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Ünlü S, Sánchez Navarro BG, Cakan E, Berchtold D, Meleka Hanna R, Vural S, Vural A, Meisel A, Fichtner ML. Exploring the depths of IgG4: insights into autoimmunity and novel treatments. Front Immunol 2024; 15:1346671. [PMID: 38698867 PMCID: PMC11063302 DOI: 10.3389/fimmu.2024.1346671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/29/2024] [Indexed: 05/05/2024] Open
Abstract
IgG4 subclass antibodies represent the rarest subclass of IgG antibodies, comprising only 3-5% of antibodies circulating in the bloodstream. These antibodies possess unique structural features, notably their ability to undergo a process known as fragment-antigen binding (Fab)-arm exchange, wherein they exchange half-molecules with other IgG4 antibodies. Functionally, IgG4 antibodies primarily block and exert immunomodulatory effects, particularly in the context of IgE isotype-mediated hypersensitivity reactions. In the context of disease, IgG4 antibodies are prominently observed in various autoimmune diseases combined under the term IgG4 autoimmune diseases (IgG4-AID). These diseases include myasthenia gravis (MG) with autoantibodies against muscle-specific tyrosine kinase (MuSK), nodo-paranodopathies with autoantibodies against paranodal and nodal proteins, pemphigus vulgaris and foliaceus with antibodies against desmoglein and encephalitis with antibodies against LGI1/CASPR2. Additionally, IgG4 antibodies are a prominent feature in the rare entity of IgG4 related disease (IgG4-RD). Intriguingly, both IgG4-AID and IgG4-RD demonstrate a remarkable responsiveness to anti-CD20-mediated B cell depletion therapy (BCDT), suggesting shared underlying immunopathologies. This review aims to provide a comprehensive exploration of B cells, antibody subclasses, and their general properties before examining the distinctive characteristics of IgG4 subclass antibodies in the context of health, IgG4-AID and IgG4-RD. Furthermore, we will examine potential therapeutic strategies for these conditions, with a special focus on leveraging insights gained from anti-CD20-mediated BCDT. Through this analysis, we aim to enhance our understanding of the pathogenesis of IgG4-mediated diseases and identify promising possibilities for targeted therapeutic intervention.
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Affiliation(s)
- Selen Ünlü
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Koç University School of Medicine, Istanbul, Türkiye
| | - Blanca G. Sánchez Navarro
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Elif Cakan
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
| | - Daniel Berchtold
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rafael Meleka Hanna
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Secil Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Dermatology and Venereology, Koç University School of Medicine, İstanbul, Türkiye
| | - Atay Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology, Koç University School of Medicine, İstanbul, Türkiye
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam L. Fichtner
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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Ran B, Qin J, Wu Y, Wen F. Causal role of immune cells in chronic obstructive pulmonary disease: Mendelian randomization study. Expert Rev Clin Immunol 2024; 20:413-421. [PMID: 38108202 DOI: 10.1080/1744666x.2023.2295987] [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: 11/09/2023] [Accepted: 12/08/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES Innate and adaptive immunity play different roles in the pathogenesis of chronic obstructive pulmonary disease (COPD). However, previous studies on the relationship between immune cells and COPD reported inconsistent results. METHODS The causal connection between 731 immune cells and COPD was established using a two-sample Mendelian randomization (MR) analysis through publicly accessible genetic data. The heterogeneity and horizontal pleiotropism of the findings were confirmed using sensitivity analysis. RESULTS In the B-cell panel, B-cell activating factor receptor (BAFF-R) on CD20- and CD20 on IgD-CD38bright (OR (95% CI): 0.93 (0.88, 0.99) and 0.97 (0.95, 0.98), respectively) were discovered to be protective. In the cDC panel, CD62L- plasmacytoid DC AC, CD80 on monocytes and CD11c on myeloid DCs (OR (95% CI): 0.94 (0.92, 0.97), 0.97 (0.94, 0.99) and (0.97 (0.95, 0.98), respectively) exerted protective effects. However, unswitched memory AC (OR (95%CI): 1.08 (1.01,1.15)) and CD 19 on IgD- CD 27- (OR (95%CI): 1.06 (1.02,1.10)) were hazardous in the B-cell panel. However, among the 731 immune cell phenotypes, no causal relationship was found for COPD on immune cells. CONCLUSION This study found a potential causal relationship between immune cells in COPD, ruling out reverse causation. This study provides new avenues for studying the mechanisms of COPD.
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Affiliation(s)
- Bi Ran
- Department of Respiratory and Critical Care Medicine, West China Hospital and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, Sichuan University. Guoxuexiang 37, Chengdu, Sichuan, China
| | - Jiangyue Qin
- Department of General Practice, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yanqiu Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, Sichuan University. Guoxuexiang 37, Chengdu, Sichuan, China
| | - Fuqiang Wen
- Department of Respiratory and Critical Care Medicine, West China Hospital and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, Sichuan University. Guoxuexiang 37, Chengdu, Sichuan, China
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Aninang MT, Baltazar-Libiran MR, Damian LF. Utility of Brainstem Auditory Evoked Response as a Diagnostic Tool and Rituximab as a Treatment for Severe Bickerstaff Brainstem Encephalitis: A Case Report. Cureus 2024; 16:e57993. [PMID: 38738130 PMCID: PMC11088453 DOI: 10.7759/cureus.57993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2024] [Indexed: 05/14/2024] Open
Abstract
Bickerstaff brainstem encephalitis (BBE) is a rare disorder that is characterized by ophthalmoplegia, ataxia, and disturbance in consciousness. Definite diagnosis is made primarily through clinical presentation and serology testing with anti-GQ1b antibody. However, in a country where access to serologic testing is scarce, electrophysiologic tests such as brainstem auditory evoked response (BAER) may contribute to the diagnosis. Due to its rarity and generally good prognosis, there is no established consensus for the treatment of BBE. Immunomodulatory treatments such as intravenous immunoglobulin (IVIG), plasma exchange, steroids, or a combination of these therapies are often used with good response. However, there are severe cases that respond poorly to these conventional treatments. We report the case of a 26-year-old Filipino man who came in for sudden onset of diplopia, with a one-week history of upper respiratory tract infection. Subsequently, he developed paresthesias, quadriparesis, and an altered level of consciousness. On initial examination, he only had partial third nerve palsy, but eventually became quadriparetic and obtunded during admission. Initial electromyography and nerve conduction velocity (EMG-NCV) study showed a reduced recruitment pattern of the right rectus femoris, absent H reflexes of bilateral posterior tibial nerves, and no abnormal increase in temporal dispersion. Cranial MRI with contrast was unremarkable. Video electroencephalogram (video-EEG) showed intermittent generalized 5-6 Hz and 6-7 Hz theta slowing of the background activity in the stimulated state. BAER was done revealing bilateral partial dysfunction of the auditory pathways to support brainstem involvement of the disease. He received IVIG and methylprednisolone pulse therapy with no significant clinical improvement. Hence, he was given a rituximab infusion. One week post-rituximab, he had sustained wakefulness and was able to move his extremities.
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Affiliation(s)
- Myra T Aninang
- Neurology, Institute for Neurosciences, St. Luke's Medical Center, Quezon City, PHL
| | | | - Ludwig F Damian
- Neurology, Institute for Neurosciences, St. Luke's Medical Center, Quezon City, PHL
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Mescia F, Salviani C, Tonoli M, Affatato S, Moratto D, Tedesco M, Guerini A, Gemmo A, Camoni M, Delbarba E, Zubani R, Garrafa E, Chiarini M, Gregorini G, Scolari F, Alberici F. Sustained post-rituximab B-cell depletion is common in ANCA-associated vasculitis and is affected by sex and renal function. Nephrol Dial Transplant 2024; 39:683-693. [PMID: 37673675 DOI: 10.1093/ndt/gfad197] [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: 05/16/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE Despite the increasing use of rituximab in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), it remains unclear what the optimal dosing is, especially for maintenance of remission. A deeper understanding of post-rituximab B-cell repopulation patterns may aid better-tailored treatment. METHODS This is a monocentric, retrospective study including ANCA-positive AAV patients receiving a single course of rituximab induction. CD19+ B cells were longitudinally monitored with flow cytometry. B-cell repopulation was defined as CD19+ >10 cells/μL. RESULTS Seventy-one patients were included, the majority with microscopic polyangiitis (75%), myeloperoxidase-ANCA positivity (75%) and with renal involvement (79%). During a median follow-up of 54 months since the first rituximab infusion, 44 patients (62%) repopulated B cells, with a median time to repopulation of 39 months (range 7-102). Patients experiencing B-cell depletion lasting longer than the overall median time to repopulation (39 months) exhibited a lower risk of flare and higher risk of serious infection. In multivariate Cox regression, higher estimated glomerular filtration rate (eGFR) [hazard ratio (HR) 1.84, 95% confidence interval (CI) 1.13-2.98 per 30 mL/min/1.73 m2 eGFR] and female sex (HR 2.70, 95% CI 1.37-5.31) were independent predictors of increased rate of B-cell repopulation. CONCLUSION A subset of AAV patients develop sustained post-rituximab B-cell depletion, which associates with reduced risk of flare and increased risk of serious infection in the long term. Preserved renal function and female sex are associated with faster B-cell repopulation. These observations further highlight the need to personalize immunosuppression to improve clinical outcomes.
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Affiliation(s)
- Federica Mescia
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Chiara Salviani
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mattia Tonoli
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Stefania Affatato
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Daniele Moratto
- Flow Cytometry Laboratory, Department of Laboratory Diagnostics, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Martina Tedesco
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Alice Guerini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Alessia Gemmo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Marta Camoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Elisa Delbarba
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Roberto Zubani
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Emirena Garrafa
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Laboratory Diagnostics, ASST Spedali Civili, Brescia, Italy
| | - Marco Chiarini
- Flow Cytometry Laboratory, Department of Laboratory Diagnostics, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
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Podestà MA, Trillini M, Portalupi V, Gennarini A, Tomatis F, Villa A, Perna A, Rubis N, Remuzzi G, Ruggenenti P. Ofatumumab in Rituximab-Resistant and Rituximab-Intolerant Patients With Primary Membranous Nephropathy: A Case Series. Am J Kidney Dis 2024; 83:340-349.e1. [PMID: 37777061 DOI: 10.1053/j.ajkd.2023.08.010] [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: 04/18/2023] [Revised: 07/26/2023] [Accepted: 08/07/2023] [Indexed: 10/02/2023]
Abstract
RATIONALE & OBJECTIVE Rituximab is the first-choice therapy for patients with primary membranous nephropathy (MN) and nephrotic syndrome. However, approximately 30% of patients are treatment-resistant or become treatment-intolerant with hypersensitivity reactions upon repeated drug exposures. We aimed to assess whether ofatumumab, a fully human second-generation anti-CD20 antibody, could be a valuable alternative to rituximab in this population. STUDY DESIGN Case series. SETTING & PARTICIPANTS 7 rituximab-intolerant and 10 rituximab-resistant patients with MN who consented to receive ofatumumab (50-300mg, single intravenous infusion) and were followed at the nephrology unit of Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII (Bergamo, Italy) between September 2015 and January 2019. FINDINGS Over a median (IQR) follow-up of 5.0 (3.0-9.8) months, all 7 rituximab-intolerant and 3 of the 10 rituximab-resistant patients exhibited complete (proteinuria<0.3g/d) or partial (proteinuria<3.5g/d with≥50% reduction vs baseline) remission of nephrotic syndrome. Circulating B cells were similarly depleted in all patients by 1 week, and serum anti-phospholipase A2 receptor antibody concentrations decreased to<2.7 relative units/mL in 3 of 4 rituximab-intolerant and 4 of 8 rituximab-resistant patients with phospholipase A2 receptor-related disease. Ofatumumab significantly reduced 24-hour urinary protein and immunoglobulin G excretion and increased serum albumin and immunoglobulin G levels. These effects were greater in rituximab-intolerant than in rituximab-resistant patients. Measured glomerular filtration rate significantly increased by an average of 13.4% at 24 months compared with baseline (P=0.036) among all patients in the series. There were 14 nonserious infusion-related adverse events in 9 patients that recovered with temporary infusion interruption. LIMITATIONS Retrospective design, limited number of patients. CONCLUSIONS Ofatumumab may represent an effective and safe treatment for rituximab-intolerant cases of MN. Larger prospective studies will be needed to validate these preliminary findings and explore the effectiveness of other second-generation anti-CD20 antibodies in this clinical setting. PLAIN-LANGUAGE SUMMARY Primary membranous nephropathy (MN) is one of the most frequent causes of nephrotic syndrome (NS) in adults. In this case series, we explored the efficacy of ofatumumab, a fully human second-generation anti-CD20 antibody, in 17 patients with MN and NS who were intolerant or unresponsive to rituximab. All 7 rituximab-intolerant patients exhibited complete or partial clinical remission, compared with only 3 of the 10 rituximab-resistant patients. Autoantibody levels decreased in all patients with phospholipase A2 receptor-related disease. Ofatumumab achieved a significant reduction in urinary protein and immunoglobulin G excretion while increasing serum albumin and immunoglobulin G levels. Ofatumumab may be a promising option for patients with MN who are rituximab-intolerant. Further investigations are warranted to validate these preliminary findings.
