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Uddin MK, Vempati R, Bhavanam S, Parven PCC, Khotele C, Chitturi RH, Shree A, Kasireddy S, Sahu S. A Rare Case of Polymyositis and Systemic Sclerosis Overlap Syndrome: Diagnosis and Treatment. Cureus 2023. [DOI: 10.7759/cureus.36434 | pmid: 37090317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2025] Open
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Uddin MK, Vempati R, Bhavanam S, Parven PCC, Khotele C, Chitturi RH, Kasireddy S, Bhandari M, Sahu S. A Rare Case of Polymyositis and Systemic Sclerosis Overlap Syndrome: Diagnosis and Treatment. Cureus 2023; 15:e36434. [PMID: 37090317 PMCID: PMC10115541 DOI: 10.7759/cureus.36434] [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] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Diffuse scleroderma is a kind of scleroderma in which the immune system malfunctions, leading to excessive production of collagen in the skin and a variety of organ abnormalities. Based on previously recognized criteria, overlap syndrome is a disorder in which two or more medical illnesses are documented in a single patient. These syndromes are significantly more prevalent in illnesses with mixed connective tissue. In this case report, we present a patient with overlapping systemic sclerosis and polymyositis symptoms. The treatment and diagnosis of this extremely uncommon condition are discussed in further detail.
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Affiliation(s)
- Mohammad K Uddin
- lnternal Medicine, Gandhi Medical College & Hospital, Hyderabad, IND
| | - Roopeessh Vempati
- Internal Medicine, Gandhi Medical College & Hospital, Hyderabad, IND
| | | | | | - Chinmay Khotele
- Internal Medicine, Indira Gandhi Government Medical College & Hospital, Nagpur, IND
| | - Raja H Chitturi
- Internal Medicine, Great Eastern Medical School and Hospital, Visakhapatnam, IND
| | - Smaran Kasireddy
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davanagere, IND
| | - Mahak Bhandari
- Medical Student, Lokmanya Tilak Municipal Medical College, Mumbai, IND
| | - Sweta Sahu
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davanagere, IND
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3
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Foocharoen C, Tonsawan P, Pongkulkiat P, Anutrakulchai S, Mahakkanukrauh A, Suwannaroj S. Management review of scleroderma renal crisis: An update with practical pointers. Mod Rheumatol 2023; 33:12-20. [PMID: 35349704 DOI: 10.1093/mr/roac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/20/2022] [Accepted: 03/14/2022] [Indexed: 01/05/2023]
Abstract
Scleroderma renal crisis (SRC) represents severe, fatal internal organ involvement brought on by systemic sclerosis. A high rate of renal replacement therapy and mortality persists despite various treatments. Depending on the stage of SRC, a vasodilator called angiotensin-converting enzyme inhibitor is the treatment of choice. The efficacy of various other vasodilators (i.e. endothelin-1 receptor antagonist) and complement cascade blocker for SRC have been investigated; however, no randomized control trial has been conducted. A new approach has been proposed for the management of SRC, categorized by specific clinical features of narrowly defined SRC and systemic sclerosis-thrombotic microangiopathy. SRC prophylaxis using angiotensin-converting enzyme inhibitor might be harmful, leading to a poor renal outcome, so the pathogenesis of SRC needs to be clarified in order to identify other possible preventions or therapies.
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Affiliation(s)
- Chingching Foocharoen
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pantipa Tonsawan
- Department of Medicine, Division of Nephrology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Patnarin Pongkulkiat
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sirirat Anutrakulchai
- Department of Medicine, Division of Nephrology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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4
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Asfaw YA, Huang H, Anand A, Taimur M, Khan AA, Shah S, Poudel S, Michel J, Michel G. Management of scleroderma renal crisis with left ventricular diastolic dysfunction in a resource-limited setting: A rare case report. SAGE Open Med Case Rep 2022; 10:2050313X221141796. [PMID: 36507063 PMCID: PMC9729983 DOI: 10.1177/2050313x221141796] [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: 09/24/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
Scleroderma renal crisis with left ventricular diastolic dysfunction can lead to significant mortality. We presented the case of a 32-year-old female with anuria for 2 days. On further inquiry, she had joint pain, difficulty turning her head sidewise, and associated difficulty in finger movement. Also, hyperpigmentation with superimposed hypopigmentation was reported, which reduced during her pregnancy and worsened post-partum. Her family history suggested similar complaints in her mother. In addition, she had a blurring of vision. She had hypertension, microangiopathic hemolytic anemia, deranged renal function, and retinopathy on ophthalmologic examination. Radiological investigations revealed pulmonary edema, pleural effusion, and left ventricular diastolic dysfunction. Hence, a diagnosis of scleroderma renal crisis complicated by left ventricular diastolic dysfunction was made. She was managed conservatively using anti-hypertensive medications and hemodialysis, which resulted in gradual improvement. Our case highlighted the management approach to this rare presentation with anti-hypertensives and hemodialysis in a resource-limited setting.
