Chronic periaortitis: A clinical approach

Chronic periaortitis (CP) is a rare disease characterised by the presence of a fibro-inflammatory tissue typically enveloping the abdominal aorta, the iliac arteries and, in some cases, the nearby structures, such as the ureters and the inferior vena cava. Imaging plays a key role in the diagnosis and follow-up: computed tomography and magnetic resonance imaging scans are used to define the extension of the pathological tissue, whereas fluorodeoxyglucose positron emission tomography is the gold standard to establish the degree of its metabolic activity. CP must be distinguished from secondary forms of periaortic infiltration, which include malignant, infectious, and drug-related aetiologies. This review focuses on the clinical aspects of CP and the differential diagnosis with secondary cases, and aims to provide the clinician with a guide through this challenging clinical approach.

POS0246 SEQUENTIAL RITUXIMAB AND MEPOLIZUMAB IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Background

Rituximab (RTX) is an effective remission-induction treatment in ANCA-associated vasculitides (AAVs). Some reports have suggested that it might be effective also in Eosinophilic Granulomatosis with Polyangiitis (EGPA), to induce and maintain remission of vasculitic manifestations [1,2]. However, its effects for preventing respiratory relapses seem to be poor. Mepolizumab (Mepo) (both 100 and 300mg/month) is effective in improving respiratory manifestations and lung function, while partially controlling also systemic activity [3,4]. Isolated case reports further indicate that the sequential therapy with RTX and Mepo might be effective [5-7].

Objectives

The study aimed to investigate the efficacy and safety of a therapeutic regimen based on sequential RTX and Mepo for the control of EGPA.

Methods

A multicenter, retrospective, cohort study was conducted on adult patients diagnosed with EGPA according to the ACR classification criteria [8] or MIRRA trial criteria [3]. Only patients who received induction therapy with RTX (any dosage), and subsequent treatment with Mepo (100-300 mg/4 weeks) within 12 months from last RTX administration were included. Patients receiving other induction therapies between RTX and Mepo were excluded. The effectiveness of sequential RTX and Mepo was assessed in terms of disease activity (by the Birmingham Vasculitis Activity Score, BVAS) and daily corticosteroid dosage. Safety data were also collected.

Results

Thirty-four EGPA patients treated with sequential RTX and Mepo were included (59% females, median age of 51 years (IQR 40-58); 41% ANCA positive).

In most cases (26/34; 76%), RTX was started at the dosage of 1g q2w, and all except two patients had active disease at time of RTX beginning [median BVAS of 9 (IQR 6-14)]. Specifically, most patients started RTX for the control of systemic manifestations (19/34; 56%), or of both systemic and respiratory symptoms (11/34; 32%). All except one patient were receiving oral corticosteroids, at a median dosage of 25 mg/day (10-38).

Mepo was started after a median of 14 months (6-23) from RTX initiation and after a median of 5 months (IQR 3-11) from the last RTX administration. Mepo was used at the dosage of 100mg/4 weeks in 32/34 (94%), mostly for the control of respiratory manifestations (25/34, 74%). At the time of starting Mepo, the median BVAS was 4 (2-8), and median prednisolone dose 10 mg/day (7-15). After a median follow-up of 28 months (IQR 23-33) from starting Mepo, the median BVAS decreased to 1.5 (IQR 0-4) and the median corticosteroid dosage to 5 mg/day (2.5-5), with 7/34 (21%) patients being off steroids. At last follow-up, most patients were off-RTX (28/34), typically due to stable disease remission (20/34; 59%).

Both RTX and Mepo were well-tolerated; 5 patients had adverse events on RTX (none serious), and 5 on Mepo (including one serious infection).

Conclusion

Sequential use of RTX and Mepo seems to be effective for remission induction and maintenance in EGPA.

References

[1]Emmi, Ann Rheum Dis, 2018

[2]Teixeira, RMD Open, 2019 3. Wechsler, NEJM, 2017

[4]Bettiol, Arthritis Rheumatol, 2021

[5]Shiroshita, Respir Med Case Rep, 2018

[6]Higashitani, Mod Rheumatol Case Rep, 2021

[7]Afiari, Cureus 2020

[8]Masi, Arthritis Rheum, 1990

Table 1.