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Affiliation(s)
- Manuel Alfredo Podestà
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (MAP)
| | - Matias Trillini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Valentina Portalupi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Alessia Gennarini
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Federica Tomatis
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Alessandro Villa
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Nadia Rubis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.
| | - Piero Ruggenenti
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Tieck MP, Vasilenko N, Ruschil C, Kowarik MC. Peripheral memory B cells in multiple sclerosis vs. double negative B cells in neuromyelitis optica spectrum disorder: disease driving B cell subsets during CNS inflammation. Front Cell Neurosci 2024; 18:1337339. [PMID: 38385147 PMCID: PMC10879280 DOI: 10.3389/fncel.2024.1337339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/16/2024] [Indexed: 02/23/2024] Open
Abstract
B cells are fundamental players in the pathophysiology of autoimmune diseases of the central nervous system, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). A deeper understanding of disease-specific B cell functions has led to the differentiation of both diseases and the development of different treatment strategies. While NMOSD is strongly associated with pathogenic anti-AQP4 IgG antibodies and proinflammatory cytokine pathways, no valid autoantibodies have been identified in MS yet, apart from certain antigen targets that require further evaluation. Although both diseases can be effectively treated with B cell depleting therapies, there are distinct differences in the peripheral B cell subsets that influence CNS inflammation. An increased peripheral blood double negative B cells (DN B cells) and plasmablast populations has been demonstrated in NMOSD, but not consistently in MS patients. Furthermore, DN B cells are also elevated in rheumatic diseases and other autoimmune entities such as myasthenia gravis and Guillain-Barré syndrome, providing indirect evidence for a possible involvement of DN B cells in other autoantibody-mediated diseases. In MS, the peripheral memory B cell pool is affected by many treatments, providing indirect evidence for the involvement of memory B cells in MS pathophysiology. Moreover, it must be considered that an important effector function of B cells in MS may be the presentation of antigens to peripheral immune cells, including T cells, since B cells have been shown to be able to recirculate in the periphery after encountering CNS antigens. In conclusion, there are clear differences in the composition of B cell populations in MS and NMOSD and treatment strategies differ, with the exception of broad B cell depletion. This review provides a detailed overview of the role of different B cell subsets in MS and NMOSD and their implications for treatment options. Specifically targeting DN B cells and plasmablasts in NMOSD as opposed to memory B cells in MS may result in more precise B cell therapies for both diseases.
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Affiliation(s)
| | | | | | - M. C. Kowarik
- Department of Neurology and Stroke, Center for Neurology, and Hertie-Institute for Clinical Brain Research Eberhard-Karls University of Tübingen, Tübingen, Germany
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [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: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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8
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Wu KY, Kulbay M, Daigle P, Nguyen BH, Tran SD. Nonspecific Orbital Inflammation (NSOI): Unraveling the Molecular Pathogenesis, Diagnostic Modalities, and Therapeutic Interventions. Int J Mol Sci 2024; 25:1553. [PMID: 38338832 PMCID: PMC10855920 DOI: 10.3390/ijms25031553] [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: 12/31/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Nonspecific orbital inflammation (NSOI), colloquially known as orbital pseudotumor, sometimes presents a diagnostic and therapeutic challenge in ophthalmology. This review aims to dissect NSOI through a molecular lens, offering a comprehensive overview of its pathogenesis, clinical presentation, diagnostic methods, and management strategies. The article delves into the underpinnings of NSOI, examining immunological and environmental factors alongside intricate molecular mechanisms involving signaling pathways, cytokines, and mediators. Special emphasis is placed on emerging molecular discoveries and approaches, highlighting the significance of understanding molecular mechanisms in NSOI for the development of novel diagnostic and therapeutic tools. Various diagnostic modalities are scrutinized for their utility and limitations. Therapeutic interventions encompass medical treatments with corticosteroids and immunomodulatory agents, all discussed in light of current molecular understanding. More importantly, this review offers a novel molecular perspective on NSOI, dissecting its pathogenesis and management with an emphasis on the latest molecular discoveries. It introduces an integrated approach combining advanced molecular diagnostics with current clinical assessments and explores emerging targeted therapies. By synthesizing these facets, the review aims to inform clinicians and researchers alike, paving the way for molecularly informed, precision-based strategies for managing NSOI.
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Affiliation(s)
- Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Merve Kulbay
- Department of Ophthalmology & Visual Sciences, McGill University, Montreal, QC H4A 0A4, Canada
| | - Patrick Daigle
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Bich H. Nguyen
- CHU Sainte Justine Hospital, Montreal, QC H3T 1C5, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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9
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Roeser A, Lazarus AH, Mahévas M. B cells and antibodies in refractory immune thrombocytopenia. Br J Haematol 2023; 203:43-53. [PMID: 37002711 DOI: 10.1111/bjh.18773] [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: 02/16/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired bleeding disorder mediated by pathogenic autoantibodies secreted by plasma cells (PCs) in many patients. In refractory ITP patients, the persistence of splenic and bone marrow autoreactive long-lived PCs (LLPCs) may explain primary failure of rituximab and splenectomy respectively. The reactivation of autoreactive memory B cells generating new autoreactive PCs contributes to relapses after initial response to rituximab. Emerging strategies targeting B cells and PCs aim to prevent the settlement of splenic LLPCs with the combination of anti-BAFF and rituximab, to deplete autoreactive PCs with anti-CD38 antibodies, and to induce deeper B-cell depletion in tissues with novel anti-CD20 monoclonal antibodies and anti-CD19 therapies. Alternative strategies, focused on controlling autoantibody mediated effects, have also been developed, including SYK and BTK inhibitors, complement inhibitors, FcRn blockers and inhibitors of platelet desialylation.
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Affiliation(s)
- Anaïs Roeser
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir TeamAI2B, Paris, France
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Alan H Lazarus
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Innovation and Portfolio Management, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Matthieu Mahévas
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir TeamAI2B, Paris, France
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
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10
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Zhu R, Tang H, Howard L, Waldman M, Zhu Q. The predictive and prognostic value of peripheral blood antigen-specific memory B cells in phospholipase A2 receptor-associated membranous nephropathy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.14.23292885. [PMID: 37790554 PMCID: PMC10543243 DOI: 10.1101/2023.08.14.23292885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Phospholipase A2 receptor-associated membranous nephropathy (PLA2R-MN) is an anti-PLA2R antibody (PLA2R-Ab) mediated autoimmune kidney disease. Although antibody titer correlates closely with disease activity, whether it can provide longer-term predictions on disease course and progression is unclear. Rituximab, a B-cell depletion therapy, has become the first-line treatment option for PLA2R-MN; however, the response to Rituximab varies among patients. Methods We developed a flow cytometry-based test that detects and quantifies PLA2R antigen-specific memory B cells (PLA2R-MBCs) in peripheral blood, the primary source for PLA2R-Ab production upon disease relapse. We applied the test to 159 blood samples collected from 28 patients with PLA2R-MN (at diagnosis, during and after immunosuppressive treatment, immunological remission, and relapse) to evaluate the relationship between circulating PLA2R-MBC levels and disease activity. Results The level of PLA2R-MBCs in healthy controls (n=56) is less than or equal to 1.5% of the total MBC compartment. High circulating PLA2R-MBC levels were detected in two patients post-Rituximab despite achieving immunologic and proteinuric remission, as well as in two patients with negative serum autoantibody but increasing proteinuria. Elimination of these cells with Rituximab improved clinical outcomes. Moreover, five patients exhibited elevated PLA2R-MBC levels before disease relapse, followed by a rapid decline to baseline when relapse became clinically evident. COVID-19 vaccination or SARS-CoV-2 infection significantly affected the dynamics of circulating PLA2R-MBCs. Conclusions This study suggests that monitoring PLA2R-MBC levels in patients with PLA2R-MN may help refine and individualize immunosuppressive therapy and predict disease course and progression. The technology and findings may also have broader applications in the clinical management of other autoimmune diseases.
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Affiliation(s)
- Richard Zhu
- ImmunoWork, Monrovia, California, CA 91016-6353
| | - Hong Tang
- ImmunoWork, Monrovia, California, CA 91016-6353
| | - Lilian Howard
- Clinical Research Center, NIDDK/Kidney Disease Section, National Institutes of Health, Bethesda, MD 20892-1455
| | - Meryl Waldman
- Clinical Research Center, NIDDK/Kidney Disease Section, National Institutes of Health, Bethesda, MD 20892-1455
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Varley JA, Strippel C, Handel A, Irani SR. Autoimmune encephalitis: recent clinical and biological advances. J Neurol 2023; 270:4118-4131. [PMID: 37115360 PMCID: PMC10345035 DOI: 10.1007/s00415-023-11685-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
In 2015, we wrote a review in The Journal of Neurology summarizing the field of autoantibody-associated neurological diseases. Now, in 2023, we present an update of the subject which reflects the rapid expansion and refinement of associated clinical phenotypes, further autoantibody discoveries, and a more detailed understanding of immunological and neurobiological pathophysiological pathways which mediate these diseases. Increasing awareness around distinctive aspects of their clinical phenotypes has been a key driver in providing clinicians with a better understanding as to how these diseases are best recognized. In clinical practice, this recognition supports the administration of often effective immunotherapies, making these diseases 'not to miss' conditions. In parallel, there is a need to accurately assess patient responses to these drugs, another area of growing interest. Feeding into clinical care are the basic biological underpinnings of the diseases, which offer clear pathways to improved therapies toward enhanced patient outcomes. In this update, we aim to integrate the clinical diagnostic pathway with advances in patient management and biology to provide a cohesive view on how to care for these patients in 2023, and the future.
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Affiliation(s)
- James A Varley
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London, W6 8RF, UK
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
| | - Christine Strippel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK.
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK.
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12
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Boyles JS, Sadowski D, Potter S, Vukojicic A, Parker J, Chang WY, Ma YL, Chambers MG, Nelson J, Barmettler B, Smith EM, Kersjes K, Himes ER, Lin C, Lucchesi J, Brahmbhatt J, Sina R, Martin JA, Maestri E, Wiethoff CM, Dyas GL, Linnik MD, Na S, Witcher DR, Budelsky A, Rubtsova K. A nondepleting anti-CD19 antibody impairs B cell function and inhibits autoimmune diseases. JCI Insight 2023; 8:e166137. [PMID: 37427592 PMCID: PMC10371335 DOI: 10.1172/jci.insight.166137] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/19/2023] [Indexed: 07/11/2023] Open
Abstract
B cells contribute to multiple aspects of autoimmune disorders, and B cell-targeting therapies, including B cell depletion, have been proven to be efficacious in treatment of multiple autoimmune diseases. However, the development of novel therapies targeting B cells with higher efficacy and a nondepleting mechanism of action is highly desirable. Here we describe a nondepleting, high-affinity anti-human CD19 antibody LY3541860 that exhibits potent B cell inhibitory activities. LY3541860 inhibits B cell activation, proliferation, and differentiation of primary human B cells with high potency. LY3541860 also inhibits human B cell activities in vivo in humanized mice. Similarly, our potent anti-mCD19 antibody also demonstrates improved efficacy over CD20 B cell depletion therapy in multiple B cell-dependent autoimmune disease models. Our data indicate that anti-CD19 antibody is a highly potent B cell inhibitor that may have potential to demonstrate improved efficacy over currently available B cell-targeting therapies in treatment of autoimmune conditions without causing B cell depletion.
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Affiliation(s)
- Jeffrey S. Boyles
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Dorota Sadowski
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Scott Potter
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Aleksandra Vukojicic
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - James Parker
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - William Y. Chang
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Yanfei L. Ma
- Immunology Discovery, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Mark G. Chambers
- Immunology Discovery, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - James Nelson
- Biotechnology Discovery Research, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Barbra Barmettler
- Biotechnology Discovery Research, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Eric M. Smith
- Biotechnology Discovery Research, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Kara Kersjes
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Evan R. Himes
- Immunology Discovery, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Chaohua Lin
- Immunology Discovery, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Jonathan Lucchesi
- Immunology Discovery, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Jaladhi Brahmbhatt
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Ramtin Sina
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Jennifer A. Martin
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Evan Maestri
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Christopher M. Wiethoff
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Gregory L. Dyas
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Matthew D. Linnik
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Songqing Na
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Derrick R. Witcher
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Alison Budelsky
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
| | - Kira Rubtsova
- Immunology Discovery, Lilly Biotechnology Center, Lilly Research Laboratories, Eli Lilly and Company, San Diego, California, USA
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13
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Ravichandran AJ, Romeo FJ, Mazurek R, Ishikawa K. Barriers in Heart Failure Gene Therapy and Approaches to Overcome Them. Heart Lung Circ 2023; 32:780-789. [PMID: 37045653 PMCID: PMC10440286 DOI: 10.1016/j.hlc.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 04/14/2023]
Abstract
With the growing prevalence and incidence of heart failure worldwide, investigation and development of new therapies to address disease burden are of great urgency. Gene therapy is one promising approach for the management of heart failure, but several barriers currently exclude safe and efficient gene delivery to the human heart. These barriers include the anatomical and biological difficulty of specifically targeting cardiomyocytes, the vascular endothelium, and immunogenicity against administered vectors and the transgene. We review approaches taken to overcome these barriers with a focus on vector modification, evasion of immune responses, and heart-targeted delivery techniques. While various modifications proposed to date show promise in managing some barriers, continued investigation into improvements to existing therapies is required to address transduction efficiency, duration of transgene expression, and immune response.
