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Wu X, Liu X, Liu L, Cao X, Zhang M, Wang S, Deng M, Luo G, Qu Q, Bian Y, Liu F, Luo J, Shang S. Anti-neutrophil cytoplasmic antibody-associated vasculitis with headache and stroke as the main symptoms: A case report. Headache 2024; 64:448-459. [PMID: 38385697 DOI: 10.1111/head.14683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/24/2023] [Accepted: 01/03/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Xiaoyu Wu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Xiao Liu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Le Liu
- Department of Neurology, Xi'an Aerospace General Hospital, Xi'an, P.R. China
| | - Xiangqi Cao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, P.R. China
| | - Mengyuan Zhang
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Sifan Wang
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Meiying Deng
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Guogang Luo
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Qiumin Qu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Yitong Bian
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Fude Liu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
| | - Jing Luo
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Suhang Shang
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, P.R. China
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Díaz Acedo R, Artacho Criado S, Ríos Herranz E, Gutiérrez Pizarraya A, Sánchez Romero I, Márquez Saavedra E. Hypogammaglobulinemia after front-line immunochemotherapy in patients with follicular lymphoma. J Oncol Pharm Pract 2023; 29:1982-1989. [PMID: 36908267 DOI: 10.1177/10781552231162540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Hypogammaglobulinemia after front-line immunochemotherapy for follicular lymphoma is a poorly studied adverse event that could be related to the appearance of severe and/or recurrent non-neutropenic infections which could affect the quality of life of the patients, even motivating a need of long-term replacement therapy with human immunoglobulins. METHODS Observational, retrospective study aiming to estimate the incidence of hypogammaglobulinemia, as well as its severity and clinical consequences, and to explore possible predictive factors for its development. Specific immunoglobulin deficiencies were also studied. RESULTS 76.5% of patients had hypogammaglobulinemia during or after front-line treatment, mostly grade 1-2; with 38.8% patients who developed clinically relevant infections and 20% patients requiring human immunoglobulins replacement therapy. A high-risk FLIPI score was identified as a risk factor for hypogammaglobulinemia (ods ratio: 4.51; 95% confidence interval: 1.29-15.68; p < 0.001) and basal gamma globulin level as a protective factor (odds ratio: 0.92; 95% confidence interval: 0.988-0.996; p = 0.018). Any type of immunochemotherapy regimen was associated with different risks of hypogammaglobulinemia in our study. CONCLUSIONS Hypogammaglobulinemia appears in a high percentage of patients with follicular lymphoma in a real-world population, identifying a high-risk FLIPI score as a risk factor for its development and basal gamma globulins as a protective factor.
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Affiliation(s)
- Rocío Díaz Acedo
- Hospital Pharmacy Service, University Hospital of Valme, South of Seville Health Management Area, Seville, Spain
| | - Silvia Artacho Criado
- Hospital Pharmacy Service, University Hospital of Valme, South of Seville Health Management Area, Seville, Spain
| | - Eduardo Ríos Herranz
- Hematology Service, University Hospital of Valme, South of Seville Health Management Area, Seville, Spain
| | - Antonio Gutiérrez Pizarraya
- Hospital Pharmacy Service, University Hospital of Valme, South of Seville Health Management Area, Seville, Spain
| | - Irene Sánchez Romero
- Hematology Service, University Hospital of Valme, South of Seville Health Management Area, Seville, Spain
| | - Esther Márquez Saavedra
- Hospital Pharmacy Service, University Hospital of Valme, South of Seville Health Management Area, Seville, Spain
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Rempe T, Elfasi A, Rodriguez E, Vasquez M, Graves J, Kinkel R. Ocrelizumab B-cell repopulation-guided extended interval dosing versus standard dosing - similar clinical efficacy with decreased immunoglobulin M deficiency rates. Mult Scler Relat Disord 2023; 79:105028. [PMID: 37813071 DOI: 10.1016/j.msard.2023.105028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/07/2023] [Accepted: 09/23/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Ocrelizumab (OCR) is a humanized anti-CD20 monoclonal antibody used in treatment of multiple sclerosis. The standard dosing (SD) regimen consists of OCR maintenance infusions every 6 months. In B-cell repopulation-guided extended interval dosing (EID), repeat infusions are delayed until there is evidence for B-cell repopulation. OBJECTIVES To compare frequencies of 'no evidence of disease activity' (NEDA-3) and immunoglobulin G (hypo-IgG; <600 mg/dL) and M (hypo-IgM; <40 mg/dL) deficiencies in persons with multiple sclerosis (PwMS) treated with OCR B-cell repopulation-guided EID versus SD. METHODS Two-center retrospective study comparing frequencies of NEDA-3 and hypo-IgG and hypo-IgM in PwMS treated with OCR B-cell repopulation-guided EID versus SD using a multivariate generalized linear model adjusted for age, sex, and treatment duration. RESULTS A total of 112 OCR-treated PwMS were included (B-cell repopulation-guided EID n = 52; SD n = 60) with average infusion intervals of 319 (246-485) days (EID) and 184 (170-218) days (SD). There was no significant difference in NEDA-3 (EID: 47/52 [90.4 %]; SD: 50/60 [83.3 %]; p = 0.161) or hypo-IgG (EID: 1/52 [1.9 %]; SD: 4/60 [6.7 %]; p = 0.298) rates. Hypo-IgM was significantly less common in EID (EID: 9/52 [17.3 %] vs. SD: 34/60 [55 %]; p<0.001) upon assessment 1099 (475-1436) days (EID) and 980 (409-1846) days (SD) post-initiation of OCR. Hypo-IgM was associated with average infusion interval length (p = 0.005) and total number of OCR cycles (p = 0.003). CONCLUSIONS OCR B-cell repopulation-guided EID may be a safe alternative to traditional SD with similar efficacy and significantly less hypo-IgM rates.
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Affiliation(s)
- Torge Rempe
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA; Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Aisha Elfasi
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Elsa Rodriguez
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Matthew Vasquez
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Jennifer Graves
- Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Revere Kinkel
- Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
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4
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Gérard M, de Boysson H, Morello R, Martin-Silva N, Leroux AC, Dumont A, Maigné G, Boutemy J, Khoy K, Mariotte D, Lobbedez T, Aouba A, Deshayes S. Early infectious risk in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis according to remission-induction therapy. Scand J Rheumatol 2023; 52:161-173. [PMID: 35048797 DOI: 10.1080/03009742.2021.2001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Few comparative data exist on early infections secondary to remission-induction therapy (RIT) with rituximab (RTX) versus cyclophosphamide (CYC) in newly diagnosed anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. We compared and analysed the rates and predictors of severe infection in such patients within the first 6 months following RIT. METHOD From the Caen University Hospital databases, we included all consecutive adults newly diagnosed with ANCA-positive granulomatosis with polyangiitis or microscopic polyangiitis between January 2006 and December 2019. We compared rates of survival without severe infection and survival without infections of any severity within 6 months of RIT and used a multivariate Cox analysis to identify predictors of infection. RESULTS We included 145 patients, 27 in the RTX and 118 in the CYC group. Patients in the RTX group more frequently had pneumococcal vaccination (p < 0.01) and creatinine < 150 µmol/L; other characteristics were comparable between the two groups. Overall, 37 severe infections and 65 infections of any severity were recorded. Rates of survival without severe infection were similar in both groups (p = 0.69), but survival without infections of any severity was lower in the RTX group (p = 0.005). In multivariate analysis, risk factors at diagnosis for severe infections included chronic urinary tract disease, dialysis, and absence of trimethoprim-sulfamethoxazole prophylaxis (p < 0.01 each). CONCLUSIONS Within 6 months of RIT, rates of survival without severe infection were similar in newly diagnosed ANCA-positive AAV patients treated with RTX or CYC, but survival rates without infections of any severity appeared to be lower with RTX treatment.
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Affiliation(s)
- M Gérard
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - H de Boysson
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - R Morello
- Functional Unit of Biostatistics and Clinical Research, CHU de Caen Normandie, Caen, France
| | - N Martin-Silva
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - A-C Leroux
- Department of Nephrology, Centre Hospitalier Mémorial, Saint-Lô, France
| | - A Dumont
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - G Maigné
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - J Boutemy
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - K Khoy
- Department of Immunology, CHU de Caen Normandie, Caen, France
| | - D Mariotte
- Department of Immunology, CHU de Caen Normandie, Caen, France
| | - T Lobbedez
- Department of Nephrology, CHU de Caen Normandie, Caen, France
| | - A Aouba
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - S Deshayes
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
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Vassilopoulos A, Vassilopoulos S, Kalligeros M, Shehadeh F, Mylonakis E. Incidence of serious infections in patients with ANCA-associated vasculitis receiving immunosuppressive therapy: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1110548. [PMID: 36936221 PMCID: PMC10014619 DOI: 10.3389/fmed.2023.1110548] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 03/05/2023] Open
Abstract
Introduction Rituximab and azathioprine are used to induce or maintain remission in patients with ANCA-associated vasculitis (AAV). We evaluated the incidence of serious infections and infection-related deaths in patients with AAV treated with rituximab and azathioprine, during the maintenance of remission period. Methods We searched PubMed and EMBASE for randomized clinical trials (RCTs) and observational studies evaluating immunosuppressive agents in patients with AAV. We defined serious or severe infections according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The study was registered on PROSPERO (CRD42022366269). Results From 1,265 abstracts, we identified 21 studies (7 RCTs and 14 observational), with relevant data. We included data from 1,284 and 2,938 individuals for assessment in our primary and secondary outcomes, respectively. The overall cumulative incidence of serious infections was 15.99% (CI 95%: 6.95-27.53%) during the total follow-up period (induction and maintenance) and 7.62% (CI 95%: 4.43-11.43%) during the maintenance period. Additionally, we found a 0.49% overall case fatality rate (CI 95%: 0.02-1.37%) and a 0.09% infection-related mortality rate (CI 95%: 0.00-0.51%) during maintenance treatment. Notably, we found a 14.61% (CI 95%: 10.19-19.61%) cumulative incidence of serious infections among patients who received rituximab and a 5.93% (CI 95%: 1.19-13.26%) cumulative incidence of serious infections among patients who received azathioprine during maintenance. Moreover, the cumulative incidence of serious infections during the total follow-up period (induction and maintenance) was 20.81% (CI 95%:4.56-43.70%) for the combination of cyclophosphamide and azathioprine and 14.12% (CI 95%: 5.20-26.00%) for rituximab. Discussion The cumulative incidence of serious infections during total follow-up and maintenance was within expected limits, while fatal infections during maintenance treatment were uncommon. Additionally, treatment with rituximab for both induction and maintenance did not exceed the anticipated by previous studies incidence of serious infections. Clinical practice and long-term follow up data are needed to corroborate these findings. Systematic review registration Identifier: PROSPERO (CRD42022366269).
