Rituximab for the treatment of glomerulonephritis in hepatitis C associated cryoglobulinaemia

Mixed-type cryoglobulins are strongly associated with hepatitis C virus (HCV) infection and may lead to vasculitis with renal involvement. The treatment of this condition is antiviral therapy for HCV, but this may be ineffective or not tolerated because of side effects. Alternative strategies such as immunosuppressive drugs and plasmapheresis are of limited use, especially in patients after liver transplantation (LTx). We describe an LTx patient with cryoglobulinaemia-associated glomerulonephritis, who was treated successfully with the B cell depleting monoclonal antibody rituximab.

Induction of interleukin-6 by hepatitis C virus core protein in hepatitis C-associated mixed cryoglobulinemia and B-cell non-Hodgkin's lymphoma

PURPOSE

Chronic hepatitis C carries the risk to develop mixed cryoglobulinemia (MC) and B-cell non-Hodgkin's lymphoma (B-NHL), possibly because viral antigens stimulate the host's inflammatory response via extracellular pattern recognition receptors (PRR). To clarify this issue, we studied whether recognition of hepatitis C virus (HCV) proteins by PRR is involved in the pathogenesis of HCV-associated MC or B-NHL.

EXPERIMENTAL DESIGN

Peripheral blood mononuclear cells of patients with HCV-associated B-NHL (n = 12), MC (n = 14), uncomplicated hepatitis C (n = 12), and healthy volunteers (n = 12) were incubated with the recombinant HCV proteins E2, core, and NS3 to study induction of cytokine production, stimulation of B-cell proliferation, and immunoglobulin secretion. In addition, serum levels of interleukin-6 (IL-6) were measured by ELISA.

RESULTS

HCV core was the only studied protein, which induced production of IL-6 and IL-8 in CD14(+) cells. IL-6 induction was mediated via Toll-like receptor 2 (TLR2) and lead to increased B-cell proliferation in vitro. TLR2 expression on monocytes and IL-6 serum concentrations were increased in all groups of HCV-infected patients compared with healthy controls and were highest in MC (P < 0.05).

CONCLUSIONS

Increased secretion of IL-6 via stimulation of TLR2 by HCV core protein may play a role in the pathogenesis of hepatitis C-associated MC and B-NHL.

Cryoglobulinaemia associated with hepatitis C virus: influence of HCV genotypes, HCV-RNA viraemia and HIV coinfection

To determine whether the clinical and immunological expression of patients with cryoglobulinaemia associated with chronic hepatitis C virus (HCV) infection varied according to HCV-RNA load, HCV genotype or human immunodeficiency virus (HIV) coinfection. We studied 340 HCV patients (188 women and 152 men, with a mean age of 49 years) consecutively diagnosed with cryoglobulinaemia between 1993 and 2003 in our hospital. HCV infection was confirmed by serum HCV-RNA determination in all patients. Two hundred and forty-eight (73%) patients had asymptomatic cryoglobulinaemia and 92 (27%) presented cryoglobulinaemic symptoms. Patients with genotype 1 had a higher mean age at diagnosis of cryoglobulinaemia (48.2 vs 40.2 yrs, P < 0.001) and a higher prevalence of cryoglobulinaemic symptoms (25%vs 10%, P = 0.02), especially of vasculitic features (19%vs 5%, P = 0.014). In comparison with monoinfected HCV patients, those with HIV coinfection had a lower mean age at diagnosis of cryoglobulinaemia (40.4 vs 52.8 years, P < 0.001), a lower prevalence of cryoglobulinaemic symptoms (15%vs 34%, P < 0.001), vasculitis (10%vs 28%, P < 0.001), associated systemic autoimmune disease (3%vs 14%, P = 0.001), rheumatoid factor (30%vs 70%, P = 0.001) and hypocomplementaemia (50%vs 78%, P = 0.01). In HCV-HIV patients, a high viral load was associated with a high frequency of symptomatic cryoglobulinaemia, especially in patients with a high viral load of the two viruses (50%vs 7%, P = 0.001) A higher frequency of cryoglobulinaemic symptoms (especially vasculitis) was found in patients with HCV monoinfection and in those carrying HCV genotype 1. In contrast, patients with HIV coinfection presented a threefold lower prevalence of vasculitis. Associated HIV infection significantly attenuated the clinical and immunological expression of cryoglobulinaemia, except in coinfected patients with high viral loads for the two viruses.

