department of Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | | | | | - Wilma Carvalho Neves Forte
- Department of Pathological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
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Mosca T, Guerra GM, Miorin LA, Malafronte P, dos Santos Sens YA, Forte WCN. Cryoglobulinemia in chronic hemodialysis patients. Ren Fail 2011; 33:801-4. [PMID: 21859249 DOI: 10.3109/0886022x.2011.601828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal failure patients submitted to chronic hemodialysis can present with cryoglobulinemia. There are few studies on cryoglobulins in chronic hemodialysis patients. The aim of the present study was to determine the prevalence and to identify the components of cryoglobulins in chronic hemodialysis patients. METHODS Fifty-four patients on chronic hemodialysis were evaluated for the presence of cryoglobulins, after inclusion and exclusion criteria. The components of the cryoprecipitate were analyzed. RESULTS Cryoglobulins were detected in 83% (45/54) of the patients on chronic hemodialysis. The cryoprecipitate was constituted by IgG, IgM, IgA, and complement fractions C3 and C4. CONCLUSION We concluded that there was a high prevalence of cryoglobulins in chronic hemodialysis patients, and the cryoprecipitate was constituted by IgG, IgM, IgA, and complement fractions C3 and C4.
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Affiliation(s)
- Tainá Mosca
- Santa Casa Medical School and Hospital, São Paulo, Brazil
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Menezes M, Malafronte P, Souza J, Sens Y, Forte W. Evaluation of neutrophilic activity in patients submitted to kidney transplantation. Ren Fail 2010; 32:464-8. [DOI: 10.3109/08860221003664272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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El-Sayed HH, Amin Husse N, Yousef Gha L, Megeed Lot AA, Raouf Raaf MA. Clinical Spectrum of Hepatitis-Associated Cryoglobulinemia: Cross-Link between Hematological and Immunological Phenomena. JOURNAL OF MEDICAL SCIENCES 2006. [DOI: 10.3923/jms.2007.31.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Basse G, Ribes D, Kamar N, Mehrenberger M, Sallusto F, Esposito L, Guitard J, Lavayssière L, Oksman F, Durand D, Rostaing L. Rituximab therapy for mixed cryoglobulinemia in seven renal transplant patients. Transplant Proc 2006; 38:2308-10. [PMID: 16980074 DOI: 10.1016/j.transproceed.2006.06.131] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Systemic B-cell depletion and clinical remission of the systemic effects of cryoglobulins have been achieved in hepatitis C virus-positive immunocompetent patients with rituximab, a human/mouse chimeric monoclonal antibody that specifically reacts with the CD20 antigen. Thus, this provides a rationale for the use of rituximab for type III cryoglobulin-related graft dysfunction in renal-transplant patients. Seven patients, of whom five were hepatitis C positive, developed renal function impairment long after transplantation, as well as de novo nephrotic syndrome (n = 5), severe hypertension (n = 5), nephritic syndrome (n = 1), and increased serum creatinine (n = 1). This type III cryoglobulinemia was associated with membranoproliferative glomerulonephritis and with thrombi within the glomeruli in one case. In addition to their baseline standard immunosuppressive medications, the patients were given weekly rituximab infusions: 375 mg/m(2) for 2 weeks in four cases, for 3 weeks in one case, and for 4 weeks in two cases. This treatment resulted in a dramatic improvement in all renal parameters, particularly a sustained remission of nephrotic syndrome in three cases, the disappearance of nephritic syndrome in one patient, and improved nephrotic syndrome in two cases, as well as a sustained clearance of cryoglobulins in six cases. However, it also resulted in severe infectious complications in two cases. We concluded that rituximab therapy is effective in cryoglobulin-related renal dysfunction in renal transplant patients but, due to chronic immunosuppression, this may be achieved at the expense of infectious complications.
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Affiliation(s)
- G Basse
- Multiorgan Transplant Unit, University Hospital, CHU Rangueil, 1 avenue Jean Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
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Basse G, Ribes D, Kamar N, Mehrenberger M, Esposito L, Guitard J, Lavayssière L, Oksman F, Durand D, Dur D, Rostaing L. Rituximab therapy for de novo mixed cryoglobulinemia in renal transplant patients. Transplantation 2006; 80:1560-4. [PMID: 16371926 DOI: 10.1097/01.tp.0000183749.79424.b4] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Type II or III cryoglobulins are fairly prevalent in renal-transplant (RT) patients, and are often related to chronic hepatitis C virus (HCV) infection. However, they rarely result in graft dysfunction. They are sustained by proliferation of oligoclonal B-cells. Systemic B-cell depletion and clinical remission of the systemic effects of cryoglobulins have been achieved in HCV-positive immunocompetent patients with a human/mouse chimeric monoclonal antibody that specifically reacts with the CD20 antigen (i.e., rituximab). Thus, this provides the rationale to use rituximab for cryoglobulin-related graft dysfunction in RT patients. METHODS Three RT patients, of whom one was HCV-positive, developed renal-function impairment long after transplantation, as well as de novo nephrotic syndrome (n=2) and severe hypertension (n=2). This latter case was related to type III cryoglobulinemia and was associated with membranoproliferative glomerulonephritis. In addition to their baseline standard immunosuppression, the patients were given weekly rituximab infusions of 375 mg/m (two infusions in patient and four infusions for the other two cases). RESULTS This treatment resulted in a dramatic improvement in renal parameters, particularly in a sustained remittence of nephrotic syndrome, a sustained clearance of cryoglobulins in two cases, but also in severe infectious complications in two cases. CONCLUSION We conclude that rituximab therapy is highly effective in cryoglobulin-related renal dysfunction in RT patients; however, due to chronic immunosuppression, this is at the expense of infectious complications.