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Affiliation(s)
- Yonathan Aliye Asfaw
- Internal medicine, Addis Hiwot Hospital, Addis Ababa, Ethiopia,Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA
| | - Helen Huang
- Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA,University of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ayush Anand
- Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA,B.P. Koirala Institute of Health Sciences, Dharan, Nepal,Ayush Anand, B.P. Koirala Institute of Health Sciences, Dharan, 56700, Nepal.
| | - Muhammad Taimur
- Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA,Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Asad Ali Khan
- Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA,Department of Cardiology, Hayatabad Medical Complex Peshawar, Peshawar, Pakistan
| | - Sangam Shah
- Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA,Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sujan Poudel
- Department of Research & Academic Affairs, Larkin Community Hospital, Miami, USA,National Medical College, Birgunj, Nepal
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5
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Lee SG, Moon KW. Epidemiology and Treatment of Systemic Sclerosis in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:200-214. [PMID: 37476430 PMCID: PMC10351407 DOI: 10.4078/jrd.22.0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 07/22/2023]
Abstract
Systemic sclerosis (SSc), a rare, chronic progressive systemic autoimmune disease of unknown etiology, is characterized by autoimmunity, tissue fibrosis, and obliterative vasculopathy. SSc can affect all major organs including the skin, blood vessels, lung, heart, kidneys, and gastrointestinal tract. Our understanding of its pathogenesis has increased over the past few decades, leading to improved diagnosis and treatment. However, the mortality rate of SSc remains considerable, mainly due to cardiopulmonary causes. A growing body of evidence suggests that geographical, regional, and ethnic differences could affect the epidemiology, clinical characteristics and prognosis of SSc. Although Korean data of this issue are lacking, a considerable amount of research has been published by many Korean researchers. To establish treatment strategies for Korean patients, extensive Korean research data are needed. This review summarizes the prevalence, incidence, mortality, and clinical and laboratory manifestations of Korean patients with SSc and discusses the current trends in evidence-based treatment and recommendations.
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Affiliation(s)
- Seung-Geun Lee
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Ki Won Moon
- Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
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6
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Kidney Involvement in Systemic Sclerosis. J Pers Med 2022; 12:jpm12071123. [PMID: 35887620 PMCID: PMC9324204 DOI: 10.3390/jpm12071123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Systemic sclerosis is a chronic multisystem autoimmune disease, characterized by diffuse fibrosis and abnormalities of microcirculation and small arterioles in the skin, joints and visceral organs. Material and Methods: We searched for the relevant articles on systemic sclerosis and kidney involvement in systemic sclerosis in the NIH library of medicine, transplant, rheumatologic and nephrological journals. Results: Half of patients with systemic sclerosis have clinical evidence of kidney involvement. Scleroderma renal crisis represents the most specific and serious renal event associated with this condition. It is characterized by an abrupt onset of moderate to marked hypertension and kidney failure. Early and aggressive treatment is mandatory to prevent irreversible organ damage and death. The advent of ACE-inhibitors revolutionized the management of scleroderma renal crisis. However, the outcomes of this serious complication are still poor, and between 20 to 50% of patients progress to end stage renal disease. Conclusions: Scleroderma renal crisis still represents a serious and life-threatening event. Thus, further studies on its prevention and on new therapeutic strategies should be encouraged.
