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Ahmed AR, Kaveri S. Reversing Autoimmunity Combination of Rituximab and Intravenous Immunoglobulin. Front Immunol 2018; 9:1189. [PMID: 30072982 PMCID: PMC6058053 DOI: 10.3389/fimmu.2018.01189] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/14/2018] [Indexed: 12/14/2022] Open
Abstract
In this concept paper, the authors present a unique and novel protocol to treat autoimmune diseases that may have the potential to reverse autoimmunity. It uses a combination of B cell depletion therapy (BDT), specifically rituximab (RTX) and intravenous immunoglobulin (IVIg), based on a specifically designed protocol (Ahmed Protocol). Twelve infusions of RTX are given in 6–14 months. Once the CD20+ B cells are depleted from the peripheral blood, IVIg is given monthly until B cells repopulation occurs. Six additional cycles are given to end the protocol. During the stages of B cell depletion, repopulation and after clinical recovery, IVIg is continued. Along with clinical recovery, significant reduction and eventual disappearance of pathogenic autoantibody occurs. Administration of IVIg in the post-clinical period is a crucial part of this protocol. This combination reduces and may eventually significantly eliminates inflammation in the microenvironment and facilitates restoring immune balance. Consequently, the process of autoimmunity and the phenomenon that lead to autoimmune disease are arrested, and a sustained and prolonged disease and drug-free remission is achieved. Data from seven published studies, in which this combination protocol was used, are presented. It is known that BDT does not affect check points. IVIg has functions that mimic checkpoints. Hence, when inflammation is reduced and the microenvironment is favorable, IVIg may restore tolerance. The authors provide relevant information, molecular mechanism of action of BDT, IVIg, autoimmunity, and autoimmune diseases. The focus of the manuscript is providing an explanation, using the current literature, to demonstrate possible pathways, used by the combination of BDT and IVIg in providing sustained, long-term, drug-free remissions of autoimmune diseases, and thus reversing autoimmunity, albeit for the duration of the observation.
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Affiliation(s)
- A Razzaque Ahmed
- Department of Dermatology, Tufts University School of Medicine, Boston, MA, United States.,Center for Blistering Diseases, Boston, MA, United States
| | - Srinivas Kaveri
- INSERM U1138 Centre de Recherche des Cordeliers, Paris, France
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Dumas G, Bigé N, Lemiale V, Azoulay E. Patients immunodéprimés, quel pathogène pour quel déficit immunitaire ? (en dehors de l’infection à VIH). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le nombre de patients immunodéprimés ne cesse d’augmenter en raison de l’amélioration du pronostic global du cancer et de l’utilisation croissante d’immunosuppresseurs tant en transplantation qu’au cours des maladies auto-immunes. Les infections sévères restent la première cause d’admission en réanimation dans cette population et sont dominées par les atteintes respiratoires. On distingue les déficits primitifs, volontiers révélés dans l’enfance, des déficits secondaires (médicamenteux ou non), les plus fréquents. Dans tous les cas, les sujets sont exposés à des infections inhabituelles de par leur fréquence, leur type et leur sévérité. À côté des pyogènes habituels, les infections opportunistes et la réactivation d’infections latentes font toute la complexité de la démarche diagnostique. Celle-ci doit être rigoureuse, orientée par le type de déficit, les antécédents, les prophylaxies éventuelles et la présentation clinicoradiologique. Elle permettra seule de guider le traitement probabiliste et les examens étiologiques, l’absence de diagnostic étant associée à une mortalité élevée.
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Maarouf A, Boutière C, Rico A, Audoin B, Pelletier J. How much progress has there been in the second-line treatment of multiple sclerosis: A 2017 update. Rev Neurol (Paris) 2018; 174:429-440. [PMID: 29779849 DOI: 10.1016/j.neurol.2018.01.369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 02/04/2023]
Abstract
In 1993, the US Food and Drug Administration (FDA) approved the first drug specifically for treating multiple sclerosis (MS). More than two decades later, a dozen such treatments are now available. Of these, four are considered second-line treatments for use in escalation strategies and two new drugs are currently undergoing accreditation procedures. Soon, they will provide clinicians with a range of six effective disease-modifying treatments (DMTs) to thwart the inflammatory processes in MS patients with active disease. However, while such a large number of DMTs for MS can help to control early inflammation, any decisions to be made by clinicians have also been made substantially more complex. This complexity is increased by the lack of head-to-head studies comparing these second-line therapies and the benefit-risk profiles for each of these drugs, which are likely to vary among patients. Ultimately, good awareness of the benefits and, more important, the risks of each MS DMT is crucial for the effective management of inflammation in MS.
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Affiliation(s)
- A Maarouf
- CRMBM UMR 7339 CNRS, Aix Marseille Université, 13005 Marseille, France; AP-HM, Hôpital de la Timone, Pôle d'Imagerie Médicale, CEMEREM, 13005 Marseille, France; AP-HM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, 13005 Marseille, France.
| | - C Boutière
- AP-HM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, 13005 Marseille, France
| | - A Rico
- AP-HM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, 13005 Marseille, France
| | - B Audoin
- CRMBM UMR 7339 CNRS, Aix Marseille Université, 13005 Marseille, France; AP-HM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, 13005 Marseille, France
| | - J Pelletier
- CRMBM UMR 7339 CNRS, Aix Marseille Université, 13005 Marseille, France; AP-HM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, 13005 Marseille, France
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Knight A, Pauksens K, Nordmark G, Kumlien E. Fatal outcome of tick-borne encephalitis in two patients with rheumatic disease treated with rituximab. Rheumatology (Oxford) 2018; 56:855-856. [PMID: 28130421 DOI: 10.1093/rheumatology/kew495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | | | - Eva Kumlien
- Neurology, Department of Neuroscience, Uppsala University, Uppsala, Sweden
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Robak T, Błoński J, Skotnicki AB, Piotrowska M, Wróbel T, Rybka J, Kłoczko J, Bołkun Ł, Budziszewska BK, Walczak U, Uss A, Fidecka M, Smolewski P. Rituximab, cladribine, and cyclophosphamide (RCC) induction with rituximab maintenance in chronic lymphocytic leukemia: PALG - CLL4 (ML21283) trial. Eur J Haematol 2018; 100:465-474. [PMID: 29427355 DOI: 10.1111/ejh.13042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES PALG CLL4 is the first, randomized, phase IIIb study with rituximab, cladribine, and cyclophosphamide (RCC) induction and subsequent maintenance with rituximab in previously untreated chronic lymphocytic leukemia (CLL) patients. METHODS The induction treatment consisted of 6 RCC cycles regimen. Patients with complete response (CR) or partial response (PR) after an induction phase were randomized into a maintenance arm with rituximab or an observational arm. RESULTS In the intention-to-treat population, 97 patients completed the induction phase with an overall response rate (ORR) of 73.2% (CR 22.7%, PR 50.5%). Subsequently, 66 patients were randomized into the rituximab maintenance arm (n = 33) or the observational arm (n = 33). CR rates were 57.1% in the maintenance group vs 50% in the observational group. PFS was significantly longer in the rituximab maintenance vs the observational arm (P = .028). The multivariate Cox model indicated that del17p (P = .006) and elevated beta-2-microglobulin (P = .015) significantly increased the hazard ratio (HR) of progression, whereas the presence of CD38 (P = .013) significantly decreased it; maintenance therapy with rituximab (P < .0001) significantly decreased the HR of disease progression. CONCLUSIONS The study confirmed the high efficacy and acceptable safety profile of induction therapy with RCC and maintenance therapy with rituximab in previously untreated patients with CLL.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
| | - Jerzy Błoński
- Department of Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
| | | | | | - Tomasz Wróbel
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Justyna Rybka
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Janusz Kłoczko
- Department of Hematology, Medical University of Białystok, Białystok, Poland
| | - Łukasz Bołkun
- Department of Hematology, Medical University of Białystok, Białystok, Poland
| | | | - Urszula Walczak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Anatoly Uss
- City Clinical Hospital No. 9, Minsk, Belarus
| | | | - Piotr Smolewski
- Department of Experimental Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
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Ueda M, Berger M, Gale RP, Lazarus HM. Immunoglobulin therapy in hematologic neoplasms and after hematopoietic cell transplantation. Blood Rev 2018; 32:106-115. [DOI: 10.1016/j.blre.2017.09.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/28/2017] [Accepted: 09/15/2017] [Indexed: 12/27/2022]
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ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Agents targeting lymphoid cells surface antigens [I]: CD19, CD20 and CD52). Clin Microbiol Infect 2018; 24 Suppl 2:S71-S82. [PMID: 29447988 DOI: 10.1016/j.cmi.2018.02.003] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting CD19, CD20 and CD52 and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Although CD19-targeted agents (blinatumomab or inebilizumab) are not associated with an increased risk of infection, they may cause IgG hypogammaglobulinaemia and neutropenia. The requirement for prolonged intravenous infusion of blinatumomab may increase the risk of catheter-associated bloodstream infections. Infection remains the most common non-haematological adverse effect of anti-CD20 monoclonal antibodies, including severe respiratory tract infection, hepatitis B virus (HBV) reactivation and varicella-zoster virus infection. Screening for chronic or resolved HBV infection is recommended for patients receiving anti-CD20 monoclonal antibodies. Antiviral prophylaxis should be offered for 12-18 months to hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative/anti-hepatitis B core antibody (HBc)-positive patients. Anti-Pneumocystis prophylaxis should be considered in patients receiving concomitant chemotherapy, particularly steroids. Alemtuzumab (anti-CD52) increases the risk of infections, in particular among leukaemia and solid organ transplant patients. These populations benefit from anti-Pneumocystis prophylaxis, prevention strategies for cytomegalovirus infection, and screening for HBV, hepatitis C virus and tuberculosis. Antiviral prophylaxis for at least 6-12 months should be provided for HBsAg-positive patients. IMPLICATIONS As there are limited clinical data for many of the reviewed agents, special attention must be given to promptly detect and report emerging infectious complications.