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Affiliation(s)
- Athanasios Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Stephanos Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Markos Kalligeros
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Fadi Shehadeh
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- *Correspondence: Eleftherios Mylonakis
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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El Mahdaoui S, Romme Christensen J, Magyari M, Wandall-Holm MF, Sellebjerg F. Intravenous ofatumumab treatment of multiple sclerosis and related disorders: An observational study. Mult Scler Relat Disord 2022; 68:104246. [PMID: 36279600 DOI: 10.1016/j.msard.2022.104246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/14/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Ofatumumab is an anti-CD20 monoclonal antibody approved for subcutaneous administration for the treatment of relapsing multiple sclerosis (MS), but intravenously administered ofatumumab has been investigated in a phase 2 trial and used off-label. The objective of the present study was to assess disease activity and side effects in relation to longer-term intravenous ofatumumab treatment of MS and related disorders. METHODS We conducted a retrospective study of patients treated off-label with intravenous ofatumumab for MS, neuromyelitis optica spectrum disease (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) at the Danish Multiple Sclerosis Center. Data was retrieved from the Danish Multiple Sclerosis Registry and through medical chart review. RESULTS Fifty patients were identified with a median treatment duration of 2.2 years. Annualized relapse rate decreased from 1.03 at baseline to 0.38 during ofatumumab treatment. At 24 months, the probability of having experienced a relapse was 55% and confirmed disability worsening 7%. Frequency of infusion-related reactions was 86% during the first infusion and 42% during the last infusion. Six experienced infections requiring hospitalization. CONCLUSION Our data indicate a reduction of relapse frequency, stabilization of disability worsening and an acceptable safety profile, although we observed a higher frequency of infusion reactions compared to data from other intravenously administered anti-CD20 monoclonal antibodies. The study supports a class effect of anti-CD20 monoclonal antibodies and the hypothesis that complement activation may be associated to a higher frequency of infusion related reactions.
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Affiliation(s)
- Sahla El Mahdaoui
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.
| | - Jeppe Romme Christensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Malthe Faurschou Wandall-Holm
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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8
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Rituximab in myasthenia gravis: efficacy, associated infections and risk of induced hypogammaglobulinemia. Neuromuscul Disord 2022; 32:664-671. [DOI: 10.1016/j.nmd.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022]
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9
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Predicting factors for relapse in patients with granulomatosis with polyangiitis: results from a long-term cohort. Clin Rheumatol 2022; 41:2457-2465. [DOI: 10.1007/s10067-022-06159-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
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10
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Bellos I, Boletis I, Lionaki S. A meta-analysis of the safety and efficacy of maintenance therapies for anti-neutrophil cytoplasmic antibody small-vessel vasculitis. Kidney Int Rep 2022; 7:1074-1083. [PMID: 35570996 PMCID: PMC9091778 DOI: 10.1016/j.ekir.2022.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/16/2022] [Accepted: 02/21/2022] [Indexed: 01/22/2023] Open
Abstract
Introduction To compare the efficacy and safety of different regimens used for maintenance of remission in patients with antineutrophil cytoplasmic antibody (ANCA) vasculitis. Methods This network meta-analysis studied adult patients with ANCA vasculitis in complete remission, who were maintained with various regimens, excluding patients with eosinophilic granulomatosis with polyangiitis (GPA) and those who have ended up in end-stage kidney disease. Outcomes of interest included relapse (any/major), relapse-free survival, and adverse effects. PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Google Scholar were systematically searched from inception. Results Overall, the meta-analysis was based on 10 reports, describing the outcomes of 7 randomized controlled trials (RCTs) including 752 patients with ANCA vasculitis. Relapse-free survival was significantly worse with the use of azathioprine (hazard ratio [HR]: 2.11, 95% CI: 1.19–3.74), methotrexate (HR: 2.51, 95% CI: 1.24–5.08), and mycophenolate mofetil (HR: 3.57, 95% CI: 1.70–7.46) compared with the use of rituximab. Outcomes estimated for azathioprine (HR: 0.59, 95% CI: 0.37–0.94), cyclophosphamide (HR: 0.39, 95% CI: 0.20–0.75), and leflunomide (HR: 0.30, 95% CI: 0.11–0.84) were better than those for mycophenolate mofetil. When examining relapse-free survival, relapses were more likely with use of azathioprine (odds ratio [OR]: 2.15, 95% CI: 1.00–4.59) and mycophenolate mofetil (OR: 4.42, 95% CI: 1.63–11.94) compared with the use of rituximab. The risk of major relapse calculated for azathioprine (OR: 2.39, 95% CI: 1.10–5.19), methotrexate (OR: 3.18, 95% CI: 1.14–8.89), and mycophenolate mofetil (OR: 5.20, 95% CI: 1.65–16.37) was higher than that for rituximab. The rates of serious adverse effects did not differ significantly among interventions. Conclusion Rituximab appears predominant in maintaining remission in patients with ANCA vasculitis with no cost in adverse events.
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Affiliation(s)
- Ioannis Bellos
- National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
- Department of Nephrology and Transplantation, Laiko Hospital, Athens, Greece
| | - Ioannis Boletis
- National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
- Department of Nephrology and Transplantation, Laiko Hospital, Athens, Greece
| | - Sophia Lionaki
- National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
- Department of Nephrology, Attikon University Hospital, Athens, Greece
- Correspondence: Sophia Lionaki, Department of Nephrology, Attikon University Hospital, 1 Rimini Street, 12462 Athens, Greece.
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11
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Aydın Tufan M, Tekkarışmaz N. Predictive factors of mortality in granulomatosis with polyangiitis: A single-center study. Arch Rheumatol 2021; 36:435-444. [PMID: 34870176 PMCID: PMC8612489 DOI: 10.46497/archrheumatol.2021.8594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/18/2021] [Indexed: 12/04/2022] Open
Abstract
Objectives
The aim of this study was to identify predictors of mortality in granulomatosis with polyangiitis (GPA) patients and to seek the ways of improving survival in GPA patients. Patients and methods
Between January 2005 and June 2020, a total of 60 patients (26 males, 34 females; median age: 49 years; range, 19 to 75 years) who were diagnosed with GPA were retrospectively analyzed. Demographic, clinical, laboratory, and radiological findings of all patients were recorded. Survival rates were analyzed using the Kaplan-Meier plot. Results
The median follow-up was 36 months, and 10 (16.7%) patients died during the study period. Univariate analysis showed that the prognostic values were attributed to high serum creatinine levels (>2.1 mg/dL; p=0.01), proteinuria (p=0.01), dialysis-requiring renal damage at the time of diagnosis (p=0.01) or at any time during follow-up (p=0.01), low lymphocyte levels (p=0.01), hypoalbuminemia (p=0.04), absence of upper respiratory tract involvement (p=0.01), presence of lung involvement with cavitary lesions (p=0.01), high Birmingham Vascular Activity Score (p=0.02), and history of serious infection (p=0.01). In the multivariate analysis, the presence of renal damage requiring dialysis at any time during follow-up (relative risk [95% confidence interval]: 21 [4.1-18.3]; p=0.01) was found to be an independent predictor of mortality. Immunosuppressive drugs exerted no effect on mortality, and the most common causes of death were infections (50%). Conclusion
The presence of dialysis-requiring renal damage is the most important risk factor for mortality in GPA patients. These patients should be followed more closely and carefully to improve survival.
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Affiliation(s)
- Müge Aydın Tufan
- Department of Internal Medicine, Division of Rheumatology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Nihan Tekkarışmaz
- Department of Nephrology, Başkent University Faculty of Medicine, Adana, Turkey
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12
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Merkel PA, Niles JL, Mertz LE, Lehane PB, Pordeli P, Erblang F. Long-Term Safety of Rituximab in Granulomatosis With Polyangiitis and in Microscopic Polyangiitis. Arthritis Care Res (Hoboken) 2021; 73:1372-1378. [PMID: 32475029 PMCID: PMC8457173 DOI: 10.1002/acr.24332] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/19/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The present study was undertaken to conduct a phase IV, open-label, prospective study to characterize the long-term safety of rituximab in a 4-year observational registry of adult patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) within the US. METHODS Patients initiating treatment with rituximab were evaluated every 6 months for up to 4 years. Outcomes included the incidence of serious adverse events (SAEs), infusion-related reactions (IRRs), and SAEs of specific interest, including serious infections, serious cardiac events, serious vascular events, and malignancies. RESULTS Overall, 97 patients (72 with GPA and 25 with MPA) received rituximab through a median of 8 (range 1-28) infusions and were followed up for a median of 3.94 years (range 0.05-4.32 years). The estimated incidence rates (95% confidence interval [95% CI]) of serious infections, serious cardiac events, and serious vascular events were 7.11 (4.55-10.58), 5.03 (2.93-8.06), and 2.37 (1.02-4.67) per 100 patient-years (PYs), respectively. No IRRs or SAEs occurred within 24 hours of an infusion of rituximab. None of the 9 deaths reported (crude mortality rate 2.67 [95% CI 1.22-5.06] per 100 PYs) were considered to be related to use of rituximab. CONCLUSION The safety profile of long-term treatment with rituximab in patients with GPA or MPA was consistent with that of rituximab administered for shorter durations and with rituximab's known safety profile in other autoimmune diseases for which it has received regulatory approval. These findings provide clinicians with long-term, practice-level safety data for rituximab in the treatment of GPA or MPA.
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13
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Six month assessment of low dose rituximab in the treatment of rheumatoid arthritis during coronavirus disease 2019 (COVID-19) pandemic. THE EGYPTIAN RHEUMATOLOGIST 2021; 43:253-256. [PMID: 36277424 PMCID: PMC8101793 DOI: 10.1016/j.ejr.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 11/22/2022]
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14
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Stabler S, Giovannelli J, Launay D, Cotteau-Leroy A, Heusele M, Lefèvre G, Terriou L, Lambert M, Dubucquoi S, Hachulla E, Sobanski V. Serious Infectious Events and Immunoglobulin Replacement Therapy in Patients With Autoimmune Disease Receiving Rituximab: A Retrospective Cohort Study. Clin Infect Dis 2021; 72:727-737. [PMID: 32067031 DOI: 10.1093/cid/ciaa127] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 02/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Rituximab (RTX) is widely administered to patients with autoimmune disease (AID). This study aimed to estimate the incidence of serious infectious events (SIEs) after RTX initiation in patients with AID. We also described the characteristics and risk factors of SIEs, and immunoglobulin replacement therapy (IgRT) strategies. METHODS Patients treated between 2005 and 2016 were included in this retrospective monocentric cohort study. An RTX course was defined as the complete RTX treatment regimen received by a given patient for AID. SIEs and IgRT were right-censored at 24 months after RTX initiation. RESULTS Two hundred twenty-one patients were included (corresponding to 276 RTX courses). Reasons for RTX initiation included connective tissue disease (38%), systemic vasculitis (36%), and autoimmune cytopenia (22%). The 1- and 2-year incidences of SIEs were 17.3 (95% confidence interval [CI], 12.0-22.5) and 11.3 (95% CI, 8.1-14.5) per 100 person-years, respectively. Forty-seven SIEs were observed, mostly comprising pneumonias (45%) and bacteremias (21%). When documented, the microorganisms were bacterial (55%) and fungal (12%). Identified risk factors of SIEs were age, history of diabetes, history of cancer, concomitant steroid treatment, and low CD4 lymphocyte count at RTX initiation. IgRT was started in 22 RTX courses (8%). CONCLUSIONS In patients with AID treated with RTX, the 1- and 2-year incidence of SIE was 17.3 and 11.3 per 100 person-years, respectively. Reports of SIE characteristics, risk factors, and IgRT strategies highlight the need for an appropriate and individualized assessment prior to and following RTX to prevent SIEs, particularly in patients with comorbidities.