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Affiliation(s)
- Anjali J Ravichandran
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Francisco J Romeo
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. https://twitter.com/FJRomeoMD
| | - Renata Mazurek
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiyotake Ishikawa
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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14
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Costa GD, Comi G. A safety review of current monoclonal antibodies used to treat multiple sclerosis. Expert Opin Drug Saf 2023; 22:1011-1024. [PMID: 37314699 DOI: 10.1080/14740338.2023.2224556] [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: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system. Monoclonal antibodies (mAbs) have shown efficacy in reducing MS relapse rates, disease progression, and brain lesion activity. AREAS COVERED This article reviews the literature on the use of mAbs for the treatment of MS, including their mechanisms of action, clinical trial data, safety profiles, and long-term outcomes. The review focuses on the three main categories of mAbs used in MS: alemtuzumab, natalizumab, and anti-CD20 drugs. A literature search was conducted using relevant keywords and guidelines and reports from regulatory agencies were reviewed. The search covered studies published from inception to 31 December 202231 December 2022. The article also discusses the potential risks and benefits of these therapies, including their effects on infection rates, malignancies, and vaccination efficacy. EXPERT OPINION Monoclonal antibodies have revolutionized the treatment of MS, but safety concerns must be considered, particularly with regards to infection rates, malignancy risk, and vaccination efficacy. Clinicians must weigh the potential benefits and risks of mAbs on an individual patient basis, taking into account factors such as age, disease severity, and comorbidities. Ongoing monitoring and surveillance are essential to ensure the long-term safety and effectiveness of monoclonal antibody therapies in MS.
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Affiliation(s)
| | - Giancarlo Comi
- Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis Center, Casa di Cura Igea, Milan, Italy
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15
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Khandelwal K, Jajoo V, Bajpai K, Madke B, Prasad R, Wanjari MB, Munjewar PK, Taksande AB. Rituximab in Pemphigus Vulgaris: A Review of Monoclonal Antibody Therapy in Dermatology. Cureus 2023; 15:e40734. [PMID: 37485224 PMCID: PMC10361785 DOI: 10.7759/cureus.40734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Pemphigus vulgaris (PV) is a rare autoimmune blistering disorder that primarily affects the skin and mucous membranes. Conventional treatments for PV, such as corticosteroids and immunosuppressive agents, have limitations in terms of efficacy and long-term safety. Monoclonal antibody therapy, specifically rituximab, has emerged as a promising therapeutic approach in the management of PV. This review article provides a comprehensive overview of rituximab in the treatment of PV, with a focus on its efficacy, safety profile, and immunological mechanisms of action. The article begins with an introduction to PV and the significance of monoclonal antibody therapy in dermatology. It then explores the clinical presentation and underlying immune-mediated mechanisms of PV, highlighting the autoimmune nature of the disease. The rationale for using monoclonal antibody therapy, particularly rituximab, in PV is discussed, emphasizing the limitations of conventional treatments and the concept of targeted therapy. The review delves into the efficacy and safety of rituximab based on clinical studies, evaluating disease remission rates, duration, and relapse rates. Furthermore, the immunological effects of rituximab, including B-cell depletion and modulation of the immune response, are explored in detail. Comparisons between rituximab and conventional treatment modalities in PV are made, assessing clinical outcomes, safety profiles, and long-term efficacy. Challenges and considerations in rituximab therapy are discussed, including factors influencing its efficacy, optimal dosing, treatment duration, and the need for maintenance therapy.
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Affiliation(s)
- Krishna Khandelwal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vedika Jajoo
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kshitij Bajpai
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Bhushan Madke
- Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Roshan Prasad
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mayur B Wanjari
- Research and Development, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pratiksha K Munjewar
- Medical Surgical Nursing, Srimati Radhikabai Meghe Memorial College of Nursing, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Avinash B Taksande
- Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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16
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Berger B, Hauck S, Runge K, Tebartz van Elst L, Rauer S, Endres D. Therapy response in seronegative versus seropositive autoimmune encephalitis. Front Immunol 2023; 14:1196110. [PMID: 37325671 PMCID: PMC10264660 DOI: 10.3389/fimmu.2023.1196110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023] Open
Abstract
Background Autoimmune encephalitis (AE) might be seropositive or seronegative, depending on whether antibodies targeting well-characterized neuronal antigens can be detected or not. Since data on treatment efficacy in seronegative cases, are scarce, the main rationale of this study was to evaluate immunotherapy response in seronegative AE in comparison to seropositive cases. Methods An electronic database search retrospectively identified 150 AE patients, treated in our tertiary care university hospital between 2010 and 2020 with an AE. Therapy response was measured using both general impression and the modified Rankin Scale (mRS). Results Seventy-four AE patients (49.3%) were seronegative and 76 (50.7%) seropositive. These cases were followed up for a mean of 15.3 (standard deviation, SD, 24.9) and 24.3 months (SD 28.1), respectively. Both groups were largely similar on the basis of numerous clinical and paraclinical findings including cerebrospinal fluid, electroencephalography, magnetic resonance imaging, and 18-F-fluor-desoxy-glucose-positron-emmission-tomography pathologies. The majority of patients (80.4%) received at least one immunotherapy, which were glucocorticoids in most cases (76.4%). Therapy response on general impression was high with 49 (92.5%) of treated seronegative, and 57 (86.4%) of treated seropositive AE cases showing improvement following immunotherapies and not significantly different between both groups. Notably, the proportion of patients with a favorable neurological deficit (mRS 0-2) was twice as high during long-term follow-up as compared to baseline in both groups. Conclusion Since both, patients with seronegative and seropositive AE, substantially benefitted from immunotherapies, these should be considered in AE patients irrespective of their antibody results.
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Affiliation(s)
- Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurology, Helios Clinic Pforzheim, Pforzheim, Germany
| | - Sophie Hauck
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kimon Runge
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Rauer
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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17
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Kelly H, Vishnevetsky A, Chibnik LB, Levy M. Hypogammaglobulinemia secondary to B-cell depleting therapies in neuroimmunology: Comparing management strategies. Mult Scler J Exp Transl Clin 2023; 9:20552173231182534. [PMID: 37377746 PMCID: PMC10291859 DOI: 10.1177/20552173231182534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Background Anti-CD20 agents are commonly used in MS, NMOSD, and MOGAD. Few studies have compared strategies to address hypogammaglobulinemia. Objective To compare strategies to manage secondary hypogammaglobulinemia in neuroimmunology patients, including reducing anti-CD20 dose and dosing frequency, IVIG/SCIG, anti-CD20 cessation, and DMT switches. Methods All MS, NMOSD, and MOGAD patients at our institution with hypogammaglobulinemia on anti-CD20 agents from 2001 to 2022 were analyzed. The median change in IgG, infection frequency, and infection severity before and after the treatment was calculated. Results In total, 257 patients were screened, and 30 had a treatment for hypogammaglobulinemia. IVIG/SCIG yielded the largest increase in IgG per year (674.0 mg/dL), followed by B-cell therapy cessation (34.7 mg/dL), and DMT switch (5.9 mg/dL). Dose reduction had the largest decrease in yearly infection frequency (2.7 fewer infections), followed by IVIG/SCIG (2.5 fewer), DMT switch (2 fewer), and reduced dosing frequency (0.5 fewer). Infection grade decreased by 1.9 for reduced dosing frequency (less severe infections), by 1.3 for IVIG/SCIG, and by 0.6 for DMT switch. Conclusion This data suggests that IVIG/SCIG may yield the greatest recovery in IgG while also reducing infection frequency and severity. Stopping anti-CD20 therapy and/or switching DMTs also increase IgG and may lower infection risk.
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Affiliation(s)
- Hannah Kelly
- Hannah Kelly, Medical Student, Case Western Reserve University, School of Medicine, 9501 Euclid Ave, Cleveland, OH 44106, USA.
| | - Anastasia Vishnevetsky
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lori B. Chibnik
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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18
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Pampusch MS, Sevcik EN, Quinn ZE, Davey BC, Berg JM, Gorrell-Brown I, Abdelaal HM, Rakasz EG, Rendahl A, Skinner PJ. Assessment of anti-CD20 antibody pre-treatment for augmentation of CAR-T cell therapy in SIV-infected rhesus macaques. Front Immunol 2023; 14:1101446. [PMID: 36825014 PMCID: PMC9941136 DOI: 10.3389/fimmu.2023.1101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
During chronic HIV and SIV infections, the majority of viral replication occurs within lymphoid follicles. In a pilot study, infusion of SIV-specific CD4-MBL-CAR-T cells expressing the follicular homing receptor, CXCR5, led to follicular localization of the cells and a reduction in SIV viral loads in rhesus macaques. However, the CAR-T cells failed to persist. We hypothesized that temporary disruption of follicles would create space for CAR-T cell engraftment and lead to increased abundance and persistence of CAR-T cells. In this study we treated SIV-infected rhesus macaques with CAR-T cells and preconditioned one set with anti-CD20 antibody to disrupt the follicles. We evaluated CAR-T cell abundance and persistence in four groups of SIVmac239-infected and ART-suppressed animals: untreated, CAR-T cell treated, CD20 depleted, and CD20 depleted/CAR-T cell treated. In the depletion study, anti-CD20 was infused one week prior to CAR-T infusion and cessation of ART. Anti-CD20 antibody treatment led to temporary depletion of CD20+ cells in blood and partial depletion in lymph nodes. In this dose escalation study, there was no impact of CAR-T cell infusion on SIV viral load. However, in both the depleted and non-depleted animals, CAR-T cells accumulated in and around lymphoid follicles and were Ki67+. CAR-T cells increased in number in follicles from 2 to 6 days post-treatment, with a median 15.2-fold increase in follicular CAR-T cell numbers in depleted/CAR-T treated animals compared to an 8.1-fold increase in non-depleted CAR-T treated animals. The increase in CAR T cells in depleted animals was associated with a prolonged elevation of serum IL-6 levels and a rapid loss of detectable CAR-T cells. Taken together, these data suggest that CAR-T cells likely expanded to a greater extent in depleted/CAR-T cell treated animals. Further studies are needed to elucidate mechanisms mediating the rapid loss of CAR-T cells and to evaluate strategies to improve engraftment and persistence of HIV-specific CAR-T cells. The potential for an inflammatory cytokine response appears to be enhanced with anti-CD20 antibody treatment and future studies may require CRS control strategies. These studies provide important insights into cellular immunotherapy and suggest future studies for improved outcomes.
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Affiliation(s)
- Mary S. Pampusch
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Emily N. Sevcik
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Zoe E. Quinn
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Brianna C. Davey
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - James M. Berg
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Ian Gorrell-Brown
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Hadia M. Abdelaal
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Eva G. Rakasz
- Wisconsin National Primate Research Center, University of Wisconsin, Madison WI, United States
| | - Aaron Rendahl
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
| | - Pamela J. Skinner
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN, United States
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ten Hagen A, Hermann S, Habermann E, Frommert LM, Arumahandi de Silva AN, Scholz V, Ghannam K, Klotsche J, Zernicke J, Alexander T, Burmester GR, Albach FN, Biesen R. Improvement of humoral immunity by repeated dose-intensified COVID-19 vaccinations in primary non- to low-responders and B cell deficient rheumatic disease patients. J Autoimmun 2023; 135:102996. [PMID: 36642057 PMCID: PMC9826996 DOI: 10.1016/j.jaut.2023.102996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine whether repeated, dose-intensified mRNA vaccinations against COVID-19 increase humoral immunity in previously low-responding patients with autoimmune rheumatic diseases (AIRD), including rituximab-treated and B cell depleted patients. METHODS Of 308 AIRD patients receiving basic immunization, 98 had a low serological response against SARS-CoV-2 with a neutralizing capacity of < 70% using surrogate neutralization assay. 38 patients received a third vaccination with 30 μg BNT162b2 16 weeks after second vaccination. If neutralizing serum capacity was below 70% four weeks after the last vaccination, then the fourth vaccination (n = 19) and the fifth (n = 4) vaccination with 100 μg mRNA-1273 took place eight weeks after the last vaccination. RESULTS Each of the three booster vaccinations resulted in a significant increase of mean serum neutralizing capacity (3rd: Δ = 42%, p < 0.001; 4th: Δ = 19%, p = 0.049 and 5th: Δ = 51%, p = 0.043) and produced a significant proportion of high-responders (3rd: 34%; 4th: 32% and 5th: 75%). Low B cell counts (p = 0.047), lower previous antibody response (p < 0.001) and rituximab therapy (p = 0.021) were negatively associated with successful response to the third but not to the fourth vaccination. Remarkably, substantial increases in neutralization capacity of up to 99% were observed after repeated vaccinations in B cell depleted patients. CONCLUSION AIRD patients with low humoral response benefited from up to three repeated dose-intensified mRNA booster vaccinations - despite low B cell count and previous rituximab therapy. Each additional vaccination substantially reduced the number of low-responding, vulnerable patients.