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Lavi N, Avivi I, Kra-Oz Z, Oren I, Hardak E. Community-acquired respiratory infections are common in patients with non-Hodgkin lymphoma and multiple myeloma. Support Care Cancer 2018; 26:2425-2431. [PMID: 29427192 DOI: 10.1007/s00520-018-4079-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/29/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Available data suggest that respiratory infections are associated with increased morbidity and mortality in patients hospitalized due to acute leukemia and allogeneic stem cell transplantation (allo-SCT). However, the precise incidence, risk factors, and severity of respiratory infection, mainly community-acquired, in patients with lymphoma and multiple myeloma (MM) are not fully determined. The current study aimed to investigate risk factors for respiratory infections and their clinical significance in patients with B cell non-Hodgkin lymphoma (NHL) and multiple myeloma (MM) in the first year of diagnosis. METHODS Data of consecutive patients diagnosed with NHL or MM and treated at the Rambam Hematology Inpatient and Outpatient Units between 01/2011 and 03/2012 were evaluated. Information regarding anticancer treatment, incidence and course of respiratory infections, and infection-related outcomes was analyzed. RESULTS One hundred and sixty episodes of respiratory infections were recorded in 103 (49%) of 211 (73-MM, 138-NHL) patients; 126 (79%) episodes were community-acquired, 47 (29%) of them required hospitalization. In univariate analysis, age < 60 years, MM diagnosis, and autologous SCT increased the respiratory infection risk (P = 0.058, 0.038, and 0.001, respectively). Ninety episodes (56% of all respiratory episodes) were examined for viral pathogens. Viral infections were documented in 25/90 (28%) episodes, 21 (84%) of them were community-acquired, requiring hospitalization in 5 (24%) cases. Anti-flu vaccination was performed in 119 (56%) patients. Two of the six patients diagnosed with influenza were vaccinated. CONCLUSIONS Respiratory infections, including viral ones, are common in NHL and MM. Most infections are community-acquired and have a favorable outcome. Rapid identification of viral pathogens allows avoiding antibiotic overuse in this patient population.
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Affiliation(s)
- Noa Lavi
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Irit Avivi
- Department of Hematology and Bone Marrow Transplantation, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zipora Kra-Oz
- Virology Laboratory, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Ilana Oren
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.,Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Emilia Hardak
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel. .,Division of Pulmonary Medicine, Rambam Health Care Campus, 8, Ha'Aliya St., 31096, Haifa, Israel.
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High albumin level is a predictor of favorable response to immunotherapy in autoimmune encephalitis. Sci Rep 2018; 8:1012. [PMID: 29343812 PMCID: PMC5772466 DOI: 10.1038/s41598-018-19490-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/28/2017] [Indexed: 01/23/2023] Open
Abstract
There is no known biomarker that predicts the response to immune therapy in autoimmune synaptic encephalitis. Thus, we investigated serum albumin as a prognostic biomarker of early immune therapies in patients with autoimmune encephalitis. We enrolled patients who were diagnosed with definite autoimmune encephalitis and underwent IVIg treatment at Seoul National University Hospital from 2012 to 2017. Patients were dichotomized according to serum albumin prior to IVIg administration with a cut-off level of 4.0 g/dL, which was the median value of 50% of patients. Seventeen (53.1%) of the 32 patients with definite autoimmune encephalitis who received IVIg treatment in our hospital had low serum albumin (<4.0 g/dL). The initial disease severity (mRS ≥ 4) was the sole factor that predicted low albumin in autoimmune encephalitis patients using multivariate analysis (P = 0.013). The low albumin group exhibited a worse response to immune therapy at the third and fourth weeks from IVIg administration (P < 0.01 and P = 0.012, respectively), and recovery to activities of daily life without assistance was faster in the high albumin group (log-rank test for trend, P < 0.01). Our study found that pretreatment low serum albumin was a significant indicator of autoimmune encephalitis prognosis in the short-term and long-term.
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Hall V, Johnson D, Torresi J. Travel and biologic therapy: travel-related infection risk, vaccine response and recommendations. J Travel Med 2018; 25:4934912. [PMID: 29635641 DOI: 10.1093/jtm/tay018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 03/01/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Biologic therapy has revolutionized the management of refractory chronic autoimmune and auto-inflammatory disease, as well as several malignancies, providing rapid symptomatic relief and/or disease remission. Patients receiving biologic therapies have an improved quality of life, facilitating travel to exotic destinations and potentially placing them at risk of a range of infections. For each biologic agent, we review associated travel-related infection risk and expected travel vaccine response and effectiveness. METHODS A PUBMED search [vaccination OR vaccine] AND/OR ['specific vaccine'] AND/OR [immunology OR immune response OR response] AND [biologic OR biological OR biologic agent] was performed. A review of the literature was performed in order to develop recommendations on vaccination for patients in receipt of biologic therapy travelling to high-risk travel destinations. RESULTS There is a paucity of literature in this area, however, it is apparent that travel-related infection risk is increased in patients on biologic therapy and when illness occurs they are at a higher risk of complication and hospitalization. Patients in receipt of biologic agents are deemed as having a high level of immunosuppression-live vaccines, including the yellow fever vaccine, are contraindicated. Inactivated vaccines are considered safe; however, vaccine response can be attenuated by the patient's biologic therapy, thereby resulting in reduced vaccine effectiveness and protection. CONCLUSIONS Best practice requires a collaborative approach between the patient's primary healthcare physician, relevant specialist and travel medicine expert, who should all be familiar with the immunosuppressive and immunomodulatory effects resulting from the biologic therapies. Timing of vaccines should be carefully planned, and if possible, vaccination provided well before established immunosuppression.
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Affiliation(s)
- Victoria Hall
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia
| | - Douglas Johnson
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of General Medicine, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Joseph Torresi
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia.,Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.,Eastern Infectious Diseases and Travel Medicine, Knox Private Hospital, Boronia, VIC, Australia
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Tadmor T, Welslau M, Hus I. A review of the infection pathogenesis and prophylaxis recommendations in patients with chronic lymphocytic leukemia. Expert Rev Hematol 2017; 11:57-70. [DOI: 10.1080/17474086.2018.1407645] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Tamar Tadmor
- The Ruth and Bruce Rappaport Faculty of Medicine, Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Manfred Welslau
- Haemato-Onkologische Schwerpunktpraxis am Klinikum Aschaffenburg, Aschaffenburg, Germany
| | - Iwona Hus
- Department of Clinical Transplantology, Medical University of Lublin, Lublin, Poland
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Tudesq JJ, Cartron G, Rivière S, Morquin D, Iordache L, Mahr A, Pourcher V, Klouche K, Cerutti D, Le Quellec A, Guilpain P. Clinical and microbiological characteristics of the infections in patients treated with rituximab for autoimmune and/or malignant hematological disorders. Autoimmun Rev 2017; 17:115-124. [PMID: 29180125 DOI: 10.1016/j.autrev.2017.11.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Rituximab is commonly used for the treatment of hematological malignancies and autoimmune diseases. Despite a reputation for good tolerance, case-series and registries reported rituximab-related infections of variable severity including opportunistic infections. We aimed at describing the natural history of infectious events (IE) after treatment by rituximab providing clinical and microbiological features and outcome. PATIENTS AND METHODS We retrospectively analyzed the medical records of patients treated with rituximab in an internal medicine department of a tertiary hospital between 2007 and 2015, and identified all IE after this therapy. Events' severity was assessed using the Common Terminological Criteria of Adverse Events (version 4.3) definitions. RESULTS Among 101 patients treated with rituximab, we identified 228 IE in 74 (73.3%) of these patients (median follow-up 30.4months). Indication for rituximab was either autoimmune disease (AID) (52.5% of patients), or monoclonal hematological disease (MHD) (47.5%). Patients received an overall median number of 5 rituximab infusions [interquartile range: 4-8], representing a cumulative dose of 4340mg [2620-6160]. After last rituximab infusion, IE occurred after 3.1months [0.7-9.4]. Respectively, IE were severe in 28.1% of cases in patients treated for AID vs 58.0% in patients treated for MHD (p<0.001), due to opportunistic pathogens in 7.8% vs 11.0% (p=0.49) and fatal in 4.7% vs 13.0% (p=0.044). Factor associated with mortality were polymicrobial infection (p<0.001), monoclonal hematological disease (p=0.035), use of steroids over 10mg/d within the last two weeks (p=0.003), and rituximab cumulative dose (p<0.001). We identified a group of 10 patients (9.9%) showing life-threatening, polymicrobial, and opportunistic infections constituting a 'catastrophic infectious syndrome', which was lethal in 7 cases. CONCLUSION IE after treatment by rituximab can be extremely severe, especially in patients immunocompromised by several other drugs. Further studies should focus on the group with life-threatening polymicrobial infections.
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Affiliation(s)
- Jean-Jacques Tudesq
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France; Medical Intensive Care Unit, Montpellier University Hospital, Montpellier F-34000, France
| | - Guillaume Cartron
- Clinical Hematology Department, Montpellier University Hospital, Montpellier, F-34000, France; Centre National de Recherche Scientifique (CNRS), UMR 5235, Montpellier University, Montpellier F-34000, France
| | - Sophie Rivière
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France
| | - David Morquin
- Infectious Diseases Department, Montpellier University Hospital, Montpellier, F-34000, France
| | - Laura Iordache
- Internal Medicine Department, Saint-Louis University Hospital, AP-HP, Paris F-75010, France
| | - Alfred Mahr
- Internal Medicine Department, Saint-Louis University Hospital, AP-HP, Paris F-75010, France
| | - Valérie Pourcher
- Infectious Diseases Department, Pitié-Salpêtrière University Hospital, AP-HP, Paris F-75005, France
| | - Kada Klouche
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier F-34000, France
| | - Diane Cerutti
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France
| | - Alain Le Quellec
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France
| | - Philippe Guilpain
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France; Institut National de la Santé Et de la Rercherche Médicale (INSERM) U1183, Institute for Regenerative Medicine and Biotherapies (IRMB), Montpellier F-34000, France.
