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Wilson JC, Sarsour K, Collinson N, Tuckwell K, Musselman D, Klearman M, Napalkov P, Jick SS, Stone JH, Meier CR. Serious adverse effects associated with glucocorticoid therapy in patients with giant cell arteritis (GCA): A nested case–control analysis. Semin Arthritis Rheum 2017; 46:819-827. [DOI: 10.1016/j.semarthrit.2016.11.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 02/03/2023]
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Abstract
IgG4-related disease (IgG4-RD) is capable of causing great morbidity and even mortality if the condition remains undiagnosed or poorly treated, yet is typically a treatment-responsive disorder. Glucocorticoids have not been studied rigorously and practices with regard to dosing and duration of treatment remain largely empiric. In addition, IgG4-RD patients are often particularly susceptible to and intolerant of the deleterious effects of glucocorticoid therapy. B cell depletion with anti-CD20 monoclonal antibodies appears to be a rapid, effective means of obtaining disease control and limiting patients' glucocorticoid exposure, but this option is frequently not available. Other therapies targeting the B cell lineage may also be efficacious, and one is under study. The means by which depletion or inhibition of B cells and their progeny ameliorate IgG4-RD is coming into focus now through careful mechanistic studies of samples from treated patients. The mechanistic understanding of IgG4-RD will bring an array of specific targets for therapeutic intervention. Plasmablast-directed therapy with a CD19 monoclonal antibody is currently in clinical trials. CD4 + cytotoxic T lymphocytes and fibrosis, both observed nearly universally in the tissue of IgG4-RD patients, present two unexploited vulnerabilities in controlling and even reversing the effects of the disease. Further development of such therapies is a major goal of the next few years.
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Affiliation(s)
- C A Perugino
- Division of Rheumatology, Allergy, & Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - J H Stone
- Harvard Medical School; The Edward Fox Chair in Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Rheumatology Clinic/Yawkey 2, Massachusetts General Hospital, 55 Fruit Street, 02114, Boston, MA, USA.
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153
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Affiliation(s)
- Eli M Miloslavsky
- From the Departments of Medicine (E.M.M., J.H.S.) and Pathology (A.P.M.), Massachusetts General Hospital, and the Departments of Medicine (E.M.M., J.H.S.) and Pathology (A.P.M.), Harvard Medical School - both in Boston
| | - John H Stone
- From the Departments of Medicine (E.M.M., J.H.S.) and Pathology (A.P.M.), Massachusetts General Hospital, and the Departments of Medicine (E.M.M., J.H.S.) and Pathology (A.P.M.), Harvard Medical School - both in Boston
| | - Andrea P Moy
- From the Departments of Medicine (E.M.M., J.H.S.) and Pathology (A.P.M.), Massachusetts General Hospital, and the Departments of Medicine (E.M.M., J.H.S.) and Pathology (A.P.M.), Harvard Medical School - both in Boston
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154
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Abstract
PURPOSE OF REVIEW Remarkable insights have been gleaned recently with regard to the pathophysiology of IgG4-related disease (IgG4-RD). These findings have direct implications for the development of targeted strategies for the treatment of this condition. RECENT FINDINGS Oligoclonal expansions of cells of both the B and T lymphocyte lineages are present in the blood of patients with IgG4-RD. Oligoclonal expansions of plasmablasts are a good biomarker for disease activity. An oligoclonally expanded population of CD4+ cytotoxic T lymphocytes is found not only in the peripheral blood but also at tissue sites of active disease. This cell elaborates cytokines that may drive the fibrosis characteristic of IgG4-RD. T follicular helper cells (Tfhc), particularly the Tfhc2 subset, appear to play a major role in driving the class switch to IgG4 that typifies this disease. The relationship between malignancy and IgG4-RD remains an area of interest. SUMMARY Advances in understanding the pathophysiology of IgG4-RD have proceeded swiftly, leading to the identification of a number of potential targeted treatment strategies. The completion of classification criteria for IgG4-RD, an effort supported jointly by the American College of Rheumatology and the European League Against Rheumatism, will further facilitate studies on this disease.
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155
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Wallace ZS, Lu N, Miloslavsky E, Unizony S, Stone JH, Choi HK. Nationwide Trends in Hospitalizations and In-Hospital Mortality in Granulomatosis With Polyangiitis (Wegener's). Arthritis Care Res (Hoboken) 2017; 69:915-921. [PMID: 27389595 DOI: 10.1002/acr.22976] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/21/2016] [Accepted: 06/28/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Granulomatosis with polyangiitis (Wegener's) (GPA) is a type of antineutrophil cytoplasmic antibody-associated vasculitis that often entails severe end-organ damage and treatment-related complications that frequently lead to hospitalization and death. Nationwide trends in hospitalizations and in-hospital mortality over the past 2 decades are unknown and were evaluated in this study. METHODS Using the National Inpatient Sample, the largest all-payer inpatient database in the US, trends in hospitalizations with a discharge diagnosis of GPA (formerly Wegener's granulomatosis; International Classification of Disease, Ninth Revision, Clinical Modification code 446.4) between 1993 and 2011 were studied. Analyses were performed using hospital-level sampling weights to obtain US national estimates. RESULTS From 1993 to 2011, the annual hospitalization rate for patients with a principal diagnosis of GPA increased by 24%, from 5.1 to 6.3 per 1 million US persons (P < 0.0001 for trend); however, in-hospital deaths in this group declined by 73%, from 9.1% to 2.5% (P < 0.0001 for trend), resulting in a 66% net reduction in the annual in-hospital mortality rate. The median length of stay declined by 20%, from 6.9 days in 1993 to 5.5 days in 2011 (P = 0.0002 for trend). Infection was the most common principal discharge diagnosis when GPA was a secondary diagnosis, including among those who died during hospitalization. CONCLUSION The findings from these nationally representative, contemporary inpatient data indicate that the in-hospital mortality of GPA has declined substantially over the past 2 decades, while the overall hospitalization rate for GPA increased slightly. Infection remains a common principal hospitalization diagnosis among GPA patients, including hospitalizations resulting in mortality.
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Affiliation(s)
- Zachary S Wallace
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Na Lu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eli Miloslavsky
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastian Unizony
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hyon K Choi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Merkel PA, Xie G, Monach PA, Ji X, Ciavatta DJ, Byun J, Pinder BD, Zhao A, Zhang J, Tadesse Y, Qian D, Weirauch M, Nair R, Tsoi A, Pagnoux C, Carette S, Chung S, Cuthbertson D, Davis JC, Dellaripa PF, Forbess L, Gewurz-Singer O, Hoffman GS, Khalidi N, Koening C, Langford CA, Mahr AD, McAlear C, Moreland L, Seo EP, Specks U, Spiera RF, Sreih A, St Clair EW, Stone JH, Ytterberg SR, Elder JT, Qu J, Ochi T, Hirano N, Edberg JC, Falk RJ, Amos CI, Siminovitch KA. Identification of Functional and Expression Polymorphisms Associated With Risk for Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis. Arthritis Rheumatol 2017; 69:1054-1066. [PMID: 28029757 PMCID: PMC5434905 DOI: 10.1002/art.40034] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [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: 09/08/2016] [Accepted: 12/20/2016] [Indexed: 01/28/2023]
Abstract
Objective To identify risk alleles relevant to the causal and biologic mechanisms of antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV). Methods A genome‐wide association study and subsequent replication study were conducted in a total cohort of 1,986 cases of AAV (patients with granulomatosis with polyangiitis [Wegener's] [GPA] or microscopic polyangiitis [MPA]) and 4,723 healthy controls. Meta‐analysis of these data sets and functional annotation of identified risk loci were performed, and candidate disease variants with unknown functional effects were investigated for their impact on gene expression and/or protein function. Results Among the genome‐wide significant associations identified, the largest effect on risk of AAV came from the single‐nucleotide polymorphism variants rs141530233 and rs1042169 at the HLA–DPB1 locus (odds ratio [OR] 2.99 and OR 2.82, respectively) which, together with a third variant, rs386699872, constitute a triallelic risk haplotype associated with reduced expression of the HLA–DPB1 gene and HLA–DP protein in B cells and monocytes and with increased frequency of complementary proteinase 3 (PR3)–reactive T cells relative to that in carriers of the protective haplotype. Significant associations were also observed at the SERPINA1 and PTPN22 loci, the peak signals arising from functionally relevant missense variants, and at PRTN3, in which the top‐scoring variant correlated with increased PRTN3 expression in neutrophils. Effects of individual loci on AAV risk differed between patients with GPA and those with MPA or between patients with PR3‐ANCAs and those with myeloperoxidase‐ANCAs, but the collective population attributable fraction for these variants was substantive, at 77%. Conclusion This study reveals the association of susceptibility to GPA and MPA with functional gene variants that explain much of the genetic etiology of AAV, could influence and possibly be predictors of the clinical presentation, and appear to alter immune cell proteins and responses likely to be key factors in the pathogenesis of AAV.
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Affiliation(s)
| | - Gang Xie
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - Paul A Monach
- Boston University and VA Boston Healthcare System, Boston, Massachusetts
| | - Xuemei Ji
- Dartmouth College, Lebanon, New Hampshire
| | | | | | - Benjamin D Pinder
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - Ai Zhao
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - Jinyi Zhang
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, Toronto General Research Institute and University of Toronto, Toronto, Ontario, Canada
| | - Yohannes Tadesse
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute and Toronto General Research Institute, Toronto, Ontario, Canada
| | - David Qian
- Dartmouth College, Lebanon, New Hampshire
| | | | | | | | - Christian Pagnoux
- Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Simon Carette
- Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - James T Elder
- University of Michigan and Ann Arbor VA Hospital, Ann Arbor, Michigan
| | - Jia Qu
- Wenzhou Medical University, Wenzhou, China
| | - Toshiki Ochi
- University of Toronto and Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Naoto Hirano
- University of Toronto and Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | | | | | - Katherine A Siminovitch
- Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, Toronto General Research Institute and University of Toronto, Toronto, Ontario, Canada
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157
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Tuckwell K, Collinson N, Dimonaco S, Klearman M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Unizony SH, Stone JH. Newly diagnosed vs. relapsing giant cell arteritis: Baseline data from the GiACTA trial. Semin Arthritis Rheum 2017; 46:657-664. [DOI: 10.1016/j.semarthrit.2016.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/02/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
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158
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Wilson JC, Sarsour K, Collinson N, Tuckwell K, Musselman D, Klearman M, Napalkov P, Jick SS, Stone JH, Meier CR. Incidence of outcomes potentially associated with corticosteroid therapy in patients with giant cell arteritis. Semin Arthritis Rheum 2017; 46:650-656. [DOI: 10.1016/j.semarthrit.2016.10.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
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159
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Mahr A, Edouard S, Cornec D, Guilpain P, Hoffman GS, Kallenberg CG, Karnell F, Langford CA, Merkel PA, Monach PA, Pichon M, St. Clair EW, Seo P, Spiera RF, Ytterberg SR, Stone JH, Raoult D, Specks U. P2_19 High Bartonella Seroprevalence in Proteinase 3-Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis. Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex130] [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: 11/13/2022] Open
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160
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Miloslavsky EM, Naden RP, Bijlsma JWJ, Brogan PA, Brown ES, Brunetta P, Buttgereit F, Choi HK, DiCaire JF, Gelfand JM, Heaney LG, Lightstone L, Lu N, Murrell DF, Petri M, Rosenbaum JT, Saag KS, Urowitz MB, Winthrop KL, Stone JH. Development of a Glucocorticoid Toxicity Index (GTI) using multicriteria decision analysis. Ann Rheum Dis 2017; 76:543-546. [PMID: 27474764 DOI: 10.1136/annrheumdis-2016-210002] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [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: 06/01/2016] [Accepted: 07/11/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To develop a Glucocorticoid Toxicity Index (GTI) to assess glucocorticoid (GC)-related morbidity and GC-sparing ability of other therapies. METHODS Nineteen experts on GC use and outcome measures from 11 subspecialties participated. Ten experts were from the USA; nine from Canada, Europe or Australia. Group consensus methods and multicriteria decision analysis (MCDA) were used. A Composite GTI and Specific List comprise the overall GTI. The Composite GTI reflects toxicity likely to change during a clinical trial. The Composite GTI toxicities occur commonly, vary with GC exposure, and are weighted and scored. Relative weights for items in the Composite GTI were derived by group consensus and MCDA. The Specific List is designed to capture GC toxicity not included in the Composite GTI. The Composite GTI was evaluated by application to paper cases by the investigators and an external group of 17 subspecialists. RESULTS Thirty-one toxicity items were included in the Composite GTI and 23 in the Specific List. Composite GTI evaluation showed high inter-rater agreement (investigators κ 0.88, external raters κ 0.90). To assess the degree to which the Composite GTI corresponds to expert clinical judgement, participants ranked 15 cases by clinical judgement in order of highest to lowest GC toxicity. Expert rankings were then compared with case ranking by the Composite GTI, yielding excellent agreement (investigators weighted κ 0.87, external raters weighted κ 0.77). CONCLUSIONS We describe the development and initial evaluation of a comprehensive instrument for the assessment of GC toxicity.
