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Bate S, McGovern D, Costigliolo F, Tan PG, Kratky V, Scott J, Chapman GB, Brown N, Floyd L, Brilland B, Martín-Nares E, Aydın MF, Ilyas D, Butt A, Nic an Riogh E, Kollar M, Lees JS, Yildiz A, Hinojosa-Azaola A, Dhaygude A, Roberts SA, Rosenberg A, Wiech T, Pusey CD, Jones RB, Jayne DR, Bajema I, Jennette JC, Stevens KI, Augusto JF, Mejía-Vilet JM, Dhaun N, McAdoo SP, Tesar V, Little MA, Geetha D, Brix SR. The Improved Kidney Risk Score in ANCA-Associated Vasculitis for Clinical Practice and Trials. J Am Soc Nephrol 2024; 35:335-346. [PMID: 38082490 PMCID: PMC10914211 DOI: 10.1681/asn.0000000000000274] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024] Open
Abstract
SIGNIFICANCE STATEMENT Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. More than 1500 patients were collated in an international longitudinal study to revise the ANCA kidney risk score. The score showed satisfactory performance, mimicking the original study (Harrell's C=0.779). In the development cohort of 959 patients, no additional parameters aiding the tool were detected, but replacing the GFR with creatinine identified an additional cutoff. The parameter interstitial fibrosis and tubular atrophy was modified to allow wider access, risk points were reweighted, and a fourth risk group was created, improving predictive ability (C=0.831). In the validation, the new model performed similarly well with excellent calibration and discrimination ( n =480, C=0.821). The revised score optimizes prognostication for clinical practice and trials. BACKGROUND Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. A retrospective international longitudinal cohort was collated to revise the ANCA renal risk score. METHODS The primary end point was ESKD with patients censored at last follow-up. Cox proportional hazards were used to reweight risk factors. Kaplan-Meier curves, Harrell's C statistic, receiver operating characteristics, and calibration plots were used to assess model performance. RESULTS Of 1591 patients, 1439 were included in the final analyses, 2:1 randomly allocated per center to development and validation cohorts (52% male, median age 64 years). In the development cohort ( n =959), the ANCA renal risk score was validated and calibrated, and parameters were reinvestigated modifying interstitial fibrosis and tubular atrophy allowing semiquantitative reporting. An additional cutoff for kidney function (K) was identified, and serum creatinine replaced GFR (K0: <250 µ mol/L=0, K1: 250-450 µ mol/L=4, K2: >450 µ mol/L=11 points). The risk points for the percentage of normal glomeruli (N) and interstitial fibrosis and tubular atrophy (T) were reweighted (N0: >25%=0, N1: 10%-25%=4, N2: <10%=7, T0: none/mild or <25%=0, T1: ≥ mild-moderate or ≥25%=3 points), and four risk groups created: low (0-4 points), moderate (5-11), high (12-18), and very high (21). Discrimination was C=0.831, and the 3-year kidney survival was 96%, 79%, 54%, and 19%, respectively. The revised score performed similarly well in the validation cohort with excellent calibration and discrimination ( n =480, C=0.821). CONCLUSIONS The updated score optimizes clinicopathologic prognostication for clinical practice and trials.
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Affiliation(s)
- Sebastian Bate
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Population Health, Health Services Research, and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Dominic McGovern
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Francesca Costigliolo
- Division of Nephrology, Dialysis and Transplantation, University of Genova, Genova, Italy
- Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Pek Ghe Tan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Renal Unit, Northern Health, Victoria, Australia
| | - Vojtech Kratky
- 1st Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, General University Hospital, Prague, Czechia
| | - Jennifer Scott
- Trinity Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Gavin B. Chapman
- University/BHF Centre for Cardiovascular Science, University of Edinburgh and Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nina Brown
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Lauren Floyd
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, CHU d’Angers, Angers, France
| | - Eduardo Martín-Nares
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Duha Ilyas
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Arslan Butt
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | | | - Marek Kollar
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jennifer S. Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Abdülmecit Yildiz
- Division of Nephrology, Bursa Uludağ University School of Medicine, Bursa, Turkey
| | - Andrea Hinojosa-Azaola
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Stephen A. Roberts
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Population Health, Health Services Research, and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thorsten Wiech
- University Medical Center Hamburg-Eppendorf, Institute of Pathology, Hamburg, Germany
| | - Charles D. Pusey
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Rachel B. Jones
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - David R.W. Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ingeborg Bajema
- Department of Pathology, Groningen University Medical Center, Groningen, The Netherlands
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kate I. Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | | | - Juan Manuel Mejía-Vilet
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Neeraj Dhaun
- University/BHF Centre for Cardiovascular Science, University of Edinburgh and Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Stephen P. McAdoo
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Vladimir Tesar
- 1st Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, General University Hospital, Prague, Czechia
| | - Mark A. Little
- Trinity Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Duruvu Geetha
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Silke R. Brix
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, United Kingdom
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Smith RM, Jones RB, Specks U, Bond S, Nodale M, Al-Jayyousi R, Andrews J, Bruchfeld A, Camilleri B, Carette S, Cheung CK, Derebail V, Doulton T, Ferraro A, Forbess L, Fujimoto S, Furuta S, Gewurz-Singer O, Harper L, Ito-Ihara T, Khalidi N, Klocke R, Koening C, Komagata Y, Langford C, Lanyon P, Luqmani R, McAlear C, Moreland LW, Mynard K, Nachman P, Pagnoux C, Peh CA, Pusey C, Ranganathan D, Rhee RL, Spiera R, Sreih AG, Tesar V, Walters G, Wroe C, Jayne D, Merkel PA. Rituximab versus azathioprine for maintenance of remission for patients with ANCA-associated vasculitis and relapsing disease: an international randomised controlled trial. Ann Rheum Dis 2023; 82:937-944. [PMID: 36958796 PMCID: PMC10313987 DOI: 10.1136/ard-2022-223559] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [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: 01/22/2023] [Accepted: 03/06/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE Following induction of remission with rituximab in anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) relapse rates are high, especially in patients with history of relapse. Relapses are associated with increased exposure to immunosuppressive medications, the accrual of damage and increased morbidity and mortality. The RITAZAREM trial compared the efficacy of repeat-dose rituximab to daily oral azathioprine for prevention of relapse in patients with relapsing AAV in whom remission was reinduced with rituximab. METHODS RITAZAREM was an international randomised controlled, open-label, superiority trial that recruited 188 patients at the time of an AAV relapse from 29 centres in seven countries between April 2013 and November 2016. All patients received rituximab and glucocorticoids to reinduce remission. Patients achieving remission by 4 months were randomised to receive rituximab intravenously (1000 mg every 4 months, through month 20) (85 patients) or azathioprine (2 mg/kg/day, tapered after month 24) (85 patients) and followed for a minimum of 36 months. The primary outcome was time to disease relapse (either major or minor relapse). RESULTS Rituximab was superior to azathioprine in preventing relapse: HR 0.41; 95% CI 0.27 to 0.61, p<0.001. 19/85 (22%) patients in the rituximab group and 31/85 (36%) in the azathioprine group experienced at least one serious adverse event during the treatment period. There were no differences in rates of hypogammaglobulinaemia or infection between groups. CONCLUSIONS Following induction of remission with rituximab, fixed-interval, repeat-dose rituximab was superior to azathioprine for preventing disease relapse in patients with AAV with a prior history of relapse. TRIAL REGISTRATION NUMBER NCT01697267; ClinicalTrials.gov identifier.
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Affiliation(s)
- Rona M Smith
- Medicine, University of Cambridge, Cambridge, UK
| | | | - Ulrich Specks
- Pulmonary Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Marianna Nodale
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Reem Al-Jayyousi
- Nephrology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jacqueline Andrews
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Annette Bruchfeld
- Nephrology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | | | - Simon Carette
- Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | | | - Vimal Derebail
- Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tim Doulton
- Nephrology, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Alastair Ferraro
- Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lindsy Forbess
- Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shouichi Fujimoto
- Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shunsuke Furuta
- Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | | | | | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nader Khalidi
- Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rainer Klocke
- Rheumatology, Dudley Group of Hospitals NHS Trust, Dudley, UK
| | - Curry Koening
- Rheumatology, The University of Utah, Salt Lake City, Utah, USA
| | - Yoshinori Komagata
- First Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Carol Langford
- Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Peter Lanyon
- Rheumatology, Nottingham University Hospital, Nottingham, UK
| | - Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Carol McAlear
- Rheumatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Larry W Moreland
- Medicine/Rheumatology, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Kim Mynard
- Vasculitis and lupus clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick Nachman
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christian Pagnoux
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Chen Au Peh
- Nephrology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | | | - Rennie L Rhee
- Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Spiera
- Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Antoine G Sreih
- Rheumatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Giles Walters
- Nephrology, Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Caroline Wroe
- Nephrology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Jayne
- Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Peter A Merkel
- Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Benichou N, Charles P, Terrier B, Jones RB, Hiemstra T, Mouthon L, Bajema I, Berden A, Thervet E, Guillevin L, Jayne D, Karras A. PROTEINURIA AND HEMATURIA AFTER REMISSION INDUCTION ARE ASSOCIATED WITH OUTCOME IN ANCA-ASSOCIATED VASCULITIS. Kidney Int 2023; 103:1144-1155. [PMID: 36940799 DOI: 10.1016/j.kint.2023.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 05/09/2022] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 03/22/2023]
Abstract
In anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), hematuria and proteinuria are biomarkers reflecting kidney involvement at diagnosis. Yet, the prognostic value of their persistence after immunosuppressive induction therapy, reflecting kidney damage or persistent disease, remains uncertain. To study this, our post-hoc analysis included participants of five European randomized clinical trials on AAV (MAINRITSAN, MAINRITSAN2, RITUXVAS, MYCYC, IMPROVE). Urine protein-creatinine ratio (UPCR) and hematuria of spot urine samples collected at the end of induction therapy (four-six months after treatment initiation) were correlated with the occurrence of a combined endpoint of death and/or kidney failure, or relapses during follow-up. Among 571 patients (59% men, median age 60), 60% had anti-proteinase 3-ANCA and 35% had anti-myeloperoxidase-ANCA, while 77% had kidney involvement. After induction therapy, 157/526 (29.8%) had persistent hematuria and 165/481 (34.3%) had UPCR of 0.05 g/mmol or more. After a median follow-up of 28 months (inter quartile range 18-42), and adjustment for age, ANCA type, maintenance therapy, serum creatinine and persistent hematuria after induction, a UPCR of 0.05 g/mmol or more after induction was associated with significant risk of death/kidney failure (adjusted Hazard Ratio (HR) 3.06, 95% confidence interval (1.09-8.59) and kidney relapse (adjusted subdistribution HR 2.22, 1.16-4.24). Persistent hematuria was associated with significant kidney relapse (adjusted subdistribution HR 2.16, (1.13-4.11) but not with relapse affecting any organ nor with death/kidney failure. Thus, in this large cohort of patients with AAV, persistent proteinuria after induction therapy was associated with death/kidney failure and kidney relapse, whereas persistent hematuria was an independent predictor of kidney relapse. Hence, these parameters must be considered to assess long-term kidney prognosis of patients with AAV.