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Cole A, Ong VH, Denton CP. Renal Disease and Systemic Sclerosis: an Update on Scleroderma Renal Crisis. Clin Rev Allergy Immunol 2022; 64:378-391. [PMID: 35648373 PMCID: PMC10167155 DOI: 10.1007/s12016-022-08945-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 12/16/2022]
Abstract
Scleroderma renal crisis (SRC) is a life-threatening complication of systemic sclerosis (SSc) with a mortality of 20% at 6 months. Once the leading cause of mortality in scleroderma (SSc), it remains a serious complication, often necessitating level three care for patients affected. Whilst renal outcomes have significantly improved following the advent of angiotensin-converting enzyme inhibitor (ACEi) therapy, SRC remains a precarious challenge for clinicians, due to lack of preventative measures and the fact that patients can rapidly decline despite best medical management. Large cohort studies spanning decades have allowed clear identification of phenotypes particularly at risk of developing SRC thus allowing enhanced monitoring and early identification in those individuals. Novel urinary biomarkers for renal disease in SSc may offer a new window for early identification of SRC patients and response to treatment. Multiple studies have demonstrated increased activity of complement pathways in SRC with some anecdotal cases exhibiting serological response to treatment with eculizumab where ACEi and therapeutic plasma exchange (TPE) were not successful. Endothelin-1 blockade, a therapeutic strategy in other SSc vasculopathies, has shown potential as a target but clinical trials are yet to show a clear treatment benefit. Clear guidelines for the management of SRC are in place to standardise care and facilitate early collaboration between rheumatology and renal physicians. Outcomes following renal transplant have improved but the mortality of SRC remains high, indicating the need for continued exploration of the mechanisms precipitating and exacerbating SRC in order to develop novel therapies.
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Affiliation(s)
- Alice Cole
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Voon H Ong
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Christopher P Denton
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
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8
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Philippe A, Kleinau G, Gruner JJ, Wu S, Postpieszala D, Speck D, Heidecke H, Dowell SJ, Riemekasten G, Hildebrand PW, Kamhieh-Milz J, Catar R, Szczepek M, Dragun D, Scheerer P. Molecular Effects of Auto-Antibodies on Angiotensin II Type 1 Receptor Signaling and Cell Proliferation. Int J Mol Sci 2022; 23:ijms23073984. [PMID: 35409344 PMCID: PMC8999261 DOI: 10.3390/ijms23073984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 11/16/2022] Open
Abstract
The angiotensin II (Ang II) type 1 receptor (AT1R) is involved in the regulation of blood pressure (through vasoconstriction) and water and ion homeostasis (mediated by interaction with the endogenous agonist). AT1R can also be activated by auto-antibodies (AT1R-Abs), which are associated with manifold diseases, such as obliterative vasculopathy, preeclampsia and systemic sclerosis. Knowledge of the molecular mechanisms related to AT1R-Abs binding and associated signaling cascade (dys-)regulation remains fragmentary. The goal of this study was, therefore, to investigate details of the effects of AT1R-Abs on G-protein signaling and subsequent cell proliferation, as well as the putative contribution of the three extracellular receptor loops (ELs) to Abs-AT1R signaling. AT1R-Abs induced nuclear factor of activated T-cells (NFAT) signaling, which reflects Gq/11 and Gi activation. The impact on cell proliferation was tested in different cell systems, as well as activation-triggered receptor internalization. Blockwise alanine substitutions were designed to potentially investigate the role of ELs in AT1R-Abs-mediated effects. First, we demonstrate that Ang II-mediated internalization of AT1R is impeded by binding of AT1R-Abs. Secondly, exclusive AT1R-Abs-induced Gq/11 activation is most significant for NFAT stimulation and mediates cell proliferation. Interestingly, our studies also reveal that ligand-independent, baseline AT1R activation of Gi signaling has, in turn, a negative effect on cell proliferation. Indeed, inhibition of Gi basal activity potentiates proliferation triggered by AT1R-Abs. Finally, although AT1R containing EL1 and EL3 blockwise alanine mutations were not expressed on the human embryonic kidney293T (HEK293T) cell surface, we at least confirmed that parts of EL2 are involved in interactions between AT1R and Abs. This current study thus provides extended insights into the molecular action of AT1R-Abs and associated mechanisms of interrelated pathogenesis.