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Affiliation(s)
- Sarah Stabler
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France
| | - Jonathan Giovannelli
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | - David Launay
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | | | - Marion Heusele
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France
| | - Guillaume Lefèvre
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,CHU Lille, Institut d'Immunologie, Lille, France
| | - Louis Terriou
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France
| | - Marc Lambert
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | - Sylvain Dubucquoi
- Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France.,CHU Lille, Institut d'Immunologie, Lille, France
| | - Eric Hachulla
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
| | - Vincent Sobanski
- University of Lille, Institute for Translational Research in Inflammation (INFINITE), Lille, France.,CHU Lille, Département de médecine interne et immunologie clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France, Lille, France.,INSERM, U1286, Lille, France
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15
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Jain K, Jawa P, Derebail VK, Falk RJ. Treatment Updates in Antineutrophil Cytoplasmic Autoantibodies (ANCA) Vasculitis. KIDNEY360 2021; 2:763-770. [PMID: 34095854 PMCID: PMC8177081 DOI: 10.34067/kid.0007142020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/03/2021] [Indexed: 02/04/2023]
Abstract
ANCA vasculitis is a small-vessel vasculitis (SVV) resulting in inflammation of small- and medium-sized blood vessels. Since the initial description of SVV, there have been tremendous advances in our understanding of its pathogenesis. Over the last decade, we have made significant progress in understanding the pathogenesis and improving the treatment and prognosis of patients with ANCA vasculitis. Patient and renal survival has improved, and treatment is moving toward individualizing care, minimizing severe adverse events, and preventing relapse. This review focuses on treatment updates in ANCA vasculitis, duration of therapy, and management of relapses. We also describe the existing treatment protocols used at our institution.
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Affiliation(s)
- Koyal Jain
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pankaj Jawa
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Vimal K. Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J. Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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16
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Almaghlouth I, Johnson SR, Pullenayegum E, Gladman D, Urowitz M. Immunoglobulin levels in systemic lupus erythematosus: A narrative review. Lupus 2021; 30:867-875. [PMID: 33779380 DOI: 10.1177/09612033211004714] [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] [Indexed: 11/15/2022]
Abstract
Immunoglobulins play a fundamental role in the protection of the human body against internal and external threats. They also contribute to the immune system homeostasis and maintenance of self-tolerance. Hypogammaglobulinemia is occasionally encountered in routine clinical practice by rheumatologists. Low levels of immunoglobulins can occur as primary or secondary issues and may predispose patients to various forms of infection. However, the impact of the low immunoglobulin level abnormality varies with the underlying condition. In this narrative review, we shed light on the overall types and functions of immunoglobulins for clinicians. We discuss important principles of immunoglobulin measurements. We then consider the primary and secondary causes of low immunoglobulins with a special focus on hypogammaglobulinemia in patients with systemic lupus erythematosus (SLE).
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Affiliation(s)
- Ibrahim Almaghlouth
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia.,College of Medicine Research Center, King Saud University, Riyadh, Saudi Arabia
| | - Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Eleanor Pullenayegum
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Program in Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
| | - Dafna Gladman
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Centre for Prognosis in Rheumatic Diseases, University Health Network, Toronto, Canada
| | - Murray Urowitz
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Centre for Prognosis in Rheumatic Diseases, University Health Network, Toronto, Canada
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17
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Segelmark L, Flores-Suárez LF, Mohammad AJ. Severe infections in patients with ANCA associated vasculitis treated with rituximab. Rheumatology (Oxford) 2021; 61:205-212. [PMID: 33757116 DOI: 10.1093/rheumatology/keab293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab (RTX) is an anti-CD20 antibody that selectively depletes B-cells and has emerged as a therapy for ANCA-associated vasculitis (AAV) during the past decade. This study sought to quantify, and determine potential risk factors for, severe infections in AAV patients treated with RTX at rheumatology clinics in Mexico City, Mexico and Lund, Sweden. METHODS The study consisted of a retrospective case-record review (2005-2015) with standardized data collection related to the occurrence of severe infection in 46 patients with AAV in Mexico City (n = 20) and Lund (n = 26) treated with RTX during their disease course. Median duration of follow-up from first RTX dose to death or end of study was 26 months. RESULTS Eleven (24%) patients suffered a total of 18 severe infections (infection rate of 11.5/100 patient-years). Thirteen of the 18 infections (72%) occurred within the first year of treatment. Risk factors for severe infection were older age at RTX initiation and absence of ENT-involvement at diagnosis. In multivariate analyses, age at RTX infusion was the only independent factor predicting severe infection. Four patients (9%) died during follow-up, all as a result of infection. CONCLUSIONS Severe infections are common following RTX treatment, and mortality due to infection is a major concern. Most severe infections occur within the first year of RTX treatment. The negative correlation of ENT involvement with severe infection might reflect GPA phenotype heterogeneity. Older age at time of RTX treatment independently predicts severe infections.
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Affiliation(s)
- Leo Segelmark
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - L F Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden.,Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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18
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Schwake C, Gold R. Severe pneumonia with formation of a pulmonary cavity associated with long-term rituximab therapy in multiple sclerosis. Neurol Res Pract 2020; 2:30. [PMID: 33324932 PMCID: PMC7650061 DOI: 10.1186/s42466-020-00074-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/19/2020] [Indexed: 11/16/2022] Open
Abstract
Nowadays B-cell depletion via anti-CD20 antibodies is commonly applied in the treatment of multiple sclerosis (MS). Yet, not much is known about infection risks associated with long-term B-cell depletion in the specific context of MS. We present the case of a 45-year-old male patient who developed severe pneumonia following 6 years of rituximab treatment for highly active relapsing-remitting MS. The patient had no additional chronic disease as well as no history of foreign travel. Although the unusual formation of a pulmonary cavity raised suspicion for tuberculosis, repeated testing via bronchoscopy and sputum remained negative. Prolonged antibiotic therapy with piperacillin/tazobactam and amoxicillin/ clavulanate led to complete recovery from symptoms. This case shows the potential risk of serious infections following continuous B-cell depletion in MS and illustrates the importance of future vigilance.
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Affiliation(s)
- Carolin Schwake
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
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19
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Tieu J, Smith R, Basu N, Brogan P, D'Cruz D, Dhaun N, Flossmann O, Harper L, Jones RB, Lanyon PC, Luqmani RA, McAdoo SP, Mukhtyar C, Pearce FA, Pusey CD, Robson JC, Salama AD, Smyth L, Watts RA, Willcocks LC, Jayne DRW. Rituximab for maintenance of remission in ANCA-associated vasculitis: expert consensus guidelines. Rheumatology (Oxford) 2020; 59:e24-e32. [PMID: 32096545 DOI: 10.1093/rheumatology/kez640] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/31/2019] [Indexed: 01/05/2023] Open
Affiliation(s)
- Joanna Tieu
- Department of Medicine, University of Cambridge, Cambridge, UK.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Rona Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow
| | - Paul Brogan
- University College London Great Ormond Institute of Child Health.,Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David D'Cruz
- Guy's and St Thomas' NHS Foundation Trust, London
| | - Neeraj Dhaun
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh.,Royal Infirmary of Edinburgh, Edinburgh
| | | | - Lorraine Harper
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Department of Renal Medicine, Cambridge University Hospitals Trust, Cambridge
| | - Peter C Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Oxford
| | | | - Chetan Mukhtyar
- Norfolk and Norwich University Hospital.,University of East Anglia, Norwich
| | - Fiona A Pearce
- University of Nottingham.,Nottingham University Hospitals NHS Trust, Nottingham
| | | | - Joanna C Robson
- Faculty of Health and Applied Sciences, University of West of England.,Department of Rheumatology, University Hospitals Bristol NHS Trust, Bristol
| | - Alan D Salama
- University College London.,Department of Renal Medicine, Royal Free Hospital, London
| | - Lucy Smyth
- Exeter Kidney Unit, Royal Devon and Exeter Hospital, Exeter
| | - Richard A Watts
- Ipswich Hospital, Ipswich.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lisa C Willcocks
- Department of Renal Medicine, Cambridge University Hospitals Trust, Cambridge
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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20
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Carpenter S, Cohen Tervaert JW, Yacyshyn E. Advances in therapeutic treatment options for ANCA-associated vasculitis. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1760837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Shealynn Carpenter
- University of Alberta, Department of Medicine, Division of Rheumatology, Edmonton, Alberta, Canada
| | - Jan Willem Cohen Tervaert
- University of Alberta, Department of Medicine, Division of Rheumatology, Edmonton, Alberta, Canada
- Maastricht University, School for Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Elaine Yacyshyn
- University of Alberta, Department of Medicine, Division of Rheumatology, Edmonton, Alberta, Canada
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21
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Charles P, Dechartres A, Terrier B, Cohen P, Faguer S, Huart A, Hamidou M, Agard C, Bonnotte B, Samson M, Karras A, Jourde-Chiche N, Lifermann F, Gobert P, Hanrotel-Saliou C, Godmer P, Martin-Silva N, Pugnet G, Matignon M, Aumaitre O, Viallard JF, Maurier F, Meaux-Ruault N, Rivière S, Sibilia J, Puéchal X, Mouthon L, Guillevin L. Reducing the initial number of rituximab maintenance-therapy infusions for ANCA-associated vasculitides: randomized-trial post-hoc analysis. Rheumatology (Oxford) 2020; 59:2970-2975. [DOI: 10.1093/rheumatology/kez621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/02/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractObjectiveThe randomized, controlled MAINRITSAN2 trial was designed to compare the capacity of an individually tailored therapy [randomization day 0 (D0)], with reinfusion only when CD19+ lymphocytes or ANCA had reappeared, or if the latter’s titre rose markedly, with that of five fixed-schedule 500-mg rituximab infusions [D0 + D14, then months (M) 6, 12 and 18] to maintain ANCA-associated vasculitis (AAV) remissions. Relapse rates did not differ at M28. This ancillary study was undertaken to evaluate the effect of omitting the D14 rituximab infusion on AAV relapse rates at M12.MethodsMAINRITSAN2 trial data were subjected to post-hoc analyses of M3, M6, M9 and M12 relapse-free survival rates in each arm as primary end points. Exploratory subgroup analyses were run according to CYC or rituximab induction and newly diagnosed or relapsing AAV.ResultsAt M3, M6, M9 and M12, respectively, among the 161 patients included, 79/80 (98.8%), 76/80 (95%), 74/80 (92.5%) and 73/80 (91.3%) from D0, and 80/81 (98.8%), 78/81 (96.3%), 76/81 (93.8%) and 76/81 (93.8%) from D0+D14 groups were alive and relapse-free. No between-group differences were observed. Results were not affected by CYC or rituximab induction, or newly diagnosed or relapsing AAV.ConclusionsWe were not able to detect a difference between the relapse-free survival rates for up to M12 for the D0 and D0+D14 rituximab-infusion groups, which could suggest that omitting the D14 rituximab remission-maintenance dose did not modify the short-term relapse-free rate. Nevertheless, results at M12 may also have been influenced by the rituximab-infusion strategies for both groups.