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Affiliation(s)
- Eli M Miloslavsky
- Rheumatology, Allergy and Immunology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ray P Naden
- Maternal-Fetal Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - Paul A Brogan
- Institute of Child Health, University College London, UCL Inst of Child Health, London, UK
| | - E Sherwood Brown
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Paul Brunetta
- Late Stage Immunology Product Development, Genentech, Inc., South San Francisco, USA
| | - Frank Buttgereit
- Department of Rheumatology and Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Hyon K Choi
- Department of Rheumatology, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, Imperial College London, London, UK
| | - Na Lu
- Department of Rheumatology, Massachusetts General Hospital, Boston, USA
| | - Dedee F Murrell
- University of New South Wales, Sydney, New South Wales, Australia
| | - Michelle Petri
- Department of Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - James T Rosenbaum
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Kenneth S Saag
- UAB Division of Clinical Immunology/Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Murray B Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Canada
| | | | - John H Stone
- Massachusetts General Hospital Rheumatology Unit, Harvard Medical School, Rheumatology Clinic, Boston, Massachusetts, USA
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161
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Affiliation(s)
- Paul A Monach
- From the Department of Medicine, Boston University School of Medicine (P.A.M.), the Medical Service, Veterans Affairs Boston Healthcare System (P.A.M.), the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Harvard Medical School - all in Boston
| | - John H Stone
- From the Department of Medicine, Boston University School of Medicine (P.A.M.), the Medical Service, Veterans Affairs Boston Healthcare System (P.A.M.), the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Harvard Medical School - all in Boston
| | - Amita Sharma
- From the Department of Medicine, Boston University School of Medicine (P.A.M.), the Medical Service, Veterans Affairs Boston Healthcare System (P.A.M.), the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Harvard Medical School - all in Boston
| | - Rosalynn M Nazarian
- From the Department of Medicine, Boston University School of Medicine (P.A.M.), the Medical Service, Veterans Affairs Boston Healthcare System (P.A.M.), the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (J.H.S.), Radiology (A.S.), and Pathology (R.M.N.), Harvard Medical School - all in Boston
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162
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Clain JM, Hummel AM, Stone JH, Fervenza FC, Hoffman GS, Kallenberg CGM, Langford CA, McCune WJ, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Ytterberg SR, Specks U. Immunoglobulin (Ig)M antibodies to proteinase 3 in granulomatosis with polyangiitis and microscopic polyangiitis. Clin Exp Immunol 2017; 188:174-181. [PMID: 28076879 DOI: 10.1111/cei.12925] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2017] [Indexed: 01/12/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA) appear to play an important role in the pathogenesis of ANCA-associated vasculitis (AAV). However, ANCA alone are not sufficient to generate disease, and some evidence suggests that infectious triggers may serve as inciting events for AAV disease activity. Antibodies of the immunoglobulin (Ig)M isotype often serve as markers of recent infection, and IgM ANCA have been identified previously in patients with AAV, although the frequency and clinical relevance of IgM ANCA is not well established. We sought to characterize IgM ANCA more clearly by creating a novel enzyme-linked immunosorbent assay (ELISA) for IgM antibodies to proteinase 3 [IgM proteinase 3 (PR3)-ANCA], which we applied to two large, clinically well-characterized trial cohorts of patients with granulomatosis with polyangiitis and microscopic polyangiitis. In the first cohort, IgM PR3-ANCA occurred with a frequency of 15·0%, and were associated with a higher degree of disease severity and a trend towards a higher rate of alveolar haemorrhage (29·6 versus 15·7%, P = 0·10). Analysis of follow-up samples in this cohort showed that the presence of IgM PR3-ANCA was transient, but could recur. In the second cohort, IgM PR3-ANCA occurred with a frequency of 41·1%, and were also associated with a higher degree of disease severity. A higher rate of alveolar haemorrhage was observed among those with IgM PR3-ANCA (45·3 versus 15·8%; P < 0·001). The association of transient IgM PR3-ANCA with an acute respiratory manifestation of AAV suggests a possible link between an infectious trigger and AAV disease activity.
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Affiliation(s)
- J M Clain
- Mayo Clinic and Foundation, Rochester, MN, USA
| | - A M Hummel
- Mayo Clinic and Foundation, Rochester, MN, USA
| | - J H Stone
- Massachusetts General Hospital, Boston, MA, USA
| | | | - G S Hoffman
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | - W J McCune
- University of Michigan, Ann Arbor, MI, USA
| | - P A Merkel
- University of Pennsylvania, Philadelphia, PA, USA
| | - P A Monach
- Boston University Medical Center, Boston, MA, USA
| | - P Seo
- Johns Hopkins University, Baltimore, MD, USA
| | - R F Spiera
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - U Specks
- Mayo Clinic and Foundation, Rochester, MN, USA
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163
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Cartin‐Ceba R, Indrakanti D, Specks U, Stone JH, Hoffman GS, Kallenberg CGM, Langford CA, Merkel PA, Spiera RF, Monach PA, St.Clair EW, Seo P, Tchao NK, Ytterberg SR, Brunetta PG, Song H, Birmingham D, Rovin BH. The Pharmacogenomic Association of Fcγ Receptors and Cytochrome P450 Enzymes With Response to Rituximab or Cyclophosphamide Treatment in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis. Arthritis Rheumatol 2016; 69:169-175. [DOI: 10.1002/art.39822] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/19/2016] [Indexed: 02/01/2023]
Affiliation(s)
| | | | - Ulrich Specks
- Mayo Clinic and Foundation, Rochester, Minnesota, and Scottsdale Arizona
| | | | | | | | | | | | | | - Paul A. Monach
- Boston University School of MedicineBoston Massachusetts
| | | | - Philip Seo
- Johns Hopkins UniversityBaltimore Maryland
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164
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Unizony S, Lu N, Tomasson G, Zhang Y, Merkel PA, Stone JH, Antonio Aviña‐Zubieta J, Choi HK. Temporal Trends of Venous Thromboembolism Risk Before and After Diagnosis of Giant Cell Arteritis. Arthritis Rheumatol 2016; 69:176-184. [DOI: 10.1002/art.39847] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 08/16/2016] [Indexed: 12/28/2022]
Affiliation(s)
| | - Na Lu
- Massachusetts General Hospital, Harvard Medical School, and Boston University School of MedicineBoston
| | - Gunnar Tomasson
- Boston University School of Medicine, Boston, Massachusetts, and University of IcelandReykjavik Iceland
| | - Yuqing Zhang
- Boston University School of MedicineBoston Massachusetts
| | | | - John H. Stone
- Massachusetts General Hospital, Harvard Medical SchoolBoston
| | | | - Hyon K. Choi
- Massachusetts General Hospital, Harvard Medical School, and Boston University School of MedicineBoston
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Miyabe C, Miyabe Y, Strle K, Kim ND, Stone JH, Luster AD, Unizony S. An expanded population of pathogenic regulatory T cells in giant cell arteritis is abrogated by IL-6 blockade therapy. Ann Rheum Dis 2016; 76:898-905. [PMID: 27927642 DOI: 10.1136/annrheumdis-2016-210070] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [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: 06/16/2016] [Revised: 09/05/2016] [Accepted: 11/09/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Randomised-controlled trials have recently proven the efficacy of the interleukin (IL)-6 receptor antagonist tocilizumab (TCZ) in giant cell arteritis (GCA). However, the mechanism of action of IL-6 blockade in this disease is unknown. Moreover, the role of regulatory T (Treg) cells in the pathogenesis of GCA remains underexplored. Given the plasticity of Tregs and the importance of IL-6 in their biology, we hypothesised that TCZ might modulate the Treg response in GCA. We therefore characterised the Treg compartment of patients with GCA treated with TCZ. METHODS We classified 41 patients with GCA into three groups: active disease (aGCA, n=11), disease remission on corticosteroids (rGCA-CS, n=19) and disease remission on TCZ (rGCA-TCZ, n=11). Healthy controls (HCs) were included for comparison. We determined the frequency, phenotype and function of peripheral blood Tregs. RESULTS Patients with aGCA demonstrated a hypoproliferating Treg compartment enriched in IL-17-secreting Tregs (IL-17+Tregs). Tregs in patients with aGCA disproportionally expressed a hypofunctional isoform of Foxp3 that lacks exon 2 (Foxp3Δ2). Foxp3Δ2-expressing Tregs coexpressed CD161, a marker commonly associated with the Th17 linage, significantly more often than full-length Foxp3-expressing Tregs. Compared with those of HCs, GCA-derived Tregs demonstrated impaired suppressor capacity. Treatment with TCZ, in contrast to CS therapy, corrected the Treg abnormalities observed in aGCA. In addition, TCZ treatment increased the numbers of activated Tregs (CD45RA-Foxp3high) and the Treg expression of markers of trafficking (CCR4) and terminal differentiation (CTLA-4). CONCLUSIONS TCZ may exert its therapeutic effects in GCA by increasing the proliferation and activation of Tregs, and by reverting the pathogenic Treg phenotype seen during active disease.
