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Montero N, Favà A, Rodriguez E, Barrios C, Cruzado JM, Pascual J, Soler MJ. Treatment for hepatitis C virus-associated mixed cryoglobulinaemia. Cochrane Database Syst Rev 2018; 5:CD011403. [PMID: 29734473 PMCID: PMC6494545 DOI: 10.1002/14651858.cd011403.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV)-associated mixed cryoglobulinaemia is the manifestation of an inflammation of small and medium-sized vessels produced by a pathogenic IgM with rheumatoid factor activity generated by an expansion of B-cells. The immune complexes formed precipitate mainly in the skin, joints, kidneys or peripheral nerve fibres. Current therapeutic approaches are aimed at elimination of HCV infection, removal of cryoglobulins and also of the B-cell clonal expansions. The optimal treatment for it has not been established. OBJECTIVES This review aims to look at the benefits and harms of the currently available treatment options to treat the HCV-associated mixed cryoglobulinaemia with active manifestations of vasculitis (cutaneous or glomerulonephritis). SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 30 November 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at interventions directed at treatment of HCV-associated cryoglobulinaemic vasculitis (immunosuppressive medications and plasma exchange therapy) have been included. DATA COLLECTION AND ANALYSIS Two authors independently assessed the retrieved titles and abstracts. Authors of included studies were contacted to obtain missing information. Statistical analyses were performed using random effects models and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). The planned primary outcomes were kidney disease, skin vasculitis, musculoskeletal symptoms, peripheral joint arthralgia, peripheral neuropathies, liver involvement, interstitial lung involvement, widespread vasculitis and death. Other planned outcomes were: therapy duration, laboratory findings, adverse effects, antiviral therapy failure, B-cell lymphoma, endocrine disorders and costs of treatment. MAIN RESULTS Ten studies were included in the review (394 participants). None of them evaluated direct-acting antivirals. Seven studies were single-centre studies and three were multicentre. The duration of the studies varied from six to 36 months. The risk of bias was generally unclear or low. Three different interventions were examined: use of rituximab (3 studies, 118 participants); interferon (IFN) (IFN compared to other strategies (5 studies, 223 participants); six IFN months versus one year (1 study, 36 participants), and immunoadsorption apheresis versus only immunosuppressive therapy (1 study, 17 participants).The use of rituximab may slightly improve skin vasculitis (2 studies, 78 participants: RR 0.57, 95% CI 0.28 to 1.16; moderate certainty evidence) and made little of no difference to kidney disease (moderate certainty evidence). In terms of laboratory data, the effect of rituximab was uncertain for cryocrit (MD -2.01%, 95% CI -10.29% to 6.27%, low certainty evidence) and HCV replication. Rituximab may slightly increase infusion reactions compared to immunosuppressive medication (3 studies, 118 participants: RR 4.33, 95%CI 0.76 to 24.75, moderate certainty evidence) however discontinuations of the treatment due to adverse reactions were similar (3 studies, 118 participants: RR 0.97, 95% CI 0.22 to 4.36, moderate certainty evidence).Effects of lFN on clinical symptoms were evaluated only in narrative results. When laboratory parameters were assessed, IFN made little or no difference in levels of alanine transaminase (ALT) at six months (2 studies, 39 participants: MD -5.89 UI/L, 95%CI -55.77 to 43.99); rheumatoid factor activity at six months (1 study, 13 participants: MD 97.00 UI/mL, 95%CI -187.37 to 381.37), or C4 levels at 18 months (2 studies, 49 participants: MD -0.04 mg/dL, 95%CI -2.74 to 2.67). On the other hand, at 18 months IFN may probably decrease ALT (2 studies, 39 participants: MD -28.28 UI/L, 95%CI -48.03 to -8.54) and Ig M (-595.75 mg/dL, 95%CI -877.2 to -314.3), but all with low certainty evidence. One study reported infusion reactions may be higher in IFN group compared to immunosuppressive therapy (RR 27.82, 95%CI 1.72 to 449.18), and IFN may lead to higher discontinuations of the treatment due to adverse reactions (4 studies, 148 participants: RR 2.32, 95%CI 0.91 to 5.90) with low certainty evidence. Interferon therapy probably improved skin vasculitis (3 studies, 95 participants: RR 0.60, 95% CI 0.36 to 1.00) and proteinuria (2 studies, 49 participants: MD -1.98 g/24 h, 95% CI -2.89 to -1.07), without changing serum creatinine at 18 months (2 studies, 49 participants: MD -30.32 μmol/L, 95%CI -80.59 to 19.95).Six months versus one year treatment with IFN resulted in differences terms of the maintenance of the response, 89% of patients in the six months group presented a relapse and only 11% maintained a long-term response at one year, while in the one year group only 78% relapsed and long-term response was observed in 22%. The one-year therapy was linked to a higher number of side-effects (severe enough to cause the discontinuation of treatment in two cases) than the six-month schedule.One study reported immunoadsorption apheresis had uncertain effects on skin vasculitis (RR 0.44, 95% CI 0.05 to 4.02), peripheral neuropathies (RR 2.70, 95%CI 0.13 to 58.24), and peripheral joint arthralgia (RR 2.70, 95%CI 0.13 to 58.24), cryocrit (MD 0.01%, 95%CI -1.86 to 1.88) at six months, and no infusion reactions were reported. However when clinical scores were evaluated, they reported changes were more favourable in immunoadsorption apheresis with higher remission of severe clinical complications (80% versus 33%, P = 0.05) compared to immunosuppressive treatment alone.In terms of death, it was not possible to present a pooled intervention effect estimate because most of the studies reported no deaths, or did not report death as an outcome. AUTHORS' CONCLUSIONS To treat HCV-associated mixed cryoglobulinaemia, it may be beneficial to eliminate HCV infection by using antiviral treatment and to stop the immune response by using rituximab. For skin vasculitis and for some laboratory findings, it may be appropriate to combine antiviral treatment with deletion of B-cell clonal expansions by using of rituximab. The applicability of evidence reviewed here is limited by the absence of any studies with direct-acting antivirals, which are urgently needed to guide therapy.
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Affiliation(s)
- Nuria Montero
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Alexandre Favà
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Eva Rodriguez
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Clara Barrios
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Josep M Cruzado
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Maria Jose Soler
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
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Kolopp-Sarda MN, Miossec P. Cryoglobulins: An update on detection, mechanisms and clinical contribution. Autoimmun Rev 2018. [PMID: 29526627 DOI: 10.1016/j.autrev.2017.11.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cryoglobulins are immunoglobulins precipitating in cold condition. They are classified in 3 types according to the Brouet classification and may lead to vasculitis of small and medium size vessels. Vasculitis is related to vessel obstruction by monoclonal cryoglobulin aggregates in type I cryoglobulins and immune complex deposition in type II and III mixed cryoglobulins. This phenomenon is favored by low temperature, especially in skin, joints, and peripheral nerves, or increased cryoglobulin concentration in kidneys. For their detection, collection and clotting at 37°C are critical pre-analytical conditions. Cryoglobulin characterization and quantification are important to identify the underlying disease. Since detection and identification of cryoglobulins lack standardization, a protocol for such detection, characterization and quantification is proposed.
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Affiliation(s)
- Marie-Nathalie Kolopp-Sarda
- Department of Immunology and Rheumatology, Immunogenomics and inflammation research Unit EA 4130, University of Lyon, Lyon, France; Immunology Laboratory, University Hospital Lyon, France
| | - Pierre Miossec
- Department of Immunology and Rheumatology, Immunogenomics and inflammation research Unit EA 4130, University of Lyon, Lyon, France.
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53
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Mahale P, Engels EA, Li R, Torres HA, Hwang LY, Brown EL, Kramer JR. The effect of sustained virological response on the risk of extrahepatic manifestations of hepatitis C virus infection. Gut 2018; 67. [PMID: 28634198 PMCID: PMC6292199 DOI: 10.1136/gutjnl-2017-313983] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Chronic HCV infection is associated with several extrahepatic manifestations (EHMs). Data on the effect of sustained virological response (SVR) on the risk of EHMs are limited. METHODS We conducted a retrospective cohort study using data of patients from the US Veterans Affairs HCV Clinical Case Registry who had a positive HCV RNA test (10/1999-08/2009). Patients receiving interferon-based antiviral therapy (AVT) were identified. SVR was defined as negative HCV RNA at least 12 weeks after end of AVT. Risks of eight incident EHMs were evaluated in Cox regression models. RESULTS Of the 160 875 HCV-infected veterans, 31 143 (19.4%) received AVT, of whom 10 575 (33.9%) experienced SVR. EHM risk was reduced in the SVR group compared with untreated patients for mixed cryoglobulinaemia (adjusted HR (aHR)=0.61; 95% CI 0.39 to 0.94), glomerulonephritis (aHR=0.62; 95% CI 0.48 to 0.79), porphyria cutanea tarda (PCT) (aHR=0.41; 95% CI 0.20 to 0.83), non-Hodgkin's lymphoma (NHL) (aHR=0.64; 95% CI 0.43 to 0.95), diabetes (aHR=0.82; 95% CI 0.76 to 0.88) and stroke (aHR=0.84; 95% CI 0.74 to 0.94), but not for lichen planus (aHR=1.11; 95% CI 0.78 to 1.56) or coronary heart disease (aHR=1.12; 95% CI 0.81 to 1.56). Risk reductions were also observed when patients with SVR were compared with treated patients without SVR for mixed cryoglobulinaemia, glomerulonephritis, PCT and diabetes. Significant reductions in the magnitude of aHRs towards the null with increasing time to initiation of AVT after HCV diagnosis were observed for glomerulonephritis, NHL and stroke. CONCLUSIONS Risks of several EHMs of HCV infection are reduced after AVT with SVR. However, early initiation of AVT may be required to reduce the risk of glomerulonephritis, NHL and stroke.