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Affiliation(s)
- Pierre Charles
- Centre de Référence Maladies Systémiques et Auto-Immunes Rares, Université Paris Descartes, APHP, Hôpital Cochin, Paris
- Département de Médecine Interne, Institut Mutualiste Montsouris, Paris, France. *See Acknowledgements section for a list of the French Vasculitis Study Group
| | - Agnès Dechartres
- Sorbonne Universitù, Institut National de la Santù et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtriére, Département de SantÕ Publique, Paris
| | - Benjamin Terrier
- Centre de Référence Maladies Systémiques et Auto-Immunes Rares, Université Paris Descartes, APHP, Hôpital Cochin, Paris
| | - Pascal Cohen
- Centre de Référence Maladies Systémiques et Auto-Immunes Rares, Université Paris Descartes, APHP, Hôpital Cochin, Paris
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d’Organes, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse
| | - Antoine Huart
- Département de Néphrologie et Transplantation d’Organes, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse
| | | | | | - Bernard Bonnotte
- Service de Médecine Interne et Immunologie Clinique, CHU de Dijon, INSERM, UMR 1098, Université de Bourgogne Franche-Comté, FHU INCREASE, Dijon
| | - Maxime Samson
- Service de Médecine Interne et Immunologie Clinique, CHU de Dijon, INSERM, UMR 1098, Université de Bourgogne Franche-Comté, FHU INCREASE, Dijon
| | - Alexandre Karras
- Centre de Néphrologie et de Transplantation Rénale, Unité de Néphrologie, APHP, Hôpital Européen Georges-Pompidou, Université Paris Descartes, Paris
| | - Noémie Jourde-Chiche
- Aix–Marseille Université, Centre de Néphrologie et de Transplantation Rénale, AP–HM, Hôpital de la Conception, Marseille
| | | | | | - Catherine Hanrotel-Saliou
- Service de Néphrologie, Dialyse et Transplantation Rénale, Hôpital la Cavale Blanche, CH Régionale Universitaire Brest, Brest
| | - Pascal Godmer
- Département de Médecine Interne, CH Bretagne Atlantique de Vannes, Vannes
| | | | | | | | - Olivier Aumaitre
- Service de Médecine Interne, CHU, Hôpital Gabriel-Montpied, Clermont-Ferrand
| | | | | | | | - Sophie Rivière
- Service de Médecine Interne, CHU de Montpellier, Montpellier
| | - Jean Sibilia
- Service de Rhumatologie, Hôpital de Hautepierre, CHU de Strasbourg, Strasbourg, France
| | - Xavier Puéchal
- Centre de Référence Maladies Systémiques et Auto-Immunes Rares, Université Paris Descartes, APHP, Hôpital Cochin, Paris
| | - Luc Mouthon
- Centre de Référence Maladies Systémiques et Auto-Immunes Rares, Université Paris Descartes, APHP, Hôpital Cochin, Paris
| | - Loïc Guillevin
- Centre de Référence Maladies Systémiques et Auto-Immunes Rares, Université Paris Descartes, APHP, Hôpital Cochin, Paris
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22
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Md Yusof MY, Vital EM, Emery P, Savic S. Reply. Arthritis Rheumatol 2020; 72:1231-1233. [PMID: 32133788 DOI: 10.1002/art.41244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Md Yuzaiful Md Yusof
- University of Leeds and NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward M Vital
- University of Leeds and NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- University of Leeds and NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sinisa Savic
- University of Leeds and NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Wijetilleka S, Jayne DR, Mukhtyar C, Ala A, Bright PD, Chinoy H, Harper L, Kazmi MA, Kiani-Alikhan S, Li CK, Misbah SA, Oni L, Price-Kuehne FE, Salama AD, Workman S, Wrench D, Karim MY. Recommendations for the management of secondary hypogammaglobulinaemia due to B cell targeted therapies in autoimmune rheumatic diseases. Rheumatology (Oxford) 2020; 58:889-896. [PMID: 30590695 DOI: 10.1093/rheumatology/key394] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/01/2018] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES The association of B cell targeted therapies with development of hypogammaglobulinaemia and infection is increasingly recognized. Our aim was to develop consensus recommendations for immunoglobulin replacement therapy for management of hypogammaglobulinaemia following B cell targeted therapies in autoimmune rheumatic diseases. METHODS A modified Delphi exercise involved a 17-member Taskforce committee, consisting of immunologists, rheumatologists, nephrologists, haematologists, a gastroenterologist, an immunology specialist nurse and a patient representative. The first round identified the most pertinent topics to address in the recommendations. A search string was agreed upon for the identification of publications in PubMed focusing on these areas, for a systematic literature review. Original data was presented from this review to the Taskforce committee. Recommendations from the British Society for Rheumatology, the UK Department of Health, EULAR, the ACR, and the American Academy of Allergy, Asthma, and Immunology were also reviewed. The evidence was discussed in a face-to-face meeting to formulate recommendation statements. The levels of evidence and statements were graded according to Scottish Intercollegiate Guidelines Network methodology. RESULTS Three overarching principles, eight recommendation statements and a research agenda were formulated. The Taskforce committee voted on these statements, achieving 82-100% agreement for each recommendation. The strength of the recommendations was restricted by the low quality of the available evidence, with no randomized controlled trial data. The recommendations cover risk factors, monitoring, referral for hypogammaglobulinaemia; indications, dosage and discontinuation of immunoglobulin replacement therapy. CONCLUSION These are the first recommendations specifically formulated for B cell targeted therapies related to hypogammaglobulinaemia in autoimmune rheumatic diseases. The recommendations are to aid health-care professionals with clinical decision making for patients with hypogammaglobulinaemia.
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Affiliation(s)
| | - David R Jayne
- Department of Medicine, University of Cambridge, Cambridge
| | - Chetan Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey County Hospital NHS Foundation Trust, Guildford
| | | | - Hector Chinoy
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | - Lorraine Harper
- Department of Nephrology, Institute of Clinical Sciences-University of Birmingham, Birmingham
| | - Majid A Kazmi
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust
| | | | - Charles K Li
- Department of Rheumatology, Royal Surrey County Hospital NHS Foundation Trust, Guildford
| | - Siraj A Misbah
- Department of Immunology, Oxford University Hospitals, Oxford
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
| | - Fiona E Price-Kuehne
- Department of Paediatrics, University of Cambridge School of Clinical Medicine, Cambridge
| | - Alan D Salama
- Department of Nephrology, University College London Centre for Nephrology
| | - Sarita Workman
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - David Wrench
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust
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24
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Post-rituximab immunoglobulin M (IgM) hypogammaglobulinemia. Autoimmun Rev 2020; 19:102466. [PMID: 31917267 DOI: 10.1016/j.autrev.2020.102466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody that targets the B cell-specific cell surface antigen CD20 and is currently used to treat several autoimmune diseases. The elimination of mature CD20-positive B lymphocytes committed to differentiate into autoantibody-producing plasma cells is considered to be the major effect of rituximab, that makes it a beneficial biological agent in treating autoimmune diseases. Hypogammaglobulinemia has been reported after rituximab therapy in patients with lymphoma and rheumatoid arthritis. Similar data are scarce for other autoimmune diseases. Low immunoglobulin G (IgG) or hypogammaglobulinemia has attracted the most attention because of its significant role in protective immunity. However, the incidence and clinical implications of low immunoglobulin M (IgM) or hypogammaglobulinemia have not been studied in detail. This review will focus on the frequency and the clinical concerns of low IgM levels that result as a consequence of the administration of rituximab. The etiopathogenic mechanisms underlying post-rituximab IgM hypogammaglobulinemia and its implications are presented. The long-term consequences, if any, are not known or documented. Multiple factors may be involved in whether IgG or IgM decreases secondary to rituximab therapy. It is possible that the autoimmune disease itself may be one of the important factors. The dose, frequency and number of infusions appear to be important variables. Post-rituximab therapy immunoglobulin levels return to normal. During this process. IgM levels take a longer time to return to normal levels when compared to IgG or other immunoglobulins. IgM deficiency persists after B cell repopulation to normal levels has occurred. Laboratory animals and humans deficient in IgM can have multiple infections. Specific pharmacologic agents or biologic therapy that address and resolve IgM deficiency are currently unavailable. If the clinical situation so warrants, then prophylactic antibiotics may be indicated and perhaps helpful. Research in this iatrogenic phenomenon will provide a better understanding of not only the biology of IgM, but also the factor(s) that control its production and regulation, besides its influence if any, on rituximab therapy.
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25
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Kant S, Azar A, Gapud EJ, Antiochos B, Manno R, Seo P, Geetha D. Subcutaneous Immunoglobulin for Antibody Deficiency in Antineutrophil Cytoplasmic Antibody (ANCA)-associated Vasculitis. Cureus 2019; 11:e6367. [PMID: 31938649 PMCID: PMC6957027 DOI: 10.7759/cureus.6367] [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] [Indexed: 02/07/2023] Open
Abstract
Objectives Intravenous immunoglobulin G (IVIG) is used to treat antineutrophil cytoplasmic antibody (ANCA) patients with recurrent infections as a result of hypogammaglobulinemia (HG) induced by treatment regimens. We sought to characterize clinical features, treatment, and outcomes for patients treated with the novel subcutaneous IgG (SCIG) for the aforementioned purpose. Methods We conducted a retrospective study of 136 patients in our ANCA database to identify patients with recurrent infections and HG subsequently treated with SCIG. Patient demographics, serologies, treatment, and immunological parameters were assessed. Results Of 136 patients, four were treated with SCIG. All were Caucasian, proteinase-3 (PR3)-positive, and the majority (n = 3) were females. All patients had pulmonary involvement, and regimens of cyclophosphamide (CYC) and/or rituximab (RTX) were employed for induction and remission. Three patients each experienced recurrent bouts of respiratory tract infections and shingles. Ig levels (G, M, and A) were reduced in all patients, except for one patient who had normal IgA levels. CD19/20 cells were depleted and CD3/4/8/NK cells were preserved in all patients. Three patients had no discernible antibody response to the pneumococcal vaccine (specific pneumococcal serotypes measured pre- and post-vaccine). The mean duration elapsed between the first rituximab administration and commencement of SCIG was 7.2 years. The IgG level normalized and none of the patients had a recurrence of infection since the initiation of SCIG. Conclusion This data, albeit preliminary, is the first series that demonstrates SCIG can be a reliable alternative to IVIG in ANCA patients with recurrent infections secondary to HG. Early identification of this subset of patients is likely to mitigate infectious risks, associated morbidity, and hospitalization.