Effectiveness of sequential RTX and Mepo in the 34 patients included in the study

RTX beginningMepo beginningLast follow-upMedian time elapsed (IQR)-14 months (6-23) from RTX beginning28 months (23-33) from Mepo beginningDosage1g q2w (26/34);100mg/4 weeks (32/34)6 patients off Mepo; 28 patients off RTX375mg/m2 for 4 weeks (8/34)300mg/4 weeks (2/34)Reason for treatment beginning (manifestations)Systemic (19/34);Respiratory (25/34);-Systemic + respiratory (11/34);Systemic (4/34);Only respiratory (3/34);Remission maintenance (5/34)Other (1/34)BVAS (median, IQR)9 (6-14)4 (2-8)1.5 (0-4)Prednisolone dosage (median, IQR), mg/day25 (10-38)10 (7-15)5 (2.5-5)

Disclosure of Interests

Alessandra Bettiol: None declared, Maria Letizia Urban: None declared, Federica Bello: None declared, Davide Fiori: None declared, Irene Mattioli: None declared, Giuseppe Lopalco: None declared, Florenzo Iannone: None declared, Allyson Egan: None declared, Luca Moroni: None declared, Lorenzo Dagna Consultant of: Consultation honoraria from GSK outside the current work, Marco Caminati: None declared, Simone Negrini: None declared, Paolo Cameli: None declared, Marco Folci: None declared, Paola Toniati: None declared, Roberto Padoan: None declared, Oliver Flossmann: None declared, Roser Solans-Laqué: None declared, Laura Losappio: None declared, Jan Schroeder Consultant of: Advisory Board fees from AstraZeneca and GSK, Marc André: None declared, Laura Moi: None declared, paola parronchi Consultant of: Consultation honoraria from GSK and Novartis, Fabrizio Conti: None declared, Savino Sciascia: None declared, David Jayne Consultant of: Consultant for Astra-Zeneca, Aurinia, BMS, Boehringer-Ingelheim, Chemocentryx, Chugai, CSL, GSK, Infla-RX, Janssen, Novartis, Roche/Genentech, Takeda and Vifor, Augusto Vaglio Consultant of: Consultation honoraria from GSK outside the current work, Giacomo Emmi Consultant of: Consultation honoraria from GSK outside the current work

The rise of complement in ANCA-associated vasculitis: from marginal player to target of modern therapy

The complement system plays a central role in autoimmune diseases, including anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Although complement deposition is scarce in AAV pathological samples, complement activation is required for the development of necrotizing crescentic glomerulonephritis (NCGN) in mouse models of AAV and occurs via the alternative pathway. The anaphylatoxin C5a, produced by the final complement pathway, is determinant to drive the disease in animal models. C5a primes human neutrophils and enhances their activation induced by ANCA; activated neutrophils, in turn, release factors that lead to C5a generation, establishing a self-amplifying loop. C5a is also significantly increased in the serum of AAV patients with active disease compared to those in remission or healthy controls. Inhibition of the C5a receptor with avacopan is an emerging therapy that will probably allow AAV treatment with glucocorticoid-free regimens.

OP0148 MEPOLIZUMAB FOR EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA): A RETROSPECTIVE REAL-WORLD EUROPEAN STUDY ON 142 PATIENTS

Background:

Evidence on the efficacy of Mepolizumab (MEPO) in Eosinophilic Granulomatosis with Polyangiitis (EGPA) is scarce [1].

Objectives:

To assess the efficacy and safety of MEPO in real-life clinical practice.

Methods:

We retrospectively included patients diagnosed with EGPA and treated with MEPO (100 or 300 mg/month). MEPO efficacy was evaluated in the first 12 months in terms of systemic disease and asthma control. The occurrence of any adverse event (AE) was recorded.

Results:

142 patients were included (38% males; median age 46.4 (IQR 36.7-54.4); 110 and 32 on MEPO 100 and 300 mg/month, respectively). General, ear-nose-throat, pulmonary, and neurological symptoms significantly decreased during treatment (table 1). MEPO accounted for a significant reduction in the BVAS (figure 1) and for a steroid sparing effect (figure 2). The proportion of patients with asthma attacks decreased by 90% at 12 months compared to t0, and asthma-related emergency accesses dropped from 17.4% to 2.3%. Overall, 21.1% of patients had a non-serious AE.

Table 1.