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Affiliation(s)
- Aurélie Philippe
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, D-10178 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Campus Virchow Klinikum, D-13353 Berlin, Germany; (J.J.G.); (S.W.); (D.P.); (R.C.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Cardiovascular Research, D-10117 Berlin, Germany
- Correspondence: (A.P.); (P.S.); Tel.: +49-30450559318 (A.P.); +49-30450524178 (P.S.)
| | - Gunnar Kleinau
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Physics and Biophysics, Group Protein X-ray Crystallography and Signal Transduction, D-10117 Berlin, Germany; (G.K.); (D.S.); (P.W.H.); (M.S.)
| | - Jason Jannis Gruner
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Campus Virchow Klinikum, D-13353 Berlin, Germany; (J.J.G.); (S.W.); (D.P.); (R.C.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Cardiovascular Research, D-10117 Berlin, Germany
- Vivantes Humboldt-Klinikum, Department of Urology, D-13509 Berlin, Germany
| | - Sumin Wu
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Campus Virchow Klinikum, D-13353 Berlin, Germany; (J.J.G.); (S.W.); (D.P.); (R.C.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Cardiovascular Research, D-10117 Berlin, Germany
| | - Daniel Postpieszala
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Campus Virchow Klinikum, D-13353 Berlin, Germany; (J.J.G.); (S.W.); (D.P.); (R.C.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Cardiovascular Research, D-10117 Berlin, Germany
| | - David Speck
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Physics and Biophysics, Group Protein X-ray Crystallography and Signal Transduction, D-10117 Berlin, Germany; (G.K.); (D.S.); (P.W.H.); (M.S.)
| | | | | | - Gabriela Riemekasten
- Priority Area Asthma & Allergy, Research Center Borstel, Airway Research Center North (ARCN), Members of the German Center for Lung Research (DZL), D-23845 Borstel, Germany;
- University of Lübeck, University Clinic Schleswig-Holstein, Department of Rheumatology and Clinical Immunology, Campus Lübeck, D-23538 Lübeck, Germany
| | - Peter W. Hildebrand
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Physics and Biophysics, Group Protein X-ray Crystallography and Signal Transduction, D-10117 Berlin, Germany; (G.K.); (D.S.); (P.W.H.); (M.S.)
- Leipzig University, Medical Faculty Leipzig, Institute for Medical Physics and Biophysics, D-04107 Leipzig, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, D-10178 Berlin, Germany
| | - Julian Kamhieh-Milz
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Transfusion Medicine, D-10117 Berlin, Germany;
| | - Rusan Catar
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Campus Virchow Klinikum, D-13353 Berlin, Germany; (J.J.G.); (S.W.); (D.P.); (R.C.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Cardiovascular Research, D-10117 Berlin, Germany
| | - Michal Szczepek
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Physics and Biophysics, Group Protein X-ray Crystallography and Signal Transduction, D-10117 Berlin, Germany; (G.K.); (D.S.); (P.W.H.); (M.S.)
| | - Duska Dragun
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, D-10178 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Campus Virchow Klinikum, D-13353 Berlin, Germany; (J.J.G.); (S.W.); (D.P.); (R.C.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Cardiovascular Research, D-10117 Berlin, Germany
| | - Patrick Scheerer
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Physics and Biophysics, Group Protein X-ray Crystallography and Signal Transduction, D-10117 Berlin, Germany; (G.K.); (D.S.); (P.W.H.); (M.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, D-13353 Berlin, Germany
- Correspondence: (A.P.); (P.S.); Tel.: +49-30450559318 (A.P.); +49-30450524178 (P.S.)