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Affiliation(s)
- Nicolas Benichou
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France.
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Benjamin Terrier
- Université de Paris, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Rachel B Jones
- Lupus and Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Thomas Hiemstra
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Luc Mouthon
- Université de Paris, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Annelies Berden
- Department of Rheumatology and Clinical immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Eric Thervet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France
| | - Loïc Guillevin
- Université de Paris, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - David Jayne
- Lupus and Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France
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- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
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McClure ME, Gopaluni S, Wason J, Henderson RB, Van Maurik A, Savage CCO, Pusey CD, Salama AD, Lyons PA, Lee J, Mynard K, Jayne DR, Jones RB. A randomised study of rituximab and belimumab sequential therapy in PR3 ANCA-associated vasculitis (COMBIVAS): design of the study protocol. Trials 2023; 24:180. [PMID: 36906660 PMCID: PMC10007661 DOI: 10.1186/s13063-023-07218-y] [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] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/03/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Sequential B cell-targeted immunotherapy with BAFF antagonism (belimumab) and B cell depletion (rituximab) may enhance B cell targeting in ANCA-associated vasculitis (AAV) through several mechanisms. METHODS Study design: COMBIVAS is a randomised, double-blind, placebo-controlled trial designed to assess the mechanistic effects of sequential therapy of belimumab and rituximab in patients with active PR3 AAV. The recruitment target is 30 patients who meet the criteria for inclusion in the per-protocol analysis. Thirty-six participants have been randomised to one of the two treatment groups in a 1:1 ratio: either rituximab plus belimumab or rituximab plus placebo (both groups with the same tapering corticosteroid regimen), and recruitment is now closed (final patient enrolled April 2021). For each patient, the trial will last for 2 years comprising a 12-month treatment period followed by a 12-month follow-up period. PARTICIPANTS Participants have been recruited from five of seven UK trial sites. Eligibility criteria were age ≥ 18 years and a diagnosis of AAV with active disease (newly diagnosed or relapsing disease), along with a concurrent positive test for PR3 ANCA by ELISA. INTERVENTIONS Rituximab 1000 mg was administered by intravenous infusions on day 8 and day 22. Weekly subcutaneous injections of 200 mg belimumab or placebo were initiated a week before rituximab on day 1 and then weekly through to week 51. All participants received a relatively low prednisolone (20 mg/day) starting dose from day 1 followed by a protocol-specified corticosteroid taper aiming for complete cessation by 3 months. OUTCOMES The primary endpoint of this study is time to PR3 ANCA negativity. Key secondary outcomes include change from baseline in naïve, transitional, memory, plasmablast B cell subsets (by flow cytometry) in the blood at months 3, 12, 18 and 24; time to clinical remission; time to relapse; and incidence of serious adverse events. Exploratory biomarker assessments include assessment of B cell receptor clonality, B cell and T cell functional assays, whole blood transcriptomic analysis and urinary lymphocyte and proteomic analysis. Inguinal lymph node and nasal mucosal biopsies have been performed on a subgroup of patients at baseline and month 3. DISCUSSION This experimental medicine study provides a unique opportunity to gain detailed insights into the immunological mechanisms of belimumab-rituximab sequential therapy across multiple body compartments in the setting of AAV. TRIAL REGISTRATION ClinicalTrials.gov NCT03967925. Registered on May 30, 2019.
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Affiliation(s)
- Mark E McClure
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK.
- Department of Medicine, University of Cambridge, Cambridge, UK.
| | - Seerapani Gopaluni
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | | | | | | | - Charles D Pusey
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Alan D Salama
- UCL Centre for Nephrology, Royal Free Hospital, London, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
| | - Jacinta Lee
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Kim Mynard
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - David R Jayne
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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McGovern D, Jones RB, Willcocks LC, Smith RM, Jayne DRW, Kronbichler A. Avacopan for ANCA-associated vasculitis – information for prescribers. Nephrol Dial Transplant 2022; 38:1067-1070. [PMID: 36496198 DOI: 10.1093/ndt/gfac330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Dominic McGovern
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
- Department of Medicine, University of Cambridge , Cambridge , UK
| | - Rachel B Jones
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
- Department of Medicine, University of Cambridge , Cambridge , UK
| | - Lisa C Willcocks
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Rona M Smith
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
- Department of Medicine, University of Cambridge , Cambridge , UK
| | - David R W Jayne
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
- Department of Medicine, University of Cambridge , Cambridge , UK
| | - Andreas Kronbichler
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
- Department of Medicine, University of Cambridge , Cambridge , UK
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Smith RM, Cooper DJ, Doffinger R, Stacey H, Al-Mohammad A, Goodfellow I, Baker S, Lear S, Hosmilo M, Pritchard N, Torpey N, Jayne D, Yiu V, Chalisey A, Lee J, Vilnar E, Cheung CK, Jones RB. SARS-COV-2 vaccine responses in renal patient populations. BMC Nephrol 2022; 23:199. [PMID: 35641961 PMCID: PMC9153874 DOI: 10.1186/s12882-022-02792-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Dialysis patients and immunosuppressed renal patients are at increased risk of COVID-19 and were excluded from vaccine trials. We conducted a prospective multicentre study to assess SARS-CoV-2 vaccine antibody responses in dialysis patients and renal transplant recipients, and patients receiving immunosuppression for autoimmune disease.
Methods
Patients were recruited from three UK centres (ethics:20/EM/0180) and compared to healthy controls (ethics:17/EE/0025). SARS-CoV-2 IgG antibodies to spike protein were measured using a multiplex Luminex assay, after first and second doses of Pfizer BioNTech BNT162b2(Pfizer) or Oxford-AstraZeneca ChAdOx1nCoV-19(AZ) vaccine.
Results
Six hundred ninety-two patients were included (260 dialysis, 209 transplant, 223 autoimmune disease (prior rituximab 128(57%)) and 144 healthy controls. 299(43%) patients received Pfizer vaccine and 379(55%) received AZ. Following two vaccine doses, positive responses occurred in 96% dialysis, 52% transplant, 70% autoimmune patients and 100% of healthy controls. In dialysis patients, higher antibody responses were observed with the Pfizer vaccination. Predictors of poor antibody response were triple immunosuppression (adjusted odds ratio [aOR]0.016;95%CI0.002–0.13;p < 0.001) and mycophenolate mofetil (MMF) (aOR0.2;95%CI 0.1–0.42;p < 0.001) in transplant patients; rituximab within 12 months in autoimmune patients (aOR0.29;95%CI 0.008–0.096;p < 0.001) and patients receiving immunosuppression with eGFR 15-29 ml/min (aOR0.031;95%CI 0.11–0.84;p = 0.021). Lower antibody responses were associated with a higher chance of a breakthrough infection.
Conclusions
Amongst dialysis, kidney transplant and autoimmune populations SARS-CoV-2 vaccine antibody responses are reduced compared to healthy controls. A reduced response to vaccination was associated with rituximab, MMF, triple immunosuppression CKD stage 4. Vaccine responses increased after the second dose, suggesting low-responder groups should be prioritised for repeated vaccination. Greater antibody responses were observed with the mRNA Pfizer vaccine compared to adenovirus AZ vaccine in dialysis patients suggesting that Pfizer SARS-CoV-2 vaccine should be the preferred vaccine choice in this sub-group.
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7
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Carr EJ, Wu M, Harvey R, Billany RE, Wall EC, Kelly G, Howell M, Kassiotis G, Swanton C, Gandhi S, Bauer DL, Graham-Brown MP, Jones RB, Smith RM, McAdoo S, Willicombe M, Beale R. Omicron neutralising antibodies after COVID-19 vaccination in haemodialysis patients. Lancet 2022; 399:800-802. [PMID: 35065703 PMCID: PMC8776276 DOI: 10.1016/s0140-6736(22)00104-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/07/2023]
Affiliation(s)
| | - Mary Wu
- The Francis Crick Institute, London NW1 1AT, UK
| | - Ruth Harvey
- The Francis Crick Institute, London NW1 1AT, UK
| | - Roseanne E Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK; NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Emma C Wall
- The Francis Crick Institute, London NW1 1AT, UK
| | - Gavin Kelly
- The Francis Crick Institute, London NW1 1AT, UK
| | | | | | | | | | | | - Matthew Pm Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK; NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rona M Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen McAdoo
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK; Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Michelle Willicombe
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK; Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Rupert Beale
- The Francis Crick Institute, London NW1 1AT, UK; UCL Dept of Renal Medicine, Royal Free Hospital, London, UK.
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8
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Affiliation(s)
- Andreas Kronbichler
- Vasculitis and Lupus Service, Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Service, Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. .,Department of Medicine, University of Cambridge, Cambridge, UK.
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9
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Suchanek O, Jayne DRW, Jones RB. Therapeutic dilemmas in relapsing renal ANCA-associated vasculitis. Rheumatology (Oxford) 2021; 60:iii60-iii62. [PMID: 34137872 DOI: 10.1093/rheumatology/keab178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/17/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ondrej Suchanek
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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10
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Trivedi S, Prasinou M, Loudon K, Jones RB, Smith RM. Fever on an airline flight: a diagnostic challenge. Rheumatology (Oxford) 2021; 60:iii21-iii23. [PMID: 34137882 DOI: 10.1093/rheumatology/keab037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/08/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sapna Trivedi
- Department of Renal Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Maria Prasinou
- Department of Renal Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Kevin Loudon
- Department of Renal Medicine, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Department of Renal Medicine, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rona M Smith
- Department of Renal Medicine, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
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11
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Mansfield Smith SC, Clare G, Jones RB. Pregnancy following rituximab for orbital eosinophilic angiocentric fibrosis. Rheumatology (Oxford) 2021; 60:iii57-iii59. [PMID: 34137878 DOI: 10.1093/rheumatology/keab034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/08/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sonja C Mansfield Smith
- Department of Ophthamology, Addenbrooke's Hospital, Cambridge University Hospital, Cambridge, UK
| | - Gerry Clare
- Department of Ophthamology, Addenbrooke's Hospital, Cambridge University Hospital, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Unit, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
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12
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Cheema K, Cox A, Coles A, Scott K, Willcocks L, Jones RB. Deciphering neurological symptoms in ANCA-associated vasculitis, uncontrolled disease or a complication of therapy. Rheumatology (Oxford) 2021; 60:iii67-iii69. [PMID: 34137879 DOI: 10.1093/rheumatology/keab103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kim Cheema
- Cummings School of Medicine, University of Calgary, Alberta, Canada
| | | | | | | | - Lisa Willcocks
- Vasculitis and Lupus Clinic, Department of Medicine, Cambridge University Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Department of Medicine, Cambridge University Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, UK
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13
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Loudon KW, Parmar J, Jayne DRW, Jones RB. Aggressive vasculitis after lung transplantation for cystic fibrosis. Rheumatology (Oxford) 2021; 60:iii47-iii49. [PMID: 34137874 DOI: 10.1093/rheumatology/keab041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kevin W Loudon
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, MRC Laboratory of Molecular Biology, Molecular Immunity Unit, University of Cambridge, Cambridge, UK
| | - Jasvir Parmar
- Department of Respiratory Medicine and Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
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14
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McClure ME, Zhu Y, Smith RM, Gopaluni S, Tieu J, Pope T, Kristensen KE, Jayne DRW, Barrett J, Jones RB. Long-term maintenance rituximab for ANCA-associated vasculitis: relapse and infection prediction models. Rheumatology (Oxford) 2021; 60:1491-1501. [PMID: 33141217 PMCID: PMC7937025 DOI: 10.1093/rheumatology/keaa541] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/14/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Following a maintenance course of rituximab (RTX) for ANCA-associated vasculitis (AAV), relapses occur on cessation of therapy, and further dosing is considered. This study aimed to develop relapse and infection risk prediction models to help guide decision making regarding extended RTX maintenance therapy. METHODS Patients with a diagnosis of AAV who received 4-8 grams of RTX as maintenance treatment between 2002 and 2018 were included. Both induction and maintenance doses were included; most patients received standard departmental protocol consisting of 2× 1000 mg 2 weeks apart, followed by 1000 mg every 6 months for 2 years. Patients who continued on repeat RTX dosing long-term were excluded. Separate risk prediction models were derived for the outcomes of relapse and infection. RESULTS A total of 147 patients were included in this study with a median follow-up of 63 months [interquartile range (IQR): 34-93]. Relapse: At time of last RTX, the model comprised seven predictors, with a corresponding C-index of 0.54. Discrimination between individuals using this model was not possible; however, discrimination could be achieved by grouping patients into low- and high-risk groups. When the model was applied 12 months post last RTX, the ability to discriminate relapse risk between individuals improved (C-index 0.65), and once again, clear discrimination was observed between patients from low- and high-risk groups. Infection: At time of last RTX, five predictors were retained in the model. The C-index was 0.64 allowing discrimination between low and high risk of infection groups. At 12 months post RTX, the C-index for the model was 0.63. Again, clear separation of patients from two risk groups was observed. CONCLUSION While our models had insufficient power to discriminate risk between individual patients they were able to assign patients into risk groups for both relapse and infection. The ability to identify risk groups may help in decisions regarding the potential benefit of ongoing RTX treatment. However, we caution the use of these prediction models until prospective multi-centre validation studies have been performed.