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Affiliation(s)
- Chie Miyabe
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yoshishige Miyabe
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Klemen Strle
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy D Kim
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Stone
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew D Luster
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Unizony
- Division of Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Byrne TN, Stone JH, Pillai SS, Rapalino O, Deshpande V. Case Records of the Massachusetts General Hospital. Case 31-2016. A 53-Year-Old Man with Diplopia, Polydipsia, and Polyuria. N Engl J Med 2016; 375:1469-1480. [PMID: 27732818 DOI: 10.1056/nejmcpc1610097] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas N Byrne
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - John H Stone
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - Shiv S Pillai
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - Otto Rapalino
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
| | - Vikram Deshpande
- From the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.), Massachusetts General Hospital, and the Departments of Neurology (T.N.B.), Rheumatology (J.H.S.), Radiology (O.R.), and Pathology (V.D.) and the Ragon Institute (S.S.P.), Harvard Medical School - all in Boston
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Lanzillotta M, Campochiaro C, Trimarchi M, Arrigoni G, Gerevini S, Milani R, Bozzolo E, Biafora M, Venturini E, Cicalese MP, Stone JH, Sabbadini MG, Della-Torre E. Deconstructing IgG4-related disease involvement of midline structures: Comparison to common mimickers. Mod Rheumatol 2016; 27:638-645. [PMID: 27622319 DOI: 10.1080/14397595.2016.1227026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE A series of destructive and tumefactive lesions of the midline structures have been recently added to the spectrum of IgG4-related disease (IgG4-RD). We examined the clinical, serological, endoscopic, radiological, and histological features that might be of utility in distinguishing IgG4-RD from other forms of inflammatory conditions with the potential to involve the sinonasal area and the oral cavity. METHODS We studied 11 consecutive patients with erosive and/or tumefactive lesions of the midline structures referred to our tertiary care center. All patients underwent serum IgG4 measurement, flow cytometry for circulating plasmablast counts, nasal endoscopy, radiological studies, and histological evaluation of tissue specimens. The histological studies included immunostaining studies to assess the number of IgG4 + plasma cells/HPF for calculation of the IgG4+/IgG + plasma cell ratio. RESULTS Five patients with granulomatosis with polyangiitis (GPA), three with cocaine-induced midline destructive lesions (CIMDL), and three with IgG4-RD were studied. We found no clinical, endoscopic, or radiological findings specific for IgG4-RD. Increased serum IgG4 and plasmablasts levels were not specific for IgG4-RD. Rather, all 11 patients had elevated blood plasmablast concentrations, and several patients with GPA and CIMDL had elevated serum IgG4 levels. Storiform fibrosis and an IgG4+/IgG + plasma cell ratio >20% on histological examination, however, were observed only in patients with IgG4-RD. CONCLUSIONS Histological examination of bioptic samples from the sinonasal area and oral cavity represents the mainstay for the diagnosis of IgG4-RD involvement of the midline structures.
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Affiliation(s)
- Marco Lanzillotta
- a Unit of Medicine and Clinical Immunology, Ospedale San Raffaele , Milan , Italy.,b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy
| | - Corrado Campochiaro
- a Unit of Medicine and Clinical Immunology, Ospedale San Raffaele , Milan , Italy.,b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy
| | - Matteo Trimarchi
- b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy.,c Department of Otorhinolaryngology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Gianluigi Arrigoni
- d Pathology Unit, IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Simonetta Gerevini
- e Neuroradiology Unit, IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Raffaella Milani
- f Immunohematology and Transfusion Medicine Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Enrica Bozzolo
- a Unit of Medicine and Clinical Immunology, Ospedale San Raffaele , Milan , Italy
| | - Matteo Biafora
- b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy.,c Department of Otorhinolaryngology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Elena Venturini
- b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy.,e Neuroradiology Unit, IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Maria Pia Cicalese
- g San Raffaele Telethon Institute for Gene Therapy (TIGET) , Milan , Italy.,h Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute , Milan , Italy , and
| | - John H Stone
- i Division of Rheumatology, Allergy, and Immunology , Massachusetts General Hospital, Harvard Medical School , Boston , MA , USA
| | - Maria Grazia Sabbadini
- a Unit of Medicine and Clinical Immunology, Ospedale San Raffaele , Milan , Italy.,b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy
| | - Emanuel Della-Torre
- a Unit of Medicine and Clinical Immunology, Ospedale San Raffaele , Milan , Italy.,b Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele , Milan , Italy
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Della-Torre E, Lanzillotta M, Campochiaro C, Bozzalla E, Bozzolo E, Bandiera A, Bazzigaluppi E, Canevari C, Modorati G, Stone JH, Manfredi A, Doglioni C. Antineutrophil cytoplasmic antibody positivity in IgG4-related disease: A case report and review of the literature. Medicine (Baltimore) 2016; 95:e4633. [PMID: 27559962 PMCID: PMC5400329 DOI: 10.1097/md.0000000000004633] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a fibroinflammatory condition characterized by serum IgG4 elevation and tissue infiltration of IgG4-positive plasma cells. Substantial overlap between IgG4-RD and antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) exists in terms of organ involvement and histopathological features. A positive ANCA assay is regarded as a highly specific finding in favor of an AAV, and generally influences away from a diagnosis of IgG4-RD. Recent reports, however, have raised the possibility that some patients with IgG4-RD are ANCA positive, thus suggesting reconsideration of the role of ANCA in the diagnostic workup. In the present work, we describe the first case of concomitant biopsy-proven IgG4-RD and granulomatosis with polyangiitis (GPA), demonstrating antiproteinase 3 (PR3) ANCA of the IgG4 subclass in the patient's serum. We also review the literature in order to provide clinicians with tools for interpreting ANCA positivity in IgG4-RD patients. CASE SUMMARY A 51-year-old woman was referred for left exopthalmos due to lacrimal gland enlargement and increased serum IgG4 concentration. IgG4-RD was suspected and further imaging studies disclosed multiple pulmonary masses in the right lung. Histological analysis of the left lacrimal gland was diagnostic for IgG4-RD, but lung biopsy showed typical features of GPA. ANCA assay was positive for anti-PR3 antibodies. Further immunofluorescence studies demonstrated anti-PR3 antibodies of IgG1 and IgG4 subclass. Treatment with rituximab induced swift remission of both IgG4-RD and GPA manifestations. We identified 9 other reports of patients with IgG4-RD and positive ANCA in the English literature, 5 cases with biopsy-proven IgG4-RD and 4 cases in whom IgG4-RD was diagnosed presumptively. Four patients had also histological evidence of concomitant AAV. CONCLUSION The present work demonstrates that ANCA positivity in patients with biopsy-proven IgG4-RD should prompt the exclusion of a concomitant vasculitic process; a positive ANCA does not exclude the diagnosis of IgG4-RD; confirmation through immunoenzymatic assays of the ANCA specificity, clinical-pathological correlation, and histopathological evaluation remain crucial steps for the differential diagnosis between AAV and IgG4-RD.
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Affiliation(s)
- Emanuel Della-Torre
- Università Vita-Salute San Raffaele, IRCCS-San Raffaele Scientific Institute
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS-San Raffaele Scientific Institute
- Unit of Medicine and Clinical Immunology, IRCCS-San Raffaele Scientific Institute
- Correspondence: Emanuel Della-Torre, Unit of Medicine and Clinical Immunology, IRCCS-San Raffaele Scientific Institute, via Olgettina 60, 20132 Milan, Italy (e-mail: )
| | - Marco Lanzillotta
- Università Vita-Salute San Raffaele, IRCCS-San Raffaele Scientific Institute
| | - Corrado Campochiaro
- Università Vita-Salute San Raffaele, IRCCS-San Raffaele Scientific Institute
- Unit of Medicine and Clinical Immunology, IRCCS-San Raffaele Scientific Institute
| | - Emanuele Bozzalla
- Università Vita-Salute San Raffaele, IRCCS-San Raffaele Scientific Institute
| | - Enrica Bozzolo
- Unit of Medicine and Clinical Immunology, IRCCS-San Raffaele Scientific Institute
| | | | | | - Carla Canevari
- Division of Nuclear Medicine, IRCCS-San Raffaele Scientific Institute
| | - Giulio Modorati
- Department of Ophthalmology, IRCCS-San Raffaele Scientific Institute, Milan, Italy
| | - John H. Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Angelo Manfredi
- Università Vita-Salute San Raffaele, IRCCS-San Raffaele Scientific Institute
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS-San Raffaele Scientific Institute
- Unit of Medicine and Clinical Immunology, IRCCS-San Raffaele Scientific Institute
| | - Claudio Doglioni
- Università Vita-Salute San Raffaele, IRCCS-San Raffaele Scientific Institute
- Pathology Unit, IRCCS-San Raffaele Scientific Institute, Milan, Italy
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Abstract
OBJECTIVES IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that can affect multiple organs and lead to tumefactive, tissue-destructive lesions. Reports have described inflammatory aortitis and periaortitis, the latter in the setting of retroperitoneal fibrosis (RPF), but have not distinguished adequately between these 2 manifestations. The frequency, radiologic features, and response of vascular complications to B cell depletion remain poorly defined. We describe the clinical features, radiology findings, and treatment response in a cohort of 36 patients with IgG4-RD affecting large blood vessels. METHODS Clinical records of all patients diagnosed with IgG4-RD in our center were reviewed. All radiologic studies were reviewed. We distinguished between primary large blood vessel inflammation and secondary vascular involvement. Primary involvement was defined as inflammation in the blood vessel wall as a principal focus of disease. Secondary vascular involvement was defined as disease caused by the effects of adjacent inflammation on the blood vessel wall. RESULTS Of the 160 IgG4-RD patients in this cohort, 36 (22.5%) had large-vessel involvement. The mean age at disease onset of the patients with large-vessel IgG4-RD was 54.6 years. Twenty-eight patients (78%) were male and 8 (22%) were female. Thirteen patients (36%) had primary IgG4-related vasculitis and aortitis with aneurysm formation comprised the most common manifestation. This affected 5.6% of the entire IgG4-RD cohort and was observed in the thoracic aorta in 8 patients, the abdominal aorta in 4, and both the thoracic and abdominal aorta in 3. Three of these aneurysms were complicated by aortic dissection or contained perforation. Periaortitis secondary to RPF accounted for 27 of 29 patients (93%) of secondary vascular involvement by IgG4-RD. Only 5 patients demonstrated evidence of both primary and secondary blood vessel involvement. Of those treated with rituximab, a majority responded positively. CONCLUSIONS IgG4-RD is a distinctive, unique, and treatable cause of large-vessel vasculitis. It can also involve blood vessels secondary to perivascular tumefactive lesions. The most common manifestation of IgG4-related vasculitis is aortitis with aneurysm formation. The most common secondary vascular manifestation is periaortitis with relative sparing of the aortic wall. Both primary vasculitis and secondary vascular involvement respond well to B cell depletion therapy.
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Affiliation(s)
| | | | | | | | | | - John H. Stone
- Massachusetts General Hospital, Boston, MA
- Correspondence: John H. Stone, Massachusetts General Hospital, Boston, MA (e-mail: )
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171
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Stone JH. IgG4-related disease: pathophysiologic insights drive emerging treatment approaches. Clin Exp Rheumatol 2016; 34:66-68. [PMID: 27586808] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 06/06/2023]
Abstract
IgG4-related disease (IgG4-RD) is a fibroinflammatory condition that can affect essentially any organ. The disease shows similar histopathology findings across organ systems, consisting of a lymphoplasmacytic infiltrate enriched in IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. IgG4 itself appears to be a reactive phenomenon rather than the primary disease driver. Recent investigations have focused on the interactions between cells of the B cell lineage and a novel CD4+ SLAMF7+ cytotoxic T cells capable of promoting fibrosis. Plasmablasts appear to play a crucial role along with B cells in the presentation of antigen to this T cell. IgG4-RD is marked by responsiveness to glucocorticoids, but frequent disease relapse, the inability to taper glucocorticoids completely, and steroid toxicity are problematic. Targeted treatment approaches against the B cell lineage appear promising, and therapeutic efforts focused upon the CD4+ SLAMF7+ cytotoxic T cell may also be feasible.