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Affiliation(s)
- Alexander ten Hagen
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sandra Hermann
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elisa Habermann
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Maria Frommert
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Amanthi Nadira Arumahandi de Silva
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Veronika Scholz
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Khetam Ghannam
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens Klotsche
- Epidemiology Unit, German Rheumatism Research Center Berlin – a Leibniz Institute (DRFZ), Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd-R. Burmester
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fredrik N. Albach
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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20
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Merino-Vico A, Frazzei G, van Hamburg JP, Tas SW. Targeting B cells and plasma cells in autoimmune diseases: From established treatments to novel therapeutic approaches. Eur J Immunol 2023; 53:e2149675. [PMID: 36314264 PMCID: PMC10099814 DOI: 10.1002/eji.202149675] [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: 07/28/2022] [Revised: 09/27/2022] [Accepted: 10/27/2022] [Indexed: 02/02/2023]
Abstract
Autoimmune diseases are characterized by the recognition of self-antigens by the immune system, which leads to inflammation and tissue damage. B cells are directly and indirectly involved in the pathophysiology of autoimmunity, both via antigen-presentation to T cells and production of proinflammatory cytokines and/or autoantibodies. Consequently, B lineage cells have been identified as therapeutic targets in autoimmune diseases. B cell depleting strategies have proven beneficial in the treatment of rheumatoid arthritis (RA), systemic lupus erythematous (SLE), ANCA-associated vasculitis (AAV), multiple sclerosis (MS), and a wide range of other immune-mediated inflammatory diseases (IMIDs). However, not all patients respond to treatment or may not reach (drug-free) remission. Moreover, B cell depleting therapies do not always target all B cell subsets, such as short-lived and long-lived plasma cells. These cells play an active role in autoimmunity and in certain diseases their depletion would be beneficial to achieve disease remission. In the current review article, we provide an overview of novel strategies to target B lineage cells in autoimmune diseases, with the focus on rheumatic diseases. Both advanced therapies that have recently become available and more experimental treatments that may reach the clinic in the near future are discussed.
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Affiliation(s)
- Ana Merino-Vico
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | - Giulia Frazzei
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | - Jan Piet van Hamburg
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | - Sander W Tas
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
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21
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Opdam MAA, de Leijer JH, den Broeder N, Thurlings RM, van der Weele W, Nurmohamed MT, Kok MR, van Bon L, Ten Cate DF, Verhoef LM, den Broeder AA. Rituximab dose-dependent infection risk in rheumatoid arthritis is not mediated through circulating immunoglobulins, neutrophils or B cells. Rheumatology (Oxford) 2022; 62:330-334. [PMID: 35686851 DOI: 10.1093/rheumatology/keac318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Rituximab (RTX) is a safe and effective treatment for RA. A dose-dependent infection risk was found in the REDO trial. Some studies associate RTX use with higher infection risks, possibly explained by low immunoglobulin levels and/or neutropenia. Additionally, a higher infection risk shortly after RTX infusion is reported. The objectives of this study were (i) to compare incidence rates of infections between doses and over time, and (ii) to assess B-cell counts, immunoglobulin levels, neutrophil counts and corticosteroid/disease modifying rheumatic drug use as mediating factors between RTX study dose and infection risk. METHODS Post hoc analyses of the REDO trial were performed. Infection incidence rates between RTX dosing groups and between time periods were compared using Poisson regression. A step-wise mediation analysis was performed to investigate if any of the factors mentioned above act as a mediator in the observed dose-dependent difference in infection risk. RESULTS The potential mediators that were investigated (circulating B-cell counts, immunoglobulin levels, neutrophil counts and drug use) did not explain the dose-dependent infection risk observed in the REDO trial. Additionally, a trend towards a time-dependent infection risk was found, with higher infection rates shortly after RTX infusion. CONCLUSIONS These secondary analyses of the REDO trial confirmed the observed dose-dependent infection risk. Additionally, we found that infection risks were higher shortly after RTX infusion. However, a mediating pathway was not found.
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Affiliation(s)
- Merel A A Opdam
- Department of Rheumatology, Sint Maartenskliniek.,Department of Rheumatology, Radboud Institute for Health Sciences, Radboudumc
| | | | | | | | | | | | - Marc R Kok
- Department of Rheumatology & Clinical Immunology, Maasstad Ziekenhuis, Rotterdam
| | - Lenny van Bon
- Department of Rheumatology, Hospital Group Twente, Almelo, the Netherlands
| | | | | | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek.,Department of Rheumatic Diseases, Radboudumc, Nijmegen
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22
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Mariette X, Barone F, Baldini C, Bootsma H, Clark KL, De Vita S, Gardner DH, Henderson RB, Herdman M, Lerang K, Mistry P, Punwaney R, Seror R, Stone J, van Daele PL, van Maurik A, Wisniacki N, Roth DA, Tak PP. A randomized, phase II study of sequential belimumab and rituximab in primary Sjögren's syndrome. JCI Insight 2022; 7:163030. [PMID: 36477362 PMCID: PMC9746921 DOI: 10.1172/jci.insight.163030] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDPrimary Sjögren's syndrome (pSS) is characterized by B cell hyperactivity and elevated B-lymphocyte stimulator (BLyS). Anti-BLyS treatment (e.g., belimumab) increases peripheral memory B cells; decreases naive, activated, and plasma B cell subsets; and increases stringency on B cell selection during reconstitution. Anti-CD20 therapeutics (e.g., rituximab) bind and deplete CD20-expressing B cells in circulation but are less effective in depleting tissue-resident CD20+ B cells. Combined, these 2 mechanisms may achieve synergistic effects.METHODSThis 68-week, phase II, double-blind study (GSK study 201842) randomized 86 adult patients with active pSS to 1 of 4 arms: placebo, s.c. belimumab, i.v. rituximab, or sequential belimumab + rituximab.RESULTSOverall, 60 patients completed treatment and follow-up until week 68. The incidence of adverse events (AEs) and drug-related AEs was similar across groups. Infections/infestations were the most common AEs, and no serious infections of special interest occurred. Near-complete depletion of minor salivary gland CD20+ B cells and a greater and more sustained depletion of peripheral CD19+ B cells were observed with belimumab + rituximab versus monotherapies. With belimumab + rituximab, reconstitution of peripheral B cells occurred, but it was delayed compared with rituximab. At week 68, mean (± standard error) total EULAR Sjögren's syndrome disease activity index scores decreased from 11.0 (1.17) at baseline to 5.0 (1.27) for belimumab + rituximab and 10.4 (1.36) to 8.6 (1.57) for placebo.CONCLUSIONThe safety profile of belimumab + rituximab in pSS was consistent with the monotherapies. Belimumab + rituximab induced enhanced salivary gland B cell depletion relative to the monotherapies, potentially leading to improved clinical outcomes.TRIAL REGISTRATIONClinicalTrials.gov NCT02631538.FUNDINGFunding was provided by GSK.
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Affiliation(s)
- Xavier Mariette
- Department of Rheumatology, Université Paris-Saclay, Hôpital Bicêtre, Assistance Publique — Hôpitaux de Paris, INSERM UMR1184, Le Kremlin Bicêtre, Paris, France
| | - Francesca Barone
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Chiara Baldini
- Centro Farmacologia Clinica AOUP, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Salvatore De Vita
- Rheumatology Clinic, Department of Medical Area, Azienda Ospedaliera Universitaria di Udine, Udine, Italy
| | - David H. Gardner
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Robert B. Henderson
- Clinical Pharmacology and Experimental Medicine, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Michael Herdman
- Clinical Pharmacology and Experimental Medicine, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Karoline Lerang
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
| | - Prafull Mistry
- R&D Biostatistics, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Raj Punwaney
- Pharmaceutical Research and Development, GSK, Collegeville, Pennsylvania, USA
| | - Raphaele Seror
- Department of Rheumatology, Université Paris-Saclay, Hôpital Bicêtre, Assistance Publique — Hôpitaux de Paris, INSERM UMR1184, Le Kremlin Bicêtre, Paris, France
| | - John Stone
- R&D, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Paul L.A. van Daele
- Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - André van Maurik
- Clinical Pharmacology and Experimental Medicine, GSK, Stevenage, Hertfordshire, United Kingdom
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23
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Blincoe A, Labrosse R, Abraham RS. Acquired B-cell deficiency secondary to B-cell-depleting therapies. J Immunol Methods 2022; 511:113385. [PMID: 36372267 DOI: 10.1016/j.jim.2022.113385] [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: 06/19/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
Abstract
The advantage of the newer biological therapies is that the immunosuppressive effect is targeted, in contrast, to the standard, traditional immunomodulatory agents, which have a more global effect. However, there are unintended targets and consequences, even to these "precise" therapeutics, leading to acquired or secondary immunodeficiencies. Besides depleting specific cellular immune subsets, these biological agents, which include monoclonal antibodies against biologically relevant molecules, often have broader functional immune consequences, which become apparent over time. This review focuses on acquired B-cell immunodeficiency, secondary to the use of B-cell depleting therapeutic agents. Among the many adverse consequences of B-cell depletion is the risk of hypogammaglobulinemia, failure of B-cell recovery, impaired B-cell differentiation, and risk of infections. Factors, which modulate the outcomes of B-cell depleting therapies, include the intrinsic nature of the underlying disease, the concomitant use of other immunomodulatory agents, and the clinical status of the patient and other co-existing morbidities. This article seeks to explore the mechanism of action of B-cell depleting agents, the clinical utility and adverse effects of these therapies, and the relevance of systematic and serial laboratory immune monitoring in identifying patients at risk for developing immunological complications, and who may benefit from early intervention to mitigate the secondary consequences. Though these biological drugs are gaining widespread use, a harmonized approach to immune evaluation pre-and post-treatment has not yet gained traction across multiple clinical specialties, because of which, the true prevalence of these adverse events cannot be determined in the treated population, and a systematic and evidence-based dosing schedule cannot be developed. The aim of this review is to bring these issues into focus, and initiate a multi-specialty, data-driven approach to immune monitoring.
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Affiliation(s)
- Annaliesse Blincoe
- Department of Paediatric Immunology and Allergy, Starship Child Health, Auckland, NZ, New Zealand
| | - Roxane Labrosse
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
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24
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Fichtner ML, Hoehn KB, Ford EE, Mane-Damas M, Oh S, Waters P, Payne AS, Smith ML, Watson CT, Losen M, Martinez-Martinez P, Nowak RJ, Kleinstein SH, O'Connor KC. Reemergence of pathogenic, autoantibody-producing B cell clones in myasthenia gravis following B cell depletion therapy. Acta Neuropathol Commun 2022; 10:154. [PMID: 36307868 PMCID: PMC9617453 DOI: 10.1186/s40478-022-01454-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/12/2022] Open
Abstract
Myasthenia gravis (MG) is an autoantibody-mediated autoimmune disorder of the neuromuscular junction. A small subset of patients (<10%) with MG, have autoantibodies targeting muscle-specific tyrosine kinase (MuSK). MuSK MG patients respond well to CD20-mediated B cell depletion therapy (BCDT); most achieve complete stable remission. However, relapse often occurs. To further understand the immunomechanisms underlying relapse, we studied autoantibody-producing B cells over the course of BCDT. We developed a fluorescently labeled antigen to enrich for MuSK-specific B cells, which was validated with a novel Nalm6 cell line engineered to express a human MuSK-specific B cell receptor. B cells (≅ 2.6 million) from 12 different samples collected from nine MuSK MG patients were screened for MuSK specificity. We successfully isolated two MuSK-specific IgG4 subclass-expressing plasmablasts from two of these patients, who were experiencing a relapse after a BCDT-induced remission. Human recombinant MuSK mAbs were then generated to validate binding specificity and characterize their molecular properties. Both mAbs were strong MuSK binders, they recognized the Ig1-like domain of MuSK, and showed pathogenic capacity when tested in an acetylcholine receptor (AChR) clustering assay. The presence of persistent clonal relatives of these MuSK-specific B cell clones was investigated through B cell receptor repertoire tracing of 63,977 unique clones derived from longitudinal samples collected from these two patients. Clonal variants were detected at multiple timepoints spanning more than five years and reemerged after BCDT-mediated remission, predating disease relapse by several months. These findings demonstrate that a reservoir of rare pathogenic MuSK autoantibody-expressing B cell clones survive BCDT and reemerge into circulation prior to manifestation of clinical relapse. Overall, this study provides both a mechanistic understanding of MuSK MG relapse and a valuable candidate biomarker for relapse prediction.