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Affiliation(s)
- Parag Mahale
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Eric A. Engels
- Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Ruosha Li
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas
| | - Harrys A. Torres
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lu-Yu Hwang
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Eric L. Brown
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Jennifer R. Kramer
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas
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54
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Mathur P, Emmanuel B, Sneller M, Zhang X, Poonia B, Kottilil S. Recovery of hepatitis C specific T-cell responses after rituximab therapy in hepatitis C mixed cryoglobulinemic vasculitis. J Med Virol 2018; 90:936-941. [PMID: 29236302 DOI: 10.1002/jmv.25002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 12/02/2017] [Indexed: 12/28/2022]
Abstract
Mixed cryoglobulinemic vasculitis is associated with monoclonal B cell expansion in patients with chronic hepatitis C (HCV) infection. B cell depletion therapy using rituximab, a CD20 monoclonal antibody, has been successful in achieving remission from symptomatic disease. This study investigated whether B cell depletion therapy has an impact on activation of HCV-specific T cell phenotype and function. Nineteen patients with Hepatitis C mixed cryoglobulinemic vasculitis were treated with 4 cycles of rituximab (375 mg/m2 ) and variables were measured 6 months after therapy. Using flow cytometry and Enzyme-Linked Immunospot assay, the number of activated and tissue-like B cells and number of T cells expressing Programmed cell death protein 1 (PD-1), T-cell immunoglobulin and mucin-domain containing-3 (TIM-3), and multiple cytokines were measured before and after rituximab therapy. B cell depletion therapy is associated with a significant (P < 0.0001) decline in peripheral T cells with exhaustive phenotype, from pre-therapy to post-therapy-of rituximab (mean ± standard error): CD4+ (16.9 ± 0.9% to 8.9 ± 1.0%) and CD8+ (6.8 ± 0.6% to 3.0 ± 0.5%) T cells expressing PD-1 and CD4+ (11.0 ± 1.0% to 6.1 ± 0.8%) and CD8+ (12.7 ± 0.7% to 6.4 ± 0.4%) T cells expressing TIM-3. In addition, there was a significantly higher percentage of peripheral CD8+ T cells responding to HCV peptide stimulation in vitro secreting IFN-γ (4.55 ± 0.3 to 9.6 ± 1.0 IFN-γ/106 PBMCs, P < 0.0001), and more than one cytokine (1.3 ± 0.1% to 3.8 ± 0.2%, P < 0.0001) after therapy compared to pre-therapy. B cell depletion therapy results in recovery of T cell exhaustion and function in patients with HCV cryoglobulinemic vasculitis.
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Affiliation(s)
- Poonam Mathur
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Benjamin Emmanuel
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sneller
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Xiaozhen Zhang
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Bhawna Poonia
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shyamasundaran Kottilil
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland.,Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
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55
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Rezania K, Pytel P, Derani L, Greenwald R, Roos RP. A Masked Marauder: Hepatitis C Neuropathy. Am J Med 2018; 131:33-36. [PMID: 28882660 DOI: 10.1016/j.amjmed.2017.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/23/2017] [Accepted: 08/23/2017] [Indexed: 01/24/2023]
Affiliation(s)
- Kourosh Rezania
- Department of Neurology University of Chicago Medical Center, Chicago, Ill.