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Bagchi S, Subbiah AK, Bhowmik D, Mahajan S, Yadav RK, Kalaivani M, Singh G, Dinda A, Kumar Agarwal S. Low-dose Rituximab therapy in resistant idiopathic membranous nephropathy: single-center experience. Clin Kidney J 2017; 11:337-341. [PMID: 29942496 PMCID: PMC6007352 DOI: 10.1093/ckj/sfx105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/15/2017] [Indexed: 12/25/2022] Open
Abstract
Background Persistent significant proteinuria has been associated with increased risk of progression to end-stage kidney disease in patients with idiopathic membranous nephropathy (IMN). Rituximab (RTX) therapy has given encouraging results in IMN, but most of the studies have used a higher dose, which is limited by the high cost as well as a potential increased risk of infections. Our study aimed to assess the efficacy and safety of low-dose RTX in patients with immunosuppression-resistant IMN. Methods A total of 21 patients with treatment-resistant IMN treated with RTX from 2015 to 2016 at our center were included in the study. They received two doses of RTX (500 mg each) infusion 7 days apart. CD19 count was performed after 4 weeks. A single dose of RTX was repeated after 4–6 weeks if CD19 count was not depleted. Results The mean standard deviation age of patients was 33.3 ± 12.3 years and 33.3% were females. Mean proteinuria before RTX therapy was 6.2 ± 2.2 g/day, serum creatinine was 0.9 ± 0.3 mg/dL and estimated glomerular filtration rate (eGFR) was 95.8 ± 26.9 mL/min/1.73 m2. All the patients were non-responders to prior immunosuppressive treatment. Twenty (95.2%) patients achieved targeted CD19 depletion with two doses of RTX. One patient required one additional RTX dose due to inadequate B-cell suppression. A total of 13 (61.9%) patients achieved remission with RTX therapy: 4 (19.0%) complete and 9 (42.9%) partial remission. Patients who did not respond to RTX had a significantly lower baseline eGFR compared with those who achieved remission (P = 0.022). One patient developed respiratory tract infection following RTX during the follow-up, which responded to a course of oral antibiotics. During median follow-up of 13.1 (10–23.9) months, four (19%) patients had deterioration in renal function and one patient relapsed after achieving partial remission. Renal survival was significantly better in patients who responded to RTX therapy as compared with those who did not achieve remission (P = 0.0037). Conclusion Low-dose RTX therapy is effective and safe in immunosuppression-resistant IMN.
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Affiliation(s)
- Soumita Bagchi
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kumar Subbiah
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Dipankar Bhowmik
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Raj Kanwar Yadav
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Geetika Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Kumar Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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Affiliation(s)
- Alyssa R Letourneau
- From the Departments of Medicine (A.R.L.), Radiology (M.C.P.), and Pathology (M.M.A.), Massachusetts General Hospital, and the Departments of Medicine (A.R.L.), Radiology (M.C.P.), and Pathology (M.M.A.), Harvard Medical School - both in Boston
| | - Melissa C Price
- From the Departments of Medicine (A.R.L.), Radiology (M.C.P.), and Pathology (M.M.A.), Massachusetts General Hospital, and the Departments of Medicine (A.R.L.), Radiology (M.C.P.), and Pathology (M.M.A.), Harvard Medical School - both in Boston
| | - Marwan M Azar
- From the Departments of Medicine (A.R.L.), Radiology (M.C.P.), and Pathology (M.M.A.), Massachusetts General Hospital, and the Departments of Medicine (A.R.L.), Radiology (M.C.P.), and Pathology (M.M.A.), Harvard Medical School - both in Boston
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65
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Bradshaw MJ, Cho TA, Chow FC. Central Nervous System Infections Associated with Immunosuppressive Therapy for Rheumatic Disease. Rheum Dis Clin North Am 2017; 43:607-619. [PMID: 29061246 DOI: 10.1016/j.rdc.2017.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients on immunosuppressive therapy for rheumatic diseases are at increased risk of infection. Although infections of the central nervous system (CNS) are less common compared with other sites, patients on broadly immunosuppressive and biologic immunomodulatory agents may be susceptible to more severe, disseminated forms of infection, including of the CNS. Certain key principles regarding infection risk apply across immunosuppressive therapies, including increased risk with higher doses and longer duration of therapy and with combination therapy. Providers should be aware of the CNS infection risk related to immunosuppressant use to help guide best practices for screening and prophylaxis.
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Affiliation(s)
- Michael J Bradshaw
- Partners Multiple Sclerosis Center, Brigham and Women's Hospital and Massachusetts General Hospital, 60 Fenwood Road, 4th floor, Boston, MA 02115, USA
| | - Tracey A Cho
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Felicia C Chow
- Department of Neurology and Division of Infectious Diseases, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, Building 1, Room 101, San Francisco, CA 94110, USA.
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66
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Christou EAA, Giardino G, Worth A, Ladomenou F. Risk factors predisposing to the development of hypogammaglobulinemia and infections post-Rituximab. Int Rev Immunol 2017; 36:352-359. [PMID: 28800262 DOI: 10.1080/08830185.2017.1346092] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rituximab (RTX) is a monoclonal antibody against CD20, commonly used in the treatment of hematological malignancies and autoimmune diseases. The use of RTX is related to the development of hypogammaglobulinemia and infections. Aim of this review is to summarize the evidence supporting the association of specific risk factors with the development of hypogammaglobulinemia and infections post-RTX. Immunological complications are more common in patients with malignant diseases as compared to non-malignant diseases. Moreover, the use of more than one dose of RTX, maintenance regimens, low pre-treatment basal immunoglobulin levels and the association with Mycophenolate and purine analogues represent risk factors for the development of hypogammaglobulinemia. The number of RTX courses, the evidence of low IgG levels for more than 6 months, the use of G-CSF, the occurrence of chronic lung disease, cardiac insufficiency, extra-articular involvement in patients with rheumatoid arthritis, low levels of IgG and older age have been correlated with a higher risk of infections. Even though the heterogeneity of the studies in terms of study population age and underlying disease, RTX schedules as well as differences in pre-treatment or concomitant therapy doesn't allow drawing definitive conclusions, the study of the literature highlight the association of specific risk factors with the occurrence of hypogammaglobulinemia and/or infections. A long term randomized controlled clinical trial could be useful to define a personalized evidence-based risk management plan for patients treated with RTX.
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Affiliation(s)
- Evangelos A A Christou
- a Division of Internal Medicine, Medical School , University of Ioannina , Ioannina , Greece
| | - Giuliana Giardino
- b Department of Translational Medical Sciences , Federico II University , Naples , Italy
| | - Austen Worth
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Fani Ladomenou
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
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67
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Li PH, Lau CS. Secondary antibody deficiency and immunoglobulin replacement. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2017. [DOI: 10.1515/hkbrd-2017-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Antibody deficiencies can be either primary or secondary, leading to significant morbidity and mortality without appropriate management. Secondary antibody deficiency can be due to various diseases or iatrogenic causes, especially with the use of immunosuppressive agents such as B-cell depleting therapies. Unlike its primary counterpart, little is known regarding the management of secondary antibody deficiency and it remains an underappreciated entity. This is a growing concern with the growing numbers of patients on various immunosuppressant therapies and increasing survivors of autoimmune diseases and haematological malignancies. In this report, we review the diagnosis and management of secondary antibody deficiency, especially after rituximab-induced hypogammaglobulinemia.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital , University of Hong Kong , Hong Kong , Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital , University of Hong Kong , Hong Kong , Hong Kong
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68
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Nixon A, Ogden L, Woywodt A, Dhaygude A. Infectious complications of rituximab therapy in renal disease. Clin Kidney J 2017; 10:455-460. [PMID: 28852481 PMCID: PMC5570071 DOI: 10.1093/ckj/sfx038] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/10/2017] [Indexed: 11/29/2022] Open
Abstract
Rituximab, an anti-CD20 monoclonal antibody, was originally used to treat B-cell malignancies. Its use has significantly increased in recent years, as it is now also used to treat a variety of autoimmune diseases including rheumatoid arthritis and ANCA-associated vasculitis (AAV). Initial studies suggested that the adverse effects of rituximab were minimal. Though the risk of malignancy with rituximab-based immunosuppressive regimens appears similar to that of the general population, there are now concerns regarding the risk of infectious complications. Rituximab has been associated with serious infections, including Pneumocystis jiroveci pneumonia (PJP) and the reactivation of hepatitis B virus (HBV) and tuberculosis (TB). The risk of infection appears to be the result of a variety of mechanisms, including prolonged B-cell depletion, B-cell–T-cell crosstalk, panhypogammaglobulinaemia, late-onset neutropenia and blunting of the immune response after vaccination. Importantly, the risk of infectious complications is also related to individual patient characteristics and the indication for rituximab. Individualization of treatment is, therefore, crucial. Particular attention should be given to strategies to minimize the risk of infectious complications, including vaccinating against bacterial and viral pathogens, monitoring white cell count and immunoglobulin levels, prophylaxis against PJP and screening for HBV and TB.