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Affiliation(s)
- Mark E McClure
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Yajing Zhu
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rona M Smith
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Seerapani Gopaluni
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Joanna Tieu
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Tasneem Pope
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Karl Emil Kristensen
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jessica Barrett
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
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15
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Brix SR, Jones RB, Jayne DRW. Glomerular basement membrane nephritis: crescentic renal inflammation and immunosuppressive intervention in the time of the severe acute respiratory syndrome coronavirus 2 pandemic. Kidney Int 2021; 99:1234-1235. [PMID: 33581197 PMCID: PMC7875705 DOI: 10.1016/j.kint.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Silke R Brix
- Renal, Urology and Transplantation Unit, Manchester University Hospitals, Manchester, UK.
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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16
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Van de Perre E, Jones RB, Jayne DRW. IgA vasculitis (Henoch-Schönlein purpura): refractory and relapsing disease course in the adult population. Clin Kidney J 2021; 14:1953-1960. [PMID: 34345419 PMCID: PMC8323141 DOI: 10.1093/ckj/sfaa251] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 05/10/2020] [Indexed: 12/26/2022] Open
Abstract
Background The disease course of adult immunoglobulin A (IgA) vasculitis (IgAV; Henoch–Schönlein purpura) has not been well defined. Methods In a retrospective survey, we studied 85 adult IgAV patients with extended follow-up (median 43 months) for 67 patients. Results Only 33 of 67 (49%) achieved complete remission. Ongoing renal disease was the most common persistent organ manifestation, but extra-renal disease activity was also present in >50% of patients not achieving complete remission. Twenty-nine of 67 (43%) had relapsing disease, with 18/67 (27%) experiencing several relapses. Skin disease was the most common feature in relapsing patients, followed by nephritis. At 4 years of follow-up, 6 of 29 (21%) experienced progressive disease and 10/29 (34%) relapsing disease. Five of 67 (7%) developed nephritis after diagnosis, within the first 6 months of follow-up. At final follow-up, 10 of 67 (15%) had chronic kidney disease Stage ≥G3a, 18 (27%) haematuria and 13 (19%) proteinuria. No therapy appeared particularly effective and only 6/17 patients treated with mycophenolate mofetil experienced a good response. Conclusions The disease course of adult IgAV is different from that seen in children, with higher frequency of persisting and relapsing disease. Renal disease is the main determinant of ongoing disease activity, but extra-renal features were seen in >50% of patients with chronic disease activity. No clear conclusions on use or choice of immunosuppressive agent could be made based on our experience.
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Affiliation(s)
- Els Van de Perre
- Department of Nephrology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
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17
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Barrett C, Willcocks LC, Jones RB, Tarzi RM, Henderson RB, Cai G, Gisbert SI, Belson AS, Savage CO. Effect of belimumab on proteinuria and anti-phospholipase A2 receptor autoantibody in primary membranous nephropathy. Nephrol Dial Transplant 2020; 35:599-606. [PMID: 31243451 PMCID: PMC7139214 DOI: 10.1093/ndt/gfz086] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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: 11/06/2018] [Accepted: 04/01/2019] [Indexed: 11/21/2022] Open
Abstract
Background Immunosuppressant drugs reduce proteinuria and anti-phospholipase A2 receptor autoantibodies (PLA2R-Ab) in primary membranous nephropathy (PMN) with varying success and associated toxicities. This study aimed to evaluate the effect of belimumab on proteinuria and PLA2R-Ab in participants with PMN. Methods In this prospective, open-label, experimental medicine study, 14 participants with PMN and persistent nephrotic-range proteinuria received up to 2 years belimumab monotherapy (10 mg/kg, every 4 weeks). Changes in proteinuria (urinary protein:creatinine ratio), PLA2R-Ab, albumin, cholesterol, B-cell subsets and pharmacokinetics were analysed during treatment and up to 6 months after treatment. Results Eleven participants completed to the primary endpoint (Week 28) and nine participants completed the study. In the intention-to-treat population population, baseline proteinuria of 724 mg/mmol [95% confidence interval (CI) 579–906] decreased to 498 mg/mmol (95% CI 383–649) and 130 mg/mmol (95% CI 54–312) at Weeks 28 and 104, respectively, with changes statistically significant from Week 36 (n = 11, P = 0.047). PLA2R-Ab decreased from 174 RU/mL (95% CI 79–384) at baseline to 46 RU/mL (95% CI 16–132) and 4 RU/mL (95% CI 2–6) at Weeks 28 and 104, respectively, becoming statistically significant by Week 12 (n = 13, P = 0.02). Nine participants achieved partial (n = 8) or complete (n = 1) remission. Participants with abnormal albumin and/or cholesterol at baseline gained normal/near normal levels by the last follow-up. Adverse events were consistent with those expected in this population. Conclusions Belimumab treatment in participants with PMN can reduce PLA2R-Ab and subsequently proteinuria, important preludes to remission induction.
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Affiliation(s)
| | | | | | - Ruth M Tarzi
- Experimental Medicine Unit, GlaxoSmithKline R&D, UK
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18
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Tieu J, Smith R, Basu N, Brogan P, D'Cruz D, Dhaun N, Flossmann O, Harper L, Jones RB, Lanyon PC, Luqmani RA, McAdoo SP, Mukhtyar C, Pearce FA, Pusey CD, Robson JC, Salama AD, Smyth L, Watts RA, Willcocks LC, Jayne DRW. Rituximab for maintenance of remission in ANCA-associated vasculitis: expert consensus guidelines. Rheumatology (Oxford) 2020; 59:e24-e32. [PMID: 32096545 DOI: 10.1093/rheumatology/kez640] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/31/2019] [Indexed: 01/05/2023] Open
Affiliation(s)
- Joanna Tieu
- Department of Medicine, University of Cambridge, Cambridge, UK.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Rona Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow
| | - Paul Brogan
- University College London Great Ormond Institute of Child Health.,Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David D'Cruz
- Guy's and St Thomas' NHS Foundation Trust, London
| | - Neeraj Dhaun
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh.,Royal Infirmary of Edinburgh, Edinburgh
| | | | - Lorraine Harper
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Department of Renal Medicine, Cambridge University Hospitals Trust, Cambridge
| | - Peter C Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Oxford
| | | | - Chetan Mukhtyar
- Norfolk and Norwich University Hospital.,University of East Anglia, Norwich
| | - Fiona A Pearce
- University of Nottingham.,Nottingham University Hospitals NHS Trust, Nottingham
| | | | - Joanna C Robson
- Faculty of Health and Applied Sciences, University of West of England.,Department of Rheumatology, University Hospitals Bristol NHS Trust, Bristol
| | - Alan D Salama
- University College London.,Department of Renal Medicine, Royal Free Hospital, London
| | - Lucy Smyth
- Exeter Kidney Unit, Royal Devon and Exeter Hospital, Exeter
| | - Richard A Watts
- Ipswich Hospital, Ipswich.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lisa C Willcocks
- Department of Renal Medicine, Cambridge University Hospitals Trust, Cambridge
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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19
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Cassia M, Jones RB, Cagna D, Smith R, Casazza G, Jeannin G, Zani R, Moroni G, Sinico RA, Emmi G, Vaglio A, Gallieni M, Scolari F, Jayne D, Alberici F. P0346THE EFFECTS OF RITUXIMAB MAINTENANCE THERAPY ON LUPUS NEPHRITIS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
Lupus Nephritis (LN) is the organ manifestation with the most severe prognosis in Systemic Lupus Erythematosus (SLE). Treatment options are limited due to partial efficacy, intolerance or side effects; moreover 10% of patients reach ESRD despite treatments. Rituximab (RTX) in LN is recommended as second line drug for induction of the remission after failure of Cyclophosphimide or Mycophenolate Mofetil. We have shown a role for RTX as maintenance therapy (RMT) in SLE however the effects of such approach on LN are still unclear. Aim of this study was a sub-analyses of a cohort of SLE patients treated with RTX focusing on the ones with active LN at the moment of the first RTX administration.
Methods
Patients with active LN at the time of the first RTX administration within a cohort of 147 patients with SLE were identified. Patients with SLE and a flare of LN were classified as treated with a “Single RTX course” (any RTX regimen administered within a single month) (SRC) or with RMT. Patients receiving at least three SRCs with the aim of relapse prevention and within 4 to 8 months between consecutive treatments, were classified as receiving RMT.
LN activity was determined according to creatinine, proteinuria and haematuria; complete response (CR) was defined as a decrease of proteinuria to <0.5 g/day, normal creatinine and negative urinary sediment; partial response (PR) was defined as ≥50% improvement in creatinine and proteinuria, treatment failure (TF) was any other condition. A renal flare (RF) was defined as an increase of creatinine and/or proteinuria >30% or the detection of an active urinary sediment due, according to the treating physician, to active disease.