| | - Peter Pytel
- Department of Pathology, University of Chicago Medical Center, Chicago, Ill
| | - Lena Derani
- Department of Neurology University of Chicago Medical Center, Chicago, Ill
| | - Reeti Greenwald
- Department of Neurology University of Chicago Medical Center, Chicago, Ill
| | - Raymond P Roos
- Department of Neurology University of Chicago Medical Center, Chicago, Ill
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56
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Nayak S, Kataria A, Sharma MK, Rastogi A, Gupta E, Singh A, Tiwari SC. Hepatitis C Virus-associated Membranoproliferative Glomerulonephritis Treated with Directly Acting Antiviral Therapy. Indian J Nephrol 2018; 28:462-464. [PMID: 30647501 PMCID: PMC6309397 DOI: 10.4103/ijn.ijn_235_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Hepatitis C virus (HCV) infection has been shown to affect kidneys with various histopathological pattern on the kidney biopsy. These commonly include a membranoproliferative glomerulonephritis (MPGN) pattern with mixed cryoglobulinemia (CG), thrombotic microangiopathy, membranous nephropathy, and vasculitis affecting medium and small vessels of the kidneys causing polyarteritis nodosa. It has been rarely associated with MPGN without detectable CG. We present one such patient who presented to us with HCV-associated MPGN without detectable CG, who recovered completely with directly acting antiviral therapy without any immunosuppression.
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Affiliation(s)
- S Nayak
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - A Kataria
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - M K Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - A Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - E Gupta
- Department of Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - A Singh
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S C Tiwari
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
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57
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Comstock E, Kim CW, Murphy A, Emmanuel B, Zhang X, Sneller M, Poonia B, Kottilil S. Transcriptional profiling of PBMCs unravels B cell mediated immunopathogenic imprints of HCV vasculitis. PLoS One 2017; 12:e0188314. [PMID: 29228031 PMCID: PMC5724854 DOI: 10.1371/journal.pone.0188314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/03/2017] [Indexed: 01/22/2023] Open
Abstract
B cell depletion therapy using rituximab has been shown to be effective in achieving remission in patients with HCV-mixed cryoglobulinemic (MC) vasculitis. Previously, we have demonstrated abnormalities in peripheral immune cells involving neutrophils, chemotaxis, and innate immune activation among patients with HCV-MC vasculitis when compared to HCV patients without vasculitis. In this study, we evaluated the effect of B cell depletion therapy on transcriptional profiles of peripheral blood mononuclear cells before and after riruximab therapy, in order to unravel the pathogenic mechanism involved in HCV-MC vasculitis induced by abnormal B cell proliferation. DNA microarray analysis was performed using RNA from PBMCs from seven patients with HCV-MC vasculitis and seven normal volunteers. DNA was hybridized to Affymetrix U133A chips. After normalization, differentially expressed gene list with treatment was generated using partitional clustering. RT-PCR, flow cytometry, and enzyme immunoassay (EIA) was used to validate DNA microarray findings. Differentially expressed genes included B cells and non-B cell genes. Validation of genes using purified cell subsets demonstrated distinct effect of B cell depletion therapy on non-B cells, such as monocytes, T cells, and NK cells. Notably, B lymphocyte stimulator (BLyS) levels were persistently elevated in patients who subsequently relapsed. In conclusion, pathogenesis of HCV-MC vasculitis is mediated by abnormal proliferation of B cells, driven by BLyS, leading to significant effects on non-B cells in mediating symptomatology. Future therapeutics using a combination approach of B cell depletion and proliferation may be desired to achieve long-term remission.
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Affiliation(s)
- Emily Comstock
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Cheol-Woo Kim
- Department of Internal Medicine, Inha University, Incheon, South Korea
| | - Alison Murphy
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, United States of America
| | - Benjamin Emmanuel
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Xi Zhang
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, United States of America
| | - Michael Sneller
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, United States of America
| | - Bhawna Poonia
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Shyamasundaran Kottilil
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States of America
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, United States of America
- * E-mail:
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Cacoub P, Vautier M, Desbois AC, Lafuma A, Saadoun D. Effectiveness and cost of hepatitis C virus cryoglobulinaemia vasculitis treatment: From interferon-based to direct-acting antivirals era. Liver Int 2017; 37:1805-1813. [PMID: 28467688 DOI: 10.1111/liv.13465] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The net benefits of new hepatitis C virus (HCV) direct-acting antiviral drugs (DAA) in patients with cryoglobulinaemia vasculitis (CryoVas) are unknown. OBJECTIVE To analyse the effectiveness and cost of all treatments used for HCV-CryoVas in the DAA vs pre-DAA era. METHODS A chart review of all HCV-CryoVas patients who received antivirals from 1993 to 2016 in a tertiary centre was performed. Treatment effectiveness was analysed for clinical, immunological and virological responses. Cost analyses included anti-HCV treatments, non-antiviral drugs, plasmapheresis, dialysis and hospitalizations. We compared main data in the pre-DAA vs DAA period. RESULTS About 201 HCV-CryoVas patients were included (women, 53.2%; mean age, 59.2 years; Metavir score F3-F4, 36.7%; genotype 1, 64.2%). Patients in the DAA era (n=27) compared to those in the pre-DAA era (n=174) showed higher rates of clinical (96.3% vs. 78.6%), immunological (89.5% vs. 77.1%), and sustained virological response (75.0% vs. 42.8%). Death rate was 14.8% vs. 24.4% respectively. In the DAA compared to pre-DAA era, mean cost of anti-HCV drugs increased from 11 855 to 57 632 € while mean CryoVas-related cost decreased for both hospitalizations (from 33 510 to 21 347€) and non-antiviral treatments (from 17 347 to 11 397€). CONCLUSION Improved antiviral efficacy of HCV drugs in the DAA era led to increased clinical and immunological efficacy and a lower death rate. Use of DAAs was associated to higher costs for HCV drugs while costs related to both hospitalizations and non-antiviral treatments decreased.