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Affiliation(s)
- Andrew Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Leanne Ogden
- Department of Renal Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ajay Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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69
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Marchesi F, Pimpinelli F, Ensoli F, Mengarelli A. Cytomegalovirus infection in hematologic malignancy settings other than the allogeneic transplant. Hematol Oncol 2017; 36:381-391. [DOI: 10.1002/hon.2453] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/28/2017] [Accepted: 06/05/2017] [Indexed: 12/13/2022]
Affiliation(s)
- F. Marchesi
- Hematology and Stem Cell Transplant Unit; Regina Elena National Cancer Institute; Rome Italy
| | - F. Pimpinelli
- Molecular Virology, Pathology and Microbiology Laboratory; San Gallicano Dermatological Institute; Rome Italy
| | - F. Ensoli
- Molecular Virology, Pathology and Microbiology Laboratory; San Gallicano Dermatological Institute; Rome Italy
| | - A. Mengarelli
- Hematology and Stem Cell Transplant Unit; Regina Elena National Cancer Institute; Rome Italy
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70
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Bagacean C, Zdrenghea M, Tempescul A, Cristea V, Renaudineau Y. Anti-CD20 monoclonal antibodies in chronic lymphocytic leukemia: from uncertainties to promises. Immunotherapy 2017; 8:569-81. [PMID: 27140410 DOI: 10.2217/imt-2015-0015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Over the last two decades, anti-CD20 monoclonal antibody (mAb) therapy has improved patient outcome in B-cell malignancies, and confirmed CD20 as an important target in chronic lymphocytic leukemia (CLL). Until recently, the gold standard was based on the utilization of rituximab combined with chemotherapy (fludarabine and cyclophosphamide), but patients often relapse. Next, with our better understanding of mAb engineering, anti-CD20 mAb therapy has evolved with the development of new mAb permitting significant clinical responses by improving pharmacokinetics, safety, activity and immunogenicity. Last but not least, the development of key tumoral tyrosine kinase inhibitors and their association with anti-CD20 mAb is a work in progress with promising results.
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Affiliation(s)
- Cristina Bagacean
- Research Unit INSERM ESPRI, ERI29/EA2216 Immunotherapy & B Cell Diseases, Réseau épigénétique et Réseau canaux ioniques du Cancéropôle Grand Ouest, Labex IGO, European University of Brittany, Brest, France.,'Iuliu Hatieganu' University of Medicine & Pharmacy, 8 Babes Street, 400012, Cluj-Napoca, Romania
| | - Mihnea Zdrenghea
- 'Iuliu Hatieganu' University of Medicine & Pharmacy, 8 Babes Street, 400012, Cluj-Napoca, Romania.,'Ion Chiricuta' Institute of Oncology, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Adrian Tempescul
- Research Unit INSERM ESPRI, ERI29/EA2216 Immunotherapy & B Cell Diseases, Réseau épigénétique et Réseau canaux ioniques du Cancéropôle Grand Ouest, Labex IGO, European University of Brittany, Brest, France.,Department of Hematology, CHRU Morvan, Brest, France
| | - Victor Cristea
- 'Iuliu Hatieganu' University of Medicine & Pharmacy, 8 Babes Street, 400012, Cluj-Napoca, Romania
| | - Yves Renaudineau
- Research Unit INSERM ESPRI, ERI29/EA2216 Immunotherapy & B Cell Diseases, Réseau épigénétique et Réseau canaux ioniques du Cancéropôle Grand Ouest, Labex IGO, European University of Brittany, Brest, France.,Laboratory of Immunology & Immunotherapy, CHRU Morvan, Brest, France
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71
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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72
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Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
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73
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Nagaharu K, Sugimoto Y, Hoshi Y, Yamaguchi T, Ito R, Matsubayashi K, Kawakami K, Ohishi K. Persistent symptomatic parvovirus B19 infection with severe thrombocytopenia transmitted by red blood cell transfusion containing low parvovirus B19 DNA levels. Transfusion 2017; 57:1414-1418. [PMID: 28369973 DOI: 10.1111/trf.14088] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/29/2016] [Accepted: 01/22/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transfusion-mediated human parvovirus B19 (PVB19) infection is rare but often causes severe hematologic disorders. In Japan, routine blood donor screening for PVB19 antigen (detection sensitivity, 106.4 IU/mL) using a chemiluminescent enzyme immunoassay (CLEIA) was introduced in 2008. However, there is no consensus on the minimal infectious dose of PVB19 permissible for red blood cells (RBCs). CASE REPORT A 64-year-old man, who had received hemodialysis for diabetic nephropathy for 5 years, underwent an RBC transfusion for anemia caused by hemorrhagic enterocolitis. He developed persistent high fever and progressive thrombocytopenia. He was diagnosed with PVB19 infection when a marrow examination showed giant erythroblasts, and his serum was positive for PVB19 DNA. His serum was negative for PVB19 immunoglobulin (Ig)M and IgG before transfusion, but positive for both after transfusion. This PVB19 infection was deemed to be transmitted by the RBC transfusion because low levels of PVB19 DNA (1.10 × 104 IU/mL) were detected in one of the blood donors. A DNA homology test of PVB19 showed complete genomic identity between the virus in the donor and our patient. CONCLUSION We report a patient who developed persistent PVB19 infection from an RBC transfusion containing low levels of PVB19. This is the second case of transfusion-mediated PVB19 infection since the introduction of CLEIA in 2008. Transmission may occur in immunocompromised patients lacking PVB19-neutralizing antibodies. The report of further such cases will allow the establishment of minimal threshold values and more effective screening tests for PBV19 transmission through RBC products.
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Affiliation(s)
- Keiki Nagaharu
- Department of Hematology and Oncology, Suzuka General Hospital, Suzuka, Mie Prefecture, Japan
| | - Yuka Sugimoto
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Mie Prefecture, Japan
| | - Yuji Hoshi
- Central Blood Institute, Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Takanori Yamaguchi
- Department of Hematology and Oncology, Suzuka General Hospital, Suzuka, Mie Prefecture, Japan
| | - Ryugo Ito
- Department of Hematology and Oncology, Suzuka General Hospital, Suzuka, Mie Prefecture, Japan
| | - Keiji Matsubayashi
- Central Blood Institute, Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Keiki Kawakami
- Department of Hematology and Oncology, Suzuka General Hospital, Suzuka, Mie Prefecture, Japan
| | - Kohshi Ohishi
- Blood Transfusion Service, Mie University Hospital, Tsu, Mie Prefecture, Japan
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74
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Li R, Rezk A, Li H, Gommerman JL, Prat A, Bar-Or A. Antibody-Independent Function of Human B Cells Contributes to Antifungal T Cell Responses. THE JOURNAL OF IMMUNOLOGY 2017; 198:3245-3254. [PMID: 28275140 DOI: 10.4049/jimmunol.1601572] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/11/2017] [Indexed: 12/16/2022]
Abstract
Fungal infections (e.g., Candida albicans) can manifest as serious medical illnesses, especially in the elderly and immune-compromised hosts. T cells are important for Candida control. Whether and how B cells are involved in antifungal immunity has been less clear. Although patients with agammaglobulinemia exhibit normal antifungal immunity, increased fungal infections are reported following B cell-depleting therapy, together pointing to Ab-independent roles of B cells in controlling such infections. To test how human B cells may contribute to fungal-associated human T cell responses, we developed a novel Ag-specific human T cell/B cell in vitro coculture system and found that human B cells could induce C. albicans-associated, MHC class II-restricted responses of naive T cells. Activated B cells significantly enhanced C. albicans-mediated Th1 and Th17 T cell responses, which were both strongly induced by CD80/CD86 costimulation. IL-6+GM-CSF+ B cells were the major responding B cell subpopulation to C. albicans and provided efficient costimulatory signals to the T cells. In vivo B cell depletion in humans resulted in reduced C. albicans-associated T responses. Of note, the decreased Th17, but not Th1, responses could be reversed by soluble factors from B cells prior to depletion, in an IL-6-dependent manner. Taken together, our results implicate an Ab-independent cytokine-defined B cell role in human antifungal T cell responses. These findings may be particularly relevant given the prospects of chronic B cell depletion therapy use in lymphoma and autoimmune disease, as patients age and are exposed to serial combination therapies.
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Affiliation(s)
- Rui Li
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Ayman Rezk
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Hulun Li
- Department of Neurobiology, Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Jennifer L Gommerman
- Department of Immunology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Alexandre Prat
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal-Hôpital Notre-Dame, Montreal, Quebec H2L 4M1, Canada; and
| | - Amit Bar-Or
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada; .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104.,Experimental Therapeutics Program, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
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75
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Beirão BCB, Raposo T, Jain S, Hupp T, Argyle DJ. Challenges and opportunities for monoclonal antibody therapy in veterinary oncology. Vet J 2016; 218:40-50. [PMID: 27938708 DOI: 10.1016/j.tvjl.2016.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 08/15/2016] [Accepted: 11/13/2016] [Indexed: 12/22/2022]
Abstract
Monoclonal antibodies (mAbs) have come to dominate the biologics market in human cancer therapy. Nevertheless, in veterinary medicine, very few clinical trials have been initiated using this form of therapy. Some of the advantages of mAb therapeutics over conventional drugs are high specificity, precise mode of action and long half-life, which favour infrequent dosing of the antibody. Further advancement in the field of biomedical sciences has led to the production of different forms of antibodies, such as single chain antibody fragment, Fab, bi-specific antibodies and drug conjugates for use in diagnostic and therapeutic purposes. This review describes the potential for mAbs in veterinary oncology in supporting both diagnosis and therapy of cancer. The technical and financial hurdles to facilitate clinical acceptance of mAbs are explored and insights into novel technologies and targets that could support more rapid clinical development are offered.
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Affiliation(s)
- Breno C B Beirão
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, EH25 9RG, United Kingdom
| | - Teresa Raposo
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, EH25 9RG, United Kingdom; Department of Veterinary Sciences, Universidade de Trás-os-Montes e Alto Douro, 5001-801, Portugal
| | - Saurabh Jain
- Edinburgh Cancer Research Centre, University of Edinburgh, EH4 2XR, United Kingdom
| | - Ted Hupp
- Edinburgh Cancer Research Centre, University of Edinburgh, EH4 2XR, United Kingdom
| | - David J Argyle
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, EH25 9RG, United Kingdom.