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Affiliation(s)
- Sam Kant
- Nephrology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Antoine Azar
- Allergy and Immunology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Eric J Gapud
- Rheumatology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Brendan Antiochos
- Rheumatology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Rebecca Manno
- Rheumatology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Philip Seo
- Rheumatology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Duvuru Geetha
- Medicine, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, USA
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26
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Berti A, Specks U. Remission maintenance in ANCA-associated vasculitis: does one size fit all? Expert Rev Clin Immunol 2019; 15:1273-1286. [PMID: 31762340 DOI: 10.1080/1744666x.2020.1693260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The majority of the patients with anti-neutrophil cytoplasmic autoantibody (ANCA) associated vasculitis (AAV) achieve remission with effective induction therapy. Therefore, prevention of relapses and avoiding long-term damage and treatment-related toxicity are major challenges.Areas covered: This review provides an update on maintenance therapy in AAV, emphasizing the available treatment options for granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Among the spectrum of all patients with AAV, those at higher risk of relapse have recently been identified. Clinical trials have yielded robust results about various options for maintenance of remission including common disease-modifying anti-rheumatic drugs (DMARDs, i.e. azathioprine, methotrexate, and mycophenolate mofetil) and rituximab (RTX). However, outcomes of these studies are not easy to compare.Expert opinion: Regardless of the treatment used, patients presenting with an anti-proteinase-3 ANCA, relapsing GPA have a substantially higher risk of relapse compared to patients with newly diagnosed MPA or positive anti-myeloperoxidase ANCA. While the efficacy of common DMARDs for remission maintenance is heterogeneous, the role of RTX seems particularly promising for the high-risk patients, although the most appropriate dose and timing of retreatment with RTX remain under controversial. Low-dose glucocorticoid use for remission maintenance versus complete discontinuation also remains under investigation.
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Affiliation(s)
- Alvise Berti
- Rheumatology Department, Santa Chiara Hospital and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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27
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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Abstract
PURPOSE OF REVIEW Induction of lymphocyte depletion is increasingly used as a therapeutic strategy for central and peripheral neuroinflammatory disease. However, there is also a growing recognition of the treatment-related complication of secondary antibody deficiency (SAD). Although the occurrence of hypogammaglobulinaemia is a recognized phenomenon during immunomodulation, robust data on the coexistence of impaired responses to immunization, and significant and/or atypical infections is scarce. Here we review the literature on SAD in anti-CD20 therapy. RECENT FINDINGS Several factors that may increase the incidence of SAD have now been identified, including low levels of immunoglobulins prior to the commencement of B-cell ablation therapy, duration of maintenance therapy, and concurrent or prior use of other immunosuppressing agents such as cyclophosphamide and steroids. Measurement of disease-specific antibodies and vaccine response are likely to be helpful adjuncts to measurement of serum immunoglobulin levels during B-cell depleting therapy. Supportive treatment may include amending the treatment schedule to limit cumulative dose. SUMMARY B-cell depleting agents offer considerable therapeutic benefit in neurology. We propose modifications in current practice that include risk stratification and early identification of SAD, with the aim of minimising morbidity and mortality related to this underappreciated condition.
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29
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Teixeira V, Mohammad AJ, Jones RB, Smith R, Jayne D. Efficacy and safety of rituximab in the treatment of eosinophilic granulomatosis with polyangiitis. RMD Open 2019; 5:e000905. [PMID: 31245051 PMCID: PMC6560673 DOI: 10.1136/rmdopen-2019-000905] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/06/2019] [Accepted: 05/15/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Eosinophilic granulomatosis with polyangiitis (EGPA) is a subset of antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis with distinct pathophysiological mechanisms, clinical features and treatment responses. Rituximab is a licensed therapy for granulomatosis with polyangiitis and microscopic polyangiitis but there is limited experience of rituximab in EGPA. Methods EGPA patients from a tertiary centre who received rituximab for mostly refractory EGPA or in whom cyclophosphamide was contra indicated were studied. A standardised dataset was collected at time of initial treatment and every 3 months for 24 months. Response was defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 and partial response as ≥50% reduction in BVAS from baseline. Remission was defined as a BVAS of 0 on prednisolone dose ≤5 mg. Results Sixty-nine patients (44 female) received rituximab between 2003 and 2017. Improvement (response and partial response) was observed in 76.8% of patients at 6 months, 82.8% at 12 months and in 93.2% by 24 months, while relapses occurred in 54% by 24 months, with asthma being the most frequent manifestation. The median BVAS decreased from 6 at baseline to 1 at 6 months, and 0 at 12 and 24 months. Prednisolone dose (mg/day, median) decreased from 12.5 to 7, 7.5 and 5 at 6, 12 and 24 months, respectively. ANCA positive patients had a longer asthma/ear, nose and throat (ENT) relapse-free survival time and a shorter time to remission. Discussion Rituximab demonstrated some efficacy in EGPA and led to a reduction in prednisolone requirement, but asthma and ENT relapse rates were high despite continued treatment. The ANCA positive subset appeared to have a more sustained response on isolated asthma/ENT exacerbations.
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Affiliation(s)
- Vítor Teixeira
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Aladdin J Mohammad
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Clinical Sciences, Rheumatology, Lund University, Lund, Skåne, Sweden
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - Rona Smith
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - David Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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Zheng Y, Zhang Y, Cai M, Lai N, Chen Z, Ding M. Central Nervous System Involvement in ANCA-Associated Vasculitis: What Neurologists Need to Know. Front Neurol 2019; 9:1166. [PMID: 30687221 PMCID: PMC6335277 DOI: 10.3389/fneur.2018.01166] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective: To provide a comprehensive review of the central nervous system (CNS) involvement in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), including the pathogenesis, clinical manifestations, ancillary investigations, differential diagnosis, and treatment. Particular emphasis is placed on the clinical spectrum and diagnostic testing of AAV. Recent Findings: AAV is a pauci-immune small-vessel vasculitis characterized by neutrophil-mediated vasculitis and granulomatousis. Hypertrophic pachymeninges is the most frequent CNS presentation. Cerebrovascular events, hypophysitis, posterior reversible encephalopathy syndrome (PRES) or isolated mass lesions may occur as well. Spinal cord is rarely involved. In addition, ear, nose and throat (ENT), kidney and lung involvement often accompany or precede the CNS manifestations. Positive ANCA testing is highly suggestive of the diagnosis, with each ANCA serotype representing different groups of AAV patients. Pathological evidence is the gold standard but not necessary. Once diagnosed, prompt initiation of induction therapy, including steroid and other immunosuppressants, can greatly mitigate the disease progression. Conclusions and Relevance: Early recognition of AAV as the underlying cause for various CNS disorders is important for neurologists. Ancillary investigations especially the ANCA testing can provide useful information for diagnosis. Future studies are needed to better delineate the clinical spectrum of CNS involvement in AAV and the utility of ANCA serotype to classify those patients. Evidence Review: We searched Pubmed for relevant case reports, case series, original research and reviews in English published between Sep 1st, 2001 and Sep 1st, 2018. The following search terms were used alone or in various combinations: “ANCA,” “proteinase 3/PR3-ANCA,” “myeloperoxidase/MPO-ANCA,” “ANCA-associated vasculitis,” “Wegener's granulomatosis,” “microscopic polyangiitis,” “Central nervous system,” “brain” and “spinal cord”. All articles identified were full-text papers.
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Affiliation(s)
- Yang Zheng
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yinxi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mengting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Nanxi Lai
- Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhong Chen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, China
| | - Meiping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Predictors of hypogammaglobulinemia during rituximab maintenance therapy in rheumatoid arthritis: A 12-year longitudinal multi-center study. Semin Arthritis Rheum 2018; 48:149-154. [DOI: 10.1016/j.semarthrit.2018.02.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/19/2018] [Accepted: 02/16/2018] [Indexed: 12/24/2022]
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32
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Shaukat MS, Ocon AJ, Peredo RA, Bhatt BD. Prostatitis, a rare presentation of granulomatosis with polyangiitis, successfully treated with rituximab and prednisone. BMJ Case Rep 2018; 2018:bcr-2018-225379. [DOI: 10.1136/bcr-2018-225379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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33
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Grygiel-Górniak B, Limphaibool N, Perkowska K, Puszczewicz M. Clinical manifestations of granulomatosis with polyangiitis: key considerations and major features. Postgrad Med 2018; 130:581-596. [PMID: 30071173 DOI: 10.1080/00325481.2018.1503920] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) presents a wide spectrum of manifestations from the common respiratory symptoms to infrequent neurological and cardiac complications. The challenge in diagnosis and management makes the rapidly progressive disorder one of the most challenging dilemmas in clinical medicine. METHOD An extensive electronic literature search was done using multiple databases (e.g. PubMed) from January 2007 to August 2017 to gather information on the etiopathogenesis, clinical presentation, and current treatment management plan of GPA. The language used was English. Search items included 'Granulomatosis with Polyangiitis symptoms,' 'Wegener's Granulomatosis,' and 'Treatment of Granulomatosis with Polyangiitis' for the databases. Inclusion criteria consisted of published articles in the English language which reported on the clinical manifestations of GPA, as well as on the treatment of the disease. Exclusion criteria included articles that: (1) did not specifically report on GPA vasculitis but also focused on discussion of other vasculitis such as MPA or Churg-Strauss; (2) reported on treatment/symptoms of GPA prior to 2007. RESULT This review provides an overview of work undertaken in key areas of GPA research, including its complex multifactorial etiology, clinical manifestations, treatment strategies, and treatment-related adverse effects. CONCLUSION Major advances in the understanding and treatment of GPA over recent decades have contributed to the notable decline in morbidity and mortality of patients. The ultimate goal is an improved prognosis through outcome measures which assesses the disease control with minimal adverse effects of intensive immunosuppressive regimens, an integral part of the clinical approach to improve the quality of life of GPA patients.
