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Looney CM, Strauli N, Cascino MD, Garma H, Schroeder AV, Takahashi C, O'Gorman W, Green C, Herman AE. Development of a novel, highly sensitive assay for quantification of minimal residual B cells in autoimmune disease and comparison to traditional methods across B-cell-depleting agents. Clin Immunol 2023; 248:109265. [PMID: 36796471 DOI: 10.1016/j.clim.2023.109265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
Targeted B-cell depletion is a useful therapy for many diseases, including autoimmune disorders and certain cancers. We developed a sensitive blood B-cell depletion assay, MRB 1.1, compared its performance with the T-cell/B-cell/NK-cell (TBNK) assay, and assessed B-cell depletion with different therapies. The empirically defined lower limit of quantification (LLOQ) for CD19+ cells in the TBNK assay was 10 cells/μL, and 0.441 cells/μL for the MRB 1.1 assay. The TBNK LLOQ was used to compare differences between B-cell depletion in similar lupus nephritis patient populations who received rituximab (LUNAR), ocrelizumab (BELONG), or obinutuzumab (NOBILITY). After 4 weeks, 10% of patients treated with rituximab retained detectable B cells vs 1.8% with ocrelizumab and 1.7% for obinutuzumab; at 24 weeks 93% of patients who received obinutuzumab remained below LLOQ vs 63% for rituximab. More-sensitive measurements of B cells may reveal differences in potency among anti-CD20 agents, which may associate with clinical outcomes.
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Furie RA, Aroca G, Cascino MD, Garg JP, Rovin BH, Alvarez A, Fragoso-Loyo H, Zuta-Santillan E, Schindler T, Brunetta P, Looney CM, Hassan I, Malvar A. B-cell depletion with obinutuzumab for the treatment of proliferative lupus nephritis: a randomised, double-blind, placebo-controlled trial. Ann Rheum Dis 2021; 81:100-107. [PMID: 34615636 PMCID: PMC8762029 DOI: 10.1136/annrheumdis-2021-220920] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/28/2021] [Indexed: 11/21/2022]
Abstract
Objective Randomised trials of type I anti-CD20 antibodies rituximab and ocrelizumab failed to show benefit in proliferative lupus nephritis (LN). We compared obinutuzumab, a humanised type II anti-CD20 monoclonal antibody that induces potent B-cell depletion, with placebo for the treatment of LN in combination with standard therapies. Methods Patients with LN receiving mycophenolate and corticosteroids were randomised to obinutuzumab 1000 mg or placebo on day 1 and weeks 2, 24 and 26, and followed through week 104. The primary endpoint was complete renal response (CRR) at week 52. Exploratory analyses through week 104 were conducted. The prespecified alpha level was 0.2. Results A total of 125 patients were randomised and received blinded infusions. Achievement of CRR was greater with obinutuzumab at week 52 (primary endpoint, 22 (35%) vs 14 (23%) with placebo; percentage difference, 12% (95% CI −3.4% to 28%), p=0.115) and at week 104 (26 (41%) vs 14 (23%); percentage difference, 19% (95% CI 2.7% to 35%), p=0.026). Improvements in other renal response measures, serologies, estimated glomerular filtration rate and proteinuria were greater with obinutuzumab. Obinutuzumab was not associated with increases in serious adverse events, serious infections or deaths. Non-serious infusion-related reactions occurred more frequently with obinutuzumab. Conclusions Improved renal responses through week 104 were observed in patients with LN who received obinutuzumab plus standard therapies compared with standard therapies alone. Obinutuzumab was well tolerated and no new safety signals were identified. Trial registration number NCT02550652.