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9
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Xiong A, Cao Y, Xiang Q, Song Z, Zhang Y, Zhou S, Qiang Y, Chen H, Hu Z, Cui H, Luo J, Wang Y, Yang Y, Yang M, Shuai S. Angiotensin-converting enzyme inhibitors prior to scleroderma renal crisis in systemic sclerosis: A systematic review and meta-analysis. J Clin Pharm Ther 2022; 47:722-731. [PMID: 35233779 DOI: 10.1111/jcpt.13621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Angiotensin-converting enzyme inhibitors (ACEIs) are widely used in the treatment of scleroderma renal crisis (SRC), and their use prior to the onset of SRC in patients with systemic sclerosis (SSc) has received wide attention in recent years. We undertook an evidence-based approach to identify whether the use of ACEIs prior to the onset of SRC is beneficial for patients with SSc. METHODS We searched PubMed and Embase for any published studies produced between database inception and 22 October 2021. Articles obtained after using appropriate keywords were selected independently by two reviewers according to the established inclusion and exclusion criteria. RESULTS Nine studies were included. Pooled results indicated that using ACEIs prior to SRC was associated with a higher incidence of SRC than no ACEIs prior to SRC (RR 2.05, 95% confidence interval 1.08-3.91, p = 0.03). Compared with patients who did not use ACEIs prior to the onset of SRC, a higher proportion of patients with SRC who used ACEIs prior to its onset had a poorer prognosis (RR 1.46, 95% confidence interval 1.20-1.78, p < 0.01). The difference in mortality between patients who used ACEIs prior to SRC onset and those who did not was not statistically significant (RR 1.12, 95% confidence interval 0.76-1.65, p = 0.57). WHAT IS NEW AND CONCLUSIONS We recommend against using ACEIs prior to SRC in SSc patients. The use of ACEIs prior to SRC is associated with a higher incidence of SRC and poorer prognosis, especially in patients with progressive SSc or SSc-related renal vasculopathy (SSc-related hypertension and proteinuria).
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, Sichuan, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zhuoyao Song
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yan Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shifeng Zhou
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yiying Qiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Huini Chen
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ziyi Hu
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Hongxu Cui
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jie Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ye Wang
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yuan Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Min Yang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital,The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, Sichuan, China
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10
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Zanatta E, Codullo V, Allanore Y. Scleroderma renal crisis: Case reports and update on critical issues. Eur J Rheumatol 2021; 8:162-167. [PMID: 33226326 PMCID: PMC9770404 DOI: 10.5152/eurjrheum.2020.20048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
To date, scleroderma renal crisis (SRC) remains a life-threatening complication in patients affected by systemic sclerosis (SSc), with high morbidity and mortality. In the last few years, some studies have tried to more precisely identify predictors of SRC and clarify the role of previous drug exposure-in particular, angiotensin-converting enzyme (ACE) inhibitors and corticosteroids-in patients with SSc presenting other well-known risk factors for SRC. Different from the findings of previous reports, more recent findings suggest that the presence of chronic kidney disease, systemic arterial hypertension, and proteinuria might all be predictors of SRC. Moreover, because about 40 to 50% of SRC cases can present signs of microangiopathy, a recent study has proposed SSc thrombotic microangiopathy (SSc-TMA) as a clinically and pathophysiologically different entity from narrowly defined SRC. Even though such clear distinction may not always be applicable/feasible in clinical practice, it highlights that complement pathway dysregulation may play a key pathogenetic role in SRC presenting as TMA. Thus, plasma exchange may be considered in severe refractory cases. Nevertheless, ACE inhibitors and prompt achievement of blood pressure control (to rapidly improve ongoing renal ischemia) remain to date the cornerstone of SRC treatment. Here, we report the cases of three SSc patients with SRC followed at our rheumatology units. While describing these patients' risk factors, clinical presentation, and therapy, we aim to discuss the state of the art in SRC and highlight critical issues.