Indication for plasma exchange for systemic necrotizing vasculidities

Plasma exchanges (PE) are a component of regimens prescribed to treat systemic necrotizing vasculidities. They are also part of the best therapeutic strategy for virus-induced vasculidities. The combination of antiviral agents and PE has proven efficacy against polyarteritis nordosa. This strategy is also effective for human immunodeficiency virus-associated vasculitis and, unlike cytotoxic agents, does not jeopardize the outcome of acquired immunodeficiency syndrome. Concerning the vasculitis seen in the context of hepatitis C virus-related cryoglobulinemia, PE contribute to better outcomes but, because of the poor efficacies of antiviral drugs, only about half of the patients achieve definitive recovery and relapses are frequent. The use of PE to treat antineutrophil cytoplasm antibody-associated vasculidities with severe renal insufficiency leads to improved renal function and thus fewer patients require dialysis. Although PE does not improve survival, their adjunction to corticosteroids and immunosuppressants for patients with alveolar hemorrhage could also limit the severity of this severe manifestation.

Efficacy of low-dose rituximab for mixed cryoglobulinemia

Rituximab at 375 mg/m(2) x 4 is effective for refractory HCV-related mixed cryoglobulinemia. We conducted a pilot study to assess the efficacy of a lower dosage, 250 mg/m(2) x 2. Six consecutive patients with mixed cryoglobulinemia were treated. All patients had severe or life-threatening disease manifestations, including necrotizing skin ulcers, renal disease, hyperviscosity or intestinal vasculitis. Four of five evaluable patients (excluding one early death) had >80% decrease of cryocrit and remission of vasculitis at the end of a 22- to 55-week (median 40) follow-up. The non-responder failed to respond to additional rituximab treatment, suggesting intrinsic resistance rather than insufficient dosage as the cause of treatment failure. No sustained increase of HCV viremia after rituximab was observed. Rituximab at 250 mg/m(2) x 2 may be as effective as at 375 mg/m(2) x 4 for treating mixed cryoglobulinemia. Larger studies are required to assess the efficacy of low-dose rituximab.

A revision on cryoglobulinaemia associated to neoplastic diseases

Cryoglobulinaemia is an infrequent process and has been classified in types I, II and III. Type I corresponds to monoclonal cryoglobulinaemia; types II and III are comprised in the group of mixed cryoglobulinaemias (MC). In MC type II, cryoglobulinaemias are made up of a monoclonal rheumatoid factor vs. a polyclonal IgG. In MC type III all compounds are polyclonal. Monoclonal cryoglobulinaemias are usually associated to malignant haematological processes, while MC are associated to systemic diseases and infection. More research is needed on the natural history, causes, treatment and evolution of cryoglobulinaemia. This revision analyses a more recent knowledge on this entity, as well as its association to neoplastic diseases.

Manifestations cutanées associées aux paraprotéines: mécanismes des atteintes cutanées

Disease entities characterized by the presence of paraproteins have a variety of cutaneous manifestations. These manifestations may be classified in the following categories as a function of their mechanisms: * extracutaneous deposition of paraproteins, as in amyloidosis * intravascular paraprotein deposition, as in cryoglobulinemia * cutaneous lesions resulting from the biologic activity of paraprotein, as in patients with normolipemic xanthoma with monoclonal immunoglobulin anti-LDL activity * abnormal cytokine secretion, as in AESOP (adenopathy and extensive skin patch overlying a plasmacytoma) or POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndromes * unknown mechanisms.

Cryoglobulinemia

Cryoglobulinemia refers to the presence in serum of immunoglobulins that precipitate at a cold temperature. Type I cryoglobulins are single monoclonal immunoglobulins usually associated with haematological disorders. Types II and III are mixed cryoglobulins, composed of monoclonal or polyclonal IgM respectively, having rheumatoid factor activity that bind to polyclonal immunoglobulins. Mixed cryoglobulinemia (MC) syndrome is a consequence of immune-complex mediated vasculitis and is characterized by a typical clinical triad: purpura, weakness, arthralgias; many organs particularly kidney and peripheral nervous system may be involved. MC may be associated with infectious and systemic disorders and since 1990 studies have demonstrated that hepatitis C virus (HCV) may be considered the principal trigger of the disease. The relation between MC and HCV infection shows new insights in the interpretation of the link between viral infection, autoimmune phenomena and lymphoproliferative disorders evolution. In fact, the virus chronically stimulates B-cell polyclonal proliferation from which a monoclonal population may emerge. In symptomatic patients with HCV related MC therapeutic strategy should include an attempt at viral eradication. Antiviral therapy may also be effective in determining the regression of B-cell lymphoproliferative disorder. Rituximab could represent a safe and effective alternative to standard immunosuppression and exerts selective B-cell control.