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Affiliation(s)
- Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, New York, USA
| | - Gustavo Aroca
- Universidad Simón Bolívar and Clínica de la Costa, Barranquilla, Colombia
| | | | - Jay P Garg
- Genentech Inc, South San Francisco, California, USA
| | - Brad H Rovin
- Division of Nephrology, Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Hilda Fragoso-Loyo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | - Imran Hassan
- Hoffmann-La Roche Ltd, Mississauga, Ontario, Canada
| | - Ana Malvar
- Organización Médica de Investigación, Buenos Aires, Argentina
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Owczarczyk K, Cascino MD, Holweg C, Tew GW, Ortmann W, Behrens T, Schindler T, Langford CA, St Clair EW, Merkel PA, Spiera R, Seo P, Kallenberg CG, Specks U, Lim N, Stone J, Brunetta P, Prunotto M. Fc receptor-like 5 and anti-CD20 treatment response in granulomatosis with polyangiitis and microscopic polyangiitis. JCI Insight 2020; 5:136180. [PMID: 32841219 PMCID: PMC7526555 DOI: 10.1172/jci.insight.136180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 08/19/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Baseline expression of FCRL5, a marker of naive and memory B cells, was shown to predict response to rituximab (RTX) in rheumatoid arthritis. This study investigated baseline expression of FCRL5 as a potential biomarker of clinical response to RTX in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). METHODS A previously validated quantitative PCR–based (qPCR-based) platform was used to assess FCRL5 expression in patients with GPA/MPA (RAVE trial, NCT00104299). RESULTS Baseline FCRL5 expression was significantly higher in patients achieving complete remission (CR) at 6, 12, and 18 months, independent of other clinical and serological variables, among those randomized to RTX but not cyclophosphamide-azathioprine (CYC/AZA). Patients with baseline FCRL5 expression ≥ 0.01 expression units (termed FCRL5hi) exhibited significantly higher CR rates at 6, 12, and 18 months as compared with FCRL5lo subjects (84% versus 57% [P = 0.016], 68% versus 40% [P = 0.02], and 68% versus 29% [P = 0.0009], respectively). CONCLUSION Our data taken together suggest that FCRL5 is a biomarker of B cell lineage associated with increased achievement and maintenance of complete remission among patients treated with RTX and warrant further investigation in a prospective manner. FUNDING The analysis for this study was funded by Genentech Inc. FcRL5 is a biomarker of B cell lineage associated with maintenance of complete remission among patients treated with rituximab in granulomatosis with polyangiitis and microscopic polyangiitis.
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Affiliation(s)
- Kasia Owczarczyk
- Department of Cancer Imaging, King's College London, London, United Kingdom
| | | | | | - Gaik W Tew
- Genentech, South San Francisco, California, USA
| | | | | | | | | | | | - Peter A Merkel
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Spiera
- Hospital for Special Surgery, New York, New York, USA
| | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Ulrich Specks
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Noha Lim
- Immune Tolerance Network (ITN), Seattle, Washington, USA
| | - John Stone
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Marco Prunotto
- Hoffmann - La Roche, Basel, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
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Kinloch AJ, Cascino MD, Dai J, Bermea RS, Ko K, Vesselits M, Dragone LL, Mor Vaknin N, Legendre M, Markovitz DM, Okoreeh MK, Townsend MJ, Clark MR. Anti-vimentin antibodies: a unique antibody class associated with therapy-resistant lupus nephritis. Lupus 2020; 29:569-577. [PMID: 32216516 DOI: 10.1177/0961203320913606] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Tubulointerstitial inflammation (TII) in lupus nephritis is associated with a worse prognosis. Vimentin, a filamental antigen, is commonly targeted by in situ activated B-cells in TII. The prognostic importance of high serum anti-vimentin antibodies (AVAs) in lupus nephritis and their relationship with common lupus autoantibody specificities is unknown. Herein we investigated associations between AVA isotypes, other autoantibodies, and response to mycophenolate mofetil (MMF) in the presence or absence of rituximab. Methods The Translational Research Initiative in the Department of Medicine (TRIDOM) cross-sectional cohort of 99 lupus patients was assayed for IgG-, IgA- and IgM- AVAs, lupus-associated and rheumatoid arthritis-associated antibodies, and hierarchically clustered. Serum from baseline, 26 and 52 weeks from 132 Lupus Nephritis Assessment with Rituximab (LUNAR) trial enrolled lupus nephritis patients was also analysed and correlated with renal function up to week 78. Results In TRIDOM, AVAs, especially IgM AVAs, clustered with IgG anti-dsDNA and away from anti-Sm and -RNP and rheumatoid arthritis-associated antibodies. In LUNAR at baseline, AVAs correlated weakly with anti-dsDNA and more strongly with anticardiolipin titers. Regardless of treatment, IgG-, but not IgM- or IgA-, AVAs were higher at week 52 than at baseline. In contrast, anti-dsDNA titers declined, regardless of therapeutic regime. High IgG AVA titers at entry predicted less response to therapy. Conclusion AVAs, especially IgG AVAs, are unique in distribution and response to therapy compared with other commonly measured autoantibody specificities. Furthermore, high-titer IgG AVAs identify lupus nephritis patients resistant to conventional therapies. These data suggest that AVAs represent an independent class of prognostic autoantibodies.