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Affiliation(s)
- Miriam L Fichtner
- Department of Neurology, Yale University School of Medicine, 300 George Street - Room 353J, New Haven, CT, 06511, USA
- Department of Immunobiology, Yale University School of Medicine, 300 George Street - Room 353J, New Haven, CT, 06511, USA
| | - Kenneth B Hoehn
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Easton E Ford
- Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Marina Mane-Damas
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Sangwook Oh
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Waters
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Aimee S Payne
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa L Smith
- Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA
- Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, KY, USA
| | - Corey T Watson
- Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA
- Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, KY, USA
| | - Mario Losen
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Richard J Nowak
- Department of Neurology, Yale University School of Medicine, 300 George Street - Room 353J, New Haven, CT, 06511, USA
| | - Steven H Kleinstein
- Department of Immunobiology, Yale University School of Medicine, 300 George Street - Room 353J, New Haven, CT, 06511, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Program in Computational Biology & Bioinformatics, Yale University, New Haven, CT, USA
| | - Kevin C O'Connor
- Department of Neurology, Yale University School of Medicine, 300 George Street - Room 353J, New Haven, CT, 06511, USA.
- Department of Immunobiology, Yale University School of Medicine, 300 George Street - Room 353J, New Haven, CT, 06511, USA.
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25
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Kim SH, Park NY, Kim KH, Hyun JW, Kim HJ. Rituximab-Induced Hypogammaglobulinemia and Risk of Infection in Neuromyelitis Optica Spectrum Disorders. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/5/e1179. [PMID: 35853752 PMCID: PMC9296048 DOI: 10.1212/nxi.0000000000001179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
Background and Objectives To investigate the frequency and predictors of hypogammaglobulinemia during long-term rituximab (RTX) treatment in patients with neuromyelitis optica spectrum disorder (NMOSD) and its association with infections. Methods We retrospectively reviewed the data of patients with NMOSD who received RTX through the maintenance regimen based on memory B-cell detection for at least 1 year from 2006 to 2021 at an institutional referral center for NMOSD. Results A total of 169 patients received a median of 10 courses (range 1–27) of RTX reinfusion after induction over a median of 8 (range, 1–15) years. Their mean serum immunoglobulin (Ig)G level began to decline significantly after 2 years of treatment, steadily declined at a rate of 2%–8% per year for the following 8 years, and then plateaued after 10 years. The proportion of patients with hypo-IgG (<6 g/L) increased from 1.2% after 1 year of treatment to 41% after 14 years of treatment. While being treated with RTX, 58 (34%) patients had 114 infections, of whom 14 (8%) patients had 15 severe infections. Multivariable logistic regression analyses identified duration of RTX treatment in years (odds ratio [OR] 1.234, 95% confidence interval [CI] 1.015–1.502), mean annual RTX dose (OR 0.063, 95% CI 0.009–0.434), history of mitoxantrone (OR 3.318, 95% CI 1.109–9.93), hypo-IgG at baseline (OR 40.552, 95% CI 3.024–543.786), and body mass index >25 kg/m2 (OR 4.798, 95% CI 1.468–15.678) as independent predictors of hypo-IgG. The risk of infection during RTX treatment was independently associated with high Expanded Disability Status Scale scores (OR 1.427, 95% CI 1.2–1.697) and relapses during RTX treatment (OR 1.665, 95% CI 1.112–2.492), but not with hypogammaglobulinemia. Discussion Over 14 years of long-term RTX treatment, IgG levels gradually decreased, and the frequency of hypo-IgG increased to 41% of the patients. Patients with prolonged memory B-cell depletion after RTX, previous mitoxantrone history, hypo-IgG at baseline, or obesity were at risk of developing RTX-induced hypogammaglobulinemia. Nevertheless, infection rates remained low during treatment, and reduced immunoglobulin levels were not associated with an increased incidence of infections.
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26
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Stefanski AL, Rincon-Arevalo H, Schrezenmeier E, Karberg K, Szelinski F, Ritter J, Chen Y, Meisel C, Jahrsdörfer B, Ludwig C, Schrezenmeier H, Lino AC, Dörner T. Persistent but atypical germinal center reaction among 3rd SARS-CoV-2 vaccination after rituximab exposure. Front Immunol 2022; 13:943476. [PMID: 36032111 PMCID: PMC9399943 DOI: 10.3389/fimmu.2022.943476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Durable vaccine-mediated immunity relies on the generation of long-lived plasma cells and memory B cells (MBCs), differentiating upon germinal center (GC) reactions. SARS-CoV-2 mRNA vaccination induces a strong GC response in healthy volunteers (HC), but limited data is available about response longevity upon rituximab treatment. Methods We evaluated humoral and cellular responses upon 3rd vaccination in seven patients with rheumatoid arthritis (RA) who initially mounted anti-spike SARS-CoV-2 IgG antibodies after primary 2x vaccination and got re-exposed to rituximab (RTX) 1-2 months after the second vaccination. Ten patients with RA on other therapies and ten HC represented the control groups. As control for known long-lived induced immunity, we analyzed humoral and cellular tetanus toxoid (TT) immune responses in steady-state. Results After 3rd vaccination, 5/7 seroconverted RTX patients revealed lower anti-SARS-CoV-2 IgG levels but similar neutralizing capacity compared with HC. Antibody levels after 3rd vaccination correlated with values after 2nd vaccination. Despite significant reduction of circulating total and antigen-specific B cells in RTX re-exposed patients, we observed the induction of IgG+ MBCs upon 3rd vaccination. Notably, only RTX treated patients revealed a high amount of IgA+ MBCs before and IgA+ plasmablasts after 3rd vaccination. IgA+ B cells were not part of the steady state TT+ B cell pool. TNF-secretion and generation of effector memory CD4 spike-specific T cells were significantly boosted upon 3rd vaccination. Summary On the basis of pre-existing affinity matured MBCs within primary immunisation, RTX re-exposed patients revealed a persistent but atypical GC immune response accompanied by boosted spike-specific memory CD4 T cells upon SARS-CoV-2 recall vaccination.
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Affiliation(s)
- Ana-Luisa Stefanski
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
- *Correspondence: Ana-Luisa Stefanski,
| | - Hector Rincon-Arevalo
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Instituto de Investigaciones Médicas, Universidad de Antioquia (UdeA), Medellín, Colombia
| | - Eva Schrezenmeier
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health Charité Universitätsmedizin Berlin, Berlin Institute of Health (BIH) Academy, Berlin, Germany
| | - Kirsten Karberg
- Rheumatology Outpatient Office RheumaPraxis Steglitz, Berlin, Germany
| | - Franziska Szelinski
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Jacob Ritter
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health Charité Universitätsmedizin Berlin, Berlin Institute of Health (BIH) Academy, Berlin, Germany
| | - Yidan Chen
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Christian Meisel
- Department of Medical Immunology, Charité University Medicine and Labor Berlin-Charité Vivantes, Berlin, Germany
| | - Bernd Jahrsdörfer
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg – Hessen and University Hospital Ulm, Ulm, Germany
| | - Carolin Ludwig
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg – Hessen and University Hospital Ulm, Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg – Hessen and University Hospital Ulm, Ulm, Germany
| | | | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
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27
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An update on novel therapeutic intervention in Rheumatoid arthritis. Int Immunopharmacol 2022; 109:108794. [DOI: 10.1016/j.intimp.2022.108794] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 12/15/2022]
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Tsuboi K, Noguchi K, Kitano M, Furukawa T, Hashimoto T, Azuma N, Matsui K. Serum B cell activating factor (BAFF) as a biomarker for induction of remission with rituximab in ANCA-associated vasculitis. Immunol Med 2022; 45:238-243. [PMID: 35802795 DOI: 10.1080/25785826.2022.2094592] [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: 10/17/2022] Open
Abstract
We examined whether serum B cell activating factor (BAFF) is useful for predicting the remission of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) following rituximab treatment. We used the Birmingham Vasculitis Activity Score (BVAS) 2008 version 3 for the evaluation of 27 patients with AAV 6 months after rituximab treatment. Those with BVAS = 0 achieved remission, whereas those with BVAS score > 0 did not achieve remission. We considered changes in serum BAFF before rituximab treatment, 1 month after treatment, and 6 months after treatment. In the remission group, the serum BAFF increased consistently. In the non-achieved group, serum BAFF was within the normal range. In addition, there was no statistically significant difference between the two groups in terms of serum BAFF before and 1 month after rituximab treatment. However, the serum BAFF level at 6 months after rituximab treatment was significantly higher in the remission group than in the non-achieved group. If serum BAFF does not increase after 6 months of rituximab in AAV, it may be assumed that there are residual B cells and plasma cells in the tissues. Enhanced treatment targeting B cells, including re-administration of rituximab or the addition of other immunosuppressive drugs, should be considered.
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Affiliation(s)
- Kazuyuki Tsuboi
- Division of Allergology and Rheumatology, Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Kazuteru Noguchi
- Division of Allergology and Rheumatology, Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Masayasu Kitano
- Division of Rheumatology, Department of Internal Medicine, Sumitomo Hospital, Nakanoshima, Japan
| | - Tetsuya Furukawa
- Division of Allergology and Rheumatology, Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Teppei Hashimoto
- Division of Allergology and Rheumatology, Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Naoto Azuma
- Division of Allergology and Rheumatology, Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Kiyoshi Matsui
- Division of Allergology and Rheumatology, Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
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29
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Tang D, Park S, Zhao H. SCADIE: simultaneous estimation of cell type proportions and cell type-specific gene expressions using SCAD-based iterative estimating procedure. Genome Biol 2022; 23:129. [PMID: 35706040 PMCID: PMC9199219 DOI: 10.1186/s13059-022-02688-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 05/11/2022] [Indexed: 12/13/2022] Open
Abstract
A challenge in bulk gene differential expression analysis is to differentiate changes due to cell type-specific gene expression and cell type proportions. SCADIE is an iterative algorithm that simultaneously estimates cell type-specific gene expression profiles and cell type proportions, and performs cell type-specific differential expression analysis at the group level. Through its unique penalty and objective function, SCADIE more accurately identifies cell type-specific differentially expressed genes than existing methods, including those that may be missed from single cell RNA-Seq data. SCADIE has robust performance with respect to the choice of deconvolution methods and the sources and quality of input data.
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Affiliation(s)
- Daiwei Tang
- Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, USA
| | - Seyoung Park
- Department of Statistics, Sungkyunkwan University, 25-2, Sungkyunkwan-ro, Jongno-gu, Seoul, South Korea
| | - Hongyu Zhao
- Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, USA.
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30
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Rituximab abrogates aquaporin-4-specific germinal center activity in patients with neuromyelitis optica spectrum disorders. Proc Natl Acad Sci U S A 2022; 119:e2121804119. [PMID: 35666871 PMCID: PMC9214492 DOI: 10.1073/pnas.2121804119] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
By studying paired blood and deep cervical lymph node samples from patients with neuromyelitis optica spectrum disorders, our data provide evidence for a germinal center–based generation of aquaporin-4 antibodies. Frequent serum aquaporin-4 immunoglobulin Ms (IgMs) and shifts in IgG subclasses were observed alongside preferential synthesis of aquaporin-4 IgGs and aquaporin-4–reactive B cells within lymph nodes. Both intranodal synthesis of aquaporin-4 antibodies and intranodal aquaporin-4–reactive B cells were robustly eliminated with rituximab administration. This study systematically explores lymph nodes that drain the central nervous system (CNS) in patients with CNS autoimmunity and offers a potential explanation as to why rituximab is clinically highly efficacious in autoantibody-mediated diseases despite no accompanying reduction in serum autoantibody levels. Neuromyelitis optica spectrum disorders (NMOSDs) are caused by immunoglobulin G (IgG) autoantibodies directed against the water channel aquaporin-4 (AQP4). In NMOSDs, discrete clinical relapses lead to disability and are robustly prevented by the anti-CD20 therapeutic rituximab; however, its mechanism of action in autoantibody-mediated disorders remains poorly understood. We hypothesized that AQP4-IgG production in germinal centers (GCs) was a core feature of NMOSDs and could be terminated by rituximab. To investigate this directly, deep cervical lymph node (dCLN) aspirates (n = 36) and blood (n = 406) were studied in a total of 63 NMOSD patients. Clinical relapses were associated with AQP4-IgM generation or shifts in AQP4-IgG subclasses (odds ratio = 6.0; range of 3.3 to 10.8; P < 0.0001), features consistent with GC activity. From seven dCLN aspirates of patients not administered rituximab, AQP4-IgGs were detected alongside specific intranodal synthesis of AQP4-IgG. AQP4-reactive B cells were isolated from unmutated naive and mutated memory populations in both blood and dCLNs. After rituximab administration, fewer clinical relapses (annual relapse rate of 0.79 to 0; P < 0.001) were accompanied by marked reductions in both AQP4-IgG (fourfold; P = 0.004) and intranodal B cells (430-fold; P < 0.0001) from 11 dCLNs. Our findings implicate ongoing GC activity as a rituximab-sensitive driver of AQP4 antibody production. They may explain rituximab’s clinical efficacy in several autoantibody-mediated diseases and highlight the potential value of direct GC measurements across autoimmune conditions.