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Affiliation(s)
- Bogna Grygiel-Górniak
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Nattakarn Limphaibool
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Katarzyna Perkowska
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Mariusz Puszczewicz
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
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de Azevedo FVA, Lima FO, de Carvalho JF, de Saboia Mont'Alverne AR, Rodrigues CEM. Granulomatosis with polyangiitis in Northeastern Brazil: study of 25 cases and review of the literature. Adv Rheumatol 2018; 58:10. [PMID: 30657074 DOI: 10.1186/s42358-018-0010-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little has been published about the epidemiology of Granulomatosis with polyangiitis (GPA) in South America, especially in the intertropical zone, and no epidemiological data from Brazil are available. The purpose of the present study was to draw a clinical and demographic profile of GPA patients living in Northeastern Brazil based on laboratory, histological and imaging findings, and evaluate the frequency of organic involvement. METHODS Clinical, epidemiological and treatment data of GPA patients were collected retrospectively and compared with the literature. RESULTS The cohort included 25 GPA patients (84% female) aged 45.8 ± 16.1 years. Renal and ear-nose-throat (ENT) manifestations were the most common (both 64%). One third (32%) of the patients had 24-h proteinuria > 1 g, 50% had creatinine clearance < 50 mL/min at the time of diagnosis, and 33% had recurrent kidney damage during disease progress. The affected organs included lungs (60%), joints (44%), skin (32%), peripheral nervous system (28%), eyes (28%) and heart (16%). ENT involvement (n = 16/64%) was less frequent in our region than in São Paulo (n = 115/85.8%). Renal (n = 16/64%) and pulmonary (n = 15/60%) involvement was less frequent in our region than in the U.K. (renal n = 30/90%; pulmonary n = 28/84.8%). CONCLUSION Most of our patients were female, presented the generalized form and were diagnosed late. The frequency of the main clinical manifestations (ENT, renal and pulmonary) was lower than that observed at higher latitudes, suggesting the existence of a Northeast Brazilian clinical and epidemiological profile and adding to our knowledge of this rare condition.
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Affiliation(s)
- Francisco Vileimar Andrade de Azevedo
- Post-Graduate Program in Medical Sciences, University of Fortaleza (UNIFOR), Fonseca Lobo 560 apto. 1202, Aldeota, Fortaleza, Ceará, CEP 60175020, Brazil.
| | - Fabrício Oliveira Lima
- Post-Graduate Program in Medical Sciences, University of Fortaleza (UNIFOR), Fonseca Lobo 560 apto. 1202, Aldeota, Fortaleza, Ceará, CEP 60175020, Brazil
| | | | | | - Carlos Ewerton Maia Rodrigues
- Post-Graduate Program in Medical Sciences, University of Fortaleza (UNIFOR), Fonseca Lobo 560 apto. 1202, Aldeota, Fortaleza, Ceará, CEP 60175020, Brazil
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Rituximab for anti-neutrophil cytoplasmic antibodies-associated vasculitis: experience of a single center and systematic review of non-randomized studies. Rheumatol Int 2018; 38:607-622. [PMID: 29322343 DOI: 10.1007/s00296-018-3928-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/02/2018] [Indexed: 10/27/2022]
Abstract
Rituximab (RTX) is becoming a standard treatment for patients with anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) but heterogeneity exists regarding its use. We present our uncontrolled experience with RTX in patients with refractory AAV and also the results of a systematic review of non-randomized studies on RTX in AAV patients. We retrospectively reviewed the records of AAV patients treated with RTX following an inadequate response to immunosuppressives between 2011 and 2015. The systematic review covered all English articles listed in PubMed until June 2017. There were 25 AAV patients (21 GPA, four unclassified) treated with RTX (median 2, IQR 1-3 courses; median follow-up 24, IQR 17-50 months). The kidney and the lung were the most commonly affected organs, observed in 14 and 16 patients, respectively. Complete remission rate was 72% at month 6 and 88% at month 12. Two patients had died and three serious adverse events occurred. The systematic review included 56 studies on 1422 patients with the majority being on refractory or relapsing disease. There was wide variability regarding disease characteristics, endpoints, concomitant immunosuppressives and RTX schedule. Most studies reported > 80% complete or partial remission rates with the lowest response (37.5%) for granulomatous lesions. The relapse rate was 30%. Infections and infusion reactions were the main adverse events. Our experience with RTX in refractory AAV is in line with the literature in terms of efficacy and safety. The systematic review underlines many uncertainties on its optimal use.
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Taha R, El-Haddad H, Almuallim A, Alshaiki F, Obaid E, Almoallim H. Systematic review of the role of rituximab in treatment of antineutrophil cytoplasmic autoantibody-associated vasculitis, hepatitis C virus-related cryoglobulinemic vasculitis, Henoch-Schönlein purpura, ankylosing spondylitis, and Raynaud's phenomenon. Open Access Rheumatol 2018; 9:201-214. [PMID: 29290695 PMCID: PMC5735990 DOI: 10.2147/oarrr.s149373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rituximab (RTX) is established for the treatment of rheumatoid arthritis. This systematic review of the literature since 2006 summarizes evidence for the use of RTX in the treatment of additional rheumatological diseases: antineutrophil cytoplasmic autoantibody-associated vasculitis (AAV), hepatitis C virus-related cryoglobulinemic vasculitis, Henoch-Schönlein purpura, ankylosing spondylitis, and Raynaud's phenomenon. Data from randomized controlled trials are available only for AAV, confirming efficacy for remission induction, including in disease resistant to conventional treatment, and maintenance of remission. Further studies are required to confirm optimal maintenance regimens in AAV, important questions needing to be addressed including protocol administration versus treatment in response to clinical relapse and the importance of maintaining B-cell depletion. Sufficient data are available in other diseases to suggest RTX to be useful and that randomized controlled trials should be conducted.
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Affiliation(s)
- Rbab Taha
- Department of Medicine, Dr Soliman Fakeeh Hospital, Jeddah
| | | | | | | | - Elaf Obaid
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Mecca
| | - Hani Almoallim
- Department of Medicine, Dr Soliman Fakeeh Hospital, Jeddah.,Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Mecca.,Rheumatic Diseases, Umm Al-Qura University, Mecca, Saudi Arabia
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Sriskandarajah S, Bostad L, Myklebust TÅ, Møller B, Skrede S, Bjørneklett R. Cancer in ANCA-Associated Glomerulonephritis: A Registry-Based Cohort Study. Int J Nephrol 2017; 2017:6013038. [PMID: 29403663 PMCID: PMC5748316 DOI: 10.1155/2017/6013038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Immunosuppressive therapy for antineutrophil cytoplasmic antibody-associated vasculitis has been associated with increased malignancy risk. OBJECTIVES To quantify the cancer risk associated with contemporary cyclophosphamide-sparing protocols. METHODS Patients from the Norwegian Kidney Biopsy Registry between 1988 and 2012 who had biopsy-verified pauci-immune glomerulonephritis and positive antineutrophil cytoplasmic antibody (ANCA) serology were included. Standardised incidence ratios (SIRs) were calculated to compare the study cohort with the general population. RESULTS The study cohort included 419 patients. During 3010 person-years, cancer developed in 41 patients (9.79%); the expected number of cancer cases was 37.5 (8.95%). The cohort had SIRs as follows: 1.09, all cancer types (95% CI, 0.81 to 1.49); 0.96, all types except nonmelanoma skin cancer (95% CI, 0.69 to 1.34); 3.40, nonmelanoma skin cancer (95% CI, 1.62 to 7.14); 3.52, hematologic cancer (95% CI, 1.32 to 9.37); 2.12, posttransplant cancer (95% CI, 1.01 to 4.44); and 1.53, during the 1-5-year follow-up after diagnosis (95% CI, 1.01 to 2.32). CONCLUSIONS Cancer risk did not increase significantly in this cohort with ANCA-associated glomerulonephritis. However, increased risk of nonmelanoma skin cancer, posttransplant cancer, and hematologic cancer indicates an association between immunosuppression and malignancy.
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Affiliation(s)
| | - Leif Bostad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Tor Åge Myklebust
- Department of Clinical and Registry-Based Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway
| | - Bjørn Møller
- Department of Clinical and Registry-Based Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
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38
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Cornec D, Cornec-Le Gall E, Specks U. Clinical trials in antineutrophil cytoplasmic antibody-associated vasculitis: what we have learnt so far, and what we still have to learn. Nephrol Dial Transplant 2017; 32:i37-i47. [PMID: 28087591 DOI: 10.1093/ndt/gfw384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
The prognosis of the antineutrophil cytoplasmic antibody associated vasculitides (AAV), microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic GPA (EGPA), has been fundamentally improved over the last five decades by the use of glucocorticoids and immunosuppressants, turning them from consistently fatal diseases into chronic conditions. The long-term course is now largely determined by the frequency of disease flares and by accruing damage caused by disease activity and treatment-related comorbidities. This review summarizes the evidence derived from clinical trials performed during the last 30 years and the remaining clinical unmet needs that new studies aim to address. In MPA and GPA, ongoing studies assess (i) different strategies to reduce cumulative glucocorticoid doses currently used for induction and maintenance of remission, (ii) the efficacy of new drugs and (iii) the optimal duration of immunosuppression and the use of biomarkers to individualize therapy. Prospective randomized trials also target disease-associated cardiovascular risk and infections. The first prospective controlled trials specifically designed for EGPA have recently been launched and could lead to new therapeutic options for patients diagnosed with this rare disease. This is an exciting time for researchers in the field of AAV, and for patients as collaborative efforts raise the hope of developing new therapies and more individualized approaches to the management of the diseases, maximizing efficacy while minimizing treatment toxicities.
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Affiliation(s)
- Divi Cornec
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, MN, USA.,European University of Brittany and Brest University Hospital, Brest, France
| | - Emilie Cornec-Le Gall
- European University of Brittany and Brest University Hospital, Brest, France.,Division of Nephrology, Mayo Clinic Rochester, MN, USA
| | - Ulrich Specks
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, MN, USA
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Abstract
The 2016 European Vasculitis Society (EUVAS) meeting, held in Leiden, the Netherlands, was centered around phenotypic subtyping in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV). There were parallel meetings of the EUVAS petals, which here report on disease assessment; database; and long-term follow-up, registries, genetics, histology, biomarker studies, and clinical trials. Studies currently conducted will improve our ability to discriminate between different forms of vasculitis. In a project that involves the 10-year follow-up of AAV patients, we are working on retrieving data on patient and renal survival, relapse rate, the cumulative incidence of malignancies, and comorbidities. Across Europe, several vasculitis registries were developed covering over 10,000 registered patients. In the near future, these registries will facilitate clinical research in AAV on a scale hitherto unknown. Current studies on the genetic background of AAV will explore the potential prognostic significance of genetic markers and further refine genetic associations with distinct disease subsets. The histopathological classification of ANCA-associated glomerulonephritis is currently evaluated in light of data coming out of a large international validation study. In our continuous search for biomarkers to predict clinical outcome, promising new markers are important subjects of current research. Over the last 2 decades, a host of clinical trials have provided evidence for refinement of therapeutic regimens. We give an overview of clinical trials currently under development, and consider refractory vasculitis in detail. The goal of EUVAS is to stimulate ongoing research in clinical, serological, and histological management and techniques for patients with systemic vasculitis, with an outlook on the applicability for clinical trials.