Control of clinical symptoms

MEPO beginning (t0)3 monthsp-value(t3 vs t0)6 monthsp-value(t6 vs t0)12 monthsp-value(t12 vs t0)N obsN=142N=135N=123N=89General symptoms40 (28.2%)17 (12.6%)<0.00119 (15.5%)<0.00113 (14.6%)0.002Cutaneous manifestations13 (9.2%)6 (4.4%)0.0085 (4.1%)0.0254 (4.5%)0.180ENT manifestations106 (74.7%)52 (38.5%)<0.00144 (35.8%)<0.00129 (32.6%)<0.001Pulmonary manifestations130 (91.6%)59 (43.7%)<0.00139 (31.7%)<0.00128 (31.5%)<0.001Cardiac manifestations6 (4.2%)2 (1.5%)0.0832 (1.6%)0.08300.157Intestinal manifestations10 (7.0%)1 (0.7%)0.0054 (3.3%)0.0593 (3.4%)0.059Renal manifestations5 (3.5%)3 (2.2%)0.41400.0461 (1.1%)0.317Neurological manifestations36 (25.4%)22 (16.3%)0.01218 (14.6%)0.00310 (11.2%)0.035Figure 1.

Changes in BVAS

Figure 2.

Steroid treatment

Conclusion:

MEPO effectively controlled systemic and respiratory EGPA symptoms in a large European cohort, with no major safety concerns.

References:

[1]Wechsler et al. MEPO or Placebo for Eosinophilic Granulomatosis with Polyangiitis. NEJM. 2017

Disclosure of Interests:

Alessandra Bettiol: None declared, Maria Letizia Urban: None declared, Federico Alberici: None declared, Carlo Agostini: None declared, Chiara Baldini: None declared, Enrica Bozzolo: None declared, Paolo Cameli: None declared, Nunzio Crimi: None declared, Stefano Del Giacco: None declared, Allyson Egan: None declared, Georgina Espigol-Frigole Consultant of: Roche and Janssen, Mara Felicetti: None declared, Marco Folci: None declared, Paolo Fraticelli: None declared, Marcello Govoni: None declared, Anna Kernder Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Carlo Lombardi: None declared, Giuseppe Lopalco: None declared, Claudio Lunardi: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Frank Moosig: None declared, Simone Negrini: None declared, Thomas Neumann: None declared, Pavel Novikov Grant/research support from: This work was supported by the 5-100 Project, Sechenov University, Moscow, Giuseppe Paolazzi: None declared, paola parronchi: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Vito Racanelli: None declared, Carlo Salvarani: None declared, Maxime Samson: None declared, Jan Schroeder: None declared, Savino Sciascia: None declared, Renato A. Sinico: None declared, Benjamin Terrier: None declared, Paola Toniati: None declared, Domenico Prisco: None declared, Augusto Vaglio: None declared, Giacomo Emmi: None declared

SAT0243 SUBPHENOTYPES IN POLYARTERITIS NODOSA (PAN): TARGET ORGAN ASSOCIATIONS OF A WORLDWIDE COLLABORATION STUDY

Background:

There is a paucity of information on the current phenotypes, ethnic and geographic differences of PAN. A global PAN study group has been working for clinical subphenotype and GWAS studies.

Objectives:

This study is aimed to look for target organ associations in PAN.

Methods:

PAN patients fulfilling the EMA vasculitis classification algorithm were recruited. In addition to baseline characteristics, treatment and outcome data, occurrence of any of the clinical manifestations related to PAN during disease course was recorded.

Factor analysis was used to analyse target organ associations of 306 patients. Five factors were identified by factor analysis of variables sex, paediatric-onset, HBV, monogenic disease relationship, cutaneous features, musculoskeletal symptoms, constitutional symptoms and involved areas (abdominal, renal, neurologic, ENT, cardiac, pulmonary).

Results:

PAN cohort from 7 countries were used (Italy: n=59, Japan: n=39, Mexico: n=29, Slovenia: n=14, Sweden:11, TUR: n=106, UK: n=48). 306 (M/F: 171/135 and Caucasian 77.1%, Asian 13.4%, and Hispanic 9.5%) patients were included. 8 were HBV-related, and 22 of TUR patients had a monogenic form of disease (FMF n=15, DADA2 n=7). 21.8% of patients were cutaneous-only PAN patients. 48.4% of patients had radiologic, 64% had biopsy-proven PAN. Median age at disease onset was 40 (IQR 27.0-57.5) years. During a median 57 (16-120) months follow-up, 39 (13%) patients died.