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Affiliation(s)
- Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France.,Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France.,Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Mathieu Vautier
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France.,Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France
| | - Anne Claire Desbois
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France.,Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France.,Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Antoine Lafuma
- CEMKA, Outcomes Research Epidemiology, Bourg la Reine, France
| | - David Saadoun
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France.,Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France.,Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Ignatova TM, Kozlovskaya LV, Gordovskaya NB, Chernova OA, Milovanova SY, Novikov PI, Nekrasova TP, Beketova TV, Mukhin NA. [Hepatitis C virus-associated cryoglobulinemic vasculitis: A 20-year experience with treatment]. TERAPEVT ARKH 2017. [PMID: 28631698 DOI: 10.17116/terarkh201789546-52] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM To summarize the experience of a multidisciplinary therapy hospital in treating patients with hepatitis C virus (HCV)-associated cryoglobulinemic vasculitis (CV). SUBJECTS AND METHODS Seventy-two patients (mean age, 49.4±10.3 years) with HCV-associated CV were examined and followed up for an average period of 2.8±3.6 years. The efficiency of traditional (corticosteroids ± cyclophosphamide) and selective (rituximab) immunosuppressive therapy (IST) was estimated in 31 and 15 observations, respectively, and that of antiviral therapy (AVT) in 25. Vasculitis activity was assessed using the Birmingham vasculitis activity score (BVAS). The patients' survival was studied; multivariate logistic regression analysis was carried out. RESULTS 24 (33.4%) of the 72 patients had a stage of liver cirrhosis (LC). The pretreatment mean BVAS was 11.9±7.2 (range 2 to 36). Severe CV (BVAS ≥15) was present in 30.6% of the patients. AVT was accompanied by achievement of sustained virologic response in 48% of the patients, clinical remission in 68% and had an advantage over IST in relation to long-term treatment results. Rituximab was significantly more effective than traditional immunosuppressants (remission rates of 73 and 13%, respectively). Combined therapy (rituximab and AVT) was most effective in patients with severe forms of vasculitis. Sixteen patients died from complications of vasculitis (37.5%), infection (37.5%), and LC (25%). The factors adversely affecting prognosis were age >55 years (odds ratio (OR), 4.49), the presence of LC (OR, 3.68), renal failure (OR, 4.66) and the use of glucocorticosteroids (OR, 3.91). CONCLUSION HCV-associated CV can determine the prognosis of chronic HСV infection. AVT is the treatment of choice in all patients with HСV-associated CV. AVT must be combined with rituximab therapy in patients with severe forms of vasculitis.