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Affiliation(s)
- Elisabetta Zanatta
- Division of Rheumatology, Department of Medicine, University of Padova, Padova,
Italy
| | - Veronica Codullo
- Unit of Rheumatology, IRCCS Foundation Policlinico San Matteo, Pavia,
Italy
| | - Yannick Allanore
- Department of Rheumatology, Paris Descartes University Cochin Hospital, Paris,
France
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Odler B, Hebesberger C, Hoeflechner L, Pregartner G, Gressenberger P, Jud P, Zenz S, Eller K, Rosenkranz AR, Moazedi‐Fuerst F. Effect of short-interval rituximab and high-dose corticosteroids on kidney function in systemic sclerosis: Long-term experience of a single centre. Int J Clin Pract 2021; 75:e14069. [PMID: 33540483 PMCID: PMC8243981 DOI: 10.1111/ijcp.14069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Scleroderma renal crisis (SRC) is a rare but one of the most recognised complications of systemic sclerosis (SSc). Corticosteroid (CS) use has been considered as a major risk factor for SRC. Several studies reported the efficacy of rituximab (RTX) with an acceptable safety profile in SSc. However, data on the long-term effect of high-dose CS concomitant to RTX on kidney function are lacking. METHODS We retrospectively analysed SSc patients (n = 35) treated with a lower dosage and short-interval RTX and concomitant high-dose CS at the Department of Internal Medicine at the Medical University of Graz between 2010 and 2019. The kidney function was assessed using the estimated glomerular filtration rate (eGFR) at every RTX admission. The annual decline of kidney function was evaluated by linear mixed model analysis. RESULTS At the RTX initiation, one patient had a decreased kidney function indicated by eGFR < 60 mL/min/1.73 m2 (median: 96 mL/min/1.73 m2 ; interquartile range (IQR): 43-136). Patients received RTX and complementary high-dose CS for a median follow-up time of 3.4 years (range 0.6-9.5). A linear mixed model analysis with the patient as random effect and time from first RTX as fixed effect estimated an annual decline of 1.98 mL/min/1.73 m2 of the eGFR (95% confidence interval: [-2.24, -1.72]; P <.001). During the follow-up period, no patient experienced SRC or a significant drop in kidney function. CONCLUSIONS A regular, high-dose CS given contemporary to RTX seems to be a safe option for kidney function in patients with SSc. Our findings provide additional knowledge in risk evaluation and planning of individualised therapies or designing clinical studies using RTX.
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Affiliation(s)
- Balazs Odler
- Division of NephrologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Carina Hebesberger
- Division of NephrologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Lukas Hoeflechner
- Division of NephrologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and DocumentationMedical University of GrazGrazAustria
| | - Paul Gressenberger
- Division of AngiologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Philipp Jud
- Division of AngiologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Sabine Zenz
- Division of Rheumatology and ImmunologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Kathrin Eller
- Division of NephrologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | | | - Florentine Moazedi‐Fuerst
- Division of Rheumatology and ImmunologyDepartment of Internal MedicineMedical University of GrazGrazAustria
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Bruni C, Cometi L, Gigante A, Rosato E, Matucci-Cerinic M. Prediction and primary prevention of major vascular complications in systemic sclerosis. Eur J Intern Med 2021; 87:51-58. [PMID: 33551291 DOI: 10.1016/j.ejim.2021.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In Systemic Sclerosis (SSc), vasculopathy is the background of major vascular complications (MVCs), like digital ulcers (DUs), pulmonary arterial hypertension (PAH) and scleroderma renal crisis (SRC). We aimed to identify the predictors and to test the primary preventive effect of vasoactive/vasodilating drugs (VVD) for the development of MVCs in SSc MVCs-naïve patients. METHODS patients fulfilling the ACR/EULAR 2013 classification criteria for SSc without history of MVCs were eligible. Data about clinical manifestations, laboratory and instrumental assessments and treatments were retrospectively collected at baseline and latest available follow-up. RESULTS 134 SSc patients were enrolled (mean age 56.5 years ± 14.2, females 88.1%, limited subset 61.9%, ACA positivity 60.4%). In a mean of 43 ± 19 months of follow-up 12 (9.0%) patients developed at least 1 MVC (10 DU, 2 PAH and 1 SRC). Dyspnoea and arthritis at baseline were independent predictors for MVCs development (p = 0.012, and p = 0.002 respectively). No primary preventive effect of VVD on MVCs development was found. However, sildenafil reduced the renal resistive index increase (p = 0.042) and alprostadil slowed the DLco decline (p = 0.029). Both iloprost and angiotensin-receptor blockers (ARBs) delayed MVCs development, while angiotensin converting enzyme inhibitors (ACEi) determined an earlier onset of such MCVs. CONCLUSIONS in SSc patients, our data confirm the role of arthritis and dyspnea as independent predictors of major vascular complications, in particular in MVCs-naïve patients. Prostanoids, sildenafil and ARBs, even in absence of a primary preventive action, might help in slowing disease progression and postponing the onset of MVCs.