Factor analysis revealed 5 factors that explained 54.1% of the original information on the matrix as follows:Factor 1,represented the association between gastrointestinal and renal involvement, male gender and negatively associated with cutaneous features;Factor 2,the association between monogenic relationship with paediatric onset disease;Factor 3,any of musculoskeletal findings with positive constitutional symptoms;Factor 4any neurologic involvement was associated with ENT and pulmonary findings;Factor 5cardiac involvement in non-HBV patients (Table).

The eigenvalues of the 5 factors were 2.034, 1.470, 1.427, 1.079 and 1.030, in decreasing order, i.e., the highest contribution to the overall variance in the matrix came from the togetherness of the 4 clinical and demographic characteristics that made up Factor 1.

Conclusion:

Target organ associations could support distinctive subphenotypes in PAN. Factor 1 seems the most severe form. Patients with FMF or DADA2 have distinct target organ associations. The jury is out to decide whether these patients should be classified as ‘vasculitis associated with probable etiology’ just as HBV-related-PAN. Factor 4 might define a different subphenotype (ANCA- medium vessel vasculitis?).

Disclosure of Interests:

Omer Karadag: None declared, Ertugrul Cagri Bolek: None declared, Shunsuke Furuta: None declared, Giacomo Emmi: None declared, ALOJZIJA HOCEVAR: None declared, Andrea Hinojosa-Azaola: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Serdal Ugurlu: None declared, Fatma Alibaz-Oner: None declared, Ayten Yazici: None declared, Luca Quartuccio: None declared, Enrica Bozzolo: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI, Giuseppe Alvise Ramirez: None declared, Luca Cantarini: None declared, Gina Gregorini: None declared, Jeannin Guido: None declared, Sara Monti: None declared, Eduardo Martin-Nares: None declared, Franco Schiavon: None declared, Roberto Padoan: None declared, Hajime Kono: None declared, Augusto Vaglio: None declared, Saadettin Kiliçkap: None declared, Ali İhsan Ertenli: None declared, Haner Direskeneli: None declared, Seza Özen Consultant of: Novartis, Pfizer, Speakers bureau: SOBI, Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim

Antenatal Diagnosis of De Novo Balanced Structural Chromosome Aberrations in Latin America

INTRODUCTION The consequences of de novo balanced structural chromosome aberrations diagnosed antenatally are unpredictable, and, as a result, they introduce uncertainty into genetic counseling decisions. OBJECTIVE Describe de novo balanced structural aberrations present at antenatal diagnosis in samples from pregnant women in five Latin American countries and determine their effect on carrier individuals. METHODS This was a retrospective observational study based on analysis of 109,011 antenatal tests conducted from January 1981 to December 2016 in Cuba, Uruguay, Costa Rica, Mexico, and Colombia. Thirteen cytogenetic laboratories provided information that included the cases analyzed during the study period; number of de novo balanced structural aberrations diagnosed antenatally; number of diagnoses with de novo balanced structural aberrations that resulted in termination of pregnancy; detailed descriptions of the karyotypes of de novo balanced structural aberration carriers, and descriptions of the form of diagnosis, including types of samples used (amniotic fluid, chorionic villus or fetal blood). Each laboratory also provided pathology reports and genetic counseling at time of diagnosis. Postnatal followup for pregnancies carried to term continued for at least two years. RESULTS Of the 109,011 antenatal tests studied, 72 (0.07%) showed de novo balanced structural aberrations. These events primarily involved chromosomes 1, 2, 7, 14, 18, and 20. Of the 79 breakpoints identified, the most common were 5p15.3, 7q11.2, 7q22, and 14q24. We identified three breakpoints corresponding to 3.8% (3q13.1, 3q13.2, and 9p12) that were not reported in other studies of de novo balanced structural aberrations diagnosed antenatally in patients from other geographic regions or in studies of chromosomal fragile sites. Two of these breakpoints (3q13.1 and 3q13.2) were associated with high risk of phenotypic abnormalities. Information on antenatal or postnatal followup was available for 62 (86%) of de novo balanced structural aberration carriers; of the 44 carriers with postnatal followup, 10 had phenotypic abnormalities. CONCLUSIONS Three new de novo breakpoints were identified, presumably related to genetic admixture characteristics in Latin America. Since some diseases associated with de novo balanced structural aberrations detected antenatally have a late onset, followup for at least two years is recommended for carriers of these aberrations. The information in this study is useful in genetic counseling for pregnant women in Latin America.

EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis

In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.