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Affiliation(s)
- John H Stone
- Rheumatology Clinic/Yawkey 2, Massachusetts General Hospital, Boston, USA.
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Maehara T, Mattoo H, Ohta M, Mahajan VS, Moriyama M, Yamauchi M, Drijvers J, Nakamura S, Stone JH, Pillai SS. Lesional CD4+ IFN-γ+ cytotoxic T lymphocytes in IgG4-related dacryoadenitis and sialoadenitis. Ann Rheum Dis 2016; 76:377-385. [PMID: 27358392 DOI: 10.1136/annrheumdis-2016-209139] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [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: 01/08/2016] [Revised: 04/11/2016] [Accepted: 05/27/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES IgG4-related disease (IgG4-RD) is a chronic, systemic, inflammatory condition of unknown aetiology. We have recently described clonally expanded circulating CD4+ cytotoxic T lymphocytes (CTLs) in IgG4-RD that infiltrate affected tissues where they secrete interleukin (IL)-1β and transforming growth factor -β1 (TGF-β1). In this study, we sought to examine the role of CD4+ CTLs in the pathogenesis of IgG4-related dacryoadenitis and sialoadenitis (IgG4-DS) and to determine whether these cells secrete interferon-gamma (IFN-γ) at lesional sites. METHODS Salivary glands of 25 patients with IgG4-DS, 22 patients with Sjögren's syndrome (SS), 12 patients with chronic sialoadenitis (CS) and 12 healthy controls were analysed in this study. Gene expression analysis was performed on submandibular glands (SMGs) from five patients with IgG4-DS, three with CS and three healthy controls. Infiltrating CD4+ CTLs were examined by quantitative multicolour imaging in tissue samples from 20 patients with IgG4-DS, 22 patients with SS, 9 patients with CS and 9 healthy controls. RESULTS In IgG4-DS tissues, nine genes associated with CD4+ CTLs were overexpressed. The expression of granzyme A (GZMA) mRNA was significantly higher in samples from patients with IgG4-RD compared with corresponding tissues from SS and healthy controls. Quantitative imaging showed that infiltrating CD4+ GZMA+ CTLs were more abundant in patients with IgG4-DS than in the other groups. The ratio of CD4+GZMA+ CTLs in SMGs from patients with IgG4-DS correlated with serum IgG4 concentrations and the number of affected organs. A large fraction of CD4+GZMA+ CTLs in SMGs from patients with IgG4-DS secreted IFN-γ. CONCLUSIONS The pathogenesis of IgG4-DS is associated with tissue infiltration by CD4+GZMA+ CTLs that secrete IFN-γ.
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Affiliation(s)
- Takashi Maehara
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Hamid Mattoo
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Miho Ohta
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Vinay S Mahajan
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Masafumi Moriyama
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan.,Faculty of Dental Science, OBT Research Center, Kyushu University, Fukuoka, Japan
| | - Masaki Yamauchi
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Jefte Drijvers
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - John H Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shiv S Pillai
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mills JR, Cornec D, Dasari S, Ladwig PM, Hummel AM, Cheu M, Murray DL, Willrich MA, Snyder MR, Hoffman GS, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Specks U, Barnidge DR. Using Mass Spectrometry to Quantify Rituximab and Perform Individualized Immunoglobulin Phenotyping in ANCA-Associated Vasculitis. Anal Chem 2016; 88:6317-25. [PMID: 27228216 DOI: 10.1021/acs.analchem.6b00544] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Therapeutic monoclonal immunoglobulins (mAbs) are used to treat patients with a wide range of disorders including autoimmune diseases. As pharmaceutical companies bring more fully humanized therapeutic mAb drugs to the healthcare market analytical platforms that perform therapeutic drug monitoring (TDM) without relying on mAb specific reagents will be needed. In this study we demonstrate that liquid-chromatography-mass spectrometry (LC-MS) can be used to perform TDM of mAbs in the same manner as smaller nonbiologic drugs. The assay uses commercially available reagents combined with heavy and light chain disulfide bond reduction followed by light chain analysis by microflow-LC-electrospray ionization-quadrupole-time-of-flight mass spectrometry (ESI-Q-TOF MS). Quantification is performed using the peak areas from multiply charged mAb light chain ions using an in-house developed software package developed for TDM of mAbs. The data presented here demonstrate the ability of an LC-MS assay to quantify a therapeutic mAb in a large cohort of patients in a clinical trial. The ability to quantify any mAb in serum via the reduced light chain without the need for reagents specific for each mAb demonstrates the unique capabilities of LC-MS. This fact, coupled with the ability to phenotype a patient's polyclonal repertoire in the same analysis further shows the potential of this approach to mAb analysis.
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Affiliation(s)
- John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Divi Cornec
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota 55905, United States.,Rheumatology Department, Brest University Hospital , 29609 Brest, Cedex, France
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Paula M Ladwig
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Amber M Hummel
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Melissa Cheu
- Genentech Inc. , South San Francisco, California 94080, United States
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Maria A Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - Gary S Hoffman
- Cleveland Clinic Foundation , Cleveland, Ohio 44195, United States
| | | | - Carol A Langford
- Cleveland Clinic Foundation , Cleveland, Ohio 44195, United States
| | - Peter A Merkel
- University of Pennsylvania , Philadelphia, Pennsylvania 19104, United States
| | - Paul A Monach
- Boston University Medical Center , Boston, Massachusetts 02115, United States
| | - Philip Seo
- Johns Hopkins University , Baltimore, Maryland 21218, United States
| | - Robert F Spiera
- Hospital for Special Surgery , New York, New York 10021, United States
| | | | - John H Stone
- Massachusetts General Hospital , Boston, Massachusetts 02114, United States
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota 55905, United States
| | - David R Barnidge
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota 55905, United States
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Abstract
To review the reported evidence on the therapeutic management of IgG4-related disease (IgG4-RD) in clinical practice.A systematic search of the literature was conducted. The primary outcome measured was the rate of efficacy of first-line therapeutic approaches. Secondary outcomes measured included the rate of disease relapse, the outcome of untreated patients, the rate of patients without drug therapy at the end of follow-up, the rate of side effects, and mortality. The MOOSE, AHRQ, STROBE, and GRACE recommendations/statements were followed.The results of the systematic search strategy yielded 62 studies that included a total of 3034 patients. Complete information about first-line therapeutic regimens was detailed in 1952 patients, including glucocorticoid-based regimens in 1437 (74%), drug-free regimens in 213 (11%), and other therapies in 38 (2%). No therapy (wait and see management) was reported in 264 (13%) patients. The efficacy of monotherapy with glucocorticoids was specified in 1220 patients, of whom 97% had a therapeutic response. Relapses, however, were reported in 464/1395 (33%) patients despite typically short follow-up periods. Therapeutic efficacy was reported in 219/231 (95%) of relapses treated with glucocorticoids, 56/69 (81%) of those treated with azathioprine, 16/22 (72%) of those treated with other immunosuppressive agents, and in the 9 cases treated with rituximab (100%). In 14 studies, the authors detailed the outcome of 159/246 patients with wait-and-see management; spontaneous improvement or resolution was reported in 68 (43%) cases. Wide heterogeneity was observed with respect to the first-line therapeutic approaches used for the different organ-specific disease subsets, including significant differences in the mean dose of glucocorticoids used.Nearly 70% of reported IgG4-RD patients are treated with oral glucocorticoids in monotherapy. However, the therapeutic management is heavily influenced by geographical, epidemiological, and clinical factors, especially with respect to the predominant organ affected. The frequency of glucocorticoid failure to induce sustained remissions both during and after treatment and the assessment of glucocorticoid toxicity in IgG4-RD require further study.
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Affiliation(s)
- Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA-Sanitas
- Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic
| | - Belchin Kostov
- Consorci d’Atenció Primària de Salut Barcelona Esquerre (CAPS-BE)
- Transverse Group for Research in Primary Care, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
| | - Xavier Bosch
- Department of Internal Medicine, ICMiD, Hospital Clínic, Barcelona, Spain
| | - Nihan Acar-Denizli
- Department of Statistics, Faculty of Science and Letters, Mimar Sinan Fine Arts University, Istanbul, Turkey
| | - Manuel Ramos-Casals
- Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic
- Department of Medicine, University of Barcelona, Barcelona, Spain
- Correspondence: Manuel Ramos-Casals, Servei de Malalties Autoimmunes, Hospital Clínic, C/Villarroel, 170, 08036-Barcelona, Spain (e-mail: )
| | - John H. Stone
- Harvard Medical School and Department of Medicine (Division of Rheumatology, Allergy, and Immunology), Massachusetts General Hospital, Boston, MA
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175
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Brito-Zerón P, Bosch X, Ramos-Casals M, Stone JH. IgG4-related disease: Advances in the diagnosis and treatment. Best Pract Res Clin Rheumatol 2016; 30:261-278. [DOI: 10.1016/j.berh.2016.07.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/17/2016] [Indexed: 02/08/2023]
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176
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Mattoo H, Mahajan VS, Maehara T, Deshpande V, Della-Torre E, Wallace ZS, Kulikova M, Drijvers JM, Daccache J, Carruthers MN, Castelino FV, Stone JR, Stone JH, Pillai S. Clonal expansion of CD4(+) cytotoxic T lymphocytes in patients with IgG4-related disease. J Allergy Clin Immunol 2016; 138:825-838. [PMID: 26971690 DOI: 10.1016/j.jaci.2015.12.1330] [Citation(s) in RCA: 240] [Impact Index Per Article: 30.0] [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: 09/11/2015] [Revised: 11/30/2015] [Accepted: 12/14/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a systemic condition of unknown cause characterized by highly fibrotic lesions with dense lymphoplasmacytic infiltrates. CD4(+) T cells constitute the major inflammatory cell population in IgG4-RD lesions. OBJECTIVE We used an unbiased approach to characterize CD4(+) T-cell subsets in patients with IgG4-RD based on their clonal expansion and ability to infiltrate affected tissue sites. METHODS We used flow cytometry to identify CD4(+) effector/memory T cells in a cohort of 101 patients with IgG4-RD. These expanded cells were characterized by means of gene expression analysis and flow cytometry. Next-generation sequencing of the T-cell receptor β chain gene was performed on CD4(+)SLAMF7(+) cytotoxic T lymphocytes (CTLs) and CD4(+)GATA3(+) TH2 cells in a subset of patients to identify their clonality. Tissue infiltration by specific T cells was examined by using quantitative multicolor imaging. RESULTS CD4(+) effector/memory T cells with a cytolytic phenotype were expanded in patients with IgG4-RD. Next-generation sequencing revealed prominent clonal expansions of these CD4(+) CTLs but not CD4(+)GATA3(+) memory TH2 cells in patients with IgG4-RD. The dominant T cells infiltrating a range of inflamed IgG4-RD tissue sites were clonally expanded CD4(+) CTLs that expressed SLAMF7, granzyme A, IL-1β, and TGF-β1. Clinical remission induced by rituximab-mediated B-cell depletion was associated with a reduction in numbers of disease-associated CD4(+) CTLs. CONCLUSIONS IgG4-RD is prominently linked to clonally expanded IL-1β- and TGF-β1-secreting CD4(+) CTLs in both peripheral blood and inflammatory tissue lesions. These active, terminally differentiated, cytokine-secreting effector CD4(+) T cells are now linked to a human disease characterized by chronic inflammation and fibrosis.