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Affiliation(s)
- Andrew J Kinloch
- Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA
| | - Matthew D Cascino
- Product Development I20, Genentech Research & Early Development, South San Francisco, USA
| | - Jian Dai
- Early Clinical Development Informatics, Genentech Research & Early Development, South San Francisco, USA
| | - Rene S Bermea
- University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA
| | - Kichul Ko
- University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA
| | - Margaret Vesselits
- Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA
| | - Leonard L Dragone
- Early Development, Infectious Disease, The Janssen Pharmaceutical Companies of Johnson & Johnson, South San Francisco, California
| | - Nirit Mor Vaknin
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - Maureen Legendre
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - David M Markovitz
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - Michael K Okoreeh
- Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA
| | - Michael J Townsend
- Biomarker Discovery OMNI, Genentech Research & Early Development, South San Francisco, USA
| | - Marcus R Clark
- Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA.,University of Chicago, Section of Rheumatology and Department of Medicine, Chicago, USA
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Redfield RR, Jordan SC, Busque S, Vincenti F, Woodle ES, Desai N, Reed EF, Tremblay S, Zachary AA, Vo AA, Formica R, Schindler T, Tran H, Looney C, Jamois C, Green C, Morimoto A, Rajwanshi R, Schroeder A, Cascino MD, Brunetta P, Borie D. Safety, pharmacokinetics, and pharmacodynamic activity of obinutuzumab, a type 2 anti-CD20 monoclonal antibody for the desensitization of candidates for renal transplant. Am J Transplant 2019; 19:3035-3045. [PMID: 31257724 PMCID: PMC6899639 DOI: 10.1111/ajt.15514] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/28/2019] [Accepted: 06/18/2019] [Indexed: 01/25/2023]
Abstract
The limited effectiveness of rituximab plus intravenous immunoglobulin (IVIG) in desensitization may be due to incomplete B cell depletion. Obinutuzumab is a type 2 anti-CD20 antibody that induces increased B cell depletion relative to rituximab and may therefore be more effective for desensitization. This open-label phase 1b study assessed the safety, pharmacokinetics, and pharmacodynamics of obinutuzumab in highly sensitized patients with end-stage renal disease. Patients received 1 (day 1, n = 5) or 2 (days 1 and 15; n = 20) infusions of 1000-mg obinutuzumab followed by 2 doses of IVIG on days 22 and 43. Eleven patients received additional obinutuzumab doses at the time of transplant and/or at week 24. The median follow-up duration was 9.4 months. Obinutuzumab was well tolerated, and most adverse events were grade 1-2 in severity. There were 11 serious adverse events (SAEs) in 9 patients (36%); 10 of these SAEs were infections and 4 occurred after kidney transplant. Obinutuzumab plus IVIG resulted in profound peripheral B cell depletion and appeared to reduce B cells in retroperitoneal lymph nodes. Reductions in anti-HLA antibodies, number of unacceptable antigens, and the calculated panel reactive antibody score as centrally assessed using single-antigen bead assay were limited and not clinically meaningful for most patients (NCT02586051).