Predicting adverse outcomes in primary Sjogren's syndrome: identification of prognostic factors

OBJECTIVE

To identify features present at diagnosis that were prospectively associated with adverse outcomes in a large cohort of patients with primary Sjögren's syndrome (SS).

METHODS

Two hundred and sixty-six patients diagnosed with primary SS in our department between 1984 and 2002 were consecutively included and followed up. Outcomes measured were vasculitis, B-cell lymphoma and death. Cox regression analysis was used to evaluate the effect of variables at diagnosis on outcomes.

RESULTS

Twenty-five (9%) patients developed vasculitis. Multivariate analysis identified parotid scintigraphy grades III or IV (HR 3.55, P = 0.05) and C4 levels <0.11 g/l (HR 8.26, P < 0.001) as variables predicting the development of vasculitis. Nine (3%) patients developed B-cell lymphoma. Multivariate analysis identified C3 levels <0.82 g/l (HR 7.54, P = 0.016) as a predictive factor of lymphoma development. Twenty-five (9%) patients died during follow-up. Systemic involvement (HR 4.51, P = 0.022), vasculitis (HR 4.58, P = 0.042), C4 levels <0.11 g/l (HR 5.47, P = 0.027) and cryoglobulins (HR 4.58, P = 0.013) were independently associated with death. The presence of at least two of the above-mentioned predictive factors (parotid scintigraphy, vasculitis, hypocomplementaemia and cryoglobulinaemia) was associated with a lower survival in comparison with patients with no factor (log rank and Breslow tests <0.001).

CONCLUSION

The main prognostic factors for an adverse outcome identified in our cohort of patients with primary SS were vasculitis, severe involvement in parotid scintigraphy, hypocomplementaemia and/or cryoglobulins at diagnosis. Patients with at least two of these factors need a closer follow-up.

68-year-old woman with hepatitis C and abnormal kidney function

A 68-year-old woman with a history of hepatitis C (contracted from a blood transfusion in 1974) complicated by cirrhosis and portal hypertension came to the Mayo Clinic in Rochester, Minn, for evaluation for possible liver transplantation. Her symptomatic ascites had been treated initially with furosemide and spironolactone, but this treatment regimen was limited because of an increase in her creatinine level. During evaluation, hypertension (an average blood pressure of 180/90 mm Hg on 6-hour ambulatory monitoring) and abnormal renal function were noted. She was referred to our institution for further evaluation of her blood pressure and abnormal urinalysis results.

Cryoglobulinaemia and autoimmune markers in hepatitis C virus infected patients on renal replacement therapy

OBJECTIVE

To investigate the association of cryoglobulinaemia and autoimmune markers with hepatitis C virus (HCV) infection in patients on maintenance haemodialysis (HD) and post renal transplantation.

METHODS

Serum samples of 103 HCV-antibody (anti-HCV) positive and 105 anti-HCV negative patients were investigated for cryoglobulins. These comprised 136 patients on HD and 72 renal transplant recipients. Serum creatinine and liver function tests were obtained on all patients. Rheumatoid factor (RF), anti nuclear antibodies (ANA), anti smooth muscle antibodies (ASMA), liver kidney microsomal antibodies (LKM), immunoglobulins (Igs) and complement levels were performed on all cryoglobulin positive (cryopositive) samples. HCV RNA and genotyping detection tests were done for cryopositive patients.

RESULTS

The prevalence of cryoglobulins in patients on HD or after renal transplantation was found to be higher (57.6%) among anti-HCV positive patients compared to the anti-HCV negative patients (42.4%) (P=0.000). RF, ANA and ASMA were also higher in cryopositive HCV infected patients. HCV RNA was present in 84.2% of anti-HCV positive patients. Cryoprecipitable RF activity was found in a higher number of symptomatic patients with HCV genotype 1 compared to HCV genotype 3.