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Smilek DE, Lim N, Ding L, Murray SG, Diamond B, Wofsy D. Correlation of hypogammaglobulinaemia with proteinuria, and the relationship between hypogammaglobulinaemia and infection in active lupus nephritis. Lupus Sci Med 2017; 4:e000229. [PMID: 29214037 PMCID: PMC5704742 DOI: 10.1136/lupus-2017-000229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/29/2022]
Abstract
Objective To evaluate hypogammaglobulinaemia and risk of serious infectious adverse events in active lupus nephritis. Methods The Abatacept and Cyclophosphamide Combination Efficacy and Safety Study (ACCESS) compared abatacept with placebo in participants with lupus nephritis undergoing treatment with Euro-Lupus Nephritis low-dose cyclophosphamide. Serum IgG levels were assessed prior to initiation of treatment and throughout the trial. Hypogammaglobulinaemia was defined as IgG <450 mg/dL. Results Hypogammaglobulinaemia was observed in 16/102 (15.7%) participants prior to initiation of induction therapy for active lupus nephritis. Participants with nephrotic range proteinuria were more likely to have hypogammaglobulinaemia, and serum IgG levels were inversely correlated with urine protein to creatinine ratio (r=−0.42, p<0.0001). Following initiation of treatment for active lupus nephritis, additional participants developed hypogammaglobulinaemia by weeks 2–4. Serum IgG levels then increased, and all but one participant had serum IgG ≥450 mg/dL at 24 weeks. Hypogammaglobulinaemia was not associated with an increased risk of serious infectious adverse events. Conclusions In active lupus nephritis in ACCESS, hypogammaglobulinaemia was common and inversely correlated with proteinuria. Serum IgG levels were lowest in the weeks immediately following initiation of induction therapy, and subsequently improved by 24 weeks. Hypogammaglobulinaemia was not associated with serious infectious adverse events. Trial registration
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Affiliation(s)
- Dawn Elaine Smilek
- Immune Tolerance Network, University of California San Franciso, San Francisco, California, USA.,Division of Rheumatology, Department of Medicine, and the Lupus Nephritis Trials Network, University of California San Francisco, San Francisco, California, USA
| | - Noha Lim
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, Maryland, USA
| | - Linna Ding
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Sara G Murray
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Betty Diamond
- Center for Autoimmune and Musculoskeletal Diseases, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - David Wofsy
- Division of Rheumatology, Department of Medicine, and the Russell/Engleman Research Center, University of California San Francisco, San Francisco, California, USA
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Christou EAA, Giardino G, Worth A, Ladomenou F. Risk factors predisposing to the development of hypogammaglobulinemia and infections post-Rituximab. Int Rev Immunol 2017; 36:352-359. [PMID: 28800262 DOI: 10.1080/08830185.2017.1346092] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rituximab (RTX) is a monoclonal antibody against CD20, commonly used in the treatment of hematological malignancies and autoimmune diseases. The use of RTX is related to the development of hypogammaglobulinemia and infections. Aim of this review is to summarize the evidence supporting the association of specific risk factors with the development of hypogammaglobulinemia and infections post-RTX. Immunological complications are more common in patients with malignant diseases as compared to non-malignant diseases. Moreover, the use of more than one dose of RTX, maintenance regimens, low pre-treatment basal immunoglobulin levels and the association with Mycophenolate and purine analogues represent risk factors for the development of hypogammaglobulinemia. The number of RTX courses, the evidence of low IgG levels for more than 6 months, the use of G-CSF, the occurrence of chronic lung disease, cardiac insufficiency, extra-articular involvement in patients with rheumatoid arthritis, low levels of IgG and older age have been correlated with a higher risk of infections. Even though the heterogeneity of the studies in terms of study population age and underlying disease, RTX schedules as well as differences in pre-treatment or concomitant therapy doesn't allow drawing definitive conclusions, the study of the literature highlight the association of specific risk factors with the occurrence of hypogammaglobulinemia and/or infections. A long term randomized controlled clinical trial could be useful to define a personalized evidence-based risk management plan for patients treated with RTX.
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Affiliation(s)
- Evangelos A A Christou
- a Division of Internal Medicine, Medical School , University of Ioannina , Ioannina , Greece
| | - Giuliana Giardino
- b Department of Translational Medical Sciences , Federico II University , Naples , Italy
| | - Austen Worth
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Fani Ladomenou
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
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42
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Nixon A, Ogden L, Woywodt A, Dhaygude A. Infectious complications of rituximab therapy in renal disease. Clin Kidney J 2017; 10:455-460. [PMID: 28852481 PMCID: PMC5570071 DOI: 10.1093/ckj/sfx038] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/10/2017] [Indexed: 11/29/2022] Open
Abstract
Rituximab, an anti-CD20 monoclonal antibody, was originally used to treat B-cell malignancies. Its use has significantly increased in recent years, as it is now also used to treat a variety of autoimmune diseases including rheumatoid arthritis and ANCA-associated vasculitis (AAV). Initial studies suggested that the adverse effects of rituximab were minimal. Though the risk of malignancy with rituximab-based immunosuppressive regimens appears similar to that of the general population, there are now concerns regarding the risk of infectious complications. Rituximab has been associated with serious infections, including Pneumocystis jiroveci pneumonia (PJP) and the reactivation of hepatitis B virus (HBV) and tuberculosis (TB). The risk of infection appears to be the result of a variety of mechanisms, including prolonged B-cell depletion, B-cell–T-cell crosstalk, panhypogammaglobulinaemia, late-onset neutropenia and blunting of the immune response after vaccination. Importantly, the risk of infectious complications is also related to individual patient characteristics and the indication for rituximab. Individualization of treatment is, therefore, crucial. Particular attention should be given to strategies to minimize the risk of infectious complications, including vaccinating against bacterial and viral pathogens, monitoring white cell count and immunoglobulin levels, prophylaxis against PJP and screening for HBV and TB.
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Affiliation(s)
- Andrew Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Leanne Ogden
- Department of Renal Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ajay Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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43
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Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
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44
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Cortazar FB, Pendergraft WF, Wenger J, Owens CT, Laliberte K, Niles JL. Effect of Continuous B Cell Depletion With Rituximab on Pathogenic Autoantibodies and Total IgG Levels in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2017; 69:1045-1053. [PMID: 28029751 DOI: 10.1002/art.40032] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the effect of rituximab on pathogenic autoantibodies and total Ig levels, and to identify serious adverse events in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) treated with continuous B cell depletion. METHODS We conducted a retrospective analysis of 239 patients with AAV treated with rituximab-induced continuous B cell depletion. Two treatment cohorts were analyzed: an induction group (n = 52) and a maintenance group (n = 237). Changes in ANCA titers and total Ig levels over time were evaluated using mixed-effects models. Risk factors for serious infections during maintenance treatment were evaluated using Poisson regression. RESULTS During induction, IgG levels fell at a mean rate of 6% per month (95% confidence interval [95% CI] 4, 8%), while ANCA levels declined at a mean rate of 47% per month (95% CI 42, 52%) and 48% per month (95% CI 42, 54%) for patients with antimyeloperoxidase (anti-MPO) antibodies and those with anti-proteinase 3 (anti-PR3) antibodies, respectively. During maintenance treatment, with a median duration of 2.4 years (interquartile range 1.5, 4.0 years), IgG levels declined a mean of 0.6% per year (95% CI -0.2, 1.4%). New significant hypogammaglobulinemia (IgG level of <400 mg/dl) during maintenance treatment occurred in 4.6% of the patients, all of whom were in the lowest baseline IgG quartile. Serious infections during maintenance therapy occurred at a rate of 0.85 per 10 patient-years (95% CI 0.66, 1.1) and were independently associated with an IgG level of <400 mg/dl. CONCLUSION B cell-targeted therapy causes a preferential decline in ANCA titers relative to total IgG levels. Despite prolonged maintenance therapy with rituximab, IgG levels remain essentially constant. Serious infections were rare.
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Affiliation(s)
| | | | - Julia Wenger
- University of North Carolina Kidney Center, Chapel Hill
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45
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Bjørneklett R, Sriskandarajah S, Bostad L. Prognostic Value of Histologic Classification of ANCA-Associated Glomerulonephritis. Clin J Am Soc Nephrol 2016; 11:2159-2167. [PMID: 27797896 PMCID: PMC5142068 DOI: 10.2215/cjn.04800516] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 08/15/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES A kidney biopsy is preferred for the diagnosis of ANCA-associated vasculitis with renal involvement. The aim of our study was to evaluate the prognostic value of a histopathologic classification scheme recently proposed by an international consortium of renal pathologists in a large Norwegian cohort. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients diagnosed with ANCA-associated GN were included from the Norwegian Kidney Biopsy Registry 1991-2012. Renal morphology was classified as focal, mixed, crescentic, or sclerotic. Study end point was ESRD. Patients were followed from kidney biopsy to end of 2012. RESULTS Two hundred fifty patients with ≥10 glomeruli in the biopsy were included in our study. During a median follow-up of 3.5 years (0.7-7.6), 60 cases of ESRD occurred. Ninety-six (38%) biopsies were classified as focal, 61 (24%) biopsies were classified as mixed, 71 (28%) biopsies were classified as crescentic, and 22 (9%) biopsies were classified as sclerotic; 1- and 5-year cumulative renal survival rates were 96% and 90%, respectively, for the focal class, 86% and 75%, respectively, for the mixed class, 81% and 69%, respectively, for the crescentic class, and 56% and 51%, respectively, for the sclerotic class. By multivariate Cox regression analyses, the sclerotic class had a significantly worse renal prognosis than the focal (hazard ratio, 9.65; 95% confidence interval, 2.38 to 39.16) or combined mixed/crescentic classes (hazard ratio, 3.27; 95% confidence interval, 1.41 to 7.61), but no significant differences in outcome were observed in the crescentic class compared with the mixed class (hazard ratio, 1.13; 95% confidence interval, 0.44 to 2.87) or the combined mixed/crescentic class compared with the focal class (hazard ratio, 1.93; 95% confidence interval, 0.61 to 6.12). Accuracy by receiver operator characteristic curve analysis was estimated to be 0.72 (95% confidence interval, 0.65 to 0.80). In 108 additional patients with three to nine glomeruli in the biopsy, the prognostic value of this classification scheme was unchanged. CONCLUSIONS The histopathologic classification is a predictor of renal outcome of moderate quality. Merging the mixed and crescentic classes in the future could simplify the scheme.