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Affiliation(s)
- Hamid Mattoo
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Vinay S Mahajan
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Takashi Maehara
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Fukuoka, Japan
| | - Vikram Deshpande
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | | | - Zachary S Wallace
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Maria Kulikova
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jefte M Drijvers
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Joe Daccache
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | | | | | - James R Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - John H Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Shiv Pillai
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
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177
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Vodopivec I, Oakley DH, Perugino CA, Venna N, Hedley-Whyte ET, Stone JH. A 44-year-old man with eye, kidney, and brain dysfunction. Ann Neurol 2016; 79:507-19. [PMID: 26691497 DOI: 10.1002/ana.24583] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 12/28/2022]
Abstract
Retinal vasculopathy with cerebral leukodystrophy (RVCL) is a rare, autosomal dominant condition caused by mutations of TREX1 (3-prime repair exonuclease-1). The phenotypic expressions range from isolated retinal involvement to varying degrees of retinopathy, cerebral infarction with calcium depositions, nephropathy, and hepatopathy. We report a case of RVCL caused by a novel TREX1 mutation. This patient's multisystem presentation, retinal involvement interpreted as "retinal vasculitis," and improvement of neuroimaging abnormalities with dexamethasone led to the accepted diagnosis of a rheumatologic disorder resembling Behçet disease. Clinicians should consider RVCL in any patient with retinal capillary obliterations associated with tumefactive brain lesions or nephropathy.
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Affiliation(s)
- Ivana Vodopivec
- Harvard Medical School, Boston, MA.,Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Derek H Oakley
- Harvard Medical School, Boston, MA.,Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA
| | - Cory A Perugino
- Harvard Medical School, Boston, MA.,Rheumatology Unit, Massachusetts General Hospital, Boston, MA
| | - Nagagopal Venna
- Harvard Medical School, Boston, MA.,Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - E Tessa Hedley-Whyte
- Harvard Medical School, Boston, MA.,Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA
| | - John H Stone
- Harvard Medical School, Boston, MA.,Rheumatology Unit, Massachusetts General Hospital, Boston, MA
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178
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Wallace ZS, Mattoo H, Mahajan VS, Kulikova M, Lu L, Deshpande V, Choi HK, Pillai S, Stone JH. Predictors of disease relapse in IgG4-related disease following rituximab. Rheumatology (Oxford) 2016; 55:1000-8. [PMID: 26888853 DOI: 10.1093/rheumatology/kev438] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [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: 03/27/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) is a relapsing-remitting condition responsible for fibroinflammatory lesions that can lead to organ damage and life-threatening complications at nearly any anatomical site. The duration of remission following treatment varies and predictors of relapse are unclear. The objectives of this study were to review our experience with rituximab as remission induction in IgG4-RD, to clarify the duration of efficacy and to identify predictors of flare following treatment. METHODS In this retrospective cohort study, all patients were treated with two doses of rituximab (1 g) separated by 15 days. Clinical, radiographic and laboratory data pertaining to rituximab response and disease relapse were collected from the electronic medical record. Kaplan-Meier curves were constructed to estimate the time to disease relapse. Log-rank analyses were performed to compare times to relapse among subgroups. Potential relapse predictors were evaluated with Cox regression analysis. RESULTS Fifty-seven of 60 patients (95%) had clinical responses to rituximab. Forty-one patients (68%) were treated without glucocorticoids. Twenty-one patients (37%) experienced relapses following treatment at a median time from the first infusion of 244 days. Baseline concentrations of serum IgG4, IgE and circulating eosinophils predicted subsequent relapses, with hazard ratios of 6.2 (95% CI: 1.2, 32.0), 8.2 (95% CI: 1.4, 50.0) and 7.9 (95% CI: 1.8, 34.7), respectively. The higher the baseline values, the greater the risk of relapse and the shorter the time to relapse. Only 10% of the patients had elevations of all three major risk factors, underscoring the importance of measuring all three at baseline. CONCLUSION Baseline elevations in serum IgG4, IgE and blood eosinophil concentrations all predict IgG4-RD relapses independently.
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Affiliation(s)
- Zachary S Wallace
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital
| | - Hamid Mattoo
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University
| | - Vinay S Mahajan
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University
| | - Maria Kulikova
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University
| | - Leo Lu
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Boston University School of Medicine
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shiv Pillai
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University, Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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179
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Unizony S, Villarreal M, Miloslavsky EM, Lu N, Merkel PA, Spiera R, Seo P, Langford CA, Hoffman GS, Kallenberg CM, St Clair EW, Ikle D, Tchao NK, Ding L, Brunetta P, Choi HK, Monach PA, Fervenza F, Stone JH, Specks U. Clinical outcomes of treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis based on ANCA type. Ann Rheum Dis 2015; 75:1166-9. [PMID: 26621483 DOI: 10.1136/annrheumdis-2015-208073] [Citation(s) in RCA: 158] [Impact Index Per Article: 17.6] [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: 06/15/2015] [Accepted: 11/07/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate whether the classification of patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) according to ANCA type (anti-proteinase 3 (PR3) or anti-myeloperoxidase (MPO) antibodies) predicts treatment response. METHODS Treatment responses were assessed among patients enrolled in the Rituximab in ANCA-associated Vasculitis trial according to both AAV diagnosis (granulomatosis with polyangiitis (GPA)/microscopic polyangiitis (MPA)) and ANCA type (PR3-AAV/MPO-AAV). Complete remission (CR) was defined as disease activity score of 0 and successful completion of the prednisone taper. RESULTS PR3-AAV patients treated with rituximab (RTX) achieved CR at 6 months more frequently than did those randomised to cyclophosphamide (CYC)/azathioprine (AZA) (65% vs 48%; p=0.04). The OR for CR at 6 months among PR3-AAV patients treated with RTX as opposed to CYC/AZA was 2.11 (95% CI 1.04 to 4.30) in analyses adjusted for age, sex and new-onset versus relapsing disease at baseline. PR3-AAV patients with relapsing disease achieved CR more often following RTX treatment at 6 months (OR 3.57; 95% CI 1.43 to 8.93), 12 months (OR 4.32; 95% CI 1.53 to 12.15) and 18 months (OR 3.06; 95% CI 1.05 to 8.97). No association between treatment and CR was observed in the MPO-AAV patient subset or in groups divided according to AAV diagnosis. CONCLUSIONS Patients with PR3-AAV respond better to RTX than to CYC/AZA. An ANCA type-based classification may guide immunosuppression in AAV. TRIAL REGISTRATION NUMBER NCT00104299; post-results.
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Affiliation(s)
| | | | | | - Na Lu
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter A Merkel
- University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Robert Spiera
- Hospital for Special Surgery, New York, New York, USA
| | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Cg M Kallenberg
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Nadia K Tchao
- Immune Tolerance Network, San Francisco, California, USA
| | - Linna Ding
- National Institute of Allergy & Infectious Disease/Division of Allergy, Immunology, & Transplantation (NIAID/DAIT), Bethesda, Maryland, USA
| | | | - Hyon K Choi
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul A Monach
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts, USA
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180
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Wallace ZS, Deshpande V, Mattoo H, Mahajan VS, Kulikova M, Pillai S, Stone JH. IgG4-Related Disease: Clinical and Laboratory Features in One Hundred Twenty-Five Patients. Arthritis Rheumatol 2015; 67:2466-75. [PMID: 25988916 DOI: 10.1002/art.39205] [Citation(s) in RCA: 408] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 05/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that can affect nearly any organ. Prior studies have focused on individual cases of IgG4-RD or small case series. This study was undertaken to report detailed clinical and laboratory findings in a larger group of patients with IgG4-RD whose diagnosis was established by strict clinicopathologic correlation. METHODS The baseline features of 125 patients with biopsy-proven IgG4-RD were reviewed. The diagnosis was confirmed by pathologists' review, based on consensus diagnostic criteria and correlation with clinicopathologic features. Disease activity and damage were assessed using the IgG4-RD Responder Index (RI). Flow cytometry was used to assess levels of circulating plasmablasts. RESULTS Of the 125 patients, 107 had active disease and 86 were not receiving treatment for IgG4-RD. Only 51% of the patients with active disease had elevated serum IgG4 concentrations. However, patients with active disease and elevated serum IgG4 concentrations were older, had a higher IgG4-RD RI score, a greater number of organs involved, lower complement levels, higher absolute eosinophil counts, and higher IgE levels compared to those with active disease but normal serum IgG4 concentrations (P < 0.01 for all comparisons). The correlation between IgG4+ plasmablast levels and the IgG4-RD RI of disease activity (Spearman's ρ = 0.45, P = 0.003) was stronger than the correlation between total plasmablast levels and the IgG4-RD RI. Seventy-six (61%) of the patients were male, but no significant differences according to sex were observed with regard to disease severity, organ involvement, or serum IgG4 concentrations. Treatment with glucocorticoids failed to produce sustained remission in 77% of patients. CONCLUSION Nearly 50% of this patient cohort with biopsy-proven, clinically active IgG4-RD had normal serum IgG4 concentrations. Elevations in the serum IgG4 concentration appeared to identify a subset of patients with a more severe disease phenotype. In addition, the levels of IgG4+ plasmablasts correlated well with the extent of disease activity.