Results
33 patients were identified; a renal biopsy had been performed in 76% with prevalence of class IV lupus nephritis in 16/33 (48%). Six months after RTX the rate of CR, PR and TF was respectively 36%, 27% and 36%; proteinuria and the prednisolone dose reduced significantly compared to baseline (respectively from a median of 2200 mg/day (IQR 499-5400) to 850 mg/day (IQR 400-1700) (p=0.005)) and from 25 mg (IQR 11-25) to 10 mg (IQR 6.125-15) (p<0.0001)). At univariate analyses the only factor associate to the risk of TF was a high number of immunosuppressive drugs employed before RTX (p=0.0077).
Of the 33 patients, 11 received RMT with a median duration of 18 months (IQR 12,6-23,4) and a median RTX dose of 5 g (IQR 4-6). During the RMT 3 patients experienced a renal flare.
The median follow-up after the last RTX administration within the SRC and the RMT groups was respectively 15 months (IQR 13,5-18,4) and 16 months (IQR 3,5-23). Comparing the RF free-survival of the two subgroups after the last RTX infusion, there was a trend towards a longer relapse free survival after the RMT (p=0.057) (figure, left panel). Of interest, the renal relapse free-survival of the 11 patients treated with RMT after the last RTX infusion was significantly longer compared to the one of the same group after the first RTX (p=0.0271) (figure, right panel).
The incidence of SAEs per 100 patient years was 0.31 in the SRC group and 0.74 in the RMT group.
Conclusion
RTX is confirmed as an effective option for patients with LN. A RMT may have a role in improving LN disease control compared to a single RTX administration.
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Affiliation(s)
| | | | | | - Rona Smith
- University of Cambridge, Cambridge, United Kingdom
| | | | | | | | | | | | | | | | | | | | - David Jayne
- University of Cambridge, Cambridge, United Kingdom
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20
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Egan A, Sivasothy P, Gore R, MartinezDel-Pero M, Willcocks L, Smith R, Burns S, Owen C, Jones RB, Jayne D. P0373MEPOLIZUMAB THERAPY FOR EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA) - ONE YEAR FOLLOW-UP STUDY USING ANTI-IL5 AS A STEROID SPARING THERAPEUTIC APPROACH. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
EGPA is a small vessel vasculitis characterised by the presence of tissue eosinophilia, necrotising vasculitis and granulomatous inflammation1. Typically, a prodromal asthmatic phase, leads to an eosinophilic stage, which can evolve to include the presence of vasculitis with renal manifestations. In the recent randomised, placebo-controlled MIRRA trial for relapsing and refractory EGPA, adjuvant therapy with anti-IL5 mAB Mepolizumab [MEPO] at 300mg s/c monthly, accrued longer times in remission, reduced steroid exposure and reduced relapse rates2. The aim of our study was to analyse the response and outcome for EGPA patients who received 100mg s/c of MEPO monthly for a minimum of 52 weeks, with particular focus on the steroid minimisation benefits.
Method
This retrospective, descriptive study analysed 13 patients with EGPA, who received 100mg s/m monthly MEPO therapy under the eosinophilic asthma care-pathway. Time points of assessment included MEPO commencement [M0] and 12 [M12] months.
Results
One patient had MEPO switched to Rituximab to treat both EGPA and new onset rheumatoid arthritis
Conclusion
The relapsing nature of EGPA places a potential dependency of therapy on steroids for asthmatic and vasculitic flares. This underscores the importance of targeted pathway specific biologic therapy to minimise steroid exposure, prevent tissue damage and ensure early response to therapy. This study demonstrates that anti-IL5 serves as a favourable model with steroid minimisation, improvement in asthma control questionnaire, reduction in BVAS and eosinophil counts at the 100mg s/c dosage. ANCA positive serology normalised in all four patients, independent of subtype. Well tolerated, it demonstrated considerable clinical benefit, with 12 patients [92.3%] continuing anti-IL5 therapy beyond 12 months. Adjuvant therapy with conventional immunosuppressants was well tolerated and renal function was preserved.
ADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. J.C.Jenette, et al Revised International Chapel Hil Consensus Conference Nomenclature of Vasculitides. 65, 1–11 (2013).
2. Wechsler, M. E. et al. Mepolizumab or Placebo for Eosinophilic Granulomatosis with Polyangiitis. N. Engl. J. Med. 376, 1921–1932 (2017).
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Affiliation(s)
- Allyson Egan
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - Pasupathy Sivasothy
- Addenbrooke's Hospital,, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - Robin Gore
- Addenbrooke's Hospital, Respiratory medicine, United Kingdom
| | - Marcos MartinezDel-Pero
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - Lisa Willcocks
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - Rona Smith
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - Stella Burns
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - Caroline Owen
- Addenbrooke's Hospital, Respiratory medicine, United Kingdom
| | - Rachel B Jones
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
| | - David Jayne
- Addenbrooke's Hospital, The Vasculitis and Lupus Centre, University of Cambridge, United Kingdom
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21
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Harper L, Jones RB. Response to: ‘MYCYC, unravelling the long road ahead in ANCA-associated vasculitis’ by Jain et al. Ann Rheum Dis 2020; 79:e58. [DOI: 10.1136/annrheumdis-2019-215254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 11/04/2022]
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22
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Tieu J, Smith R, Basu N, Brogan P, D’Cruz D, Dhaun N, Flossmann O, Harper L, Jones RB, Lanyon PC, Luqmani RA, McAdoo SP, Mukhtyar C, Pearce FA, Pusey CD, Robson JC, Salama AD, Smyth L, Watts RA, Willcocks LC, Jayne DRW. Rituximab for maintenance of remission in ANCA-associated vasculitis: expert consensus guidelines—Executive summary. Rheumatology (Oxford) 2020; 59:727-731. [DOI: 10.1093/rheumatology/kez632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/31/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joanna Tieu
- Department of Medicine, University of Cambridge, Cambridge, UK
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Rona Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Paul Brogan
- University College London Great Ormond Institute of Child Health, London, UK
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David D’Cruz
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Neeraj Dhaun
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, UK
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Lorraine Harper
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | | | - Chetan Mukhtyar
- Norfolk and Norwich University Hospital, Norwich, UK
- University of East Anglia, Norwich, UK
| | - Fiona A Pearce
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Joanna C Robson
- Faculty of Health and Applied Sciences, University of West of England, Bristol, UK
- Department of Rheumatology, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Alan D Salama
- University College London, London, UK
- Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Lucy Smyth
- Exeter Kidney Unit, Royal Devon and Exeter Hospital, Exeter, UK
| | - Richard A Watts
- Ipswich Hospital, Ipswich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lisa C Willcocks
- Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
- Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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23
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Pepper RJ, McAdoo SP, Moran SM, Kelly D, Scott J, Hamour S, Burns A, Griffith M, Galliford J, Levy JB, Cairns TD, Gopaluni S, Jones RB, Jayne D, Little MA, Pusey CD, Salama AD. A novel glucocorticoid-free maintenance regimen for anti-neutrophil cytoplasm antibody-associated vasculitis. Rheumatology (Oxford) 2019; 58:260-268. [PMID: 30239910 DOI: 10.1093/rheumatology/key288] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 01/03/2023] Open
Abstract
Objectives Glucocorticoids (GCs) are a mainstay of treatment for patients with ANCA-associated vasculitis (AAV) but are associated with significant adverse effects. Effective remission induction in severe AAV using extremely limited GC exposure has not been attempted. We tested an early rapid GC withdrawal induction regimen for patients with severe AAV. Methods Patients with active MPO- or PR3-ANCA vasculitis or ANCA-negative pauci-immune glomerulonephritis were included. Induction treatment consisted of two doses of rituximab, 3 months of low-dose CYC and a short course of oral GC (for between 1 and 2 weeks). Clinical, biochemical and immunological outcomes as well as adverse events were recorded. Results A total of 49 patients were included, with at least 12 months of follow-up in 46. All patients achieved remission, with decreases observed in creatinine, proteinuria, CRP, ANCA level and BVAS. Three patients requiring dialysis at presentation became dialysis independent. Two patients required the introduction of maintenance GC for treatment of vasculitis. Overall outcomes were comparable to those of two matched cohorts (n = 172) from previous European Vasculitis Society (EUVAS) trials, but with lower total exposure to CYC and GCs (P < 0.001) and reduced rates of severe infections (P = 0.02) compared with the RITUXVAS (rituximab versus cyclophosphamide in AAV) trial. We found no new cases of diabetes in the first year compared with historic rates of 8.2% from the EUVAS trials (P = 0.04). Conclusion Early GC withdrawal in severe AAV is as effective for remission induction as the standard of care and is associated with reduced GC-related adverse events.
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Affiliation(s)
- Ruth J Pepper
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Stephen P McAdoo
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah M Moran
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Dearbhla Kelly
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Jennifer Scott
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Sally Hamour
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Aine Burns
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Megan Griffith
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jack Galliford
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy B Levy
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Thomas D Cairns
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | | | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, Trinity College, Dublin, Ireland
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Alan D Salama
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
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24
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Cassia MA, Alberici F, Jones RB, Smith RM, Casazza G, Urban ML, Emmi G, Moroni G, Sinico RA, Messa P, Hall F, Vaglio A, Gallieni M, Jayne DR. Rituximab as Maintenance Treatment for Systemic Lupus Erythematosus: A Multicenter Observational Study of 147 Patients. Arthritis Rheumatol 2019; 71:1670-1680. [PMID: 31102498 DOI: 10.1002/art.40932] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/14/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The efficacy of rituximab (RTX) in systemic lupus erythematosus (SLE) is a subject of debate. This study was undertaken to investigate the outcomes of RTX treatment in a European SLE cohort, with an emphasis on the role of RTX as a maintenance agent. METHODS All patients with SLE who were receiving RTX as induction therapy in 4 centers were included. Patients who received a single course of RTX and those who received RTX maintenance treatment (RMT) were followed up after treatment. Disease flares during the follow-up period were defined as an increase in disease activity and the number or dose of immunosuppressive drugs. RESULTS Of 147 patients, 27% experienced treatment failure at 6 months. In a multivariate analysis, a low number of previous immunosuppressive therapies (P = 0.034) and low C4 levels (P = 0.008) reduced the risk of treatment failure. Eighty patients received RMT over a median of 24.5 months during which 85 relapses, mainly musculoskeletal, were recorded (1.06 per patient). At the time of the last RTX course, 84% of the patients were in remission. Twenty-eight (35%) of 80 patients never experienced a flare during RMT and had low damage accrual. Active articular disease at the time of the first RTX administration was associated with a risk of flare during RMT (P = 0.011). After RMT, relapse-free survival was similar to that in patients receiving a single RTX course (P = 0.72). CONCLUSION RMT is a potential treatment option for patients with difficult-to-treat disease. Relapses occur during RMT and are more likely in those with active articular disease at the time of the first RTX administration. Relapse risk after RMT remains high and apparently comparable to that seen after a single RTX course.