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76
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Catroux M, Lauda-Maillen M, Pathe M, De Boisgrollier de Ruolz AC, Cazenave-Roblot F, Roblot P, Souchaud-Debouverie O. [Infectious events during the course of autoimmune diseases treated with rituximab: A retrospective study of 93 cases]. Rev Med Interne 2016; 38:160-166. [PMID: 27836224 DOI: 10.1016/j.revmed.2016.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Describe the occurring infections in patients treated with rituximab for an autoimmune disease. METHODS Retrospective and monocentric study of 93 adult patients treated with rituximab for autoimmune indications over a nine years period. RESULTS Thirty-eight patients suffered from a total of 95 infections. Out of them, 18 patients (19 %) had had at least an infectious episode triggering a hospital admission and/or intravenous treatment. The infections occurred mainly during the first year of the treatment (65 %) and if the courses are repeated (P=0.04). They were mainly pulmonary infections. Severe infections, recorded in 79 % of the cases, were mostly of bacterial origin (43 %) and viral (23 %). Two cases of pneumocystis pneumonia and one case of invasive pulmonary aspergillosis were also recorded. The notion of vaccination was present in less than half of the cases, and 39 % of the patients were already receiving a prophylactic treatment against pneumocystis pneumonia. Patients over the age of 65 years (40 %) had developed less infections (P<0.05). Eight of the initial 93 patients died, half of them because of infectious complications. CONCLUSION Infectious complications are frequent, become early and are potentially severe. Imputability to rituximab is not certain. However, this could lead to better codify rituximab prescriptions and take adapted and associated measures in order to facilitate infection prevention and, if an infection does occur, to treat it at the earliest stage possible. The age doesn't seem to be a risk factor.
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Affiliation(s)
- M Catroux
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France.
| | - M Lauda-Maillen
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | - M Pathe
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | | | - F Cazenave-Roblot
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | - P Roblot
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | - O Souchaud-Debouverie
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
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77
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Moccia AA, Zucca E, Ghielmini M. Is there a role for a maintenance rituximab in indolent lymphoproliferative diseases other than follicular lymphoma? Leuk Lymphoma 2016; 58:30-36. [PMID: 27813427 DOI: 10.1080/10428194.2016.1248963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Rituximab (R) is an anti-CD20 monoclonal antibody which has become an essential component for the treatment of B-cell lymphomas. When associated to chemotherapy it improves the outcome of the patients with diffuse large B-cell lymphoma, follicular lymphoma, and other lymphoproliferative diseases in comparison to chemotherapy alone. For patients with newly diagnosed follicular lymphoma achieving at least a partial response to initial immuno-chemotherapy, maintenance R was associated with an improvement in progression-free survival and a meta-analysis of randomized maintenance trials suggests an overall survival advantage. The role of maintenance R in other indolent diseases is less well-defined. In this article, we summarize the data available for this strategy in less frequent subtypes of indolent B-cell lymphomas.
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Affiliation(s)
- Alden A Moccia
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Emanuele Zucca
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Michele Ghielmini
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
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78
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Targeting Epstein-Barr virus-transformed B lymphoblastoid cells using antibodies with T-cell receptor-like specificities. Blood 2016; 128:1396-407. [PMID: 27338099 DOI: 10.1182/blood-2016-03-707836] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/18/2016] [Indexed: 12/30/2022] Open
Abstract
Epstein-Barr virus (EBV) is an oncovirus associated with several human malignancies including posttransplant lymphoproliferative disease in immunosuppressed patients. We show here that anti-EBV T-cell receptor-like monoclonal antibodies (TCR-like mAbs) E1, L1, and L2 bound to their respective HLA-A*0201-restricted EBV peptides EBNA1562-570, LMP1125-133, and LMP2A426-434 with high affinities and specificities. These mAbs recognized endogenously presented targets on EBV B lymphoblastoid cell lines (BLCLs), but not peripheral blood mononuclear cells, from which they were derived. Furthermore, these mAbs displayed similar binding activities on several BLCLs, despite inherent heterogeneity between different donor samples. A single weekly administration of the naked mAbs reduced splenomegaly, liver tumor spots, and tumor burden in BLCL-engrafted immunodeficient NOD-SCID/Il2rg(-/-) mice. In particular, mice that were treated with the E1 mAb displayed a delayed weight loss and significantly prolonged survival. In vitro, these TCR-like mAbs induced early apoptosis of BLCLs, thereby enhancing their Fc-dependent phagocytic uptake by macrophages. These data provide evidence for TCR-like mAbs as potential therapeutic modalities to target EBV-associated diseases.
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Knight A, Sundström Y, Börjesson O, Bruchfeld A, Malmström V, Gunnarsson I. Late-onset neutropenia after rituximab in ANCA-associated vasculitis. Scand J Rheumatol 2016; 45:404-7. [PMID: 26948245 DOI: 10.3109/03009742.2016.1138318] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Rituximab (RTX) is being used increasingly in anti-neutrophil cytoplasmatic antibody (ANCA)-associated vasculitis (AAV). Late-onset neutropenia (LON) and risks of infections have been observed following RTX therapy in rheumatological diseases including granulomatosis with polyangiitis (GPA) but data on microscopic polyangiitis (MPA) are lacking. METHOD We studied the occurrence of LON in 59 AAV (47 GPA/12 MPA) patients treated with RTX. Patient charts were retrospectively reviewed for the occurrence of LON and clinical data were extracted and included in the analysis. RESULTS Seven of the total 59 patients (11.9%) developed LON after a median time of 86 days (range 56-168 days) since their latest RTX treatment. Of these seven LON patients, 5/47 (10.6%) had a diagnosis of GPA and 2/12 (16.7%) of MPA. Three of the patients developed LON after the first RTX treatment and four had received repeated courses. Five LON patients developed infectious symptoms. Six of the patients were hospitalized. Retreatment with RTX was given in three cases without further LON episodes. CONCLUSIONS LON is a potentially severe side-effect of RTX occurring in both GPA and MPA and may develop after both single and repeated treatment courses. As infections are commonly seen, the condition requires an increased awareness. No predisposing factors for LON were identified.
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Affiliation(s)
- A Knight
- a Department of Rheumatology , Institution of Medical Sciences, Uppsala University , Uppsala , Sweden
| | - Y Sundström
- b Department of Medicine, Unit of Rheumatology , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - O Börjesson
- c Department of Renal Medicine , CLINTEC, Karolinska Institute , Stockholm , Sweden
| | - A Bruchfeld
- c Department of Renal Medicine , CLINTEC, Karolinska Institute , Stockholm , Sweden
| | - V Malmström
- b Department of Medicine, Unit of Rheumatology , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - I Gunnarsson
- b Department of Medicine, Unit of Rheumatology , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
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80
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Matsuda G, Imadome KI, Kawano F, Mochizuki M, Ochiai N, Morio T, Shimizu N, Fujiwara S. Cellular immunotherapy with ex vivo expanded cord blood T cells in a humanized mouse model of EBV-associated lymphoproliferative disease. Immunotherapy 2016; 7:335-41. [PMID: 25917625 DOI: 10.2217/imt.15.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Donor lymphocyte infusion is not feasible in recipients of cord blood transplantation. AIM We investigated whether infusion of T cells expanded from cord blood is effective in the treatment of model mice of Epstein-Barr virus (EBV)-associated lymphoproliferative disease (LPD). MATERIALS & METHODS Humanized mice with reconstituted human immune system were prepared and LPD was induced by inoculating EBV intravenously. T cells were expanded from the same sample of cord blood as used for generation of humanized mice and infused to EBV-infected humanized mice. RESULTS Mice treated with expanded cord blood T cells lived significantly longer than control mice (p = 0.036). CONCLUSION Infusion of T cells expanded from cord blood was effective in the treatment of model mice for EBV-associated LPD.
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Affiliation(s)
- Go Matsuda
- Department of Infectious Diseases, National Research Institute for Child Health & Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
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81
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Savsek L, Opaskar TR. Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient. Radiol Oncol 2016; 50:87-93. [PMID: 27069454 PMCID: PMC4825343 DOI: 10.1515/raon-2014-0042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/21/2014] [Indexed: 12/26/2022] Open
Abstract
Background Toxoplasmosis is an opportunistic protozoal infection that has, until now, probably been an underestimated cause of encephalitis in patients with hematological malignancies, independent of stem cell or bone marrow transplant. T and B cell depleting regimens are probably an important risk factor for reactivation of a latent toxoplasma infection in these patients. Case report We describe a 62-year-old HIV-negative right-handed Caucasian female with systemic diffuse large B cell lymphoma who presented with sudden onset of high fever, headache, altered mental status, ataxia and findings of pancytopenia, a few days after receiving her final, 8th cycle of rituximab, cyclophosphamide, vincristine, doxorubicin, prednisolone (R-CHOP) chemotherapy regimen. A progression of lymphoma to the central nervous system was suspected. MRI of the head revealed multiple on T2 and fluid attenuated inversion recovery (FLAIR) hyperintense parenchymal lesions with mild surrounding edema, located in both cerebral and cerebellar hemispheres that demonstrated moderate gadolinium enhancement. The polymerase chain reaction on cerebrospinal fluid (CSF PCR) was positive for Toxoplasma gondii. The patient was diagnosed with toxoplasmic encephalitis and successfully treated with sulfadiazine, pyrimethamine and folic acid. Due to the need for maintenance therapy with rituximab for lymphoma remission, the patient now continues with secondary prophylaxis of toxoplasmosis. Conclusions With this case report, we wish to emphasize the need to consider cerebral toxoplasmosis in patients with hematological malignancies on immunosuppressive therapy when presenting with new neurologic deficits. In such patients, there are numerous differential diagnoses for cerebral toxoplasmosis, and the CNS lymphoma is the most difficult among all to distinguish it from. If left untreated, cerebral toxoplasmosis has a high mortality rate; therefore early recognition and treatment are of essential importance.