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31
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Rivellese F, Surace AEA, Goldmann K, Sciacca E, Çubuk C, Giorli G, John CR, Nerviani A, Fossati-Jimack L, Thorborn G, Ahmed M, Prediletto E, Church SE, Hudson BM, Warren SE, McKeigue PM, Humby F, Bombardieri M, Barnes MR, Lewis MJ, Pitzalis C. Rituximab versus tocilizumab in rheumatoid arthritis: synovial biopsy-based biomarker analysis of the phase 4 R4RA randomized trial. Nat Med 2022; 28:1256-1268. [PMID: 35589854 PMCID: PMC9205785 DOI: 10.1038/s41591-022-01789-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/21/2022] [Indexed: 12/29/2022]
Abstract
Patients with rheumatoid arthritis (RA) receive highly targeted biologic therapies without previous knowledge of target expression levels in the diseased tissue. Approximately 40% of patients do not respond to individual biologic therapies and 5-20% are refractory to all. In a biopsy-based, precision-medicine, randomized clinical trial in RA (R4RA; n = 164), patients with low/absent synovial B cell molecular signature had a lower response to rituximab (anti-CD20 monoclonal antibody) compared with that to tocilizumab (anti-IL6R monoclonal antibody) although the exact mechanisms of response/nonresponse remain to be established. Here, in-depth histological/molecular analyses of R4RA synovial biopsies identify humoral immune response gene signatures associated with response to rituximab and tocilizumab, and a stromal/fibroblast signature in patients refractory to all medications. Post-treatment changes in synovial gene expression and cell infiltration highlighted divergent effects of rituximab and tocilizumab relating to differing response/nonresponse mechanisms. Using ten-by-tenfold nested cross-validation, we developed machine learning algorithms predictive of response to rituximab (area under the curve (AUC) = 0.74), tocilizumab (AUC = 0.68) and, notably, multidrug resistance (AUC = 0.69). This study supports the notion that disease endotypes, driven by diverse molecular pathology pathways in the diseased tissue, determine diverse clinical and treatment-response phenotypes. It also highlights the importance of integration of molecular pathology signatures into clinical algorithms to optimize the future use of existing medications and inform the development of new drugs for refractory patients.
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Affiliation(s)
- Felice Rivellese
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anna E A Surace
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katriona Goldmann
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Elisabetta Sciacca
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Cankut Çubuk
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Giovanni Giorli
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christopher R John
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alessandra Nerviani
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Liliane Fossati-Jimack
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgina Thorborn
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Manzoor Ahmed
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Edoardo Prediletto
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | | | - Paul M McKeigue
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Frances Humby
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michele Bombardieri
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael R Barnes
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Myles J Lewis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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32
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Chan EYH, Ma ALT, Tullus K. Hypogammaglobulinaemia following rituximab therapy in childhood nephrotic syndrome. Pediatr Nephrol 2022; 37:927-931. [PMID: 34999985 DOI: 10.1007/s00467-021-05345-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
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33
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Stathopoulos P, Dalakas MC. Evolution of Anti-B Cell Therapeutics in Autoimmune Neurological Diseases. Neurotherapeutics 2022; 19:691-710. [PMID: 35182380 PMCID: PMC9294112 DOI: 10.1007/s13311-022-01196-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 02/08/2023] Open
Abstract
B cells have an ever-increasing role in the etiopathology of a number of autoimmune neurological disorders, acting as antigen-presenting cells facilitating antibody production but also as sensors, coordinators, and regulators of the immune response. In particular, B cells can regulate the T cell activation process through their participation in antigen presentation, production of proinflammatory cytokines (bystander activation or suppression), and contribution to ectopic lymphoid aggregates. Such an important interplay between B and T cells makes therapeutic depletion of B cells an attractive treatment strategy. The last decade, anti-B cell therapies using monoclonal antibodies against B cell surface molecules have evolved into a rational approach for successfully treating autoimmune neurological disorders, even when T cells seem to be the main effector cells. The paper summarizes basic aspects of B cell biology, discusses the roles of B cells in neurological autoimmunities, and highlights how the currently available or under development anti-B cell therapeutics exert their action in the wide spectrum and immunologically diverse neurological disorders. The efficacy of the various anti-B cell therapies and practical issues on induction and maintenance therapy is specifically detailed for the treatment of patients with multiple sclerosis, neuromyelitis-spectrum disorders, autoimmune encephalitis and hyperexcitability CNS disorders, autoimmune neuropathies, myasthenia gravis, and inflammatory myopathies. The success of anti-B cell therapies in inducing long-term remission in IgG4 neuroautoimmunities is also highlighted pointing out potential biomarkers for follow-up infusions.
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Affiliation(s)
- Panos Stathopoulos
- 1st Department of Neurology, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece.
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34
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Kmeid M, Aldyab M, Brar R, Lee H. Histologic Findings and Tissue B-Cell Depletion in Endoscopic Mucosal Biopsy Specimens of the Gastrointestinal Tract After Treatment With Rituximab. Am J Clin Pathol 2022; 157:353-364. [PMID: 34520518 DOI: 10.1093/ajcp/aqab133] [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: 03/15/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Rituximab (RTX) is associated with variable adverse gastrointestinal (GI) events. However, the histologic correlate in affected patients is not well defined. METHODS Patients (n = 93) who had received RTX and undergone endoscopic biopsies were identified. CD20 and PAX5 immunostains were performed on biopsy specimens showing inflammatory pathology (group A, 36 patients) and 35 of 57 noninflammatory biopsies (group B) that were taken within 1 year from the last RTX infusion. Histologic findings were correlated with tissue B-cell depletion (CD20/PAX5-/-). RESULTS B cells were depleted in 12 (33%) of 36 group A biopsy specimens. After excluding biopsies taken more than 1 year from the last RTX infusion, the frequencies of tissue B-cell depletion were similar between group A (12/26; 46.2%) and group B (17/35; 48.6%) (P > .05). Also, the frequencies of inflammatory pathology were not statistically different whether B cells were depleted or not (P > .05). In group A with tissue B-cell depletion (n = 12), causality was indicated in two (17%) cases showing lymphocytic colitis pattern of injury (LCPI). CONCLUSIONS In RTX-treated patients, tissue B-cell depletion does not appear to be the main cause of inflammatory pathology in the GI tract. A minor subset, however, develops histologic evidence of potential RTX-induced effect, notably in the form of LCPI.
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Affiliation(s)
- Michel Kmeid
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Mahmoud Aldyab
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Rupinder Brar
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
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35
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Fiechter RH, Bolt JW, van de Sande MGH, Aalbers CJ, Landewé RBM, Maas M, Tas SW, van Baarsen LGM. Ultrasound-guided lymph node biopsy sampling to study the immunopathogenesis of rheumatoid arthritis: a well-tolerated valuable research tool. Arthritis Res Ther 2022; 24:36. [PMID: 35115042 PMCID: PMC8812012 DOI: 10.1186/s13075-022-02728-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background Analyses of lymphoid organs are required to further elucidate the pathogenesis of inflammatory diseases like rheumatoid arthritis (RA). Yet, invasive tissue collection methods are scarcely applied, because they are often considered burdensome, although patients do not always consider invasive methods as a high burden. We aimed to investigate the perspectives of study participants undergoing ultrasound-guided inguinal lymph node (LN) needle biopsy sampling and determine the molecular and cellular quantity and quality of LN biopsies. Methods Together with patient research partners, questionnaires were developed to evaluate the motives, expectations, and experiences of participants undergoing a LN biopsy. Healthy controls and RA(-risk) patients were asked to complete these questionnaires before and after the procedure. RNA and lymphocyte yields from obtained LN biopsies were also calculated. Results We included 50 individuals, of which 43 (86%) reported their pre- and post-procedure experiences. The median reported pain on a 5-point Likert scale (1 not to 5 very painful) was 1. Interestingly, almost all (n = 32; 74%) study participants would undergo a second procedure and more than half (n = 23; 54%) would encourage others to take part in the LN biopsy study. Motives for current and future participation were mostly altruistic. Inguinal hematoma occurred frequently, but no other significant or unexpected complications ensued. The LN biopsies yielded sufficient and high-quality RNA and lymphocyte numbers. Conclusions Ultrasound-guided inguinal LN biopsy sampling is well-tolerated, safe, and provides sufficient material for further molecular and cellular analyses. Our participants’ positive experiences endorse the application of this research tool to further elucidate the pathogenesis of RA and other inflammatory diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02728-7.
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Affiliation(s)
- Renée H Fiechter
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Janne W Bolt
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marleen G H van de Sande
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Caroline J Aalbers
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robert B M Landewé
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sander W Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Lisa G M van Baarsen
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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36
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Dalla Costa G, Leocani L, Comi G. Ofatumumab subcutaneous injection for the treatment of relapsing forms of multiple sclerosis. Expert Rev Clin Immunol 2022; 18:105-114. [PMID: 35107057 DOI: 10.1080/1744666x.2022.2031982] [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: 11/04/2022]
Abstract
INTRODUCTION In recent years, different studies have highlighted the importance of B cells in the pathophysiology of multiple sclerosis (MS): they secrete cytokines to modulate the inflammatory environment, present antigens for the activation of T lymphocytes, and they secrete antibodies contributing to the destruction of the myelin sheath. Combined, these findings have lead to new possible means for treating MS. AREAS COVERED In this review, we provide an up-to-date overview of the characteristics of ofatumumab (aka Kesimpta), and the differences between this drug and the other anti-CD20 monoclonal antibodies used to treat MS. EXPERT OPINION The evolution of disease-modifying treatment algorithms in MS underlines the importance of starting treatment as soon as the diagnosis is defined, and with adequate "treatment intensity". Monoclonal antibodies and other aggressive treatments are now considered as an option at the clinical presentation of the disease, based to the prognostic profile emerging through clinical and paraclinical investigations. The recent adoption of new diagnostic criteria allows for the early diagnosis of MS. This, together with the availability of disease-modifying therapies (DMTs), such as ofatumumab, with a good efficacy/safety profile and which are easy to administer, could contribute to significant improvements in the long-term prognosis of MS.
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Affiliation(s)
- G Dalla Costa
- Institute of Experimental Neurophysiology of San Raffaele Hospital, via Olgettina 60, Milan, Italy.,Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy
| | - L Leocani
- Institute of Experimental Neurophysiology of San Raffaele Hospital, via Olgettina 60, Milan, Italy.,Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy
| | - G Comi
- Vita-Salute San Raffaele University, via Olgettina 60, Milan, Italy.,Casa di Cura Privata del Policlinico, via Dezza 48, Milan, Italy
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37
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Papadimitriou TI, van Caam A, van der Kraan PM, Thurlings RM. Therapeutic Options for Systemic Sclerosis: Current and Future Perspectives in Tackling Immune-Mediated Fibrosis. Biomedicines 2022; 10:biomedicines10020316. [PMID: 35203525 PMCID: PMC8869277 DOI: 10.3390/biomedicines10020316] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023] Open
Abstract
Systemic sclerosis (SSc) is a severe auto-immune, rheumatic disease, characterized by excessive fibrosis of the skin and visceral organs. SSc is accompanied by high morbidity and mortality rates, and unfortunately, few disease-modifying therapies are currently available. Inflammation, vasculopathy, and fibrosis are the key hallmarks of SSc pathology. In this narrative review, we examine the relationship between inflammation and fibrosis and provide an overview of the efficacy of current and novel treatment options in diminishing SSc-related fibrosis based on selected clinical trials. To do this, we first discuss inflammatory pathways of both the innate and acquired immune systems that are associated with SSc pathophysiology. Secondly, we review evidence supporting the use of first-line therapies in SSc patients. In addition, T cell-, B cell-, and cytokine-specific treatments that have been utilized in SSc are explored. Finally, the potential effectiveness of tyrosine kinase inhibitors and other novel therapeutic approaches in reducing fibrosis is highlighted.