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Affiliation(s)
| | | | | | | | | | | | | | - Gabriella Moroni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milan, Milan, Italy
| | | | - Piergiorgio Messa
- Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milan and University of Milan, Milan, Italy
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25
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Affiliation(s)
- Mark McClure
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom; and .,Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom; and
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26
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Jones RB, Hiemstra TF, Walsh M, Jayne D, Harper L. Response to: 'Mycophenolate mofetil: a step forward in the induction treatment of ANCA-associated vasculitis? Comment on the article by Jones et al' by Vandergheynst et al. Ann Rheum Dis 2019; 79:e101. [PMID: 31217171 DOI: 10.1136/annrheumdis-2019-215658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 06/09/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Rachel B Jones
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | | | - Michael Walsh
- Population Health Research Institute, Hamilton, Ontario, Canada.,Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Jayne
- Division of Nephrology, Addenbrooke's Hospital, Cambridge, UK
| | - Lorraine Harper
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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27
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Teixeira V, Mohammad AJ, Jones RB, Smith R, Jayne D. Efficacy and safety of rituximab in the treatment of eosinophilic granulomatosis with polyangiitis. RMD Open 2019; 5:e000905. [PMID: 31245051 PMCID: PMC6560673 DOI: 10.1136/rmdopen-2019-000905] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/06/2019] [Accepted: 05/15/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Eosinophilic granulomatosis with polyangiitis (EGPA) is a subset of antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis with distinct pathophysiological mechanisms, clinical features and treatment responses. Rituximab is a licensed therapy for granulomatosis with polyangiitis and microscopic polyangiitis but there is limited experience of rituximab in EGPA. Methods EGPA patients from a tertiary centre who received rituximab for mostly refractory EGPA or in whom cyclophosphamide was contra indicated were studied. A standardised dataset was collected at time of initial treatment and every 3 months for 24 months. Response was defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 and partial response as ≥50% reduction in BVAS from baseline. Remission was defined as a BVAS of 0 on prednisolone dose ≤5 mg. Results Sixty-nine patients (44 female) received rituximab between 2003 and 2017. Improvement (response and partial response) was observed in 76.8% of patients at 6 months, 82.8% at 12 months and in 93.2% by 24 months, while relapses occurred in 54% by 24 months, with asthma being the most frequent manifestation. The median BVAS decreased from 6 at baseline to 1 at 6 months, and 0 at 12 and 24 months. Prednisolone dose (mg/day, median) decreased from 12.5 to 7, 7.5 and 5 at 6, 12 and 24 months, respectively. ANCA positive patients had a longer asthma/ear, nose and throat (ENT) relapse-free survival time and a shorter time to remission. Discussion Rituximab demonstrated some efficacy in EGPA and led to a reduction in prednisolone requirement, but asthma and ENT relapse rates were high despite continued treatment. The ANCA positive subset appeared to have a more sustained response on isolated asthma/ENT exacerbations.
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Affiliation(s)
- Vítor Teixeira
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Aladdin J Mohammad
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Clinical Sciences, Rheumatology, Lund University, Lund, Skåne, Sweden
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - Rona Smith
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - David Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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28
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Pepper RJ, McAdoo SP, Moran SM, Kelly D, Scott J, Hamour S, Burns A, Griffith M, Galliford J, Levy JB, Cairns TD, Gopaluni S, Jones RB, Jayne D, Little MA, Pusey CD, Salama AD. A novel glucocorticoid-free maintenance regimen for anti-neutrophil cytoplasm antibody–associated vasculitis. Rheumatology (Oxford) 2019; 58:373. [DOI: 10.1093/rheumatology/kez001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ruth J Pepper
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Stephen P McAdoo
- Renal and Vascular Inflammation Section, Imperial College London, London, UK
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah M Moran
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Dearbhla Kelly
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Jennifer Scott
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Sally Hamour
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Aine Burns
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Megan Griffith
- Renal and Vascular Inflammation Section, Imperial College London, London, UK
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jack Galliford
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy B Levy
- Renal and Vascular Inflammation Section, Imperial College London, London, UK
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Thomas D Cairns
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | | | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Trinity College, Dublin, Ireland
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Imperial College London, London, UK
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Alan D Salama
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
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29
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Jones RB, Hiemstra TF, Ballarin J, Blockmans DE, Brogan P, Bruchfeld A, Cid MC, Dahlsveen K, de Zoysa J, Espigol-Frigolé G, Lanyon P, Peh CA, Tesar V, Vaglio A, Walsh M, Walsh D, Walters G, Harper L, Jayne D. Mycophenolate mofetil versus cyclophosphamide for remission induction in ANCA-associated vasculitis: a randomised, non-inferiority trial. Ann Rheum Dis 2019; 78:399-405. [PMID: 30612116 DOI: 10.1136/annrheumdis-2018-214245] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [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: 08/06/2018] [Revised: 11/30/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Cyclophosphamide induction regimens are effective for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), but are associated with infections, malignancies and infertility. Mycophenolate mofetil (MMF) has shown high remission rates in small studies of AAV. METHODS We conducted a randomised controlled trial to investigate whether MMF was non-inferior to cyclophosphamide for remission induction in AAV. 140 newly diagnosed patients were randomly assigned to MMF or pulsed cyclophosphamide. All patients received the same oral glucocorticoid regimen and were switched to azathioprine following remission. The primary endpoint was remission by 6 months requiring compliance with the tapering glucocorticoid regimen. Patients with an eGFR <15 mL/min were excluded from the study. RESULTS At baseline, ANCA subtype, disease activity and organ involvement were similar between groups. Non-inferiority was demonstrated for the primary remission endpoint, which occurred in 47 patients (67%) in the MMF group and 43 patients (61%) in the cyclophosphamide group (risk difference 5.7%, 90% CI -7.5% to 19%). Following remission, more relapses occurred in the MMF group (23 patients, 33%) compared with the cyclophosphamide group (13 patients, 19%) (incidence rate ratio 1.97, 95% CI 0.96 to 4.23, p=0.049). In MPO-ANCA patients, relapses occurred in 12% of the cyclophosphamide group and 15% of the MMF group. In PR3-ANCA patients, relapses occurred in 24% of the cyclophosphamide group and 48% of the MMF group. Serious infections were similar between groups (26% MMF group, 17% cyclophosphamide group) (OR 1.67, 95% CI 0.68 to 4.19, p=0.3). CONCLUSION MMF was non-inferior to cyclophosphamide for remission induction in AAV, but resulted in higher relapse rate. TRIAL REGISTRATION NUMBER NCT00414128.
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Affiliation(s)
- Rachel B Jones
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Thomas F Hiemstra
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Trials Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Jose Ballarin
- Department of Nephrology, Fundació Puigvert, Barcelona, Spain
| | | | - Paul Brogan
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health, London, UK
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Annette Bruchfeld
- Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Karen Dahlsveen
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Janak de Zoysa
- Renal Service, Waitemata District Health Board, Auckland, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Georgína Espigol-Frigolé
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Peter Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Chen Au Peh
- Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vladimir Tesar
- Department of Nephrology, Charles University and General University Hospital, Prague, Czech Republic
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Firenze, Italy
- Nephrology and Dialysis Unit, Meyer Children's University Hospital, Firenze, Italy
| | - Michael Walsh
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dorothy Walsh
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Giles Walters
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Lorraine Harper
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - David Jayne
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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30
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Banham GD, Flint SM, Torpey N, Lyons PA, Shanahan DN, Gibson A, Watson CJE, O'Sullivan AM, Chadwick JA, Foster KE, Jones RB, Devey LR, Richards A, Erwig LP, Savage CO, Smith KGC, Henderson RB, Clatworthy MR. Belimumab in kidney transplantation: an experimental medicine, randomised, placebo-controlled phase 2 trial. Lancet 2018; 391:2619-2630. [PMID: 29910042 DOI: 10.1016/s0140-6736(18)30984-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND B cells produce alloantibodies and activate alloreactive T cells, negatively affecting kidney transplant survival. By contrast, regulatory B cells are associated with transplant tolerance. Immunotherapies are needed that inhibit B-cell effector function, including antibody secretion, while sparing regulators and minimising infection risk. B lymphocyte stimulator (BLyS) is a cytokine that promotes B-cell activation and has not previously been targeted in kidney transplant recipients. We aimed to determine the safety and activity of an anti-BLyS antibody, belimumab, in addition to standard-of-care immunosuppression in adult kidney transplant recipients. We used an experimental medicine study design with multiple secondary and exploratory endpoints to gain further insight into the effect of belimumab on the generation of de-novo IgG and on the regulatory B-cell compartment. METHODS We undertook a double-blind, randomised, placebo-controlled phase 2 trial of belimumab, in addition to standard-of-care immunosuppression (basiliximab, mycophenolate mofetil, tacrolimus, and prednisolone) at two centres, Addenbrooke's Hospital, Cambridge, UK, and Guy's and St Thomas' Hospital, London, UK. Participants were eligible if they were aged 18-75 years and receiving a kidney transplant and were planned to receive standard-of-care immunosuppression. Participants were randomly assigned (1:1) to receive either intravenous belimumab 10 mg per kg bodyweight or placebo, given at day 0, 14, and 28, and then every 4 weeks for a total of seven infusions. The co-primary endpoints were safety and change in the concentration of naive B cells from baseline to week 24, both of which were analysed in all patients who received a transplant and at least one dose of drug or placebo (the modified intention-to-treat [mITT] population). This trial has been completed and is registered with ClinicalTrials.gov, NCT01536379, and EudraCT, 2011-006215-56. FINDINGS Between Sept 13, 2013, and Feb 8, 2015, of 303 patients assessed for eligibility, 28 kidney transplant recipients were randomly assigned to receive belimumab (n=14) or placebo (n=14). 25 patients (12 [86%] patients assigned to the belimumab group and 13 [93%] patients assigned to the placebo group) received a transplant and were included in the mITT population. We observed similar proportions of adverse events in the belimumab and placebo groups, including serious infections (one [8%] of 12 in the belimumab group and five [38%] of 13 in the placebo group during the 6-month on-treatment phase; and none in the belimumab group and two [15%] in the placebo group during the 6-month follow-up). In the on-treatment phase, one patient in the placebo group died because of fatal myocardial infarction and acute cardiac failure. The co-primary endpoint of a reduction in naive B cells from baseline to week 24 was not met. Treatment with belimumab did not significantly reduce the number of naive B cells from baseline to week 24 (adjusted mean difference between the belimumab and placebo treatment groups -34·4 cells per μL, 95% CI -109·5 to 40·7). INTERPRETATION Belimumab might be a useful adjunct to standard-of-care immunosuppression in renal transplantation, with no major increased risk of infection and potential beneficial effects on humoral alloimmunity. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Gemma D Banham
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Shaun M Flint
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Nicholas Torpey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Don N Shanahan
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Adele Gibson
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ann-Marie O'Sullivan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Joseph A Chadwick
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Katie E Foster
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Luke R Devey
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Anna Richards
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Lars-Peter Erwig
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Caroline O Savage
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Menna R Clatworthy
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.