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Affiliation(s)
- Rune Bjørneklett
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; and
- Emergency Care Clinic and
| | | | - Leif Bostad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; and
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
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46
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Trivin C, Tran A, Moulin B, Choukroun G, Gatault P, Courivaud C, Augusto JF, Ficheux M, Vigneau C, Thervet E, Karras A. Infectious complications of a rituximab-based immunosuppressive regimen in patients with glomerular disease. Clin Kidney J 2016; 10:461-469. [PMID: 28852482 PMCID: PMC5570029 DOI: 10.1093/ckj/sfw101] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/24/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Recent years have seen increasing use of rituximab (RTX) for various types of primary and secondary glomerulopathies. However, there are no studies that specifically address the risk of infection related to this agent in patients with these conditions. METHODS We reviewed the outcomes of all patients who received RTX therapy for glomerular disease between June 2000 and October 2011 in eight French nephrology departments. Each case was analysed for survival, cause of death if a non-survivor and/or the presence of infectious complications, including severe or opportunistic infection occurring within the 12 months following RTX infusion. RESULTS Among 98 patients treated with RTX, 25 presented with at least one infection. We report an infection rate of 21.6 per 100 patient-years. Five patients died within 12 months following an RTX infusion, of whom four also presented with an infection. The median interval between the last RTX infusion and the first infectious episode was 2.1 months (interquartile range 0.5-5.1). Most infections were bacterial (79%) and pneumonia was the most frequent infection reported (27%). The presence of diabetes mellitus (P = 0.006), the cumulative RTX dose (P = 0.01) and the concomitant use of azathioprine (P = 0.03) were identified as independent risk factors. Renal failure was significantly associated with an increased infection risk by bivariate analysis (P = 0.03) and was almost significant by multivariate analysis (P = 0.05). Nephrotic syndrome did not further increase the risk of infection and/or death. CONCLUSION The risk of infection after RTX-based immunosuppression among patients with glomerulopathy must be considered and patients should receive close monitoring and appropriate infection prophylaxis, especially in those with diabetes and high-dose RTX regimens.
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Affiliation(s)
- Claire Trivin
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Antoine Tran
- Pediatric Emergency, Hopitaux pediatrique CHU Nice Lenval, France
| | - Bruno Moulin
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, France
| | | | | | - Cécile Courivaud
- Nephrology, Dialysis and Renal Transplantation, CHU Saint Jacques, Besançon, France
| | - Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Angers, France.,University of Angers, INSERM, U892-CRCNA, France
| | | | - Cécile Vigneau
- Service de Néphrologie, CHU Rennes, France.,Université Rennes 1, CNRS UMR 6290 equipe Kyca, France
| | - Eric Thervet
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
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47
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Haris Á, Dolgos S, Polner K. Therapy and prognosis of ANCA-associated vasculitis from the clinical nephrologist's perspective. Int Urol Nephrol 2016; 49:91-102. [PMID: 27671907 DOI: 10.1007/s11255-016-1419-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
This paper reviews the recently published scientific information regarding ANCA-associated vasculitis (AAV), aiming to highlight the most important data from the clinical nephrologists' perspective. The classification, pathomechanism, recent achievements of the treatment, short-term and long-term outcomes of the disease, and the difficulties nephrologists face when taking care for patients with AAV are summarized. There has been significant progress in the understanding of the genetic and pathologic background of the disease in the last years, and results of histological studies guide us to predict long-term renal function. Findings of several multicentered trials with reasonable number of participants provide comparison of the efficacy and safety of different remission induction and maintenance therapies, and evaluate recently introduced immunosuppressive agents. Although the clinical outcome of patients with AAV has improved significantly since modern immunosuppressive drugs are available, the treatment-related complications still contribute to the morbidity and mortality. To improve the survival and quality of life of patients with AAV further, knowledge of the predictors of relapse, end-stage kidney disease, and mortality, also prevention of infections and other treatment-related adverse events are important. The eligibility for renal transplantation and the option for successful pregnancies for young women are also important factors which influence the patients' quality of life. In order to provide favorable outcome, the clinicians need to establish personalized treatment strategies to optimize the intensity and minimize the toxicity of the immunosuppressive therapy.
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Affiliation(s)
- Ágnes Haris
- Nephrology Department, Szent Margit Hospital, 132 Bécsi Street, Budapest, 1032, Hungary.
| | - Szilveszter Dolgos
- Nephrology Department, Szent Margit Hospital, 132 Bécsi Street, Budapest, 1032, Hungary
| | - Kálmán Polner
- Nephrology Department, Szent Margit Hospital, 132 Bécsi Street, Budapest, 1032, Hungary
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Besada E, Nossent JC. CD4 cell count and CD4/CD8 ratio increase during rituximab maintenance in granulomatosis with polyangiitis patients. PeerJ 2016; 4:e2487. [PMID: 27688979 PMCID: PMC5036106 DOI: 10.7717/peerj.2487] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/25/2016] [Indexed: 12/31/2022] Open
Abstract
Introduction Rituximab (RTX) is a B cell-depleting agent approved for the treatment of granulomatosis with polyangiitis (GPA). RTX reduces antibody producing precursor plasma cells and inhibits B and T cells interaction. Infections related to T cell immunodeficiency are not infrequent during RTX treatment. Our study investigated CD4 cell count and CD4/CD8 ratio in GPA patients during the first two years of long-term RTX treatment. Methods A single centre cohort study of 35 patients who received median total cumulative dose of cyclophosphamide (CYC) of 15 g and were treated with RTX 2 g followed by retreatment with either 2 g once annually or 1 g biannually. Serum levels of total immunoglobulin (Ig) and lymphocytes subsets were recorded at RTX initiation and at 3, 6, 12, 18 and 24 months. Low CD4 count and inverted CD4/CD8 ratio were defined as CD4 < 0.3 × 109/l and ratio < 1. Results The CD4 cell count and CD4/CD8 ratio decreased slightly following the initial RTX treatment and then increased gradually during maintenance treatment. While the proportion of patients with low CD4 cell count decreased from 43% at baseline to 18% at 24 months, the ratio remained inverted in 40%. Oral daily prednisolone dose at baseline, CYC exposure and the maintenance regimen did not influence the CD4 cell count and ratio. Being older (p = 0.012) and having a higher CRP (p = 0.044) and ESR (p = 0.024) at baseline significantly increased the risk of inverted CD4/CD8 ratio at 24 months. Inverted ratio at baseline associated with lower total Ig levels during the study. Conclusions Overall, the CD4 and CD4/CD8 ratio increased during maintenance RTX therapy in GPA with no discernible impact of other immunosuppressive therapy. However the increase in CD4 was not followed by an increase in the CD4/CD8 ratio, especially in older patients. Inverted CD4/CD8 ratio associated with lower Ig levels, suggesting a more profound B cell depleting effect of RTX with a relative increase in CD8+ lymphocytes.
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Affiliation(s)
- Emilio Besada
- Bone and Joint Research Group, Institute of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway , Tromsø , Norway
| | - Johannes C Nossent
- School of Medicine & Pharmacology QEII Medical Centre Unit, University of Western Australia, Australia; Rheumatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Pagnoux C. Updates in ANCA-associated vasculitis. Eur J Rheumatol 2016; 3:122-133. [PMID: 27733943 PMCID: PMC5058451 DOI: 10.5152/eurjrheum.2015.0043] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/13/2015] [Indexed: 12/15/2022] Open
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are small-vessel vasculitides that include granulomatosis with polyangiitis (formerly Wegener's granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Renal-limited ANCA-associated vasculitides can be considered the fourth entity. Despite their rarity and still unknown cause(s), research pertaining to ANCA-associated vasculitides has been very active over the past decades. The pathogenic role of antimyeloperoxidase ANCA (MPO-ANCA) has been supported using several animal models, but that of antiproteinase 3 ANCA (PR3-ANCA) has not been as strongly demonstrated. Moreover, some MPO-ANCA subsets, which are directed against a few specific MPO epitopes, have recently been found to be better associated with disease activity, but a different method than the one presently used in routine detection is required to detect them. B cells possibly play a major role in the pathogenesis because they produce ANCAs, as well as neutrophil abnormalities and imbalances in different T-cell subtypes [T helper (Th)1, Th2, Th17, regulatory cluster of differentiation (CD)4+ CD25+ forkhead box P3 (FoxP3)+ T cells] and/or cytokine-chemokine networks. The alternative complement pathway is also involved, and its blockade has been shown to prevent renal disease in an MPO-ANCA murine model. Other recent studies suggested strongest genetic associations by ANCA type rather than by clinical diagnosis. The induction treatment for severe granulomatosis with polyangiitis and microscopic polyangiitis is relatively well codified but does not (yet) really differ by precise diagnosis or ANCA type. It comprises glucocorticoids combined with another immunosuppressant, cyclophosphamide or rituximab. The choice between the two immunosuppressants must consider the comorbidities, past exposure to cyclophosphamide for relapsers, plans for pregnancy, and also the cost of rituximab. Once remission is achieved, maintenance strategy following cyclophosphamide-based induction relies on less toxic agents such as azathioprine or methotrexate. The optimal maintenance strategy following rituximab-based induction therapy remains to be determined. Preliminary results on rituximab for maintenance therapy appear promising. Efforts are still under way to determine the optimal duration of maintenance therapy, ideally tailored according to the characteristics of each patient and the previous treatment received.
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Affiliation(s)
- Christian Pagnoux
- Department of Medicine, Division of Rheumatology, Vasculitis Clinic, Mount Sinai Hospital, University Health Network, University of Toronto, Ontario, Canada
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Sise ME, Wisocky J, Rosales IA, Chute D, Holmes JA, Corapi KM, Babitt JL, Tangren JS, Hashemi N, Lundquist AL, Williams WW, Mount DB, Andersson KL, Rennke HG, Smith RN, Colvin R, Thadhani RI, Chung RT. Lupus-like Immune Complex-mediated Glomerulonephritis in Patients with Hepatitis C Virus Infection Treated with Oral, Interferon-free, Direct-acting Antiviral Therapy. Kidney Int Rep 2016; 1:135-143. [PMID: 27990496 PMCID: PMC5155703 DOI: 10.1016/j.ekir.2016.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jessica Wisocky
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Donald Chute
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jacinta A Holmes
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Kristin M Corapi
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jodie L Babitt
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jessica S Tangren
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nikroo Hashemi
- Department of Gastroenterology and Hepatology, Brigham and Women's Hospital, Boston, MA
| | - Andrew L Lundquist
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Winfred W Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - David B Mount
- Renal Unit, Brigham and Women's Hospital, Boston, MA
| | - Karin L Andersson
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - R Neal Smith
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Robert Colvin
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Raymond T Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
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