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Affiliation(s)
| | | | | | | | | | - Niraj Desai
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Elaine F. Reed
- David Geffen School of MedicineUniversity of CaliforniaLos AngelesCalifornia
| | - Simon Tremblay
- University of Cincinnati College of MedicineCincinnatiOhio
| | | | - Ashley A. Vo
- Cedars‐Sinai Medical CenterLos AngelesCalifornia
| | | | | | - Ha Tran
- Genentech, Inc.South San FranciscoCalifornia
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Gomez Mendez LM, Cascino MD, Katsumoto TR, Brakeman P, Brunetta P, Jayne D, Dall'Era M, Rovin B, Garg J. Outcome of participants with nephrotic syndrome in combined clinical trials of lupus nephritis. Lupus Sci Med 2019; 6:e000308. [PMID: 31080631 PMCID: PMC6485211 DOI: 10.1136/lupus-2018-000308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/31/2018] [Accepted: 01/06/2019] [Indexed: 12/23/2022]
Abstract
Objective The outcome of participants with nephrotic syndrome in clinical trials of lupus nephritis has not been studied in detail. Methods Collated data from two randomised controlled trials in lupus nephritis, Lupus Nephritis Assessment of Rituximab (LUNAR) and A Study to Evaluate Ocrelizumab in Patients With Nephritis due to Systemic Lupus Erythematosus (BELONG) were analysed. Nephrotic syndrome was defined as albumin <3 g/dL and urine protein/creatinine ratio ≥3.5 g/g at start of trial. Renal response was defined as a first morning urine protein/creatinine ratio ≤0.5 g/g in addition to ≤25% increase in creatinine from trial entry assessed at week 48. Logistic regression was used to evaluate the association of nephrotic syndrome with renal response while adjusting for treatment received and ACE inhibitor or angiotensin receptor blocker use. Results 28 (26%) participants with nephrotic syndrome achieved renal response as compared with 130 (52.5%) of those without (p<0.001). Having nephrotic syndrome at baseline significantly lowered the likelihood of achieving renal response (OR 0.32, 95 % CI 0.19 to 0.54, p<0.001). 125 (80%) participants achieved resolution of their nephrotic syndrome in a median time of 16 weeks. Conclusions Nephrotic syndrome at baseline decreases the likelihood of renal response at 1 year. Longer clinical trials or better short-term predictors of long-term outcomes may better assess the effect of novel therapeutic approaches on subjects with nephrotic syndrome.
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Affiliation(s)
| | - Matthew D Cascino
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA
| | - Tamiko R Katsumoto
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA.,Early Development, Genentech Inc, South San Francisco, CA, United States
| | - Paul Brakeman
- Department of Pediatric Nephrology, University of California San Francisco, San Francisco, California, USA
| | - Paul Brunetta
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA
| | - David Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Maria Dall'Era
- Department of Rheumatology, University of California San Francisco, San Francisco, CA, United States
| | - Brad Rovin
- Department of Internal Medicine/Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jay Garg
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA
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Winthrop KL, Saag K, Cascino MD, Pei J, John A, Jahreis A, Haselkorn T, Furst DE. Long-Term Safety of Rituximab in Rheumatoid Arthritis: Analysis From the SUNSTONE Registry. Arthritis Care Res (Hoboken) 2018; 71:993-1003. [PMID: 30295434 PMCID: PMC6806017 DOI: 10.1002/acr.23781] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 10/02/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the long-term safety of rituximab in an observational cohort of patients with rheumatoid arthritis (RA) who had an inadequate response to ≥ 1 antitumor necrosis factor therapies in the United States (SUNSTONE Registry). METHODS In this prospective, observational cohort study, patients received rituximab according to their physician's standard practice and were evaluated at standard-of-care follow-up visits at least every 6 months. The primary outcome was