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Affiliation(s)
- Lina Savsek
- Department of Neurology, General Hospital Celje, Celje, Slovenia
| | - Tanja Ros Opaskar
- Unit of Neurology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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82
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Gulleroglu K, Baskin E, Moray G, Ozdemir H, Arslan H, Haberal M. Rituximab Therapy and Infection Risk in Pediatric Renal Transplant Patients. EXP CLIN TRANSPLANT 2016; 14:172-5. [PMID: 26742572 DOI: 10.6002/ect.2014.0156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Rituximab is a monoclonal antibody directed against the CD20 molecule on pre-B and mature B cells and is used in transplant recipients for the prevention and treatment of alloantibody-mediated rejection or for the treatment of disease recurrence after transplant. In most patients, rituximab has been safe and well-tolerated, but the long-term adverse effects of rituximab are currently unknown. MATERIALS AND METHODS We retrospectively evaluated 78 pediatric renal transplant recipients for the occurrence of infectious disease. Patients who received rituximab therapy were divided into 2 groups: those who developed an infection and those who did not. The 2 groups were compared for serious infections, hospitalization, graft loss, and death rates. RESULTS Eighteen transplant patients received rituximab therapy for various causes. The number of rituximab courses given varied according to the cause and ranged from 1 to 8 courses. The dose at each course was 375 mg/m(2). Median age of all recipients was 16.00 years (min-max:, 5.00-22.00 y), and median follow-up time was 2.00 years (min-max:, 1.00-3.00 y). Serious infections (bacterial sepsis, tuberculosis, Cytomegalovirus infection, varicella-zoster virus infection, Polyomavirus-associated nephropathy, and acute pyelonephritis) were observed in 8 patients who received rituximab therapy. We observed that patients with antibody-mediated rejection had significantly increased infection rate. Patients who had used rituximab combined with antithymocyte globulin and higher rituximab course number and higher pretreatment CD19 and CD20 levels had higher risk of infection (P < .05). CONCLUSIONS The combined use of rituximab with additional treatments such as antithymocyte globulin, intravenous immunoglobulin, and repeated plasma exchange may be associated with high risk of infectious disease. Especially for those patients who required intensive and repetitive treatment, such as antibody-mediated rejection, rituximab treatment should be used with caution. Infection risk should be closely monitored, although mainly in patients who receive T-cell-depleting agents.
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Affiliation(s)
- Kaan Gulleroglu
- From the Department of Pediatric Nephrology, Baskent University, Ankara, Turkey
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83
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Vacunación en el paciente con linfoma no hodgkiniano en tratamiento con rituximab u otros fármacos inmunodepresores. Med Clin (Barc) 2016; 146:43-4. [DOI: 10.1016/j.medcli.2015.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/26/2015] [Indexed: 11/18/2022]
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Kessler RA, Mealy MA, Levy M. Treatment of Neuromyelitis Optica Spectrum Disorder: Acute, Preventive, and Symptomatic. Curr Treat Options Neurol 2015; 18:2. [PMID: 26705758 DOI: 10.1007/s11940-015-0387-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OPINION STATEMENT Neuromyelitis optica spectrum disorder (NMOSD) is a rare, autoimmune disease of the central nervous system that primarily attacks the optic nerves and spinal cord leading to blindness and paralysis. The spectrum of the disease has expanded based on the specificity of the autoimmune response to the aquaporin-4 water channel on astrocytes. With wider recognition of NMOSD, a standard of care for treatment of this condition has condition based on a growing series of retrospective and prospective studies. This review covers the present state of the field in the treatment of acute relapses, preventive approaches, and therapies for symptoms of NMOSD.
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Affiliation(s)
- Remi A Kessler
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Maureen A Mealy
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Michael Levy
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA.
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85
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Cerebral toxoplasmosis after rituximab therapy for splenic marginal zone lymphoma: a case report and review of the literature. JMM Case Rep 2015. [DOI: 10.1099/jmmcr.0.005010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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86
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Stewart JM, Tarantal AF, Hawthorne WJ, Salvaris EJ, O'Connell PJ, Nottle MB, d'Apice AJF, Cowan PJ, Kearns-Jonker M. Clonidine inhibits anti-non-Gal IgM xenoantibody elicited in multiple pig-to-primate models. Xenotransplantation 2015; 22:413-26. [PMID: 26490547 DOI: 10.1111/xen.12199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 08/25/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Survival of vascularized xenografts is dependent on pre-emptive inhibition of the xenoantibody response against galactosyltransferase knockout (GTKO) porcine organs. Our analysis in multiple GTKO pig-to-primate models of xenotransplantation has demonstrated that the anti-non-gal-α-1,3-gal (anti-non-Gal) xenoantibody response displays limited structural diversity. This allowed our group to identify an experimental compound which selectively inhibited induced anti-non-Gal IgM xenoantibodies. However, because this compound had an unknown safety profile, we extended this line of research to include screening small molecules with known safety profiles allowing rapid advancement to large animal models. METHODS The NIH clinical collections of small molecules were screened by ELISA for their ability to inhibit xenoantibody binding to GTKO pig endothelial cells. Serum collected from non-immunosuppressed rhesus monkeys at day 14 post-injection with GTKO pig endothelial cells was utilized as a source of elicited xenoantibody for initial screening. Virtual small molecule screening based on xenoantibody structure was used to assess the likelihood that the identified small molecules bound xenoantibody directly. As a proxy for selectivity, ELISAs against tetanus toxoid and the natural antigens laminin, thyroglobulin, and single-stranded DNA (ssDNA) were utilized to assess the ability of the identified reagents to inhibit additional antibody responses. The identified inhibitory small molecules were further tested for their ability to inhibit xenoantibody elicited in multiple settings, including rhesus monkeys pre-treated with an anti-non-Gal selective anti-idiotypic antibody, non-immunosuppressed rhesus monkeys immunized with wild-type fetal pig isletlike cell clusters, and non-immunosuppressed baboons transplanted with GTKO multiple transgenic pig kidneys. RESULTS Four clinically relevant small molecules inhibited anti-non-Gal IgM binding to GTKO pig endothelial cells in vitro. Three of these drugs displayed a limited region of structural similarity suggesting they may inhibit xenoantibody by a similar mechanism. One of these, the anti-hypertensive agent clonidine, displayed only minimal inhibition of antibodies elicited by vaccination against tetanus toxoid or pre-existing natural antibodies against laminin, thyroglobulin, or ssDNA. Furthermore, clonidine inhibited elicited anti-non-Gal IgM from all animals that demonstrated a xenoantibody response in each experimental setting. CONCLUSIONS Clinically relevant small molecule drugs with known safety profiles can inhibit xenoantibody elicited against non-Gal antigens in diverse experimental xenotransplantation settings. These molecules are ready to be tested in large animal models. However, it will first be necessary to optimize the timing and dosing required to inhibit xenoantibodies in vivo.
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Affiliation(s)
- John M Stewart
- Department of Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, and California National Primate Research Center, University of California, Davis, CA, USA
| | - Wayne J Hawthorne
- Centre for Transplant and Renal Research, Westmead Millennium Institute, Westmead, NSW, Australia.,National Pancreas Transplant Unit, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Evelyn J Salvaris
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Philip J O'Connell
- Centre for Transplant and Renal Research, Westmead Millennium Institute, Westmead, NSW, Australia.,National Pancreas Transplant Unit, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Mark B Nottle
- Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, SA, Australia
| | - Anthony J F d'Apice
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Mary Kearns-Jonker
- Department of Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Gupta N, Lawrence RM, Nguyen C, Modica RF. Review article: BK virus in systemic lupus erythematosus. Pediatr Rheumatol Online J 2015; 13:34. [PMID: 26293687 PMCID: PMC4545992 DOI: 10.1186/s12969-015-0033-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/16/2015] [Indexed: 02/08/2023] Open
Abstract
BK virus (BKV) is a human polyomavirus with a seroprevalence of 60-80 % in the general population. In renal transplant patients, it is known to cause renal failure, ureteric stenosis and hemorrhagic cystitis. In bone marrow transplant patients, it is evident that BKV can also cause hemorrhagic cystitis along with BK virus nephropathy (BKVN) in the native kidneys, with subsequent renal failure. However, little is known about BVKN in non-transplanted immune-compromised patients, such as systemic lupus erythematosus (SLE) who may have underlying nephritis and have a compromised immune system due to therapy and/or systemic illness. Thus, this article will focus on the clinical aspects of BKV and its association in patients with SLE.
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Affiliation(s)
- Nirupama Gupta
- Division of Nephrology, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, 32610, USA.
| | - Robert M. Lawrence
- Division of Immunology, Rheumatology and Infectious Diseases, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610 USA
| | - Cuong Nguyen
- Department of Infectious Diseases and Pathology, College of Veterinary Medicine, University of Florida, Gainesville, FL, 32610, USA.
| | - Renee F. Modica
- Division of Immunology, Rheumatology and Infectious Diseases, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610 USA
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88
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Salama A. Treatment Options for Primary Autoimmune Hemolytic Anemia: A Short Comprehensive Review. Transfus Med Hemother 2015; 42:294-301. [PMID: 26696797 PMCID: PMC4678315 DOI: 10.1159/000438731] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 07/15/2015] [Indexed: 12/26/2022] Open
Abstract
Until now, treatment of primary autoimmune hemolytic anemia of the warm type (wAIHA) is primarily based on immunosuppression. However, many patients do not respond adequately to treatment, and treated patients may develop severe side effects due to uncontrolled, mixed and/or long-lasting immunosuppression. Unfortunately, the newly used therapeutic monoclonal antibodies are unspecific and remain frequently ineffective. Thus, development of a specific therapy for AIHA is necessary. The ideal therapy would be the identification and elimination of the causative origin of autoimmunization and/or the correction or reprogramming of the dysregulated immune components. Blood transfusion is the most rapidly effective measure for patients who develop or may develop hypoxic anemia. Although some effort has been made to guide physicians on how to adequately treat patients with AIHA, a number of individual aspects should be considered prior to treatment. Based on my serological and clinical experience and the analysis of evidence-based studies, we remain far from any optimized therapeutic measures for all AIHA patients. Today, the old standard therapy using controlled steroid administration, with or without azathioprine or cyclophosphamide, is, when complemented with erythropoiesis-stimulating agents, still the most effective therapy in wAIHA. Rituximab or other monoclonal antibodies may be used instead of splenectomy in therapy-refractory patients.