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Affiliation(s)
- T M Ignatova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - L V Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - N B Gordovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - O A Chernova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - S Yu Milovanova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - T P Nekrasova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - T V Beketova
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - N A Mukhin
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
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Emery JS, Kuczynski M, La D, Almarzooqi S, Kowgier M, Shah H, Wong D, Janssen HLA, Feld JJ. Efficacy and Safety of Direct Acting Antivirals for the Treatment of Mixed Cryoglobulinemia. Am J Gastroenterol 2017; 112:1298-1308. [PMID: 28291241 DOI: 10.1038/ajg.2017.49] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 01/01/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Mixed cryoglobulinemia is strongly associated with hepatitis C virus (HCV) infection and ranges from being asymptomatic to causing life-threatening vasculitis. In those with symptoms, treatment with pegylated interferon (pegIFN) and ribavirin (RBV) reduces mortality. However, few data are available on the safety and efficacy of antiviral therapy with direct acting antivirals (DAAs) in the treatment of HCV-related cryoglobulinemia. METHODS Patients treated for HCV-related cryoglobulinemia with DAA±pegIFN were retrospectively evaluated at a tertiary care center. Primary outcomes were virological, immunological, and clinical response. Complete (normalization), partial (>50% reduction), or non-response (<50% reduction) were used to describe change in cryocrit or vasculitic manifestations at week 12 post treatment. Side effects, hospitalizations, and decompensating events were recorded. RESULTS Eighteen symptomatic and 65 asymptomatic patients were reviewed (61% male, median age 58 years) including 10 with severe/life-threatening vasculitis. Sixty-six (79.5%) patients received pegIFN-free therapy. Sustained virological response (SVR) was attained in 16 (88.9%) symptomatic and 59 (90.8%) asymptomatic patients. Cryoglobulins disappeared in 5 (29.4%) symptomatic and 27 (52.9%) asymptomatic patients. Of symptomatic patients with SVR, clinical response was complete in 7 (38.8%) and partial response in 4 (22.2%). Of the 5 viral relapsers, 1 had a complete response during therapy with no symptomatic recurrence, while the other patients had no clinical response. Among 7 with severe vasculitis, 6 achieved SVR but only 1 had a complete clinical response, with 3 showing a partial response and 2 showing no improvement. All four with life-threatening vasculitis required plasmapheresis and three received rituximab. All achieved SVR leading to partial clinical response in two, but no response in two. Skin manifestations (39% reduction) were most likely to completely resolve with lower responses seen in renal (11.2% reduction) and neurological symptoms (11.1%). Eighty-two (98.8%) patients completed therapy, with 19 (22.8%) reporting adverse events. Hospitalization for decompensation or worsening vasculitis occurred in five (6.0%) and four (22.2) patients respectively. CONCLUSIONS DAAs resulted in high rates of SVR in patients with cryoglobulinemia. Safety and tolerability were excellent; however, most patients did not have a complete clinical or immunological response, suggesting a delay to clinical response particularly in those with severe/life-threatening vasculitis. Further follow-up will be required to determine if clinical improvement continues after viral clearance.
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Affiliation(s)
- Joel S Emery
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Magdalena Kuczynski
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Danie La
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Saeed Almarzooqi
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Kowgier
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Wong
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Polo ML, Laufer N. Extrahepatic manifestations of HCV: the role of direct acting antivirals. Expert Rev Anti Infect Ther 2017; 15:737-746. [PMID: 28696154 DOI: 10.1080/14787210.2017.1354697] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV) represents a major health concern, as nearly 3 million people become newly infected by this pathogen annually. The majority of infected individuals fail to clear the virus, and chronicity is established. Chronic HCV patients are at high risk for liver disease, ranging from mild fibrosis to cirrhosis and severe hepatocellular carcinoma. Over the last few years, the development of multiple direct acting antivirals (DAA) have revolutionized the HCV infection treatment, demonstrating cure rates higher than 90%, and showing less side effects than previous interferon-based regimens. Areas covered: Besides liver, HCV infection affects a variety of organs, therefore inducing diverse extrahepatic manifestations. This review covers clinical, experimental, and epidemiological publications regarding systemic manifestations of HCV, as well as recent studies focused on the effect of DAA in such conditions. Expert commentary: Though further research is needed; available data suggest that HCV eradication is often associated with the improvement of extrahepatic symptoms. Therefore, the emergence of DAA would offer the opportunity to treat both HCV infection and its systemic manifestations, requiring shorter treatment duration and driving minor adverse effects.
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Affiliation(s)
- María Laura Polo
- a Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS) , Universidad de Buenos Aires- CONICET , Buenos Aires , Argentina
| | - Natalia Laufer
- a Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS) , Universidad de Buenos Aires- CONICET , Buenos Aires , Argentina
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Visentini M, Fiorilli M, Casato M. From the pathogenesis to the cure of indolent B-cell lymphoproliferative disorders associated with hepatitis C virus infection: which role for direct-acting antivirals? Expert Rev Hematol 2017; 10:719-727. [PMID: 28675071 DOI: 10.1080/17474086.2017.1349607] [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] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV) causes monoclonal B cell lymphoproliferative disorders ranging from benign, such as in mixed cryoglobulinemia (MC), to indolent or aggressive lymphomas. MC and indolent lymphomas commonly regress when HCV is eradicated with interferon (IFN) therapy; however, sustained virologic response (SVR) to IFN is achieved only in ~50% of patients. The new all oral direct-acting antivirals (DAA), yielding nearly 100% SVR, promise a breakthrough in the treatment of HCV-associated lymphoproliferative disorders, but experience is still scanty. Areas covered: A literature search was performed to summarize current pathogenetic hypotheses in HCV-associated indolent lymphoproliferative disorders and to identify clinical trials focused on the use of antiviral therapy. Hematological outcomes of IFN-based and IFN-free DAA-based regimens were compared. Expert commentary: While MC appears to regress in most patients after DAA therapy, the still very limited experience with indolent lymphomas suggests that hematologic responses might be less than those observed with IFN. Furthermore, anecdotal observations of early progression to aggressive lymphoma after DAA are disquieting. Large studies are needed to determine the values and limits of DAA for treating HCV-associated indolent lymphomas and to identify subgroups at risk of non-response.