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Affiliation(s)
| | - Vikram Deshpande
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Hamid Mattoo
- Massachusetts General Hospital Cancer Center, Boston
| | | | | | - Shiv Pillai
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston
| | - John H Stone
- Massachusetts General Hospital and Harvard Medical School, Boston
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181
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Khosroshahi A, Wallace ZS, Crowe JL, Akamizu T, Azumi A, Carruthers MN, Chari ST, Della-Torre E, Frulloni L, Goto H, Hart PA, Kamisawa T, Kawa S, Kawano M, Kim MH, Kodama Y, Kubota K, Lerch MM, Löhr M, Masaki Y, Matsui S, Mimori T, Nakamura S, Nakazawa T, Ohara H, Okazaki K, Ryu JH, Saeki T, Schleinitz N, Shimatsu A, Shimosegawa T, Takahashi H, Takahira M, Tanaka A, Topazian M, Umehara H, Webster GJ, Witzig TE, Yamamoto M, Zhang W, Chiba T, Stone JH. International Consensus Guidance Statement on the Management and Treatment of IgG4-Related Disease. Arthritis Rheumatol 2015; 67:1688-99. [PMID: 25809420 DOI: 10.1002/art.39132] [Citation(s) in RCA: 589] [Impact Index Per Article: 65.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 03/19/2015] [Indexed: 02/06/2023]
Affiliation(s)
- A Khosroshahi
- Emory University School of Medicine, Atlanta, Georgia
| | | | - J L Crowe
- University of Tennessee College of Medicine, Chattanooga
| | - T Akamizu
- Wakayama Medical University, Tokyo, Japan
| | - A Azumi
- Kobe Kaisei Hospital, Kobe, Japan
| | - M N Carruthers
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - H Goto
- Tokyo Medical University, Tokyo, Japan
| | - P A Hart
- The Ohio State University Medical College and The Ohio State University Wexner Medical Center, Columbus
| | - T Kamisawa
- Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - S Kawa
- Shinshu University, Matsumoto, Japan
| | - M Kawano
- Kanazawa University Graduate School of Medical Sciences and Kanazawa University Hospital, Kanazawa, Japan
| | - M H Kim
- University of Ulsan College of Medicine and Asan Medical Center, Ulsan, Republic of Korea
| | - Y Kodama
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - K Kubota
- Yokohama City University and Yokohama City University Hospital, Yokohama, Japan
| | - M M Lerch
- University of Greifswald Medical School, Greifswald, Germany
| | - M Löhr
- Karolinska Institutet, Stockholm, Sweden
| | - Y Masaki
- Kanazawa Medical University, Kanazawa, Japan
| | - S Matsui
- University of Toyama, Toyama, Japan
| | - T Mimori
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - S Nakamura
- Kyushu University and Kyushu University Dental Hospital, Fukuoka, Japan
| | - T Nakazawa
- Nagoya City University Graduate School of Medicine, Nagoya, Japan
| | - H Ohara
- Nagoya City University Graduate School of Medicine, Nagoya, Japan
| | - K Okazaki
- Kansai Medical University, Hirakata, Japan
| | - J H Ryu
- Mayo Clinic, Rochester, Minnesota
| | - T Saeki
- Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - N Schleinitz
- Aix-Marseille Université, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - A Shimatsu
- National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - H Takahashi
- Sapporo Medical University School of Medicine, Sapporo, Japan
| | - M Takahira
- Kanazawa University Graduate School of Medical Sciences and Kanazawa University Hospital, Kanazawa, Japan
| | - A Tanaka
- Teikyo University School of Medicine, Tokyo, Japan
| | | | - H Umehara
- Kanazawa Medical University, Kanazawa, Japan
| | - G J Webster
- University College London and University College London Hospitals, London, UK
| | | | - M Yamamoto
- Sapporo Medical University School of Medicine, Sapporo, Japan
| | - W Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing, China
| | - T Chiba
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - J H Stone
- Massachusetts General Hospital, Boston
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- Japanese Ministry of Health, Labor, and Welfare, Amgen, and Genetech
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182
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Grayson PC, Carmona-Rivera C, Xu L, Lim N, Gao Z, Asare AL, Specks U, Stone JH, Seo P, Spiera RF, Langford CA, Hoffman GS, Kallenberg CGM, St Clair EW, Tchao NK, Ytterberg SR, Phippard DJ, Merkel PA, Kaplan MJ, Monach PA. Neutrophil-Related Gene Expression and Low-Density Granulocytes Associated With Disease Activity and Response to Treatment in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2015; 67:1922-32. [PMID: 25891759 DOI: 10.1002/art.39153] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 04/07/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To discover biomarkers involved in the pathophysiology of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and to determine whether low-density granulocytes (LDGs) contribute to gene expression signatures in AAV. METHODS The source of clinical data and linked biologic specimens was a randomized controlled treatment trial in AAV. RNA sequencing of whole blood from patients with AAV was performed during active disease at the baseline visit and during remission 6 months later. Gene expression was compared between patients who met versus those who did not meet the primary trial outcome of clinical remission at 6 months (responders versus nonresponders). Measurement of neutrophil-related gene expression was confirmed in peripheral blood mononuclear cells (PBMCs) to validate the findings in whole blood. A negative-selection strategy isolated LDGs from PBMC fractions. RESULTS Differential expression between responders (n = 77) and nonresponders (n = 35) was detected in 2,346 transcripts at the baseline visit (P < 0.05). Unsupervised hierarchical clustering demonstrated a cluster of granulocyte-related genes, including myeloperoxidase (MPO) and proteinase 3 (PR3). A granulocyte multigene composite score was significantly higher in nonresponders than in responders (P < 0.01) and during active disease than during remission (P < 0.01). This signature strongly overlapped an LDG signature identified previously in lupus (false discovery rate by gene set enrichment analysis <0.01). Transcription of PR3 measured in PBMCs was associated with active disease and treatment response (P < 0.01). LDGs isolated from patients with AAV spontaneously formed neutrophil extracellular traps containing PR3 and MPO. CONCLUSION In AAV, increased expression of a granulocyte gene signature is associated with disease activity and decreased response to treatment. The source of this signature is likely LDGs, a potentially pathogenic cell type in AAV.
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Affiliation(s)
- Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Carmelo Carmona-Rivera
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Lijing Xu
- Immune Tolerance Network, Bethesda, Maryland
| | - Noha Lim
- Immune Tolerance Network, Bethesda, Maryland
| | - Zhong Gao
- Immune Tolerance Network, Bethesda, Maryland
| | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | | | - Mariana J Kaplan
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Paul A Monach
- Boston University School of Medicine, Boston, Massachusetts
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183
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Miloslavsky EM, Specks U, Merkel PA, Seo P, Spiera R, Langford CA, Hoffman GS, Kallenberg CGM, St Clair EW, Tchao NK, Ding L, Iklé D, Villareal M, Lim N, Brunetta P, Fervenza FC, Monach PA, Stone JH. Outcomes of nonsevere relapses in antineutrophil cytoplasmic antibody-associated vasculitis treated with glucocorticoids. Arthritis Rheumatol 2015; 67:1629-36. [PMID: 25776953 DOI: 10.1002/art.39104] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/03/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Nonsevere relapses are more common than severe relapses in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), but their clinical course and treatment outcomes remain largely unexamined. We undertook this study to analyze the outcomes of patients with nonsevere relapses in the Rituximab in ANCA-Associated Vasculitis (RAVE) trial who were treated with prednisone according to a prespecified protocol. METHODS RAVE was a randomized, double-blind, placebo-controlled trial comparing rituximab (RTX) to cyclophosphamide (CYC) followed by azathioprine (AZA) for induction of remission. Patients who experienced nonsevere relapses between months 1 and 18 were treated with a prednisone increase without a concomitant change in their nonglucocorticoid immunosuppressants, followed by a taper. RESULTS Forty-four patients with a first nonsevere relapse were analyzed. In comparison to the 71 patients who maintained relapse-free remission over 18 months, these patients were more likely to have proteinase 3-ANCAs, diagnoses of granulomatosis with polyangiitis (Wegener's), and a history of relapsing disease at baseline. A prednisone increase led to remission in 35 patients (80%). However, only 13 patients (30%) were able to maintain second remissions through the followup period (mean 12.5 months); 31 patients (70%) had a second disease relapse, 14 of them with severe disease. The mean time to second relapse was 9.4 months (4.7 months in the group treated with RTX versus 13.7 months in the group treated with CYC/AZA; P < 0.01). Patients who experienced nonsevere relapses received more glucocorticoids than those who maintained remission (6.7 grams versus 3.8 grams; P < 0.01). CONCLUSION Treatment of nonsevere relapses in AAV with an increase in glucocorticoids is effective in restoring temporary remission in the majority of patients, but recurrent relapses within a relatively short interval remain common. Alternative treatment approaches are needed for this important subset of patients.
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Affiliation(s)
| | - U Specks
- Mayo Clinic, Rochester, Minnesota
| | - P A Merkel
- University of Pennsylvania, Philadelphia
| | - P Seo
- Johns Hopkins University, Baltimore, Maryland
| | - R Spiera
- Hospital for Special Surgery, New York, New York
| | | | - G S Hoffman
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - C G M Kallenberg
- University of Groningen and University Medical Center, Groningen, The Netherlands
| | - E W St Clair
- Duke University Medical Center, Durham, North Carolina
| | - N K Tchao
- Immune Tolerance Network, South San Francisco, California
| | - L Ding
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - D Iklé
- Rho, Chapel Hill, North Carolina
| | | | - N Lim
- Immune Tolerance Network, Bethesda, Maryland
| | - P Brunetta
- Genentech, South San Francisco, California
| | | | - P A Monach
- Boston University and Boston Medical Center, Boston, Massachusetts
| | - J H Stone
- Massachusetts General Hospital, Boston
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184
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Wallace ZS, Lu N, Unizony S, Stone JH, Choi HK. Improved survival in granulomatosis with polyangiitis: A general population-based study. Semin Arthritis Rheum 2015; 45:483-9. [PMID: 26323883 DOI: 10.1016/j.semarthrit.2015.07.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [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: 04/03/2015] [Revised: 07/06/2015] [Accepted: 07/30/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is associated with an increased risk of mortality; however, recent mortality trends in GPA are unknown. We evaluated this issue in a general population context. METHODS Using data collected between 1992 and 2013 by The Health Improvement Network in the United Kingdom, we identified individuals diagnosed as incident cases of GPA and up to 10 non-GPA controls matched on sex, age, year of birth, and year of GPA diagnosis. The cohort was divided into two based on the year of diagnosis (i.e., 1992-2002 and 2003-2013) to evaluate changes in mortality. We calculated hazard ratios for death using a Cox-proportional hazards model and the rate differences using an additive hazard model, while adjusting for potential confounders. RESULTS We identified 465 cases of GPA (mean age: 60 years, 52% male). The early cohort (1992-2002) GPA patients had considerably higher mortality rates than the late cohort (2003-2013) (i.e., 72.0 vs. 35.7 cases per 1000 person-years), as compared with a moderate improvement in the comparison cohorts between the two periods (19.8 vs. 17.0 cases per 1000 person-years). The corresponding absolute mortality rate difference was 52.2 (95% CI: 25.1-79.2) cases and 18.7 (95% CI: 8.3-29.1) cases per 1000 person-years (p for interaction = 0.025). The resulting HRs for mortality were 4.34 (95% CI: 2.72-6.92) and 2.41 (95% CI: 1.74-3.34), respectively (p for interaction = 0.043). CONCLUSION This population-based study suggests that survival of GPA patients has improved considerably over the past 2 decades, affirming the benefits of recent trends in the management of GPA and its complications.