Exome Sequencing Identified a Splice Site Mutation in FHL1 that Causes Uruguay Syndrome, an X-Linked Disorder With Skeletal Muscle Hypertrophy and Premature Cardiac Death

BACKGROUND

Previously, we reported a rare X-linked disorder, Uruguay syndrome in a single family. The main features are pugilistic facies, skeletal deformities, and muscular hypertrophy despite a lack of exercise and cardiac ventricular hypertrophy leading to premature death.

METHODS AND RESULTS

An ≈19 Mb critical region on X chromosome was identified through identity-by-descent analysis of 3 affected males. Exome sequencing was conducted on one affected male to identify the disease-causing gene and variant. A splice site variant (c.502-2A>G) in the FHL1 gene was highly suspicious among other candidate genes and variants. FHL1A is the predominant isoform of FHL1 in cardiac and skeletal muscle. Sequencing cDNA showed the splice site variant led to skipping of exons 6 of the FHL1A isoform, equivalent to the FHL1C isoform. Targeted analysis showed that this splice site variant cosegregated with disease in the family. Western blot and immunohistochemical analysis of muscle from the proband showed a significant decrease in protein expression of FHL1A. Real-time polymerase chain reaction analysis of different isoforms of FHL1 demonstrated that the FHL1C is markedly increased.

CONCLUSIONS

Mutations in the FHL1 gene have been reported in disorders with skeletal and cardiac myopathy but none has the skeletal or facial phenotype seen in patients with Uruguay syndrome. Our data suggest that a novel FHL1 splice site variant results in the absence of FHL1A and the abundance of FHL1C, which may contribute to the complex and severe phenotype. Mutation screening of the FHL1 gene should be considered for patients with uncharacterized myopathies and cardiomyopathies.

Idiopathic and secondary forms of retroperitoneal fibrosis: a diagnostic approach

Retroperitoneal fibrosis (RPF) is an uncommon disease characterized by a fibrous reaction that takes place in the peri-aortic retroperitoneum and often entraps the ureters causing obstructive uropathy. RPF is idiopathic in the majority of cases, but can also be secondary to malignancies, infections, drugs, radiotherapy, and rare histiocytic disorders such as Erdheim-Chester disease. Idiopathic RPF is an immune-mediated disease, which can either be isolated, associated with other autoimmune diseases, or arise in the context of a multifocal fibro-inflammatory disorder recently renamed as IgG4-related disease. The differential diagnosis between idiopathic, IgG4-related and secondary RPF is crucial, essentially because the therapeutic approaches - especially of idiopathic vs. secondary RPF - can be dramatically different. This review focuses on the clinical, laboratory and imaging features of the different RPF forms, and also provides an overview of the available treatment options.

Vingt et une recommandations en faveur de l’empowerment des usagers et aidants en santé mentale

Les 30 et 31 janvier 2014, les 4es Rencontres internationales du centre collaborateur de l’Organisation mondiale de la santé pour la recherche et la formation en santé mentale de Lille (CCOMS, Lille, France) ont permis d’énoncer de nouvelles orientations en faveur de l’empowerment des usagers et des aidants en santé mentale (site du CCOMS : http://www.ccomssantementalelillefrance.org). Deux chantiers ont été initiés dans le cadre de ce congrès : la construction avec l’ensemble des partenaires intéressés d’un questionnaire basé sur des indicateurs d’empowerment, d’une part, et l’écriture commune d’une série de recommandations en faveur de l’empowerment des usagers et aidants en santé mentale, d’autre part.

Des recommandations ont été proposées par les participants à toutes les étapes du congrès, depuis sa préparation (via les nombreuses propositions de communication reçues ou par les conseils scientifiques) jusqu’aux séances plénières et ateliers, en passant par les réponses au questionnaire en ligne. Au total, plus de 200 recommandations ont été recueillies. Un premier travail de regroupement et de synthèse a permis d’identifier 21 pistes de travail, regroupées en trois catégories :

– défense des droits fondamentaux;

– participation à l’organisation et l’évaluation des soins;

– information et communication.

Cette communication présentera la genèse du projet conjoint de l’Organisation mondiale de la santé (OMS) et de la commission européenne (CE) sur l’empowerment des usagers et aidants en santé mentale, les 21 recommandations issues du congrès ainsi que les exemples internationaux de bonnes pratiques les illustrant.

Les perspectives envisagées afin de développer ce projet européen seront également détaillées.