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Affiliation(s)
- Grégoire Basse
- Multiorgan Transplant Unit, University Hospital, Chu Rangueil, Toulouse, France
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Sens YAS, Malafronte P, Souza JF, Bruno S, Gonzalez RBC, Miorin LA, Jabur P, Forte WCN. Cryoglobulinemia in Kidney Transplant Recipients. Transplant Proc 2005; 37:4273-5. [PMID: 16387095 DOI: 10.1016/j.transproceed.2005.11.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2005] [Indexed: 11/18/2022]
Abstract
The aim of this study was to assess the presence of cryoglobulins, the constitution of the cryoprecipitate, as well as the possible etiology and clinical features in kidney transplant recipients. We excluded patients with clinical or laboratory evidence of autoimmune, liver or neoplasm disease, infections, blood transfusions or immunizations in the previous 3 months. Detection of cryoglobulins was obtained from the peripheral venous blood. In cases of cryoprecipitate formation it was analyzed using anti-IgG, anti-IgM, anti-IgA, anti-C3, and anti-C4 antibodies. The hepatitis C virus (HCV) was detected by the polymerase chain reaction. Thirty-nine patients were selected, of whom 23 were men and the overall mean age was 40.6 +/- 12.7 years. Cryoprecipitate was detected in 74.4% (29/39) patients. Among patients with or without cryoprecipitate formation, the serum creatinine values, the percentage of patients with proteinuria, and the posttransplantation times were similar. In patients with cryoglobulins, 37.9% (11/29) were HCV positive. The etiology was not determined for the other patients. The IgG, IgM, and IgA immunoglobulins and the complement fractions C3 and C4 were found in the cryoprecipitate. Their compositions were similar among patients with or without HCV. Few clinical features were associated with the presence of cryoglobulins, including deep venous thrombosis, cutaneous purpura and peripheral neuropathy. In conclusion, cryoglobulinemia was prevalent in kidney transplant recipients, but appeared to not affect graft function. HCV infection was the most frequently associated etiology and clinical features were infrequent.
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Affiliation(s)
- Y A S Sens
- Santa Casa of Sao Paulo School of Medical Sciences, Sao Paulo, Brazil.
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Au WY, Kwok JSY, Chu KM, Ma ESK. Life-threatening cryoglobulinemia in HCV-negative Southern Chinese and a novel association with structural aortic abnormalities. Ann Hematol 2004; 84:95-8. [PMID: 15503020 DOI: 10.1007/s00277-004-0955-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 09/06/2004] [Indexed: 10/26/2022]
Abstract
Cryoglobulinemia is uncommon in Southern Chinese in Hong Kong, with tropical climates and low incidence of hepatitis C virus (HCV) infection. Eight positive cases were detected among 481 patients screened for cryoglobulins over a 10-year period. Three HCV carriers (38%) ran benign courses. The others included two carriers of hepatitis B virus (HBV), two patients with adenocarcinoma, and one with chronic lymphocytic lymphoma. Four of them (except one HBV carrier) ran fulminant courses and died of cryoglobulin-related complications. Interestingly, all four cases also had structural aortic abnormalities, including multiple dissections, aneurysms, and congenital aortic arch abnormalities, which were often life threatening. The association of aortic abnormality and cryoglobulinemia is hitherto unreported and may be peculiar to our ethnic group. Aggressive control of the cryoglobulin may help to reduce aortic intima damage.
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Affiliation(s)
- Wing Y Au
- Department of Medicine, Queen Mary Hospital, Hong Kong, China.
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Weiner SM, Thiel J, Berg T, Weber S, Krumme B, Peter HH, Rump LC, Grotz WH. Impact of in vivo complement activation and cryoglobulins on graft outcome of HCV-infected renal allograft recipients. Clin Transplant 2004; 18:7-13. [PMID: 15108765 DOI: 10.1111/j.1399-0012.2004.00103.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection is closely associated with mixed cryoglobulinemia. Cryoglobulins can activate complement leading to vascular damage. We examined whether cryoglobulinemia and complement turnover is associated with HCV infection in renal transplant recipients and whether this has an adverse effect on graft outcome. METHODS Sera and fresh plasma from 31 HCV-RNA-positive patients after renal transplantation (group I) were studied for cryoglobulins, complement hemolytic activity (CH50), and complement split product C3d. In total, 80 HCV-negative renal transplant recipients (group II) and 72 untreated patients with chronic hepatitis C (group III) without renal transplantation served as controls. RESULTS Cryoglobulins were detected in 45, 28, and 26% of the patients in group I, II, and III, respectively. A high cryocrit ( > 5%) was present only in patients of group III (p < 0.01%). Mean CH50 values were lower and C3d levels higher in HCV-positive patients (group I and III) compared with HCV-negative patients (p < 0.0001). Cryoglobulins were not associated with extrahepatic manifestations or graft dysfunction, except in five patients of group III demonstrating cryoglobulinemic vasculitis. HCV-positive renal transplant recipients with signs of complement activation showed a significantly greater increase of serum creatinine (0.88 +/- 1.14 mg/dL) when compared with baseline than patients without complement activation (0.34 +/- 0.37 mg/dL; p = 0.035). There was also a tendency toward a higher extent of proteinuria in patients with complement activation (1.38 +/- 2.17 g/d vs. 0.50 +/- 0.77 g/d; p = 0.25, NS). CONCLUSIONS Cryoglobulins are common in renal allograft recipients, but do not affect graft function. However, complement activation appears to be involved in chronic allograft dysfunction in HCV-infected recipients.
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Affiliation(s)
- Stefan M Weiner
- Department of Medicine, Marienhospital, Ruhr-University Bochum, Hoelkeskampring 40, Herne, Germany.
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