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Affiliation(s)
- Zachary S Wallace
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Na Lu
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Clinical Epidemiology and Training Unit, Boston University School of Medicine, Boston, MA
| | - Sebastian Unizony
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John H Stone
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hyon K Choi
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Clinical Epidemiology and Training Unit, Boston University School of Medicine, Boston, MA
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Kaushik P, Stone JH, Anderson JT, Dugar S, Mathew R, Nikolic B, Patel R. Medical mirroring: granulomatosis with polyangiitis (formerly Wegener's) mimicking immunoglobulin-G4 related disease. Int J Rheum Dis 2015; 21:885-889. [DOI: 10.1111/1756-185x.12687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Prashant Kaushik
- Albany Stratton Veterans Affairs Medical Center (VAMC); Albany New York USA
- Albany Medical College; Albany New York USA
| | - John H. Stone
- Harvard Medical School; Massachusetts General Hospital; Boston Massachusetts USA
- Clinical Rheumatology; Massachusetts General Hospital; Boston Massachusetts USA
| | | | | | - Roy Mathew
- Albany Stratton Veterans Affairs Medical Center (VAMC); Albany New York USA
- Albany Medical College; Albany New York USA
| | - Boris Nikolic
- Albany Stratton Veterans Affairs Medical Center (VAMC); Albany New York USA
| | - Raina Patel
- Albany Stratton Veterans Affairs Medical Center (VAMC); Albany New York USA
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Della-Torre E, Campochiaro C, Bozzolo EP, Dagna L, Scotti R, Nicoletti R, Stone JH, Sabbadini MG. Methotrexate for maintenance of remission in IgG4-related disease: Fig. 1. Rheumatology (Oxford) 2015; 54:1934-6. [DOI: 10.1093/rheumatology/kev244] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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187
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Stone JH, Brito-Zerón P, Bosch X, Ramos-Casals M. Diagnostic Approach to the Complexity of IgG4-Related Disease. Mayo Clin Proc 2015; 90:927-39. [PMID: 26141331 DOI: 10.1016/j.mayocp.2015.03.020] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a systemic disease characterized by the infiltration of IgG4-bearing plasma cells and, more importantly, distinctive histopathological features: storiform fibrosis, obliterative phlebitis, a lymphoplasmacytic infiltrate, and mild-to-moderate tissue eosinophilia. The diagnostic approach is complex and relies on the coexistence of various clinical, laboratory, and histopathological findings, none of which is pathognomonic in and of itself. IgG4-related disease should be suspected in patients presenting with unexplained enlargement or swelling of 1 or more organs or tissue organs. Four laboratory abnormalities often provide initial clues to the diagnosis of IgG4-RD: peripheral eosinophilia, hypergammaglobulinemia, elevated serum IgE levels, and hypocomplementemia. Elevated serum IgG4 levels provided critical information in identifying the first cases of IgG4-RD, but recent studies have reported substantial limitations to the measurement of serum IgG4 concentrations, precluding reliance on serum IgG4 concentrations for diagnostic purposes. In contrast, new studies have suggested a promising role of flow cytometry studies in the diagnosis and longitudinal management of IgG4-RD. Demonstration of the classic histopathological features of IgG4-RD remains crucial to diagnosis in most cases, and biopsy proof is preferred strongly by most disease experts before the initiation of treatment. Of note, the multiorgan nature of IgG4-RD was first established in 2003. This review intends to provide most recent knowledge about the clinical, laboratory, radiological, and pathological characteristics of IgG4-RD that may guide the physician to establish an early diagnosis. We searched PubMed and MEDLINE for relevant articles published between January 1, 2000, and November 1, 2014, using the search terms IgG4 and IgG4-related.
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Affiliation(s)
- John H Stone
- Harvard Medical School, Boston, MA; Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA.
| | - Pilar Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Spain
| | - Xavier Bosch
- Department of Internal Medicine (ICMiD), Hospital Clínic, University of Barcelona, Spain
| | - Manuel Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Spain
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189
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Jimenez X, Psutka SP, Stone JH, Carruthers MN. A 53-Year-Old Man With Dysuria, Pyuria, and Genital Ulcers. Arthritis Care Res (Hoboken) 2015; 68:1371-7. [PMID: 25989159 DOI: 10.1002/acr.22617] [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: 01/18/2015] [Revised: 03/12/2015] [Accepted: 05/05/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Xavier Jimenez
- Pennsylvania Hospital of the University of Pennsylvania, Philadelphia
| | | | - John H Stone
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mollie N Carruthers
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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190
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Stone JH, Carruthers MN, Topazian MD, Khosroshahi A, Witzig TE, Wallace ZS, Hart PA, Deshpande V, Smyrk TC, Chari S. Response to: ‘Is rituximab effective for IgG4-related disease in the long term? Experience of cases treated with rituximab for 4 years’ by Yamamotoet al. Ann Rheum Dis 2015; 74:e47. [DOI: 10.1136/annrheumdis-2015-207640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/11/2015] [Indexed: 12/24/2022]
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191
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Unizony S, Lim N, Phippard DJ, Carey VJ, Miloslavsky EM, Tchao NK, Iklé D, Asare AL, Merkel PA, Monach PA, Seo P, St Clair EW, Langford CA, Spiera R, Hoffman GS, Kallenberg CGM, Specks U, Stone JH. Peripheral CD5+ B cells in antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheumatol 2015; 67:535-44. [PMID: 25332071 DOI: 10.1002/art.38916] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 10/09/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE CD5+ B cells have been conceptualized as a possible surrogate for Breg cells. The aim of the present study was to determine the utility of CD5+ B cells as biomarkers in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS The absolute and relative numbers (percentages) of CD5+ B cells (explanatory variables) were measured longitudinally during 18 months in 197 patients randomized to receive either rituximab (RTX) or cyclophosphamide (CYC) followed by azathioprine (AZA) for the treatment of AAV (Rituximab in ANCA-Associated Vasculitis [RAVE] trial). Outcome variables included disease activity (status of active disease versus complete remission), responsiveness to induction therapy, disease relapse, disease severity, and, in RTX-treated patients, relapse-free survival according to the percentage of CD5+ B cells detected upon B cell repopulation. RESULTS CD5+ B cell numbers were comparable between the treatment groups at baseline. After an initial decline, absolute CD5+ B cell numbers progressively increased in patients in the RTX treatment arm, but remained low in CYC/AZA-treated patients. In both groups, the percentage of CD5+ B cells increased during remission induction and slowly declined thereafter. During relapse, the percentage of CD5+ B cells correlated inversely with disease activity in RTX-treated patients, but not in patients who received CYC/AZA. No significant association was observed between the numbers of CD5+ B cells and induction treatment failure or disease severity. The dynamics of the CD5+ B cell compartment did not anticipate disease relapse. Following B cell repopulation, the percentage of CD5+ B cells was not predictive of time to flare in RTX-treated patients. CONCLUSION The percentage of peripheral CD5+ B cells might reflect disease activity in RTX-treated patients. However, sole staining for CD5 as a putative surrogate marker for Breg cells did not identify a subpopulation of B cells with clear potential for meaningful clinical use. Adequate phenotyping of Breg cells is required to further explore the value of these cells as biomarkers in AAV.
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Abstract
IgG4-related disease is a protean condition that mimics many malignant, infectious, and inflammatory disorders. This multi-organ immune-mediated condition links many disorders previously regarded as isolated, single-organ diseases without any known underlying systemic condition. It was recognised as a unified entity only 10 years ago. Histopathology is the key to diagnosis. The three central pathology features of IgG4-related disease are lymphoplasmacytic infiltration, storiform fibrosis, and obliterative phlebitis. The extent of fibrosis is an important determinant of responsiveness to immunosuppressive therapies. IgG4-related disease generally responds to glucocorticoids in its inflammatory stage, but recurrent or refractory cases are common. Important mechanistic insights have been derived from studies of patients treated by B-cell depletion. Greater awareness of this disease is needed to ensure earlier diagnoses, which can prevent severe organ damage, disabling tissue fibrosis, and even death. Identification of specific antigens and T-cell clones that drive the disease will be the first steps to elucidate the pathogenesis of IgG4-related disease.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Yoh Zen
- Department of Pathology, Kobe University, Kobe, Japan
| | - Shiv Pillai
- Center for Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Ramos-Casals M, Brito-Zerón P, Kostov B, Sisó-Almirall A, Bosch X, Buss D, Trilla A, Stone JH, Khamashta MA, Shoenfeld Y. Google-driven search for big data in autoimmune geoepidemiology: analysis of 394,827 patients with systemic autoimmune diseases. Autoimmun Rev 2015; 14:670-9. [PMID: 25842074 DOI: 10.1016/j.autrev.2015.03.008] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [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: 03/16/2015] [Accepted: 03/30/2015] [Indexed: 01/08/2023]
Abstract
Systemic autoimmune diseases (SADs) are a significant cause of morbidity and mortality worldwide, although their epidemiological profile varies significantly country by country. We explored the potential of the Google search engine to collect and merge large series (>1000 patients) of SADs reported in the Pubmed library, with the aim of obtaining a high-definition geoepidemiological picture of each disease. We collected data from 394,827 patients with SADs. Analysis showed a predominance of medical vs. administrative databases (74% vs. 26%), public health system vs. health insurance resources (88% vs. 12%) and patient-based vs. population-based designs (82% vs. 18%). The most unbalanced gender ratio was found in primary Sjögren syndrome (pSS), with nearly 10 females affected per 1 male, followed by systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and antiphospholipid syndrome (APS) (ratio of nearly 5:1). Each disease predominantly affects a specific age group: children (Kawasaki disease, primary immunodeficiencies and Schonlein-Henoch disease), young people (SLE Behçet disease and sarcoidosis), middle-aged people (SSc, vasculitis and pSS) and the elderly (amyloidosis, polymyalgia rheumatica, and giant cell arteritis). We found significant differences in the geographical distribution of studies for each disease, and a higher frequency of the three SADs with available data (SLE, inflammatory myopathies and Kawasaki disease) in African-American patients. Using a "big data" approach enabled hitherto unseen connections in SADs to emerge.
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Affiliation(s)
- Manuel Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, CELLEX, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
| | - Pilar Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, CELLEX, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
| | - Belchin Kostov
- Primary Care Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Primary Care Centre Les Corts, CAPSE, Barcelona, Spain
| | - Antoni Sisó-Almirall
- Primary Care Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Primary Care Centre Les Corts, CAPSE, Barcelona, Spain
| | - Xavier Bosch
- Department of Internal Medicine, ICMiD, Hospital Clínic, Barcelona, Spain
| | - David Buss
- Josep Font Laboratory of Autoimmune Diseases, CELLEX, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
| | - Antoni Trilla
- Preventive Medicine and Epidemiology Unit, Hospital Clínic-Universitat de Barcelona, Barcelona Centre for International Health Research, Barcelona, Catalonia, Spain
| | - John H Stone
- Harvard Medical School, Boston, MA 02114, USA; Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Munther A Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas' Hospital, King's College University, London, UK
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel Hashomer, Israel Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Unizony S, Menendez ME, Rastalsky N, Stone JH. Inpatient complications in patients with giant cell arteritis: decreased mortality and increased risk of thromboembolism, delirium and adrenal insufficiency. Rheumatology (Oxford) 2015; 54:1360-8. [PMID: 25667435 DOI: 10.1093/rheumatology/keu483] [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] [Received: 08/05/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The morbidity and mortality of hospitalized GCA patients have been unexplored. The aim of this study was to analyse inpatient complications experienced by patients with GCA. METHODS We used the Nationwide Inpatient Sample database to study a large group of patients admitted for pneumonia, myocardial infarction (MI), ischaemic stroke and femoral neck fracture. Patients were divided into two groups based on whether or not they had a diagnosis of GCA upon admission. Outcomes evaluated included inpatient mortality and the occurrence of adrenal insufficiency, deep vein thrombosis, pulmonary embolism and delirium. RESULTS From 2008 to 2011, 8 203 447 patients ≥50 years of age were discharged from US hospitals after admission with pneumonia, MI, stroke and femoral neck fracture. Among these patients, 9311 (0.11%) had GCA. Admissions for pneumonia, stroke and hip fracture were more frequent in GCA patients compared with those without GCA, accounting for 41.5% vs 39.4%, 24.9% vs 19.8% and 15.4% vs 14.2% of hospitalizations, respectively (P ≤ 0.001). Admissions for MI were more common in non-GCA patients (26.6% vs 18.2%, P < 0.001). During hospitalization, 4.1% of the GCA patients died, compared with 4.8% of those without GCA [odds ratio (OR) 0.73, P < 0.001). The GCA population suffered significantly more often from deep vein thrombosis (OR 2.08, P < 0.001), pulmonary embolism (OR 1.58, P < 0.001), delirium (OR 1.60, P < 0.001) and adrenal insufficiency (OR 4.95, P < 0.001). CONCLUSION Hospitalized GCA patients have lower mortality compared with the general inpatient population but greater risk of venous thromboembolism, delirium and adrenal insufficiency.