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Wang Z, Huang J, Xie D, He D, Lu A, Liang C. Toward Overcoming Treatment Failure in Rheumatoid Arthritis. Front Immunol 2022; 12:755844. [PMID: 35003068 PMCID: PMC8732378 DOI: 10.3389/fimmu.2021.755844] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/06/2021] [Indexed: 12/29/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disorder characterized by inflammation and bone erosion. The exact mechanism of RA is still unknown, but various immune cytokines, signaling pathways and effector cells are involved. Disease-modifying antirheumatic drugs (DMARDs) are commonly used in RA treatment and classified into different categories. Nevertheless, RA treatment is based on a "trial-and-error" approach, and a substantial proportion of patients show failed therapy for each DMARD. Over the past decades, great efforts have been made to overcome treatment failure, including identification of biomarkers, exploration of the reasons for loss of efficacy, development of sequential or combinational DMARDs strategies and approval of new DMARDs. Here, we summarize these efforts, which would provide valuable insights for accurate RA clinical medication. While gratifying, researchers realize that these efforts are still far from enough to recommend specific DMARDs for individual patients. Precision medicine is an emerging medical model that proposes a highly individualized and tailored approach for disease management. In this review, we also discuss the potential of precision medicine for overcoming RA treatment failure, with the introduction of various cutting-edge technologies and big data.
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Affiliation(s)
- Zhuqian Wang
- Department of Biology, School of Life Sciences, Southern University of Science and Technology, Shenzhen, China.,Institute of Integrated Bioinfomedicine and Translational Science (IBTS), School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China.,Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China
| | - Jie Huang
- Department of Biology, School of Life Sciences, Southern University of Science and Technology, Shenzhen, China
| | - Duoli Xie
- Institute of Integrated Bioinfomedicine and Translational Science (IBTS), School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China.,Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China
| | - Dongyi He
- Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China.,Department of Rheumatology, Shanghai Guanghua Hospital of Integrative Medicine, Shanghai, China
| | - Aiping Lu
- Institute of Integrated Bioinfomedicine and Translational Science (IBTS), School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China.,Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China.,Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China.,Guangdong-Hong Kong-Macau Joint Lab on Chinese Medicine and Immune Disease Research, Guangzhou, China
| | - Chao Liang
- Department of Biology, School of Life Sciences, Southern University of Science and Technology, Shenzhen, China.,Institute of Integrated Bioinfomedicine and Translational Science (IBTS), School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China.,Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China
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Shenoy P, Umesh R, Paul A, Shenoy V, Ahmed S, Cherian S, Prasad A. Humoral responses to SARS-CoV-2 vaccination in rituximab-treated patients depend on peripheral B cell re-population rather than the timings of the dosing. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_215_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Stefanski AL, Rincon-Arevalo H, Schrezenmeier E, Karberg K, Szelinski F, Ritter J, Jahrsdörfer B, Schrezenmeier H, Ludwig C, Sattler A, Kotsch K, Chen Y, Claußnitzer A, Haibel H, Proft F, Guerra G, Durek P, Heinrich F, Ferreira-Gomes M, Burmester GR, Radbruch A, Mashreghi MF, Lino AC, Dörner T. B cell numbers predict humoral and cellular response upon SARS-CoV-2 vaccination among patients treated with rituximab. Arthritis Rheumatol 2021; 74:934-947. [PMID: 34962360 PMCID: PMC9011692 DOI: 10.1002/art.42060] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/25/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Patients with autoimmune inflammatory rheumatic diseases receiving rituximab (RTX) therapy are at higher risk for poor COVID-19 outcomes and show substantially impaired humoral anti-SARS-CoV-2 vaccine responses. However, the complex relationship between antigen-specific B and T cells and the level of B cell repopulation necessary to achieve anti-vaccine responses remain largely unknown. METHODS Antibody responses to SARS-CoV-2 vaccines and induction of antigen-specific B and CD4/CD8 T cell subsets were studied in 19 rheumatoid arthritis (RA) and ANCA-associated vasculitis (AAV) patients receiving RTX, 12 RA patients on other therapies and 30 healthy controls after SARS-CoV-2 vaccination with either mRNA or vector based vaccines. RESULTS A minimum of 10 B cells/μL (0,4% of lymphocytes) in the peripheral circulation appeared to be required in RTX patients to mount seroconversion to anti-S1 IgG upon SARS-CoV-2 vaccination. RTX patients lacking IgG seroconversion showed reduced RBD+ B cells, lower frequency of TfH-like cells as well as less activated CD4 and CD8 T cells compared to IgG seroconverted RTX patients. Functionally relevant B cell depletion resulted in impaired IFNγ secretion by spike-specific CD4 T cells. In contrast, antigen-specific CD8 T cells were reduced in patients, independently of IgG formation. CONCLUSIONS In patients receiving RTX, a minimum of 10 B cells/μl in the peripheral circulation candidates as biomarker for a high likelihood of an appropriate cellular and humoral response after SARS-CoV-2 vaccination. Mechanistically, the data emphasize the crucial role of co-stimulatory B cell functions for the proper induction of CD4 responses propagating vaccine-specific B and plasma cell differentiation.
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Affiliation(s)
- Ana L Stefanski
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Hector Rincon-Arevalo
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany.,Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany.,Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Instituto de Investigaciones Médicas, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Eva Schrezenmeier
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany.,Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Universitätsmedizin Berlin, BIH Academy, Berlin, Germany
| | - Kirsten Karberg
- Rheumatology outpatient office RheumaPraxis Steglitz, Berlin, Germany
| | - Franziska Szelinski
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Jacob Ritter
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Berlin Institute of Health Charité Universitätsmedizin Berlin, BIH Academy, Berlin, Germany
| | - Bernd Jahrsdörfer
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg - Hessen and University Hospital Ulm, Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg - Hessen and University Hospital Ulm, Ulm, Germany
| | - Carolin Ludwig
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg - Hessen and University Hospital Ulm, Ulm, Germany
| | - Arne Sattler
- Department for General, Visceral and Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Katja Kotsch
- Department for General, Visceral and Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Yidan Chen
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Anne Claußnitzer
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany
| | - Hildrun Haibel
- Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Proft
- Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Pawel Durek
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | | | | | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | | | | | - Andreia C Lino
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin; Berlin, Germany.,Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
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Chalayer E, Gramont B, Zekre F, Goguyer-Deschaumes R, Waeckel L, Grange L, Paul S, Chung AW, Killian M. Fc receptors gone wrong: A comprehensive review of their roles in autoimmune and inflammatory diseases. Autoimmun Rev 2021; 21:103016. [PMID: 34915182 DOI: 10.1016/j.autrev.2021.103016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 12/16/2022]
Abstract
Systemic autoimmune and inflammatory diseases have a complex and only partially known pathophysiology with various abnormalities involving all the components of the immune system. Among these components, antibodies, and especially autoantibodies are key elements contributing to autoimmunity. The interaction of antibody fragment crystallisable (Fc) and several distinct receptors, namely Fc receptors (FcRs), have gained much attention during the recent years, with possible major therapeutic perspectives for the future. The aim of this review is to comprehensively describe the known roles for FcRs (activating and inhibitory FcγRs, neonatal FcR [FcRn], FcαRI, FcεRs, Ro52/tripartite motif containing 21 [Ro52/TRIM21], FcδR, and the novel Fc receptor-like [FcRL] family) in systemic autoimmune and inflammatory disorders, namely rheumatoid arthritis, Sjögren's syndrome, systemic lupus erythematosus, systemic sclerosis, idiopathic inflammatory myopathies, mixed connective tissue disease, Crohn's disease, ulcerative colitis, immunoglobulin (Ig) A vasculitis, Behçet's disease, Kawasaki disease, IgG4-related disease, immune thrombocytopenia, autoimmune hemolytic anemia, antiphospholipid syndrome and heparin-induced thrombocytopenia.
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Affiliation(s)
- Emilie Chalayer
- Department of Hematology and Cell Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Etienne, France; INSERM U1059-Sainbiose, dysfonction vasculaire et hémostase, Université de Lyon, Saint-Etienne, France
| | - Baptiste Gramont
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; Department of Internal Medicine, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Franck Zekre
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; Department of Pediatrics, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Roman Goguyer-Deschaumes
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France
| | - Louis Waeckel
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; Department of Immunology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Lucile Grange
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; Department of Internal Medicine, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Stéphane Paul
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; Department of Immunology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Amy W Chung
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Martin Killian
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, INSERM, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; Department of Internal Medicine, Saint-Etienne University Hospital, Saint-Etienne, France.
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Smets I, Giovannoni G. Derisking CD20-therapies for long-term use. Mult Scler Relat Disord 2021; 57:103418. [PMID: 34902761 DOI: 10.1016/j.msard.2021.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Anti-CD20 have quickly become the mainstay in the treatment of multiple sclerosis (MS) and other neuroinflammatory conditions. However, when they are used as a maintenance therapy the balance between risks and benefits changes. In this review, we suggested six steps to derisk anti-CD20. Firstly and secondly, adequate infectious screening followed by vaccinations before starting anti-CD20 are paramount. Third, family planning needs to be discussed upfront with every woman of childbearing age. Fourth, infusion reactions should be adequately managed to avoid treatment interruption. After repeated infusions, it becomes important to detect and prevent anti-CD20-related adverse events. Fifth, we recommended measuring immunoglobulin levels and reviewing vaccinations annually as well as counselling adequate fever management. For female patients, we emphasised the importance to engage with the local breast cancer screening programs. Sixth, to fundamentally derisk anti-CD20 therapies, we need evidence-based approaches to reduce dosing intervals and guide retreatment.
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Affiliation(s)
- Ide Smets
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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Bounia CA, Liossis SNC. B cell depletion treatment decreases Th17 cells in patients with rheumatoid arthritis. Clin Immunol 2021; 233:108877. [PMID: 34740842 DOI: 10.1016/j.clim.2021.108877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/30/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION We aimed to evaluate for any possible effects of treatment with rituximab (RTX) on the peripheral Th17 and Treg subpopulations in patients with rheumatoid arthritis (RA). PATIENTS AND METHODS We analyzed 16 patients with RA initiating RTX treatment, 11 patients with RA initiating abatacept treatment, 11 patients with RA treated with other medications, 8 patients with other autoimmune rheumatic diseases initiating RTX, and 14 healthy volunteers. Th17 cells (CD4+IL23R+IL17A+) and Treg cells (CD4+CD25hiFoxP3+) were evaluated flow-cytometrically. RESULTS Th17 cells from patients treated with RTX decreased significantly at weeks 8 and 16 (mean ± SEΜ: 3.01% ± 0.54℅ CD4+ cells at week 0 vs. 1.53% ± 0.24℅ at week 8 vs 1.10% ± 0.20℅ at week 16, p = 0.0004). Reductions of Th17 cells were evident in clinical responders (DAS28 score ≤ 3.2), ACPA (+) and RF (-) patients; circulating Tregs remained stable. Th17 and Tregs were not affected by ABA treatment or by changes in disease activity. Tregs, but not Th17 cells, decreased following treatment with RTX in patients with other autoimmune diseases (0.75% ± 0.16% at week 0 vs. 0.43% ± 0.16% at week 8, p = 0.033). CONCLUSION RTX-induced B cell depletion results in a significant reduction of circulating Th17 cell percentages, whereas it has no effect on Tregs of patients with RA. This reduction of Th17 cells was evident particularly in responders to RTX treatment, ACPA+ and RF (-) patients with RA.
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Affiliation(s)
- Constantina A Bounia
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, Rion, Patras, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, Rion, Patras, Greece; Department of Medicine, University of Patras Medical School, Rion, Patras, Greece.
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Yeaman MR. Immunosuppression in Glomerular Diseases: Implications for SARS-CoV-2 Vaccines and COVID-19. GLOMERULAR DISEASES 2021; 1:277-293. [PMID: 34935004 PMCID: PMC8678218 DOI: 10.1159/000519182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Glomerular diseases (GD) are chronic conditions that often involve immune dysfunction and require immunosuppressive therapy (IST) to control underlying pathogenesis. Unfortunately, such diseases appear to heighten risks of severe outcomes in COVID-19 and predispose to other infections that may be life-threatening. Thus, averting preventable infections is imperative in GD patients. SUMMARY The advent of vaccines demonstrated to be safe and efficacious against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has favorably impacted the COVID-19 pandemic epidemiology. However, patients on ISTs were excluded from initial vaccine clinical trials. Thus, only limited and incomplete data are available currently regarding the potential impact of immunosuppression on immune response to or efficacy of the SARS-CoV-2 vaccines. However, new insights are emerging from SARS-CoV-2 vaccine studies, and impacts of ISTs on conventional vaccines are useful to consider. Mechanisms of immunosuppressive agents commonly used in the treatment of GD are reviewed with respect to implications for immune responses induced by SARS-CoV-2 vaccines. ISTs discussed include corticosteroids; alkylating agents; antimetabolites; calcineurin or mammalian target of rapamycin inhibitors; CD38+, CD20+, or CD19+ cell depletion; and complement protein C5 inhibition. KEY MESSAGES Many immunosuppressive therapies may potentially attenuate or impair protective immunity of the SARS-CoV-2 vaccines. However, as vaccines currently in use employ mRNA or nonreplicative viral vectors, they appear to be safe in patients on immunosuppression, further favoring vaccination. Moreover, predominant SARS-CoV-2 vaccines are likely to afford at least partial protective immunity through one or more immune mechanisms even in patients on IST. Guidelines and emerging strategies are also considered to optimize vaccine protection from COVID-19.