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Affiliation(s)
- Marcella Visentini
- a Department of Clinical Medicine , Sapienza University of Rome , Rome , Italy
| | - Massimo Fiorilli
- a Department of Clinical Medicine , Sapienza University of Rome , Rome , Italy
| | - Milvia Casato
- a Department of Clinical Medicine , Sapienza University of Rome , Rome , Italy
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Saadoun D, Pol S, Ferfar Y, Alric L, Hezode C, Si Ahmed SN, de Saint Martin L, Comarmond C, Bouyer AS, Musset L, Poynard T, Resche Rigon M, Cacoub P. Efficacy and Safety of Sofosbuvir Plus Daclatasvir for Treatment of HCV-Associated Cryoglobulinemia Vasculitis. Gastroenterology 2017; 153:49-52.e5. [PMID: 28288791 DOI: 10.1053/j.gastro.2017.03.006] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 02/07/2023]
Abstract
Circulating mixed cryoglobulins are detected in 40%-60% of patients with hepatitis C virus (HCV) infection, and overt cryoglobulinemia vasculitis (CryoVas) develops in approximately 15% of patients. Remission of vasculitis has been associated with viral clearance, but few studies have reported the effectiveness of direct-acting antiviral drugs in these patients. We performed an open-label, prospective, multicenter study of the effectiveness and tolerance of an all-oral, interferon- and ribavirin-free regimen of sofosbuvir plus daclatasvir in patients with HCV-associated CryoVas. Forty-one consecutive patients with active HCV-associated CryoVas (median age, 56 y; 53.6% women) were recruited from hospitals in Paris, France, from 2014 through 2016. They received sofosbuvir (400 mg/day) plus daclatasvir (60 mg/day) for 12 weeks (n = 32) or 24 weeks (n = 9), and were evaluated every 4 weeks until week 24 and at week 36. Blood samples were analyzed for complete blood count, serum chemistry profile, level of alanine aminotransferase, rheumatoid factor activity, C4 fraction of complement, and cryoglobulin; peripheral blood mononuclear cells were isolated for flow cytometry analysis. Thirty-seven patients (90.2%) had a complete clinical response (defined by improvement of all the affected organs involved at baseline and no clinical relapse) after a median time of 12 weeks of therapy; all had a sustained virologic response (no detectable serum HCV RNA 12 weeks after the end of antiviral therapy). Patients' mean cryoglobulin level decreased from 0.56 ± 0.18 at baseline to 0.21 ± 0.14 g/L at week 36, and no cryoglobulin was detected in 50% of patients at this time point. After antiviral therapy, patients had increased numbers of T-regulatory cells, IgM+CD21-/low-memory B cells, CD4+CXCR5+ interleukin 21+ cells, and T-helper 17 cells, compared with before therapy. After a median follow-up period of 26 months (interquartile range, 20-30 mo), no patients had a serious adverse event or relapse of vasculitis.