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Mohammad AJ, Mortensen KH, Babar J, Smith R, Jones RB, Nakagomi D, Sivasothy P, Jayne DRW. Pulmonary Involvement in Antineutrophil Cytoplasmic Antibodies (ANCA)-associated Vasculitis: The Influence of ANCA Subtype. J Rheumatol 2017; 44:1458-1467. [PMID: 28765242 DOI: 10.3899/jrheum.161224] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe pulmonary involvement at time of diagnosis in antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV), as defined by computed tomography (CT). METHODS Patients with thoracic CT performed on or after the onset of AAV (n = 140; 75 women; granulomatosis with polyangiitis, n = 79; microscopic polyangiitis MPA, n = 61) followed at a tertiary referral center vasculitis clinic were studied. Radiological patterns of pulmonary involvement were evaluated from the CT studies using a predefined protocol, and compared to proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA specificity. RESULTS Of the patients, 77% had an abnormal thoracic CT study. The most common abnormality was nodular disease (24%), of which the majority were peribronchial nodules, followed by bronchiectasis and pleural effusion (19%, each), pulmonary hemorrhage and lymph node enlargement (14%, each), emphysema (13%), and cavitating lesions (11%). Central airways disease and a nodular pattern of pulmonary involvement were more common in PR3-ANCA-positive patients (p < 0.05). Usual interstitial pneumonitis (UIP) and bronchiectasis were more prevalent in MPO-ANCA-positive patients (p < 0.05). Alveolar hemorrhage, pleural effusion, lymph node enlargement, and pulmonary venous congestion were more frequent in MPO-ANCA-positive patients. CONCLUSION Pulmonary involvement is frequent and among 140 patients with AAV who underwent a thoracic CT study, almost 80% have pulmonary abnormalities on thoracic CT. Central airway disease occurs exclusively among patients with PR3-ANCA while UIP were mainly seen in those with MPO-ANCA. These findings may have important implications for the investigation, management, and pathogenesis of AAV.
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Affiliation(s)
- Aladdin J Mohammad
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK. .,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital.
| | - Kristian H Mortensen
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Judith Babar
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Rona Smith
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Rachel B Jones
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Daiki Nakagomi
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Pasupathy Sivasothy
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - David R W Jayne
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
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Gopaluni S, Smith RM, Lewin M, McAlear CA, Mynard K, Jones RB, Specks U, Merkel PA, Jayne DRW. Rituximab versus azathioprine as therapy for maintenance of remission for anti-neutrophil cytoplasm antibody-associated vasculitis (RITAZAREM): study protocol for a randomized controlled trial. Trials 2017; 18:112. [PMID: 28270229 PMCID: PMC5341185 DOI: 10.1186/s13063-017-1857-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/20/2017] [Indexed: 12/17/2022] Open
Abstract
Background Rituximab is effective as therapy for induction of remission in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, the effect of rituximab is not sustained, and subsequent relapse rates are high, especially in patients with a history of relapse. There is a need to identify whether maintenance therapy with rituximab is superior to the current standard of azathioprine or methotrexate for prevention of relapse following induction with rituximab. Methods/design RITAZAREM is an international, multicenter, open-label, randomized controlled trial designed to demonstrate the superiority of repeated doses of intravenous rituximab compared to daily orally administered azathioprine as a relapse prevention strategy in patients with AAV with relapsing disease who undergo induction of remission with rituximab. Patients with AAV will be recruited at the time of relapse and will receive rituximab and glucocorticoid induction therapy. If the disease is controlled by 4 months, patients will be randomized in a 1:1 ratio to receive rituximab (1000 mg every 4 months for five doses) or azathioprine (2 mg/kg/day) as maintenance therapy. Patients will be followed for a minimum of 36 months. The primary outcome is the time to disease relapse. It is estimated that 190 patients will need to be recruited to ensure that at least 160 are randomized. Discussion The RITAZAREM trial will provide the largest trial dataset for the use of rituximab as remission-induction therapy for patients with AAV comparing two remission-maintenance strategies following induction with rituximab, and explore whether prolonged B-cell depletion leads to sustained treatment-free remissions after discontinuation of immunosuppressive therapy. Trial registration ClinicalTrials.gov identifier: NCT01697267. Registered on 31 August 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1857-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Rona M Smith
- University of Cambridge Hospitals NHS Foundation Trust, Cambridge, UK. .,Addenbrooke's Hospital, Box 118, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Michelle Lewin
- University of Cambridge Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carol A McAlear
- Division of Rheumatology and Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim Mynard
- University of Cambridge Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rachel B Jones
- University of Cambridge Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ulrich Specks
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter A Merkel
- Division of Rheumatology and Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - David R W Jayne
- University of Cambridge Hospitals NHS Foundation Trust, Cambridge, UK
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Andersson BS, Thall PF, Valdez BC, Milton DR, Al-Atrash G, Chen J, Gulbis A, Chu D, Martinez C, Parmar S, Popat U, Nieto Y, Kebriaei P, Alousi A, de Lima M, Rondon G, Meng QH, Myers A, Kawedia J, Worth LL, Fernandez-Vina M, Madden T, Shpall EJ, Jones RB, Champlin RE. Fludarabine with pharmacokinetically guided IV busulfan is superior to fixed-dose delivery in pretransplant conditioning of AML/MDS patients. Bone Marrow Transplant 2016; 52:580-587. [PMID: 27991894 PMCID: PMC5382042 DOI: 10.1038/bmt.2016.322] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
Abstract
We hypothesized that IV Busulfan (Bu) dosing could be safely intensified through pharmacokinetic (PK-) dose guidance to minimize the inter-patient variability in systemic exposure (SE) associated with body-sized dosing, and this should improve outcome of AML/MDS patients undergoing allogeneic stem cell transplantation (allo-HSCT). To test this hypothesis, we treated 218 patients (median age 50.7 years, male/female 50/50%) with fludarabine (Flu) 40 mg/m2 once daily ×4, each dose followed by IV Bu, randomized to 130 mg/m2 (N=107) or PK-guided to average daily SE, AUC of 6,000 µM-min (N=111), stratified for remission-status, and allo-grafting from HLA-matched donors. Toxicity and graft vs. host disease (GvHD) rates in the groups were similar; the risk of relapse or treatment-related mortality remained higher in the fixed-dose group throughout the 80-month observation period. Further, PK-guidance yielded safer disease-control, leading to improved overall and progression-free survival, most prominently in MDS-patients and in AML-patients not in remission at allo-HSCT. We conclude that AML/MDS patients receiving pretransplant conditioning treatment with our 4-day regimen may benefit significantly from PK-guided Bu-dosing. This could be considered an alternative to fixed dose delivery since it provides the benefit of precise dose delivery to a predetermined SE without increasing risk(s) of serious toxicity and/or GvHD.
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Affiliation(s)
- B S Andersson
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B C Valdez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Al-Atrash
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Chen
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Chu
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Martinez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Parmar
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - U Popat
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Alousi
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M de Lima
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Rondon
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Q H Meng
- Division of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Myers
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Kawedia
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L L Worth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - T Madden
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - E J Shpall
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R B Jones
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lord RW, Pearson JS, Barry PJ, Whorwell PJ, Jones RB, McNamara P, Beynon R, Smith JA, Jones AM. P97 Gastro-oesophageal reflux in cystic fibrosis. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chetcuti S, Jones RB, Varley J. Heritable connective tissue diseases, vasculitides, and the anaesthetist. BJA Educ 2016. [DOI: 10.1093/bjaed/mkw016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Van de Perre E, Jones RB, Jayne DR. SP133IGA VASCULITIS (HENOCH-SCHÖNLEIN PURPURA): REFRACTORY AND RELAPSING DISEASE COURSE IN THE ADULT POPULATION. Nephrol Dial Transplant 2016. [DOI: 10.1093/ndt/gfw160.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nieto Y, Tu SM, Bassett R, Jones RB, Gulbis AM, Tannir N, Kingham A, Ledesma C, Margolin K, Holmberg L, Champlin R, Pagliaro L. Bevacizumab/high-dose chemotherapy with autologous stem-cell transplant for poor-risk relapsed or refractory germ-cell tumors. Ann Oncol 2015; 26:2507-8. [PMID: 26487577 DOI: 10.1093/annonc/mdv479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nieto Y, Tu SM, Bassett R, Jones RB, Gulbis AM, Tannir N, Kingham A, Ledesma C, Margolin K, Holmberg L, Champlin R, Pagliaro L. Bevacizumab/high-dose chemotherapy with autologous stem-cell transplant for poor-risk relapsed or refractory germ-cell tumors. Ann Oncol 2015. [PMID: 26199392 DOI: 10.1093/annonc/mdv310] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 11/13/2022] Open
Abstract
BACKGROUND High-dose chemotherapy (HDC) using sequential cycles of carboplatin/etoposide is curative for relapsed germ-cell tumors (GCT). However, outcomes of high-risk patients in advanced relapse remain poor. We previously developed a new HDC regimen combining infusional gemcitabine with docetaxel/melphalan/carboplatin (GemDMC), with preliminary high activity in refractory GCT. Given the high vascular endothelial growth factor expression in metastatic GCT and the synergy between bevacizumab and chemotherapy, we studied concurrent bevacizumab and sequential HDC using GemDMC and ifosfamide/carboplatin/etoposide (ICE) in patients with poor-risk relapsed or refractory disease. PATIENTS AND METHODS Eligibility criteria included intermediate/high-risk relapse (Beyer Model), serum creatinine ≤ 1.8 mg/dl and adequate pulmonary/cardiac/hepatic function. Patients received sequential HDC cycles with bevacizumab preceding GemDMC (cycle 1) and ICE (cycle 2). The trial was powered to distinguish a target 50% 2-year relapse-free survival (RFS) from an expected 25% 2-year RFS in this population. RESULTS We enrolled 43 male patients, median age 30 (20-49) years, with absolute refractory (N = 20), refractory (N = 17) or cisplatin-sensitive (N = 6) disease, after a median 3 (1-5) prior relapses. Disease status right before HDC was unresponsive (N = 24, progressive disease 22, stable disease 2), partial response with positive markers (PRm(+)) (N = 8), PRm(-) (N = 7) or complete response (N = 4). Main toxicities were mucositis and renal. Four patients (three with baseline marginal renal function) died from HDC-related complications. Tumor markers normalized in 85% patients. Resection of residual lesions (N = 13) showed necrosis (N = 4), mature teratoma (N = 2), necrosis/teratoma (N = 3) and viable tumor (N = 4). At median follow-up of 46 (9-84) months, the RFS and overall survival rates are 55.8% and 58.1%, respectively. CONCLUSIONS Sequential bevacizumab/GemDMC-bevacizumab/ICE shows encouraging outcomes in heavily pretreated and refractory GCT, exceeding the results expected in this difficult to treat population. CLINICALTRIALSGOV NCT00936936.