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Affiliation(s)
- Abdulgabar Salama
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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89
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Robak P, Smolewski P, Robak T. Emerging immunological drugs for chronic lymphocytic leukemia. Expert Opin Emerg Drugs 2015; 20:423-47. [PMID: 26153226 DOI: 10.1517/14728214.2015.1046432] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Over the last few years, several new immunological drugs, particularly monoclonal antibodies (mAbs), immunomodulatory drugs and B-cell receptor (BCR) pathway inhibitors have been developed and investigated in chronic lymphocytic leukemia (CLL). This article summarizes recent discoveries regarding their mechanism of action, pharmacological properties, clinical activity and toxicity, as well as the emerging role of these agents in CLL. AREAS COVERED A literature review of mAbs, BCR pathway inhibitors and immunomodulating drugs was conducted of the MEDLINE database via PubMed for articles in English. Publications from 2000 through February 2015 were scrutinized. The search terms used were alemtuzumab, BI 836826, duvelisib ibrutinib, idelalisib, lenalidomide, monoclonal antibodies, MEDI-551, MOR208, obinutuzumab, ocaratuzumab, ofatumumab, ONO-4059, otlertuzumab, spebrutinib, veltuzumab and XmAb5574 in conjunction with CLL. Conference proceedings from the previous 5 years of the American Society of Hematology, European Hematology Association, American Society of Clinical Oncology, and ACR/ARHP Annual Scientific Meetings were searched manually. Additional relevant publications were obtained by reviewing the references from the chosen articles. EXPERT OPINION The use of mAbs, BCR inhibitors and immunomodulating drugs is a promising new strategy for chemotherapy-free treatment of CLL. However, definitive data from ongoing and future clinical trials will aid in better defining the status of immunological drugs in the treatment of this disease.
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Affiliation(s)
- Pawel Robak
- a Medical University of Lodz, Departments of Experimental Hematology and Hematology, Copernicus Memorial Hospital , 93-510 Lodz, Ul. Ciolkowskiego 2, Poland +48 42 689 51 91 ; +48 42 689 51 92 ;
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90
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Pulmonary Mucormycosis in a Patient with Systemic Lupus Erythematosus: A Diagnostic and Treatment Challenge. Case Rep Infect Dis 2015; 2015:478789. [PMID: 26185693 PMCID: PMC4491550 DOI: 10.1155/2015/478789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 11/18/2022] Open
Abstract
Pulmonary mucormycosis is commonly encountered in patients with diabetic ketoacidosis, hematologic malignancies, neutropenia, organ or hematopoietic stem cell transplantation, and malignancy, but it rarely occurs in high-risk patients with systemic lupus erythematosus (SLE). We present the case of a 40-year-old SLE female with fulminant pneumonia after remission of nephritis treated with rituximab, who developed severe pulmonary mucormycosis that led to her rapid death from acute respiratory failure and acute respiratory distress syndrome. Pulmonary mucormycosis has a high mortality rate. However, with early diagnosis and antifungal therapy with lipid formulation-liposomal amphotericin B and surgical removal of the infected area, the outcome can be improved.
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91
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Schachtner T, Stein M, Reinke P. ABO desensitization affects cellular immunity and infection control after renal transplantation. Transpl Int 2015; 28:1179-94. [PMID: 26033637 DOI: 10.1111/tri.12616] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/07/2015] [Accepted: 05/27/2015] [Indexed: 02/06/2023]
Abstract
The impact of ABO desensitization on overall immunity, infectious control, and alloreactivity remains unknown. We compared 35 ABO-incompatible kidney transplant recipients (KTRs) to a control of 62 ABO compatible KTRs. Samples were collected before, at +1, +2, +3, +6, and +12 months post-transplantation. CMV-, BKV-specific, and alloreactive T cells were measured using an interferon-γ ELISPOT assay. The extent of immunosuppression was quantified by enumeration of lymphocyte subpopulations and cytokines. No differences were observed for 5-year allograft survival and function between both groups (P > 0.05). However, ABO-incompatible KTRs were more likely to develop CMV infection, BKV-associated nephropathy, and severe sepsis (P = 0.001). Interestingly, ABO-incompatible KTRs with poor HLA-match showed the highest rates of infections and inferior allograft function (P < 0.05). CD3+, CD4+ T-cell counts, interferon-γ and IL-10 levels were lower in ABO-incompatible KTRs early post-transplantation (P < 0.05). Likewise, ABO-incompatible KTRs showed impaired BKV- and CMV-specific T-cell immunity (P < 0.05). ABO-incompatible KTRs showed lower frequencies of alloreactive T cells (P < 0.05). Our data suggest T-cell depletion due to ABO desensitization, which may contribute to the increased risk of T-cell-dependent infections. Elimination of B cells serving as antigen-presenting cells, thereby causing impaired T-cell activation, plays a significant role in both impaired infection control and reduced alloreactive T-cell activation.
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Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
| | - Maik Stein
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
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92
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Septic arthritis in immunocompetent and immunosuppressed hosts. Best Pract Res Clin Rheumatol 2015; 29:275-89. [PMID: 26362744 DOI: 10.1016/j.berh.2015.05.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/08/2015] [Indexed: 12/12/2022]
Abstract
Septic arthritis has long been considered an orthopedic emergency. Historically, Neisseria gonorrhoeae and Staphylococcus aureus have been the most common causes of septic arthritis worldwide but in the modern era of biological therapy and extensive use of prosthetic joint replacements, the spectrum of microbiological causes of septic arthritis has widened considerably. There are also new approaches to diagnosis but therapy remains a challenge, with a need for careful consideration of a combined medical and surgical approach in most cases.
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93
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Bockenstedt MM, Boggiatto PM, Jones DE. Characterization of the B cell response to Leishmania infection after anti-CD20 B cell depletion. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2015; 8:6192-6202. [PMID: 26261496 PMCID: PMC4525830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/25/2015] [Indexed: 06/04/2023]
Abstract
Anti-CD20 depletion therapies targeting B cells are commonly used in malignant B cell disease and autoimmune diseases. There are concerns about the ability of B cells to respond to infectious diseases acquired either before or after B cell depletion. There is evidence that the B cell response to existing or acquired viral infections is compromised during treatment, as well as the antibody response to vaccination. Our laboratory has an experimental system using co-infection of C3H mice with both Leishmania major and Leishmania amazonensis that suggests that the B cell response is important to healing infected mice. We tested if anti-CD20 treatment would completely restrict the B cell response to these intracellular pathogens. Infected mice that received anti-CD20 B cell depletion therapy had a significant decrease in CD19(+) cells within their lymph nodes and spleens. However, splenic B cells were detected in depleted mice and an antigen-specific antibody response was produced. These results indicate that an antigen-specific B cell response towards intracellular pathogens can be generated during anti-CD20 depletion therapy.
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Affiliation(s)
- Marie M Bockenstedt
- Department of Veterinary Pathology and Preventive Medicine, Iowa State University1600 S 16th St, Ames, IA 50011, USA
| | - Paola M Boggiatto
- Department of Veterinary Microbiology, College of Veterinary Medicine, Iowa State University1600 S 16th St, Ames, IA 50011, USA
| | - Douglas E Jones
- Department of Veterinary Pathology and Preventive Medicine, Iowa State University1600 S 16th St, Ames, IA 50011, USA
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Hornbeak DM, Thorne JE. Immunosuppressive therapy for eye diseases: Effectiveness, safety, side effects and their prevention. Taiwan J Ophthalmol 2015; 5:156-163. [PMID: 29018691 PMCID: PMC5602133 DOI: 10.1016/j.tjo.2015.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/25/2015] [Accepted: 03/30/2015] [Indexed: 12/17/2022] Open
Abstract
Ocular inflammation is a significant cause of ocular morbidity and visual impairment. Topical, periocular, intraocular, and systemic corticosteroids are highly effective for treating appropriate forms of ocular inflammation. However, their use may be constrained by local and/or systemic side effects, especially if long-term therapy is required. As a result, immunosuppressive agents increasingly have been used to manage ocular inflammation alongside or in place of corticosteroids. The four categories of agents used today are antimetabolites [primarily methotrexate, mycophenolate mofetil (MMF), and azathioprine]; T-cell inhibitors (usually cyclosporine, less often tacrolimus or sirolimus); alkylating agents (cyclophos-phamide and chlorambucil); and biologic agents [tumor necrosis factor (TNF) inhibitors, lymphocyte inhibitors, and interleukin inhibitors]. The primary goals of immunosuppressive therapy are (1) to control inflammation when corticosteroids fail to do so; (2) to prevent corticosteroid-induced toxicity when the necessary corticosteroid dosage exceeds the desired or safe level (corticosteroid sparing); and (3) to treat specific high-risk uveitis syndromes known to respond poorly to corticosteroids alone. Growing evidence shows the effectiveness of immunosuppressive drugs in achieving these goals, as well as improved visual function, prevention of ocular complications, and in some cases even disease remission. However, these agents also have side effects, which must be considered in each patient's management. In this report, we summarize the effectiveness and safety of immunosuppressive drug therapy utilized in the treatment of ocular inflammatory diseases.