CONCLUSION

There is an association of cryoglobulinaemia and autoimmune markers in HCV infected patients on HD, and in HCV positive renal transplant recipients. Also HCV genotype 1 is associated with symptomatic mixed cryoglobulinaemia.

Plasma exchange for systemic lupus erythematosus

Efficacy of plasma exchange in patients with systemic lupus erythematosus has not been supported by the results of the first non-controlled and retrospective studies. Nonetheless, they remain relevant for some selected patients with life-threatening manifestations and/or severe therapy-resistant manifestations. They can be used as an adjuvant therapy in combination with corticosteroids and, when required, other immunosuppressant(s) for refractory renal disease, alveolar hemorrhage, some neuropsychiatric manifestations, thrombotic thrombocytopenic purpura, catastrophic antiphospholipid syndrome, hyperviscosity syndrome or symptomatic cryoglobulinemia. The use of newer technologies, like immunoadsorption, possibly in combination with recent biologics, might, in the future, offer some new perspectives for extracorporeal therapy of systemic lupus erythematosus.

Autonomic neuropathy in mixed cryoglobulinemia

A retrospective, cross-sectional study was performed on a series of HCV-related mixed cryoglobulinemia (HCV-MC) patients to assess autonomic neuropathy (AN) and its relation to peripheral neuropathy (PN). Thirty consecutive patients affected by HCV-MC underwent clinical, neurological and electrodiagnostic examinations. Autonomic nervous system (ANS) involvement was assessed by functional cardiovascular tests and sympathetic skin response (SSR) evaluation. Sural nerve biopsy was performed in 10 patients with PN. All patients received steroids, 15 also received recombinant interferon-alpha2b (RIfn-alpha2b). PN occurred in 27 patients (90.0%) and AN in 4 (13.3 %) all with signs of PN. SSR was the autonomic test more frequently altered. Biopsy disclosed axonal degeneration more evident in the 4 patients with AN. Three out of 4 patients with AN received steroids and rIFN-alpha2b and 1 steroids alone. In our study on HCV-MC, it was concluded that AN can occur also without dysautonomic symptoms, SSR appears to be one of the optional tests to use together with dysautonomic tests to identify AN and finally PN and AN do not seem to be positively influenced by addition of rIFN-alpha2b to steroid treatment.

Type III mixed cryoglobulinemia and antiphospholipid syndrome in a patient with partial DiGeorge syndrome

We studied a 14 year-old boy with partial DiGeorge syndrome (DGS), status post complete repair of Tetralogy of Fallot, who developed antiphospholipid syndrome (APS) and type III mixed cryoglobulinemia. He presented with recurrent fever and dyspnea upon exertion secondary to right pulmonary embolus on chest computed tomography (CT). Coagulation studies revealed homozygous methylene tetrahydrofolate reductase 677TT mutations, elevated cardiolipin IgM antibodies, and elevated beta(2)-glycoprotein I IgM antibodies. Infectious work-up revealed only positive anti-streptolysin O (ASO) and anti-DNAse B titers. Autoimmune studies showed strongly positive anti-platelet IgM, elevated rheumatoid factor (RF), and positive cryocrit. Renal biopsy for evaluation of proteinuria and hematuria showed diffuse proliferative glomerulonephritis (DPGN) with membranoproliferative features consistent with cryoglobulinemia. Immunofixation showed polyclonal bands. Our patient was treated successfully with antibiotics, prednisone, and mycophenolate mofetil (MMF). This is the first report of a patient with partial DGS presenting with APS and type III mixed cryoglobulinemia possibly due to Streptococcal infection.

Lymphoplasmacytic lymphoma associated with polyradiculoneuritis and cryoglobulinemia mimicking polyarteritis nodosa

INTRODUCTION

Systemic vasculitis is sometimes associated with malignant blood disease.

CASE

We describe the case of a 77-year-old woman who had extensive livedo racemosa, acute polyradiculoneuritis, and meningeal hemorrhage. The skin biopsy showed evidence of necrotizing angiitis. This vascular involvement resembled polyarteritis nodosa (PAN). Despite corticosteroid and cyclophosphamide treatment, the polyradiculoneuritis worsened and the patient died of acute respiratory failure. Type II cryoglobulinemia was detected late, and the autopsy revealed lymphoplasmacytic lymphoma involving the spleen and infiltrating nerve roots, together with necrotizing angiitis involving small-sized arteries.