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Affiliation(s)
- Y Nieto
- Department of Stem Cell Transplantation and Cellular Therapy
| | - S-M Tu
- Department of Genitourinary Medical Oncology
| | | | - R B Jones
- Department of Stem Cell Transplantation and Cellular Therapy
| | - A M Gulbis
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - N Tannir
- Department of Genitourinary Medical Oncology
| | - A Kingham
- Department of Stem Cell Transplantation and Cellular Therapy
| | - C Ledesma
- Department of Stem Cell Transplantation and Cellular Therapy
| | - K Margolin
- Department of Medical Oncology, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - L Holmberg
- Department of Medical Oncology, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - R Champlin
- Department of Stem Cell Transplantation and Cellular Therapy
| | - L Pagliaro
- Department of Genitourinary Medical Oncology
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Jones RB, Furuta S, Tervaert JWC, Hauser T, Luqmani R, Morgan MD, Peh CA, Savage CO, Segelmark M, Tesar V, van Paassen P, Walsh M, Westman K, Jayne DR. Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis: 2-year results of a randomised trial. Ann Rheum Dis 2015; 74:1178-82. [PMID: 25739829 DOI: 10.1136/annrheumdis-2014-206404] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [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: 08/03/2014] [Accepted: 02/08/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The RITUXVAS trial reported similar remission induction rates and safety between rituximab and cyclophosphamide based regimens for antineutrophil cytoplasm antibody (ANCA)-associated vasculitis at 12 months; however, immunosuppression maintenance requirements and longer-term outcomes after rituximab in ANCA-associated renal vasculitis are unknown. METHODS Forty-four patients with newly diagnosed ANCA-associated vasculitis and renal involvement were randomised, 3:1, to glucocorticoids plus either rituximab (375 mg/m(2)/week×4) with two intravenous cyclophosphamide pulses (n=33, rituximab group), or intravenous cyclophosphamide for 3-6 months followed by azathioprine (n=11, control group). RESULTS The primary end point at 24 months was a composite of death, end-stage renal disease and relapse, which occurred in 14/33 in the rituximab group (42%) and 4/11 in the control group (36%) (p=1.00). After remission induction treatment all patients in the rituximab group achieved complete B cell depletion and during subsequent follow-up, 23/33 (70%) had B cell return. Relapses occurred in seven in the rituximab group (21%) and two in the control group (18%) (p=1.00). All relapses in the rituximab group occurred after B cell return. CONCLUSIONS At 24 months, rates of the composite outcome of death, end-stage renal disease and relapse did not differ between groups. In the rituximab group, B cell return was associated with relapse. TRIAL REGISTRATION NUMBER ISRCTN28528813.
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Affiliation(s)
| | | | | | | | - Raashid Luqmani
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK
| | - Matthew D Morgan
- Department of Renal Immunobiology, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Chen Au Peh
- Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia
| | - Caroline O Savage
- Department of Renal Immunobiology, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Marten Segelmark
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Vladimir Tesar
- The First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pieter van Paassen
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Michael Walsh
- Departments of Medicine (Nephrology) and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Kerstin Westman
- Department of Nephrology and Transplantation in Malmo, University Hospital of Skane and Lund University, Malmo, Sweden
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Roberts DM, Jones RB, Smith RM, Alberici F, Kumaratne DS, Burns S, Jayne DRW. Rituximab-associated hypogammaglobulinemia: incidence, predictors and outcomes in patients with multi-system autoimmune disease. J Autoimmun 2014; 57:60-5. [PMID: 25556904 DOI: 10.1016/j.jaut.2014.11.009] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [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: 07/08/2014] [Revised: 11/16/2014] [Accepted: 11/28/2014] [Indexed: 12/25/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody used to treat lymphoma and autoimmune disease. Hypogammaglobulinemia has occurred after rituximab for lymphoma and rheumatoid arthritis but data are scarce for other autoimmune indications. This study describes the incidence and severity of hypogammaglobulinemia in patients receiving rituximab for small vessel vasculitis and other multi-system autoimmune diseases. Predictors for and clinical outcomes of hypogammaglobulinemia were explored. We conducted a retrospective study in a tertiary referral specialist clinic. The severity of hypogammaglobulinemia was categorized by the nadir serum IgG concentration measured during clinical care. We identified 288 patients who received rituximab; 243 were eligible for inclusion with median follow up of 42 months. 26% were IgG hypogammaglobulinemic at the time that rituximab was initiated and 56% had IgG hypogammaglobulinemia during follow-up (5-6.9 g/L in 30%, 3-4.9 g/L in 22% and <3 g/L in 4%); IgM ≤0.3 g/L in 58%. The nadir IgG was non-sustained in 50% of cases with moderate/severe hypogammaglobulinemia. A weak association was noted between prior cyclophosphamide exposure and nadir IgG concentration, but not cumulative rituximab dose. IgG concentrations prior to and at the time of rituximab correlated with the nadir IgG post rituximab. IgG replacement was initiated because of recurrent infection in 12 (4.2%) patients and a lower IgG increased the odds ratio of receiving IgG replacement. Rituximab is associated with an increased risk of hypogammaglobulinemia but recovery of IgG level can occur. IgG monitoring may be useful for patients receiving rituximab.
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Affiliation(s)
- Darren M Roberts
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK; School of Medicine, University of Queensland, Butterfield Street, Herston, Queensland, 4006, Australia.
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - Rona M Smith
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - Federico Alberici
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK; Department of Clinical Medicine, University of Parma, Via Gramsci 14, Parma 43126, Italy; Department of Nephrology, University of Parma, Via Gramsci 14, Parma 43126, Italy
| | - Dinakantha S Kumaratne
- Department of Clinical Immunology, Box 109, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - Stella Burns
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
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Alberici F, Smith RM, Jones RB, Roberts DM, Willcocks LC, Chaudhry A, Smith KGC, Jayne DRW. Long-term follow-up of patients who received repeat-dose rituximab as maintenance therapy for ANCA-associated vasculitis. Rheumatology (Oxford) 2014; 54:1153-60. [PMID: 25477054 DOI: 10.1093/rheumatology/keu452] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE ANCA-associated vasculitis (AAV) is characterized by a chronic relapsing course. Rituximab (RTX) is an effective maintenance treatment; however, the long-term outcomes after its discontinuation are unclear. The aim of this study was to explore the long-term outcomes of AAV patients treated with repeat-dose RTX maintenance therapy. METHODS AAV patients receiving a RTX treatment protocol consisting of an induction and maintenance phase were included. For initial remission induction, RTX was dosed at 1 g every 2 weeks or 375 mg/m(2) weekly for 4 consecutive weeks and for remission maintenance at 1 g every 6 months for 24 months. At the first RTX administration, ongoing immunosuppressives were withdrawn. RESULTS Sixty-nine patients were identified, 67 of whom were failing other therapies. Nine relapsed during the RTX treatment protocol; however, all 69 were in remission at the end of the maintenance phase on a median prednisolone dose of 2.5 mg/day and 9% were receiving additional immunosuppression. During subsequent observation, 28 patients relapsed a median of 34.4 months after the last RTX infusion. Risk factors for relapse were PR3-associated disease (P = 0.039), B cell return within 12 months of the last RTX infusion (P = 0.0038) and switch from ANCA negativity to positivity (P = 0.0046). Two patients died and two developed severe hypogammaglobulinaemia. CONCLUSION This study supports the efficacy and safety of a fixed-interval RTX maintenance regimen in relapsing/refractory AAV. Relapses after discontinuation of maintenance therapy did occur, but at a lower rate than after a single RTX induction course. PR3-associated disease, the switch from ANCA negative to positive and the return of B cells within 12 months of the last RTX administration were risk factors for further relapse.
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Affiliation(s)
- Federico Alberici
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Rona M Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Darren M Roberts
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Lisa C Willcocks
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Afzal Chaudhry
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK Department of Medicine, University of Cambridge School of Clinical Medicine, Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK, Department of Clinical and Experimental Medicine, University of Parma, Italy and Cambridge Institute for Medical Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
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Jones RB, Walsh M, Chaudhry AN, Smith KGC, Jayne DRW. Randomized trial of enteric-coated mycophenolate sodium versus mycophenolate mofetil in multi-system autoimmune disease. Clin Kidney J 2014; 7:562-8. [PMID: 25859373 PMCID: PMC4389135 DOI: 10.1093/ckj/sfu096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 08/02/2014] [Accepted: 08/19/2014] [Indexed: 12/13/2022] Open
Abstract
Background The use of mycophenolate mofetil (MMF) in autoimmune disease is often limited by adverse effects. In this single-centre, open label, parallel design study, we investigated whether enteric-coated mycophenolate sodium (MS) is better tolerated and therefore more efficacious than MMF in primary systemic vasculitis (PSV) and systemic lupus erythematosus (SLE). Methods Forty patients with vasculitis or systemic lupus erythematosus (SLE) due to commence MMF for active disease or remission maintenance were randomized to receive either 1440 mg/day MS or 2000 mg/day MMF (18 PSV, 2 SLE per group) in addition to corticosteroids. Random allocation was performed by minimization for age, diagnosis and renal function using a computer algorithm. Twenty-five were treated for active disease (5 first-line therapy, 20 salvage therapy) and 15 for remission maintenance. The composite primary end point was treatment failure and/or drug intolerance over 12 months. Treatment failure was defined as failure to achieve remission by 6 months or disease relapse and treatment intolerance was defined as inability to tolerate and maintain the target dose of MS or MMF within 12 months. Results Forty patients were included in the analyses. MS was associated with a lower primary end point rate [hazard ratio (HR) 0.37; 95% CI 0.17–0.80; P = 0.012] (11/20, 55% patients) compared with MMF (17/20, 85% patients). Treatment failure alone was less common in the MS group (HR 0.28; 95% CI 0.095–0.82; P = 0.020), although drug intolerance did not differ between groups (HR 0.53; 95% CI 0.20–1.42; P = 0.21). Despite randomization, patients in the MMF group may have had a higher baseline risk for treatment failure; more MMF patients had refractory disease and granulomatosis with polyangiitis (Wegener's). A glomerular filtration rate (GFR) ≤40 mL/min was associated with intolerance. Serious adverse events were common (55% MMF and 45% MS patients). Conclusions No differences in treatment tolerance were observed between the MS and MMF groups. Despite similar treatment intolerance, MS was associated with improved efficacy in PSV and SLE compared with MMF. However, baseline group imbalances in factors potentially affecting remission and relapse may have influenced the results. Treatment intolerance was common and strongly associated with low GFR. Further treatment trials are warranted to investigate the effect of GFR on mycophenolic acid pharmacokinetics and clinical outcomes (ISRCTN83027184; EUDRACT 2005-002207-16; Funding Novartis UK).
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Affiliation(s)
- Rachel B Jones
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK
| | - Michael Walsh
- Departments of Medicine and Clinical Epidemiology & Biostatistics , McMaster University , Hamilton, Canada
| | - Afzal N Chaudhry
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK
| | - Kenneth G C Smith
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK ; Cambridge Institute of Medical Research , University of Cambridge School of Clinical Medicine , Cambridge , UK ; Department of Medicine , University of Cambridge School of Clinical Medicine , Cambridge , UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK ; Department of Medicine , University of Cambridge School of Clinical Medicine , Cambridge , UK
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Felderhof BU, Jones RB. Optimal translational swimming of a sphere at low Reynolds number. Phys Rev E Stat Nonlin Soft Matter Phys 2014; 90:023008. [PMID: 25215821 DOI: 10.1103/physreve.90.023008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Indexed: 06/03/2023]
Abstract
Swimming velocity and rate of dissipation of a sphere with surface distortions are discussed on the basis of the Stokes equations of low-Reynolds-number hydrodynamics. At first the surface distortions are assumed to cause an irrotational axisymmetric flow pattern. The efficiency of swimming is optimized within this class of flows. Subsequently, more general axisymmetric polar flows with vorticity are considered. This leads to a considerably higher maximum efficiency. An additional measure of swimming performance is proposed based on the energy consumption for given amplitude of stroke.