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Affiliation(s)
- Cosimo Bruni
- Div. Rheumatology, Department of Experimental and Clinical Medicine, AOU Careggi, University of Florence, Florence, Italy.
| | - Laura Cometi
- Div. Rheumatology, Department of Experimental and Clinical Medicine, AOU Careggi, University of Florence, Florence, Italy
| | - Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Matucci-Cerinic
- Div. Rheumatology, Department of Experimental and Clinical Medicine, AOU Careggi, University of Florence, Florence, Italy
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Shen W, Zhang Z, Ma J, Lu D, Lyu L. The Ubiquitin Proteasome System and Skin Fibrosis. Mol Diagn Ther 2021; 25:29-40. [PMID: 33433895 DOI: 10.1007/s40291-020-00509-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 12/15/2022]
Abstract
The ubiquitin proteasome system (UPS) is a highly conserved way to regulate protein turnover in cells. The UPS hydrolyzes and destroys variant or misfolded proteins and finely regulates proteins involved in differentiation, apoptosis, and other biological processes. This system is a key regulatory factor in the proliferation, differentiation, and collagen secretion of skin fibroblasts. E3 ubiquitin protein ligases Parkin and NEDD4 regulate multiple signaling pathways in keloid. Tumor necrosis factor (TNF) receptor-associated factor 4 (TRAF4) binding with deubiquitinase USP10 can induce p53 destabilization and promote keloid-derived fibroblast proliferation. The UPS participates in the occurrence and development of hypertrophic scars by regulating the transforming growth factor (TGF)-β/Smad signaling pathway. An initial study suggests that TNFα-induced protein 3 (TNFAIP3) polymorphisms may be significantly associated with scleroderma susceptibility in individuals of Caucasian descent. Sumoylation and multiple ubiquitin ligases, including Smurfs, UFD2, and KLHL42, play vital roles in scleroderma by targeting the TGF-β/Smad signaling pathway. In the future, drugs targeting E3 ligases and deubiquitinating enzymes have great potential for the treatment of skin fibrosis.
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Affiliation(s)
- Wanlu Shen
- Science and Technology Achievement Incubation Center, Kunming Medical University, 1168 West Chunrong Road, Yuhua Avenue, Chenggong District, Kunming, 650500, Yunnan, China
| | - Zhigang Zhang
- Science and Technology Achievement Incubation Center, Kunming Medical University, 1168 West Chunrong Road, Yuhua Avenue, Chenggong District, Kunming, 650500, Yunnan, China
| | - Jiaqing Ma
- School of Basic Medical Sciences, Kunming Medical University, Kunming, China
| | - Di Lu
- Science and Technology Achievement Incubation Center, Kunming Medical University, 1168 West Chunrong Road, Yuhua Avenue, Chenggong District, Kunming, 650500, Yunnan, China
| | - Lechun Lyu
- Science and Technology Achievement Incubation Center, Kunming Medical University, 1168 West Chunrong Road, Yuhua Avenue, Chenggong District, Kunming, 650500, Yunnan, China.
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D’Silva KM, Bolster MB. Systemic Sclerosis: A Comprehensive Approach to Diagnosis and Management. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Simms RW. Expert Perspectives On Clinical Challenges: Expert Perspectives: Challenges in Scleroderma. Arthritis Rheumatol 2020; 72:1415-1426. [PMID: 32562363 DOI: 10.1002/art.41406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/12/2020] [Indexed: 11/11/2022]
Abstract
You are consulted to evaluate a 56-year-old woman with known Raynaud's phenomenon, finger swelling of several; months' duration, and new hypertension with a blood pressure of 160/100 mm/Hg. She also reports progressive shortness of breath. Physical examination reveals telangiectasias, sclerodactyly, and proximal skin sclerosis (thick shiny skin on the chest and upper arms), and bibasilar crackles are found on chest examination. Laboratory tests reveal evidence of microangiopathic hemolytic anemia, thrombocytopenia, and elevation of the serum creatinine level (previously normal), and chest computed tomography shows evidence of ground-glass opacification in both lower lung fields.
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Affiliation(s)
- Robert W Simms
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire
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