The Kidney Donor Profile Index (KDPI) of marginal donors allocated by standardized pretransplant donor biopsy assessment: distribution and association with graft outcomes

Pretransplant donor biopsy (PTDB)-based marginal donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the United States. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score<4 [median KDPI: 87; interquartile range (IQR): 78-94] and 62 with a score=4 [median KDPI: 87; IQR: 76-93]; 102 dual transplants [median KDPI: 93; IQR: 86-96]) and 248 single standard transplant controls (median KDPI: 36; IQR: 18-51). PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year estimated GFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9 and -18.8 mL/min, for dual transplants, single kidneys with PTDB score<4 and =4, respectively; p<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80-1.79; p=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded.

Révision et développement de la classification des troubles mentaux et du comportement, CIM-10, dans la francophonie

Contexte

La révision de la classification internationale des maladies (CIM) est une responsabilité constitutionnelle de l’Organisation mondiale de la santé (OMS). La CIM est une norme diagnostique internationale utilisée par les 194 États Membres de l’OMS pour recueillir des statistiques de santé. Le département de santé mentale et abus de substance est responsable de la révision du chapitre des troubles mentaux et du comportement qui répond à une large série d’applications cliniques, de santé publique, de politique et de statistiques. Cette révision s’inscrit dans un processus global, multidisciplinaire, multilingue, transparent et indépendant de l’industrie pharmaceutique. Avec environ 220 millions de locuteurs de français dans le monde, la participation des francophones à la révision est essentielle. Ainsi le centre collaborateur de l’OMS (CCOMS) pour la santé mentale de Lille s’est associé aux CCOMS de Casablanca, Genève, Montréal, l’hôpital Razi de Tunis et l’université américaine de Beyrouth pour créer un consortium francophone d’appui à la révision.

Objectifs

– promouvoir la participation de la communauté francophone à la révision ;

– maximiser l’utilité clinique de la classification ;

– garantir la participation des usagers et des aidants.

Méthode

Il s’agit d’un projet international, participatif, multicentrique, impliquant professionnels de santé mentale et de soins primaires, usagers et aidants, mené de 2013 à 2015 et se déclinant en quatre missions :

– promotion de la participation des professionnels de santé mentale francophones au Réseau Mondial de Pratique Clinique ;

– traduction du matériel CIM de l’anglais vers le français ;

– mise en place d’études cliniques en francophonie pour tester la validité et l’utilité clinique de la classification ;

– création d’un réseau mondial d’usagers et d’aidants en vue de leur implication dans la révision ;

Résultats attendus

Ce projet permettra de valoriser dans la prochaine version de la CIM les spécificités francophones en associant toutes les parties prenantes.

Trends in immune cell function assay and donor-specific HLA antibodies in kidney transplantation: A 3-year prospective study

The immune cell function assay (ICFA) and de novo anti-donor-specific HLA antibodies (DSA) have been proposed as assays for immune monitoring in renal transplantation, but longitudinal studies examining the modification of both parameters over time and their relation with clinical events are lacking. We prospectively measured longitudinal changes in ICFA and DSA levels in 55 kidney transplant recipients over 3-year follow-up (534 visits) and analyzed their relation with the risk of developing acute rejections or infections. Seven patients (12.7%) developed biopsy-proven acute rejection, and 20 (36.4%) developed viral infections. At 3 years posttransplant, 28% of the patients had developed de novo DSA. ICFA levels peaked at 1-2 months posttransplant (p = 0.005) and leveled off thereafter. They were not associated with the risk of acute rejections, viral infections or development of de novo DSA. Instead, the incidence of de novo DSA was higher in patients who previously had viral infections (adjusted-odds ratio of de novo DSA associated with prior infections: 6.03 [95% CI, 1.64-22.06; p = 0.007]). Our prospective, longitudinal study does not support using ICFA to quantify the immune risk in kidney transplantation. Further studies are needed to confirm the relationship between viral infections and the subsequent development of de novo DSA.