the incidence of protocol-defined significant infections. Secondary outcomes included serious adverse events potentially associated with rituximab, cardiovascular or thrombotic (CVT) events, seizures, deaths and pregnancies. Posthoc analyses assessed outcomes by concomitant medication use. RESULTS Overall, 989 patients (safety-evaluable population) received ≥ 1 dose of rituximab, with a total follow-up of 3844 patient-years (PYs; mean duration, 3.9 years). In total, 341 significant infections occurred in 197 patients (19.9%). The incidence rates (95% CI) for significant infections, CVT events, and seizures were 8.87 (7.98, 9.86), 1.95 (1.56, 2.45), and 0.18 (0.09, 0.38) per 100 PYs, respectively. The incidence of significant infections did not increase with time or with cumulative rituximab exposure. During the study, 64 patients died (crude mortality [95% CI]: 1.66 per 100 PYs [1.30, 2.13]). The most common causes of death were infections (19 patients), malignancy (14), and cardiovascular events (13). Eight pregnancies were reported in 7 patients. CONCLUSION In patients with RA treated with rituximab for up to 5 years, the rates of significant infections were stable over time and higher in patients who received long-term systemic steroid treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | - Jinglan Pei
- Genentech, Inc.South San FranciscoCalifornia
| | - Ani John
- Genentech, Inc.South San FranciscoCalifornia
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Gomez Mendez LM, Cascino MD, Garg J, Katsumoto TR, Brakeman P, Dall’Era M, Looney RJ, Rovin B, Dragone L, Brunetta P. Peripheral Blood B Cell Depletion after Rituximab and Complete Response in Lupus Nephritis. Clin J Am Soc Nephrol 2018; 13:1502-1509. [PMID: 30089664 PMCID: PMC6218830 DOI: 10.2215/cjn.01070118] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/17/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Incomplete peripheral blood B cell depletion after rituximab in lupus nephritis might correlate with inability to reduce tubulointerstitial lymphoid aggregates in the kidney, which together could be responsible for inadequate response to treatment. We utilized data from the Lupus Nephritis Assessment with Rituximab (LUNAR) study to characterize the variability of peripheral blood B cell depletion after rituximab and assess its association with complete response in patients with lupus nephritis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We analyzed 68 participants treated with rituximab. Peripheral blood B cell depletion was defined as 0 cells/µl, termed "complete peripheral depletion," assessed over 78 weeks. Logistic regression was used to estimate the association between characteristics of complete peripheral depletion and complete response (defined as urine protein-to-creatinine ratio <0.5 mg/mg, and normal serum creatinine or an increase in creatinine <15%, if normal at baseline), assessed at week 78. RESULTS A total of 53 (78%) participants achieved complete peripheral depletion (0 cells/µl) in a median time of 182 days (interquartile range, 80-339).The median duration of complete peripheral depletion was 71 days (interquartile range, 14-158). Twenty-five (47%) participants with complete peripheral depletion achieved complete response, compared with two (13%) without. Complete peripheral depletion was associated with complete response (unadjusted odds ratio [OR], 5.8; 95% confidence interval [95% CI], 1.2 to 28; P=0.03). Longer time to achieving complete peripheral depletion was associated with a lower likelihood of complete response (unadjusted OR, 0.89; 95% CI, 0.81 to 0.98; P=0.02). Complete peripheral depletion lasting >71 days (the median) was associated with complete response (unadjusted OR, 4.1; 95% CI, 1.5 to 11; P=0.008). CONCLUSIONS There was substantial variability in peripheral blood B cell depletion in patients with lupus nephritis treated with rituximab from the LUNAR trial. Achievement of complete peripheral depletion, as well as the rapidity and duration of complete peripheral depletion, were associated with complete response at week 78. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_09_06_CJASNPodcast_18_10_.mp3.