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Affiliation(s)
- B U Felderhof
- Institut für Theorie der Statistischen Physik, RWTH Aachen University, Templergraben 55, 52056 Aachen, Germany
| | - R B Jones
- Queen Mary University of London, The School of Physics and Astronomy, Mile End Road, London E1 4NS, United Kingdom
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Jones RB, Mills AD, Faure JM. Social discrimination in Japanese quail Coturnix japonica chicks genetically selected for low or high social reinstatement motivation. Behav Processes 2014; 36:117-24. [PMID: 24896679 DOI: 10.1016/0376-6357(95)00024-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/1995] [Indexed: 10/16/2022]
Abstract
Japanese quail chicks of two lines genetically selected for low levels of social reinstatement behaviour (LSR) or high levels of social reinstatement behaviour (HSR) were housed in groups of three. The approach/avoidance tendencies of an individual chick from each group towards a familiar cagemate and a stranger from another group placed at opposite ends of a runway were measured at 7 days of age. Quail chicks of both genetic lines preferentially approached, spent longer near, and showed shorter mean distances from the cagemate than the stranger. Irrespective of stimulus type, the HSR quail generally showed shorter approach latencies, spent longer within 15 cm of the goal boxes, made more entries into these areas, and travelled further during the test than did their LSR counterparts. These findings demonstrated that Japanese quail chicks, of two genetic lines reared in small groups, successfully discriminated between familiar cagemates and strangers. They also suggest that there are no straightforward relationships between underlying social motivation and social preferences.
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Affiliation(s)
- R B Jones
- Roslin Institute (Edinburgh), Roslin, Midlothian EH25 9PS, UK
| | - A D Mills
- Station de Recherches Avicoles, Institut National de la Recherche Agronomique, Centre de Tours - Nouzilly, 37380 Nouzilly, France
| | - J M Faure
- Station de Recherches Avicoles, Institut National de la Recherche Agronomique, Centre de Tours - Nouzilly, 37380 Nouzilly, France
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Marco H, Smith RM, Jones RB, Guerry MJ, Catapano F, Burns S, Chaudhry AN, Smith KGC, Jayne DRW. The effect of rituximab therapy on immunoglobulin levels in patients with multisystem autoimmune disease. BMC Musculoskelet Disord 2014; 15:178. [PMID: 24884562 PMCID: PMC4038057 DOI: 10.1186/1471-2474-15-178] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 05/15/2014] [Indexed: 02/07/2023] Open
Abstract
Background Rituximab is a B cell depleting anti-CD20 monoclonal antibody. CD20 is not expressed on mature plasma cells and accordingly rituximab does not have immediate effects on immunoglobulin levels. However, after rituximab some patients develop hypogammaglobulinaemia. Methods We performed a single centre retrospective review of 177 patients with multisystem autoimmune disease receiving rituximab between 2002 and 2010. The incidence, severity and complications of hypogammaglobulinaemia were investigated. Results Median rituximab dose was 6 g (1–20.2) and total follow-up was 8012 patient-months. At first rituximab, the proportion of patients with IgG <6 g/L was 13% and remained stable at 17% at 24 months and 14% at 60 months. Following rituximab, 61/177 patients (34%) had IgG <6 g/L for at least three consecutive months, of whom 7/177 (4%) had IgG <3 g/L. Low immunoglobulin levels were associated with higher glucocorticoid doses during follow up and there was a trend for median IgG levels to fall after ≥ 6 g rituximab. 45/115 (39%) with IgG ≥6 g/L versus 26/62 (42%) with IgG <6 g/L experienced severe infections (p = 0.750). 6/177 patients (3%) received intravenous immunoglobulin replacement therapy, all with IgG <5 g/L and recurrent infection. Conclusions In multi-system autoimmune disease, prior cyclophosphamide exposure and glucocorticoid therapy but not cumulative rituximab dose was associated with an increased incidence of hypogammaglobulinaemia. Severe infections were common but were not associated with immunoglobulin levels. Repeat dose rituximab therapy appears safe with judicious monitoring.
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Affiliation(s)
| | - Rona M Smith
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
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Smith RM, Jones RB, Guerry MJ, Laurino S, Catapano F, Chaudhry A, Smith KGC, Jayne DRW. Rituximab for remission maintenance in relapsing antineutrophil cytoplasmic antibody-associated vasculitis. ACTA ACUST UNITED AC 2013; 64:3760-9. [PMID: 22729997 DOI: 10.1002/art.34583] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Rituximab is effective induction therapy in refractory or relapsing antineutrophil cytoplasmic antibody-associated vasculitis (AAV). However, further relapse is common, and maintenance strategies are required. The aim of this study was to reduce relapse rates using a fixed-interval rituximab re-treatment protocol. METHODS Retrospective, standardized collection of data from sequential patients receiving rituximab for refractory or relapsing AAV at a single center was studied. Group A patients (n = 28) received rituximab induction therapy (4 infusions of 375 mg/m(2) or 2 infusions 1 gm) and further rituximab at the time of subsequent relapse. Group B patients (n = 45) received routine rituximab re-treatment for 2 years: 2 doses of 1 gm each for remission induction, then 1 gm every 6 months (total of 6 gm). Group C patients (n = 19) comprised patients in group A who subsequently relapsed and began routine re-treatment for 2 years. RESULTS Response (complete/partial remission) occurred in 26 of the 28 patients (93%) in group A, 43 of the 45 patients (96%) in group B, and 18 of the 19 patients (95%) in group C. At 2 years, relapses had occurred in 19 of 26 patients (73%) in group A, 5 of 43 (12%) in group B (P < 0.001), and 2 of 18 (11%) in group C (P < 0.001). At the last followup (median of 44 months), relapses had occurred in 85% of those in group A (22 of 26), 26% of those in group B (11 of 43; P < 0.001), and 56% of those in group C (10 of 18; P = 0.001). Glucocorticoid dosages were decreased and immunosuppression therapy was withdrawn in the majority of patients. Routine rituximab re-treatment was well tolerated, and no new safety issues were identified. CONCLUSION Two-year, fixed-interval rituximab re-treatment was associated with a reduction in relapse rates during the re-treatment period and a more prolonged period of remission during subsequent followup. In the absence of biomarkers that accurately predict relapse, routine rituximab re-treatment may be an effective strategy for remission maintenance in patients with refractory and relapsing AAV.
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Kebriaei P, Madden T, Wang X, Thall PF, Ledesma C, de Lima M, Shpall EJ, Hosing C, Qazilbash M, Popat U, Alousi A, Nieto Y, Champlin RE, Jones RB, Andersson BS. Intravenous BU plus Mel: an effective, chemotherapy-only transplant conditioning regimen in patients with ALL. Bone Marrow Transplant 2013; 48:26-31. [PMID: 22732703 PMCID: PMC4346146 DOI: 10.1038/bmt.2012.114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 02/28/2012] [Revised: 04/30/2012] [Accepted: 04/30/2012] [Indexed: 11/08/2022]
Abstract
We investigated the administration of i.v. BU combined with melphalan (Mel) in patients with ALL undergoing allogeneic hematopoietic SCT. Forty-seven patients with a median age of 33 years (range 20-61) received a matched sibling (n=27) or matched unrelated donor transplant (n=20) for ALL in first CR (n=26), second CR (n=13), or with more advanced disease (n=8). BU was infused daily for 4 days, either at a fixed dose of 130 mg/m² (5 patients) or using pharmacokinetic (PK) dose adjustment (42 patients), to target an average daily area-under-the-curve (AUC) of 5000 μmol/min, determined by a test dose of i.v. BU at 32 mg/m². This was followed by a rest day, then two daily doses of Mel at 70 mg/m². Stem cells were infused on the following day. The 2-year OS, PFS and non-relapse mortality (NRM) rates were 35% (95% confidence interval (CI), 23-51%), 31% (95% CI, 21-48%) and 37% (95% CI, 23-50%), respectively. Acute NRM at 100 days was favorable at 12% (95% CI, 5-24%); however, the 2-year NRM was significantly higher for patients older than 40 years, 58% vs 20%, mainly due to GVHD.
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Affiliation(s)
- P Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Kebriaei P, Basset R, Ledesma C, Ciurea S, Parmar S, Shpall EJ, Hosing C, Khouri I, Qazilbash M, Popat U, Alousi A, Nieto Y, Jones RB, de Lima M, Champlin RE, Andersson BS. Clofarabine combined with busulfan provides excellent disease control in adult patients with acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 18:1819-26. [PMID: 22750645 PMCID: PMC4319530 DOI: 10.1016/j.bbmt.2012.06.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [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: 05/28/2012] [Accepted: 06/13/2012] [Indexed: 11/21/2022]
Abstract
We investigated the safety and early disease control data for i.v. busulfan (Bu) in combination with clofarabine (Clo) in patients with acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation (SCT). Fifty-one patients (median age, 36 years; range, 20-64 years) received a matched sibling (n = 24), syngeneic (n = 2), or matched unrelated donor transplant (n = 25) for acute lymphoblastic leukemia in first complete remission (n = 30), second complete remission (n = 13), or active disease (n = 8). More than one-half of the patients had a high-risk cytogenetic profile, as defined by the presence of t(9;22) (n = 17), t(4;11) (n = 3), or complex cytogenetics (n = 7). Clo 40 mg/m(2) was given once daily, with each dose followed by pharmacokinetically dosed Bu infused over 3 hours daily for 4 days, followed by hematopoietic SCT 2 days later. The Bu dose was based on drug clearance, as determined by the patient's response to a 32-mg/m(2) Bu test dose given 48 hours before the high-dose regimen. The target daily area under the receiver-operating characteristic curve was 5500 μM/min for patients age <60 years and 4000 μM/min for those age ≥60 years. The regimen was well tolerated, with a 100-day nonrelapse mortality rate of 6%. With a median follow-up of 14 months among surviving patients (range, 6-28 months), the 1-year overall survival, disease-free survival, and nonrelapse mortality rates were 67% (95% confidence interval [CI], 55%-83%), 54% (95% CI, 41%-71%), and 32% (95% CI, 16%-45%), respectively. For patients undergoing SCT in first remission, these respective rates were 74%, 64%, and 25%. Our data indicate that the combination of Clo and Bu provides effective disease control while maintaining a favorable safety profile.
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Affiliation(s)
- Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, USA.
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Affiliation(s)
- KA McWhirter
- Department of Gastroenterology, University Hospital of South Manchester, Manchester M23 9LT and
| | - RB Jones
- Department of Gastroenterology, University Hospital of South Manchester, Manchester M23 9LT
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