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): state of the art

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss, EGPA) is a systemic small-vessel vasculitis associated with asthma and eosinophilia. Histology of EGPA shows tissue eosinophilia, necrotizing vasculitis, and eosinophil-rich granulomatous inflammation. EGPA commonly presents with upper airway tract and lung involvement, peripheral neuropathy, cardiac and skin lesions. Antineutrophil cytoplasmic antibodies (ANCA) are positive in ~40% of the cases and more often in patients with clinical manifestations due to small-vessel vasculitis. The pathogenesis of EGPA is multifactorial: the disease can be triggered by exposure to allergens or drugs, but a genetic background has also been recognized, particularly an association with HLA-DRB4. Th2 responses are prominent, with up-regulation of IL-4, IL-13, and IL-5; however, Th1 and Th17 responses are not negligible. Eosinophils are activated, have a prolonged lifespan and probably cause tissue damage by releasing their granule proteins; their tissue recruitment can be regulated by chemokines such as eotaxin-3 and CCL17. Humoral immunity is also dysregulated, as demonstrated by prominent IgG4 and IgE responses. EGPA promptly responds to glucocorticoid therapy, although combinations of glucocorticoids and immunosuppressants (e.g., cyclophosphamide, azathioprine) are eventually required in most cases. Newer therapeutic options include the anti-IL5 antibody mepolizumab, whose efficacy has been described in small clinical trials, and the B-cell-depleting agent rituximab, reported in several case series.

Genotype-phenotype analysis of 4q deletion syndrome: proposal of a critical region

Chromosome 4q deletion syndrome (4q- syndrome) is a rare condition, with an estimated incidence of 1 in 100,000. Although variable, the clinical spectrum commonly includes craniofacial, developmental, digital, skeletal, and cardiac involvement. Data on the genotype-phenotype correlation within the 4q arm are limited. We present detailed clinical and genetic information by array CGH on 20 patients with 4q deletions. We identified a patient who has a ∼465 kb deletion (186,770,069-187,234,800, hg18 coordinates) in 4q35.1 with all clinical features for 4q deletion syndrome except for developmental delay, suggesting that this is a critical region for this condition and a specific gene responsible for orofacial clefts and congenital heart defects resides in this region. Since the patients with terminal deletions all had cleft palate, our results provide further evidence that a gene associated with clefts is located on the terminal segment of 4q. By comparing and contrasting our patients' genetic information and clinical features, we found significant genotype-phenotype correlations at a single gene level linking specific phenotypes to individual genes. Based on these data, we constructed a hypothetical partial phenotype-genotype map for chromosome 4q which includes BMP3, SEC31A, MAPK10, SPARCL1, DMP1, IBSP, PKD2, GRID2, PITX2, NEUROG2, ANK2, FGF2, HAND2, and DUX4 genes.

Subclinical interstitial lung abnormalities in stable renal allograft recipients in the era of modern immunosuppression

BACKGROUND

Interstitial lung abnormalities have been detected in up to 24% of kidney transplant patients receiving traditional immunosuppressive therapies (eg, cyclosporine, azathioprine); they usually occur early after transplantation and tend to resolve over time. Newer immunosuppressants such as mycophenolic acid and, particularly, mammalian target of rapamycin (mTOR) inhibitors (eg, sirolimus) may cause significant lung toxicity. However, the prevalence and severity of interstitial lung lesions in long-term, stable kidney transplant patients receiving either traditional or newer immunosuppressants is not known.

METHODS

We conducted a prospective, cross-sectional study examining high-resolution lung computed tomography (CT) scans in 63 stable kidney transplant recipients whose immunosuppressive therapy had remained unchanged for over 24 months. We compared CT findings of patients taking newer (mycophenolic acid and mTOR inhibitors) and traditional (calcineurin inhibitors and azathioprine) immunosuppressive drugs.

RESULTS

Interstitial lung alterations were observed in only 3/63 patients (4.8%); the prevalence was 11.5% (3/26) versus 0% (0/37) among the newer versus traditional immunosuppressive therapy groups, respectively (P = .065). The CT patterns were usual interstitial pneumonia and nonspecific interstitial pneumonia-like. The median time between transplant and CT was 49 months in the three patients with CT alterations and 95 months in the remaining 23 patients on newer immunosuppressants. It was 75 months for all patients on newer immunosuppressive drugs and 133 months for those on traditional therapies (P = .0015). A follow-up CT, performed in 2/3 patients with interstitial abnormalities, showed that the lesions were stable in one, while they had disappeared in the other.

CONCLUSIONS

Interstitial lung abnormalities are infrequent and mild in stable kidney transplant patients treated with newer as well as traditional immunosuppressive drugs. As such abnormalities were detected in patients screened earlier after transplantation, the time since transplantation rather than the drug type is probably the major determinant.