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Affiliation(s)
| | | | - Jay Garg
- Genentech, Inc., San Francisco, California
| | | | - Paul Brakeman
- University of California, San Francisco, San Francisco, California
| | - Maria Dall’Era
- University of California, San Francisco, San Francisco, California
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Cornec D, Kabat BF, Mills JR, Cheu M, Hummel AM, Schroeder DR, Cascino MD, Brunetta P, Murray DL, Snyder MR, Fervenza F, Hoffman GS, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Barnidge DR, Specks U. Pharmacokinetics of rituximab and clinical outcomes in patients with anti-neutrophil cytoplasmic antibody associated vasculitis. Rheumatology (Oxford) 2018; 57:639-650. [PMID: 29340623 PMCID: PMC5888934 DOI: 10.1093/rheumatology/kex484] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 11/10/2017] [Indexed: 12/16/2022] Open
Abstract
Objectives To study the determinants of the pharmacokinetics (PK) of rituximab (RTX) in patients with ANCA-associated vasculitis (AAV) and its association with clinical outcomes. Methods This study included data from 89 patients from the RTX in AAV trial who received the full dose of RTX (four weekly infusions of 375 mg/m2). RTX was quantified at weeks 2, 4, 8, 16 and 24, and summarized by computing the trapezoidal area under the curve. We explored potential determinants of the PK-RTX, and analysed its association with clinical outcomes: achievement of remission at 6 months, duration of B-cell depletion and time to relapse in patients who achieved complete remission. Results RTX serum levels were significantly lower in males and in newly diagnosed patients, and negatively correlated with body surface area, baseline B-cell count and degree of disease activity. In multivariate analyses, the main determinants of PK-RTX were sex and new diagnosis. Patients reaching complete remission at month 6 had similar RTX levels compared with patients who did not reach complete remission. Patients with higher RTX levels generally experienced longer B-cell depletion than patients with lower levels, but RTX levels at the different time points and area under the curve were not associated with time to relapse. Conclusion Despite the body-surface-area-based dosing protocol, PK-RTX is highly variable among patients with AAV, its main determinants being sex and newly diagnosed disease. We did not observe any relevant association between PK-RTX and clinical outcomes. The monitoring of serum RTX levels does not seem clinically useful in AAV.
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Affiliation(s)
- Divi Cornec
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Rheumatology Department, Brest University Hospital, and INSERM U1227, Brest, France
| | - Brian F Kabat
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Amber M Hummel
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Gary S Hoffman
- Division of Rheumatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Carol A Langford
- Division of Rheumatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Paul A Monach
- Rheumatology, Boston University Medical Center, Boston, MA
| | - Philip Seo
- Rheumatology, Johns Hopkins University, Baltimore, MD
| | | | | | - John H Stone
- Rheumatology, Massachusetts General Hospital, Boston, MA, USA
| | - David R Barnidge
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
OBJECTIVE We describe a young woman with previously undiagnosed thyrotoxicosis who presented with acute liver failure (ALF). METHODS We present a case report and review the relevant literature. RESULTS An extensive evaluation excluded possible causes of ALF other than thyrotoxicosis. The management of thyrotoxicosis posed several unique challenges in the setting of ALF, particularly because we did not want to use potentially hepatotoxic thionamides. The patient was treated with prednisone and propranolol and was started on potassium iodide when she was listed for liver transplantation. She underwent an uncomplicated liver transplant and subsequent thyroidectomy and is doing well. CONCLUSION This well-characterized case describes thyrotoxicosis as a possible cause of ALF after thoroughly excluding other possible causes and illustrates the challenges of simultaneously managing both disorders. To our knowledge, this is the first report of ALF possibly resulting from untreated thyrotoxicosis that was successfully treated with liver transplantation.
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Affiliation(s)
- Matthew D Cascino
- Department of Medicine, University of California, San Francisco, California, USA
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11
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Dingli D, Cascino MD, Josić K, Russell SJ, Bajzer Z. Mathematical modeling of cancer radiovirotherapy. Math Biosci 2006; 199:55-78. [PMID: 16376950 DOI: 10.1016/j.mbs.2005.11.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 10/05/2005] [Accepted: 11/10/2005] [Indexed: 12/21/2022]
Abstract
Cancer virotherapy represents a dynamical system that requires mathematical modeling for complete understanding of the outcomes. The combination of virotherapy with radiation (radiovirotherapy) has been recently shown to successfully eliminate tumors when virotherapy alone failed. However, it introduces a new level of complexity. We have developed a mathematical model, based on population dynamics, that captures the essential elements of radiovirotherapy. The existence of corresponding equilibrium points related to complete cure, partial cure, and therapy failure is proved and discussed. The parameters of the model were estimated by fitting to experimental data. By using simulations we analyzed the influence of parameters that describe the interaction between virus and tumor cell on the outcome of the therapy. Furthermore, we evaluated relevant therapeutic scenarios for radiovirotherapy, and offered elements for optimization.
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Affiliation(s)
- David Dingli
- Molecular Medicine Program, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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