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Affiliation(s)
| | - Mariano E Menendez
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Naina Rastalsky
- Division of Rheumatology, Allergy and Immunology Division and
| | - John H Stone
- Division of Rheumatology, Allergy and Immunology Division and
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Carruthers MN, Topazian MD, Khosroshahi A, Witzig TE, Wallace ZS, Hart PA, Deshpande V, Smyrk TC, Chari S, Stone JH. Rituximab for IgG4-related disease: a prospective, open-label trial. Ann Rheum Dis 2015; 74:1171-7. [PMID: 25667206 DOI: 10.1136/annrheumdis-2014-206605] [Citation(s) in RCA: 412] [Impact Index Per Article: 45.8] [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: 09/10/2014] [Accepted: 01/06/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the efficacy of rituximab (RTX) in IgG4-related disease (IgG4-RD) in an open-label pilot trial. METHODS We treated 30 IgG4-RD patients with two doses of RTX (1000 mg each). The participants were either treated with RTX alone (n = 26; 87%) or required to discontinue baseline glucocorticoids (GC) within 2 months (n = 4; 13%). Disease activity was measured by the IgG4-RD Responder Index (IgG4-RD RI) and physician's global assessment (PGA). Disease response was defined as the improvement of the IgG4-RD RI by two points. The primary outcome, measured at 6 months, was defined as: (1) decline of the IgG4-RD RI ≥2 points compared with baseline; (2) no disease flares before month 6; and (3) no GC use between months 2 and 6. Complete remission was defined as an IgG4-RD RI score of 0 with no GC use. RESULTS Disease responses occurred in 97% of participants. The baseline IgG4-RD RI and PGA values, 11±7 and 63±22 mm, respectively, declined to 1±2 and 11±16 mm at 6 months (both p<0.00001). The primary outcome was achieved by 23 participants (77%). Fourteen (47%) were in complete remission at 6 months, and 12 (40%) remained in complete remission at 12 months. Among the 19 with elevated baseline serum IgG4, IgG4 concentrations declined from a mean of 911 mg/dL (range 138-4780 mg/dL) to 422 mg/dL (range 56-2410 mg/dL) at month 6 (p<0.05). However, only 8 (42%) of the 19 achieved normal values. CONCLUSIONS RTX appears to be an effective treatment for IgG4-RD, even without concomitant GC therapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT01584388.
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Affiliation(s)
- Mollie N Carruthers
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Arezou Khosroshahi
- Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas E Witzig
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachary S Wallace
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Philip A Hart
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Thomas C Smyrk
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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196
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Unizony SH, Stone JH. Antineutrophil cytoplasmic antibody–associated vasculitis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00157-1] [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: 10/23/2022] Open
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197
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Wallace ZS, Mattoo H, Carruthers M, Mahajan VS, Della Torre E, Lee H, Kulikova M, Deshpande V, Pillai S, Stone JH. Plasmablasts as a biomarker for IgG4-related disease, independent of serum IgG4 concentrations. Ann Rheum Dis 2015; 74:190-5. [PMID: 24817416 PMCID: PMC4656194 DOI: 10.1136/annrheumdis-2014-205233] [Citation(s) in RCA: 296] [Impact Index Per Article: 32.9] [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] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We examined the utility of circulating total and IgG4+ plasmablasts as biomarkers of diagnosis and disease activity in IgG4-related disease (IgG4-RD). MATERIALS METHODS We evaluated patients with active, untreated, biopsy-proven IgG4-RD affecting various organs. Flow cytometry was used to measure total plasmablast and IgG4+ plasmablast counts by gating peripheral blood for CD19lowCD38+CD20-CD27+ cells and CD19lowCD38+CD20-CD27+IgG4+ cells. Serum IgG4 concentrations were measured by nephelometry. We compared 37 IgG4-RD patients to 35 controls, including healthy individuals (n=14) and patients with other inflammatory diseases before treatment (n=21). RESULTS The IgG4-RD patients' mean age was 59, and 68% were male. Fourteen patients (38%) had three or more organs involved. The IgG4-RD patients had substantially elevated total plasmablast counts (median 4698/mL, range 610-79524/mL) compared to both untreated disease controls (median 592/mL, range 19-4294/mL; p < 0.001) and healthy controls (median 94/mL, range 1-653/mL; p < 0.001). Thirteen IgG4-RD patients (36%) had normal serum IgG4 concentrations (mean 60 mg/dL, range 5-123 mg/dL, normal <135 mg/dL). However, the median plasmablast count was not significantly lower in that subset with normal serum IgG4 concentrations (3784/mL) compared to those with elevated serum IgG4 (5155/mL) (p = 0.242). Among the 12 rituximab (RTX)-treated patients, the median plasmablast level during disease flare was 6356/mL (range 1123-41589/mL), declining to 1419/mL (range 386/mL-4150/mL) during remission (p < 0.01). CONCLUSIONS Circulating plasmablasts are elevated in active IgG4-RD, even in patients with normal serum IgG4 concentrations. Plasmablast counts are a potentially useful biomarker for diagnosis, assessing response to treatment, and determining the appropriate time for re-treatment.
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Affiliation(s)
- Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hamid Mattoo
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Mollie Carruthers
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vinay S Mahajan
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | | | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria Kulikova
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shiv Pillai
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
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198
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Geetha D, Specks U, Stone JH, Merkel PA, Seo P, Spiera R, Langford CA, Hoffman GS, Kallenberg CGM, St Clair EW, Fessler BJ, Ding L, Tchao NK, Ikle D, Jepson B, Brunetta P, Fervenza FC. Rituximab versus cyclophosphamide for ANCA-associated vasculitis with renal involvement. J Am Soc Nephrol 2014; 26:976-85. [PMID: 25381429 DOI: 10.1681/asn.2014010046] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Rituximab (RTX) is non-inferior to cyclophosphamide (CYC) followed by azathioprine (AZA) for remission-induction in severe ANCA-associated vasculitis (AAV), but renal outcomes are unknown. This is a post hoc analysis of patients enrolled in the Rituximab for ANCA-Associated Vasculitis (RAVE) Trial who had renal involvement (biopsy proven pauci-immune GN, red blood cell casts in the urine, and/or a rise in serum creatinine concentration attributed to vasculitis). Remission-induction regimens were RTX at 375 mg/m(2) × 4 or CYC at 2 mg/kg/d. CYC was replaced by AZA (2 mg/kg/d) after 3-6 months. Both groups received glucocorticoids. Complete remission (CR) was defined as Birmingham Vasculitis Activity Score/Wegener's Granulomatosis (BVAS/WG)=0 off prednisone. Fifty-two percent (102 of 197) of the patients had renal involvement at entry. Of these patients, 51 were randomized to RTX, and 51 to CYC/AZA. Mean eGFR was lower in the RTX group (41 versus 50 ml/min per 1.73 m(2); P=0.05); 61% and 75% of patients treated with RTX and 63% and 76% of patients treated with CYC/AZA achieved CR by 6 and 18 months, respectively. No differences in remission rates or increases in eGFR at 18 months were evident when analysis was stratified by ANCA type, AAV diagnosis (granulomatosis with polyangiitis versus microscopic polyangiitis), or new diagnosis (versus relapsing disease) at entry. There were no differences between treatment groups in relapses at 6, 12, or 18 months. No differences in adverse events were observed. In conclusion, patients with AAV and renal involvement respond similarly to remission induction with RTX plus glucocorticoids or CYC plus glucocorticoids.
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Affiliation(s)
- Duvuru Geetha
- Division of Nephrology and Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine and Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John H Stone
- Rheumatology Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philip Seo
- Division of Nephrology and Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland
| | - Robert Spiera
- Rheumatology Division, Hospital for Special Surgery, New York, New York
| | - Carol A Langford
- Center for Vasculitis Care and Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gary S Hoffman
- Center for Vasculitis Care and Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cees G M Kallenberg
- Department of Rheumatology and Clinical Immunology University Medical Center, Groningen, The Netherlands
| | - E William St Clair
- Division of Rheumatology and Immunology, Duke University, Durham, North Carolina
| | - Barri J Fessler
- Division of Clinical Immunology and Rheumatology, University of Alabama, Birmingham, Alabama
| | - Linna Ding
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | | | - David Ikle
- Rho, Inc., Chapel Hill, North Carolina; and
| | | | | | - Fernando C Fervenza
- Division of Pulmonary and Critical Care Medicine and Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota;
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Miloslavsky EM, Specks U, Merkel PA, Seo P, Spiera R, Langford CA, Hoffman GS, Kallenberg CGM, St Clair EW, Tchao NK, Viviano L, Ding L, Iklé D, Villarreal M, Jepson B, Brunetta P, Allen NB, Fervenza FC, Geetha D, Keogh K, Kissin EY, Monach PA, Peikert T, Stegeman C, Ytterberg SR, Stone JH. Rituximab for the treatment of relapses in antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheumatol 2014; 66:3151-9. [PMID: 25047592 PMCID: PMC4229846 DOI: 10.1002/art.38788] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [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: 01/27/2014] [Accepted: 07/15/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Disease relapses are frequent in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). This study was undertaken to evaluate outcomes in patients with AAV who are re-treated with rituximab (RTX) and prednisone for severe disease relapses. METHODS The Rituximab in AAV trial was a randomized, double-blind, placebo-controlled trial comparing the rates of remission induction among patients treated with RTX (n = 99) and patients treated with cyclophosphamide (CYC) followed by azathioprine (AZA) (n = 98). Prednisone was tapered to discontinuation after 5.5 months. After remission was achieved, patients who experienced a severe disease relapse between months 6 and 18 were eligible to receive RTX and prednisone on an open-label basis according to a prespecified protocol. Investigators remained blinded with regard to the original treatment assignment. RESULTS Twenty-six patients received RTX for disease relapse after remission had initially been achieved with their originally assigned treatment. Fifteen of these patients were initially randomized to receive RTX and 11 to receive CYC/AZA. Thirteen (87%) of the patients originally assigned to receive RTX and 10 (91%) originally assigned to receive CYC/AZA achieved remission again with open-label RTX (an overall percentage of 88%). In half of the patients treated with open-label RTX, prednisone could be discontinued entirely. Patients in this cohort experienced fewer adverse events compared to the overall study population (4.7 adverse events per patient-year versus 11.8 adverse events per patient-year). CONCLUSION Re-treatment of AAV relapses with RTX and glucocorticoids appears to be a safe and effective strategy, regardless of previous treatment.
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Khosroshahi A, Cheryk LA, Bloch DB, Stone JH. Reply. Arthritis Rheumatol 2014; 66:3247-8. [DOI: 10.1002/art.38751] [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] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Donald B. Bloch
- Massachusetts General Hospital, and Harvard Medical School; Boston MA
| | - John H. Stone
- Massachusetts General Hospital, and Harvard Medical School; Boston MA
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