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Affiliation(s)
- Dana M Hornbeak
- Division of Ocular Immunology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer E Thorne
- Division of Ocular Immunology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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95
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Jiang X, Mei X, Feng D, Wang X. Prophylaxis and Treatment of Pneumocystis jiroveci Pneumonia in Lymphoma Patients Subjected to Rituximab-Contained Therapy: A Systemic Review and Meta-Analysis. PLoS One 2015; 10:e0122171. [PMID: 25909634 PMCID: PMC4409297 DOI: 10.1371/journal.pone.0122171] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 02/08/2015] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis jiroveci pneumonia (PCP) is frequently reported in lymphoma patients treated with rituximab-contained regimens. There is a trend toward a difference in PCP risk between bi- and tri-weekly regimens. The aims of this systemic review and meta-analysis were to estimate the risk for PCP in these patients, compare the impact of different regimens on the risk, and evaluate the efficacy of prophylaxis. The cohort studies with incept up to January 2014 were retrieved from the Cochrane Library, Medline, Embase, and Web of Science databases. Studies that compared the incidence of PCP in patients with and without rituximab treatment were conducted. Studies that reported the results of prophylaxis were concentrated to evaluate the efficacy of prophylaxis. Fixed effect Mantel-Haenszel model was chosen as the main analysis method. Funnel plots were examined to estimate the potential selection bias. Egger's test and Begg's test were used for the determination of possible small study bias. Eleven cohort studies that met the inclusion criteria were finally included. Results indicated that rituximab was associated with a significantly increased risk for PCP (28/942 vs 5/977; risk ratio: 3.65; 95% confidence interval 1.65 to 8.07; P=0.001), and no heterogeneity existed between different studies (I2=0%). Little significant difference in PCP risk was found between bi-weekly and tri-weekly regimens (risk ratio: 3.11; 95% confidence interval 0.92 to 10.52, P=0.068). PCP risk was inversely associated with prophylaxis in patients treated with rituximab (0/222 vs 26/986; risk ratio: 0.28; 95% confidence interval 0.09 to 0.94; P=0.039). In conclusion, PCP risk was increased significantly in lymphoma patients subjected to rituximab-contained chemotherapies. Difference in PCP risk between bi-weekly and tri-weekly regimens was not significant. Additionally, prophylaxis was dramatically effective in preventing PCP in rituximab-received lymphoma patients, suggesting that rituximab should be recommended for these patients.
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Affiliation(s)
- Xuqin Jiang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Xiaodong Mei
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Di Feng
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Xiaojing Wang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
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96
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Nixon AE, Chen J, Sexton DJ, Muruganandam A, Bitonti AJ, Dumont J, Viswanathan M, Martik D, Wassaf D, Mezo A, Wood CR, Biedenkapp JC, TenHoor C. Fully human monoclonal antibody inhibitors of the neonatal fc receptor reduce circulating IgG in non-human primates. Front Immunol 2015; 6:176. [PMID: 25954273 PMCID: PMC4407741 DOI: 10.3389/fimmu.2015.00176] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/29/2015] [Indexed: 12/24/2022] Open
Abstract
The therapeutic management of antibody-mediated autoimmune disease typically involves immunosuppressant and immunomodulatory strategies. However, perturbing the fundamental role of the neonatal Fc receptor (FcRn) in salvaging IgG from lysosomal degradation provides a novel approach - depleting the body of pathogenic immunoglobulin by preventing IgG binding to FcRn and thereby increasing the rate of IgG catabolism. Herein, we describe the discovery and preclinical evaluation of fully human monoclonal IgG antibody inhibitors of FcRn. Using phage display, we identified several potent inhibitors of human-FcRn in which binding to FcRn is pH-independent, with over 1000-fold higher affinity for human-FcRn than human IgG-Fc at pH 7.4. FcRn antagonism in vivo using a human-FcRn knock-in transgenic mouse model caused enhanced catabolism of exogenously administered human IgG. In non-human primates, we observed reductions in endogenous circulating IgG of >60% with no changes in albumin, IgM, or IgA. FcRn antagonism did not disrupt the ability of non-human primates to mount IgM/IgG primary and secondary immune responses. Interestingly, the therapeutic anti-FcRn antibodies had a short serum half-life but caused a prolonged reduction in IgG levels. This may be explained by the high affinity of the antibodies to FcRn at both acidic and neutral pH. These results provide important preclinical proof of concept data in support of FcRn antagonism as a novel approach to the treatment of antibody-mediated autoimmune diseases.
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Affiliation(s)
| | - Jie Chen
- Dyax Corp. , Burlington, MA , USA
| | | | | | - Alan J Bitonti
- Syntonix Pharmaceuticals (a wholly-owned subsidiary of Biogen Idec.) , Waltham, MA , USA
| | | | | | | | | | - Adam Mezo
- Syntonix Pharmaceuticals (a wholly-owned subsidiary of Biogen Idec.) , Waltham, MA , USA
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97
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Worch J, Makarova O, Burkhardt B. Immunreconstitution and infectious complications after rituximab treatment in children and adolescents: what do we know and what can we learn from adults? Cancers (Basel) 2015; 7:305-28. [PMID: 25643241 PMCID: PMC4381260 DOI: 10.3390/cancers7010305] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 01/19/2023] Open
Abstract
Rituximab, an anti CD20 monoclonal antibody, is widely used in the treatment of B-cell malignancies in adults and increasingly in pediatric patients. By depleting B-cells, rituximab interferes with humoral immunity. This review provides a comprehensive overview of immune reconstitution and infectious complications after rituximab treatment in children and adolescents. Immune reconstitution starts usually after six months with recovery to normal between nine to twelve months. Extended rituximab treatment results in a prolonged recovery of B-cells without an increase of clinically relevant infections. The kinetic of B-cell recovery is influenced by the concomitant chemotherapy and the underlying disease. Intensive B-NHL treatment such as high-dose chemotherapy followed by rituximab bears a risk for prolonged hypogammaglobulinemia. Overall transient alteration of immune reconstitution and infections after rituximab treatment are acceptable for children and adolescent without significant differences compared to adults. However, age related disparities in the kinetic of immune reconstitution and the definitive role of rituximab in the treatment for children and adolescents with B-cell malignancies need to be evaluated in prospective controlled clinical trials.
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Affiliation(s)
- Jennifer Worch
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, 48149, Germany.
| | - Olga Makarova
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, 48149, Germany.
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, 48149, Germany.
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98
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Belhassen-Garcia M, Rábano-Gutiérrez A, Velasco-Tirado V, Romero-Alegria A, Pérez-Garcia ML, Martin-Oterino JA. Atypical progressive multifocal leukoencephalopathy in a patient with antisynthetase syndrome. Intern Med 2015; 54:519-24. [PMID: 25758081 DOI: 10.2169/internalmedicine.54.2748] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Antisynthetase syndrome is a disorder belonging to the dermatomyositis/polymyositis group, with high rates of morbidity and mortality. We herein present the case of a 71-year-old man who was diagnosed with antisynthetase syndrome and treated with rituximab. Almost three years later, the patient showed right-sided hemiparesis that ultimately progressed to complete hemiplegia and advancing cognitive deterioration with a poor clinical outcome. The neuropathological diagnosis was progressive multifocal leukoencephalopathy. Treatment with rituximab for antisynthetase syndrome itself plays a fundamental role in the development of infectious complications.
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Affiliation(s)
- Moncef Belhassen-Garcia
- Department of Internal Medicine, Unit of Infectious Diseases. IBSAL. University Hospital of Salamanca. CIETUS, University of Salamanca, Spain
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99
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Compagno N, Malipiero G, Cinetto F, Agostini C. Immunoglobulin replacement therapy in secondary hypogammaglobulinemia. Front Immunol 2014; 5:626. [PMID: 25538710 PMCID: PMC4259107 DOI: 10.3389/fimmu.2014.00626] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/24/2014] [Indexed: 12/02/2022] Open
Abstract
Immunoglobulin (Ig) replacement therapy dramatically changed the clinical course of primary hypogammaglobulinemias, significantly reducing the incidence of infectious events. Over the last two decades its use has been extended to secondary antibody deficiencies, particularly those related to hematological disorders as lymphoproliferative diseases (LPDs) and multiple myeloma. In these malignancies, hypogammaglobulinemia can be an intrinsic aspect of the disease or follow chemo-immunotherapy regimens, including anti-CD20 treatment. Other than in LPDs the broadening use of immunotherapy (e.g., rituximab) and immune-suppressive therapy (steroids, sulfasalazine, and mycophenolate mofetil) has extended the occurrence of iatrogenic hypogammaglobulinemia. In particular, in both autoimmune diseases and solid organ transplantation Ig replacement therapy has been shown to reduce the rate of infectious events. Here, we review the existing literature about Ig replacement therapy in secondary hypogammaglobulinemia, with special regard for subcutaneous administration route, a safe, effective, and well-tolerated treatment approach, currently well established in primary immunodeficiencies and secondary hypogammaglobulinemias.
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Affiliation(s)
- Nicolò Compagno
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Giacomo Malipiero
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Francesco Cinetto
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Carlo Agostini
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
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100
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Andréasson K, Jönsson G, Lindell P, Gülfe A, Ingvarsson R, Lindqvist E, Saxne T, Grankvist A, Wennerås C, Marsal J. Recurrent fever caused by Candidatus Neoehrlichia mikurensis in a rheumatoid arthritis patient treated with rituximab. Rheumatology (Oxford) 2014; 54:369-71. [PMID: 25416710 DOI: 10.1093/rheumatology/keu441] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kristofer Andréasson
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Göran Jönsson
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Pia Lindell
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Anders Gülfe
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Ragnar Ingvarsson
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Elisabet Lindqvist
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Tore Saxne
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Anna Grankvist
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Christine Wennerås
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
| | - Jan Marsal
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden Department of Clinical Sciences, Section of Rheumatology, Lund University, Department of Infectious Diseases, University Hospital of Skåne, Lund, Department of Clinical Microbiology/Infectious Diseases, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Department of Experimental Science, Section of Immunology, Lund University and Department of Clinical Sciences, Section of Medicine, Lund University, Lund, Sweden
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