CONCLUSION

This case shows that necrotizing angiitis involving small arteries may occur with type II cryoglobulinemia.

Complex regional pain syndrome (reflex sympathetic dystrophy) in a patient with essential mixed cryoglobulinemia and chronic hepatitis C

Essential mixed cryoglobulinemia (EMC) is a common extra-hepatic manifestation of hepatitis C virus (HCV). Complex Regional Pain Syndrome type I (CRPS) or Reflex sympathetic dystrophy (RSD) has never been reported in association with HCV. This is the first case report of RSD in a patient with HCV related cirrhosis and EMC.

Dermatologic disorders associated with chronic hepatitis C: effect of interferon therapy

Chronic hepatitis C virus infection (HCV) is associated with extrahepatic manifestations, including such dermatologic conditions as mixed cryoglobulinemia, porphyria cutanea tarda, and lichen planus. Patients with chronic HCV and extrahepatic manifestations are often excluded from clinical trials evaluating interferon (IFN) therapy due to concerns about poor response, adverse events, and toxicity. Thus, data regarding the efficacy of IFN not only on the underlying chronic HCV, but also on extrahepatic manifestations, are limited in these patients. Case reports suggest that the response of dermatologic extrahepatic manifestations to IFN in patients with chronic HCV is highly variable. This review summarizes available data on dermatologic conditions associated with chronic HCV and their response to IFN therapy.

[Mixed cryoglobulinemia-associated membranoproliferative glomerulonephritis, disclosing gastric MALT lymphoma]

We report a case of a mixed cryoglobulinemia-associated membranoproliferative glomerulonephritis, disclosing gastric lymphoma of MALT-type. In the reported case, glomerulonephritis was associated with joint and skin symptoms related to type II mixed cryoglobulinemia. MALT lymphoma diagnosis was made by gastric biopsy. Renal pathological examination showed relatively uncommon findings, ie mesangioproliferative glomerulonephritis lacking usual intraluminal thrombi. Although classical, renal manifestations of malignant lymphomas are uncommon, and rarely allow lymphoma diagnosis. The renal biological function improves as the lymphoma regresses with appropriated treatment. This case underlines the benefit of gastroscopy in cryoglobulinemia etiological research.

Hepatitis C virus infection, type III cryoglobulinemia, and necrotizing vasculitis

A 53-year-old man with chronic hepatitis-C virus infection presented with livedo reticularis, purpura, and leg ulcers. A skin biopsy specimen showed a necrotizing vasculitis. The skin biopsy specimen and serology confirmed the diagnosis of type-III cryoglobulinemia. Bone marrow and peripheral blood showed proliferation of atypical CD5-positive B cells that included a monoclonal population. There is growing evidence that chronic hepatitis-C infection can result in immune dysregulation and expansion of autoimmune B cells that produce cryoglobulins.

Extrahepatic manifestations of Hepatitis C Virus infection: a general overview and guidelines for a clinical approach

Hepatitis C Virus is associated with a wide series of extrahepatic manifestations. Based on available data the link between the virus and some of these extrahepatic diseases is only suggested and needs further confirmation. Hepatitis C Virus-related lymphoproliferative disorders, whose prototype is mixed cryoglobulinaemia, represent the most closely related extrahepatic manifestations of Hepatitis C Virus. Other Hepatitis C Virus-associated disorders include nephropathies, thyreopathies, sicca syndrome, idiopathic pulmonary fibrosis, porphyria cutanea tarda, lichen planus, diabetes, chronic polyarthritis, cardiopathy and atherosclerosis. A pathogenetic link between Hepatitis C Virus and some extrahepatic manifestations was confirmed by their responsiveness to antiviral therapy, which is now deemed the first therapeutic option to consider. By contrast, there are diseases where treatment with interferon was ineffective or dangerous. The aim of the present paper is to outline the most recent evidence concerning extrahepatic disorders that are possibly associated with Hepatitis C Virus infection. Special emphasis will be given to discussion of the most appropriate clinical approaches to be adopted in order to diagnose, treat (possibly prevent) and follow-up extrahepathic diseases in patients with Hepatitis C Virus infection.