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Affiliation(s)
- Michael R. Yeaman
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Divisions of Molecular Medicine & Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
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Asplund Högelin K, Ruffin N, Pin E, Månberg A, Hober S, Gafvelin G, Grönlund H, Nilsson P, Khademi M, Olsson T, Piehl F, Al Nimer F. Development of humoral and cellular immunological memory against SARS-CoV-2 despite B cell depleting treatment in multiple sclerosis. iScience 2021; 24:103078. [PMID: 34490414 PMCID: PMC8410640 DOI: 10.1016/j.isci.2021.103078] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/17/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
B cell depleting therapies (BCDTs) are widely used as immunomodulating agents for autoimmune diseases such as multiple sclerosis. Their possible impact on development of immunity to severe acute respiratory syndrome virus-2 (SARS-CoV-2) has raised concerns with the coronavirus disease 2019 (COVID-19) pandemic. We here evaluated the frequency of COVID-19-like symptoms and determined immunological responses in participants of an observational trial comprising several multiple sclerosis disease modulatory drugs (COMBAT-MS; NCT03193866) and in eleven patients after vaccination, with a focus on BCDT. Almost all seropositive and 17.9% of seronegative patients on BCDT, enriched for a history of COVID-19-like symptoms, developed anti-SARS-CoV-2 T cell memory, and T cells displayed functional similarity to controls producing IFN-γ and TNF. Following vaccination, vaccine-specific humoral memory was impaired, while all patients developed a specific T cell response. These results indicate that BCDTs do not abrogate SARS-CoV-2 cellular memory and provide a possible explanation as to why the majority of patients on BCDTs recover from COVID-19. BCDT might blunt antibody responses after COVID-19 infection or vaccination Patients with no detectable B cells in the blood might still produce antibodies A majority of patients that do not develop antibodies still display a T cell response SARS-CoV-2 T-cells produce Th1 cytokines both in patients on BCDT and untreated
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Affiliation(s)
- Klara Asplund Högelin
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:04, 171 76 Stockholm, Sweden
| | - Nicolas Ruffin
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:04, 171 76 Stockholm, Sweden
| | - Elisa Pin
- Division of Affinity Proteomics, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, 17165 Stockholm, Sweden
| | - Anna Månberg
- Division of Affinity Proteomics, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, 17165 Stockholm, Sweden
| | - Sophia Hober
- Division of Protein Technology, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, 17165 Stockholm, Sweden
| | - Guro Gafvelin
- Therapeutic Immune Design Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:02, 171 76 Stockholm, Sweden
| | - Hans Grönlund
- Therapeutic Immune Design Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:02, 171 76 Stockholm, Sweden
| | - Peter Nilsson
- Division of Affinity Proteomics, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, 17165 Stockholm, Sweden
| | - Mohsen Khademi
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:04, 171 76 Stockholm, Sweden
| | - Tomas Olsson
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:04, 171 76 Stockholm, Sweden
| | - Fredrik Piehl
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:04, 171 76 Stockholm, Sweden
| | - Faiez Al Nimer
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Center for Molecular Medicine L8:04, 171 76 Stockholm, Sweden
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Singh A, Behl T, Sehgal A, Singh S, Sharma N, Naved T, Bhatia S, Al-Harrasi A, Chakrabarti P, Aleya L, Vargas-De-La-Cruz C, Bungau S. Mechanistic insights into the role of B cells in rheumatoid arthritis. Int Immunopharmacol 2021; 99:108078. [PMID: 34426116 DOI: 10.1016/j.intimp.2021.108078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease epitomized by severe inflammation that induces tendon, cartilage, and bone damage over time. Although different types of cells undertake pathogenic functions in RA, the B cell's significant involvement has increasingly been known following the development of rheumatoid factor and it has been re-emphasized in recent years. Therefore, the rheumatoid factors and anti-cyclic citrullinated peptide antibodies are well-known indications of infection and clinical manifestations, and that they can precede the development of illness by several years. The emergence of rituximab a B cell reducing chimeric antidote in 1997 and 1998 transformed B-cell-targeted therapy for inflammatory disorder from a research hypothesis to a functional fact. Ever since, several autoantibody-related conditions were addressed, including the more intriguing indications of effectiveness seen in rheumatoid arthritis patients. Numerous types of B-cell-targeted compounds are currently being researched. From the beginning, one of the primary goals of B-cell therapy was to reinstate some kind of immune tolerance. While B cells have long been recognized as essential autoantibody producers, certain antibody-independent functions and usefulness as a key targeted therapy were not recognized until recently. The knowledge of B cells' diverse physical and pathogenic roles in autoimmune diseases is growing. As a result, the number of successful agents targeting the B cell complex is becoming more ubiquitous. Therefore, in this article, we explore fresh perspectives upon the roles of B cells in arthritis treatment, as well as new evidence regarding the effectiveness of B lymphocytes reduction and the therapeutic outcome of biological markers.
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Affiliation(s)
- Anuja Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Sukhbir Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Neelam Sharma
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tanveer Naved
- Amity Institute of Pharmacy, Amity University, Noida, India
| | - Saurabh Bhatia
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa, Oman; School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa, Oman
| | | | - Lotfi Aleya
- Chrono-Environment Laboratory, UMR CNRS 6249, Bourgogne Franche-Comté University, France
| | - Celia Vargas-De-La-Cruz
- Faculty of Pharmacy and Biochemistry, Academic Department of Pharmacology, Bromatology and Toxicology, Centro Latinoamericano de Ensenanza e Investigacion en Bacteriologia Alimentaria, Universidad Nacinol Mayor de San Marcos, Lima, Peru; E-Health Research Center, Universidad de Ciencias y Humanidades, Lima, Peru
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
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47
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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Bolt JW, van Ansenwoude CMJ, Hammoura I, van de Sande MG, van Baarsen LGM. Translational Research Studies Unraveling the Origins of Psoriatic Arthritis: Moving Beyond Skin and Joints. Front Med (Lausanne) 2021; 8:711823. [PMID: 34485340 PMCID: PMC8415974 DOI: 10.3389/fmed.2021.711823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with psoriatic arthritis (PsA) are suffering from a decreased quality of life despite currently available treatments. In the latest years, novel therapies targeting the IL-17/IL-23 and TNF pathways improved clinical outcome. Despite this, remission of disease is not achieved in a considerable group of patients, continuous treatment is very often required to reach clinical remission, and prevention of PsA in patients with psoriasis (PsO) is currently impossible. A better understanding of PsA pathogenesis is required to develop novel treatment strategies that target inflammation and destruction more effectively and at an early stage of the disease, or even before clinically manifest disease. The skin is considered as one of the sites of onset of immune activation, triggering the inflammatory cascade in PsA. PsO develops into PsA in 30% of the PsO patients. Influenced by environmental and genetic factors, the inflammatory process in the skin, entheses, and/or gut may evolve into synovial tissue inflammation, characterized by influx of immune cells. The exact role of the innate and adaptive immune cells in disease pathogenesis is not completely known. The involvement of activated IL-17A+ T cells could implicate early immunomodulatory events generated in lymphoid organs thereby shaping the pathogenic inflammatory response leading to disease. In this perspective article, we provide the reader with an overview of the current literature regarding the immunological changes observed during the earliest stages of PsA. Moreover, we will postulate future areas of translational research aimed at increasing our knowledge on the molecular mechanisms driving disease development, which will aid the identification of novel potential therapeutic targets to limit the progression of PsA.
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Affiliation(s)
- Janne W. Bolt
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Chaja M. J. van Ansenwoude
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Ihsan Hammoura
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Marleen G. van de Sande
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Lisa G. M. van Baarsen
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
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49
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Mancinelli CR, Rossi ND, Capra R. Ocrelizumab for the Treatment of Multiple Sclerosis: Safety, Efficacy, and Pharmacology. Ther Clin Risk Manag 2021; 17:765-776. [PMID: 34354358 PMCID: PMC8331077 DOI: 10.2147/tcrm.s282390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/18/2021] [Indexed: 11/23/2022] Open
Abstract
The success of selective B-cells depleting therapies, as the anti-CD20 antibodies, in patients with multiple sclerosis (MS) has confirmed that B-cells are critical in the immune pathogenesis of the disease. Ocrelizumab, a humanized monoclonal antibody that selectively targets CD20+ B-cells, profoundly suppresses acute inflammatory disease activity, representing a highly effective therapy for relapsing-remitting multiple sclerosis (RRMS). It is also the first proven therapy able to slow disability progression in primary progressive multiple sclerosis (PPMS), particularly in patients with signs of acute radiological activity before being enrolled. Effectiveness has widely been demonstrated in randomized clinical trials (RCTs), and recently confirmed in open-label extension trials. Here, we review the role of B-cells in MS, the mechanism of action of ocrelizumab, its pharmacokinetics and pharmacodynamics, and the clinical data supporting its use, as well as safety data. We focus on issues related to the maintenance of immunocompetence, essential to ensure an immune response to either a primary infection or a vaccination. Lastly, we discuss about the possible role of ocrelizumab as an exit strategy from natalizumab-treated patients at risk of developing multifocal progressive leukoencephalopathy. In view of using ocrelizumab chronically, collecting long-term safety data and finding strategies to minimize adverse events will be extremely relevant.
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Affiliation(s)
| | - Nicola De Rossi
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Brescia, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Brescia, Italy
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50
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Crickx E, Chappert P, Sokal A, Weller S, Azzaoui I, Vandenberghe A, Bonnard G, Rossi G, Fadeev T, Storck S, Fadlallah J, Meignin V, Rivière E, Audia S, Godeau B, Michel M, Weill JC, Reynaud CA, Mahévas M. Rituximab-resistant splenic memory B cells and newly engaged naive B cells fuel relapses in patients with immune thrombocytopenia. Sci Transl Med 2021; 13:13/589/eabc3961. [PMID: 33853929 DOI: 10.1126/scitranslmed.abc3961] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/29/2020] [Accepted: 03/22/2021] [Indexed: 01/19/2023]
Abstract
Rituximab (RTX), an antibody targeting CD20, is widely used as a first-line therapeutic strategy in B cell-mediated autoimmune diseases. However, a large proportion of patients either do not respond to the treatment or relapse during B cell reconstitution. Here, we characterize the cellular basis responsible for disease relapse in secondary lymphoid organs in humans, taking advantage of the opportunity offered by therapeutic splenectomy in patients with relapsing immune thrombocytopenia. By analyzing the B and plasma cell immunoglobulin gene repertoire at bulk and antigen-specific single-cell level, we demonstrate that relapses are associated with two responses coexisting in germinal centers and involving preexisting mutated memory B cells that survived RTX treatment and naive B cells generated upon reconstitution of the B cell compartment. To identify distinctive characteristics of the memory B cells that escaped RTX-mediated depletion, we analyzed RTX refractory patients who did not respond to treatment at the time of B cell depletion. We identified, by single-cell RNA sequencing (scRNA-seq) analysis, a population of quiescent splenic memory B cells that present a unique, yet reversible, RTX-shaped phenotype characterized by down-modulation of B cell-specific factors and expression of prosurvival genes. Our results clearly demonstrate that these RTX-resistant autoreactive memory B cells reactivate as RTX is cleared and give rise to plasma cells and further germinal center reactions. Their continued surface expression of CD19 makes them efficient targets for current anti-CD19 therapies. This study thus identifies a pathogenic contributor to autoimmune diseases that can be targeted by available therapeutic agents.
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Affiliation(s)
- Etienne Crickx
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France.,Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Pascal Chappert
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France.,Inovarion, 75005 Paris, France
| | - Aurélien Sokal
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Sandra Weller
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Imane Azzaoui
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Alexis Vandenberghe
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Guillaume Bonnard
- INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Geoffrey Rossi
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Tatiana Fadeev
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Sébastien Storck
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Jehane Fadlallah
- Service d'immunologie clinique, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, 75010 Paris, France
| | - Véronique Meignin
- Service d'anatomopathologie, Hôpital Saint-Louis (AP-HP), 75010 Paris, France
| | - Etienne Rivière
- Service de médecine interne, Hôpital Haut-Lévêque, 33604 Pessac, France
| | - Sylvain Audia
- Service de médecine interne, Hôpital du Bocage, 21000 Dijon, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Jean-Claude Weill
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Claude-Agnès Reynaud
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Matthieu Mahévas
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France. .,Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
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