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Affiliation(s)
- David Saadoun
- Sorbonne Universités, Université Pierre et Marie Curie University of Paris 06, Unité Médicale de Recherche 7211, Inflammation-Immunopathology-Biotherapy Department (Département Hospitalo Universitaire Inflammation, Immunopathology and Biotherapy), Paris, France; INSERM, Unité Médicale de Recherche_S 959, Paris, France; Centre National de la Recherche Scientifique, FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
| | - Stanislas Pol
- Université Paris Descartes, Assistance Publique Hôpitaux de Paris, Unité d'Hépatologie, Hôpital Cochin, INSERM U-1223 et USM20, Institut Pasteur, Paris, France
| | - Yasmina Ferfar
- Sorbonne Universités, Université Pierre et Marie Curie University of Paris 06, Unité Médicale de Recherche 7211, Inflammation-Immunopathology-Biotherapy Department (Département Hospitalo Universitaire Inflammation, Immunopathology and Biotherapy), Paris, France; INSERM, Unité Médicale de Recherche_S 959, Paris, France; Centre National de la Recherche Scientifique, FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Laurent Alric
- Department of Internal Medicine-Digestive, Centre Hospitalier Universitaire Purpan, Unité Médicale de Recherche 152 Toulouse 3 University, Toulouse, France
| | - Christophe Hezode
- Department of Hepatology, Assistance Publique Hôpitaux de Paris, Hôpital Henri Mondor, Créteil, France
| | | | - Luc de Saint Martin
- Department of Internal Medicine, Centre Hospitalier Universitaire Brest, Brest, France
| | - Cloé Comarmond
- Sorbonne Universités, Université Pierre et Marie Curie University of Paris 06, Unité Médicale de Recherche 7211, Inflammation-Immunopathology-Biotherapy Department (Département Hospitalo Universitaire Inflammation, Immunopathology and Biotherapy), Paris, France; INSERM, Unité Médicale de Recherche_S 959, Paris, France; Centre National de la Recherche Scientifique, FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Anne Sophie Bouyer
- Sorbonne Universités, Université Pierre et Marie Curie University of Paris 06, Unité Médicale de Recherche 7211, Inflammation-Immunopathology-Biotherapy Department (Département Hospitalo Universitaire Inflammation, Immunopathology and Biotherapy), Paris, France; INSERM, Unité Médicale de Recherche_S 959, Paris, France; Centre National de la Recherche Scientifique, FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Lucile Musset
- Department of Immunology, UF d'Immunochimie et d'Autoimmunité, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Thierry Poynard
- Department of Hepatology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Matthieu Resche Rigon
- Department of Biostatistics and Medical Data Processing, INSERM U717, Hôpital Saint-Louis, Paris, France
| | - Patrice Cacoub
- Sorbonne Universités, Université Pierre et Marie Curie University of Paris 06, Unité Médicale de Recherche 7211, Inflammation-Immunopathology-Biotherapy Department (Département Hospitalo Universitaire Inflammation, Immunopathology and Biotherapy), Paris, France; INSERM, Unité Médicale de Recherche_S 959, Paris, France; Centre National de la Recherche Scientifique, FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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Russi S, Sansonno D, Monaco S, Mariotto S, Ferrari S, Pavone F, Lauletta G, Dammacco F. HCV RNA Genomic sequences and HCV-E2 glycoprotein in sural nerve biopsies from HCV-infected patients with peripheral neuropathy. Neuropathol Appl Neurobiol 2017; 44:427-438. [PMID: 28543916 DOI: 10.1111/nan.12413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 12/24/2022]
Abstract
AIMS Peripheral neuropathy (PN), the major neurological complication of chronic HCV infection, is frequently associated with mixed cryoglobulinaemia (MC) and small-vessel systemic vasculitis. While humoral and cell-mediated immune mechanisms are suspected to act together in an aberrant immune response that results in peripheral nerve damage, the role of HCV remains largely speculative. The possible demonstration of HCV in peripheral nerve tissue would obviously assume important pathogenic implications. METHODS We studied sural nerve biopsies from 11 HCV-positive patients with neuropathic symptoms: five with and six without MC. In situ hybridization (ISH) and immunofluorescence studies were carried out to detect genomic and antigenomic HCV RNA sequences and HCV-encoded E2-glycoprotein, respectively. RESULTS Epineurial vascular deposits of E2-glycoprotein were found in four (80%) MC and in two (33.3%) non-MC patients, respectively. These findings were enhanced by the perivascular deposition of positive-, though not negative-strand replicative RNA, as also found in the nerve extracts of all patients. Mild inflammatory cell infiltrates with no deposits of immunoglobulins and/or complement proteins were revealed around small vessels, without distinct vasculitis changes between MC and non-MC patients. CONCLUSIONS These results indicate that nerve vascular HCV RNA/E2 deposits associated to perivascular inflammatory infiltrates were similar in chronically HCV-infected patients, regardless of cryoglobulin occurrence. Given the failure to demonstrate HCV productive infection in the examined sural nerve biopsies, nerve damage is likely to result from virus-triggered immune-mediated mechanisms.
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Affiliation(s)
- S Russi
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - D Sansonno
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - S Monaco
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - S Mariotto
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - S Ferrari
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - F Pavone
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - G Lauletta
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - F Dammacco
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
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Comarmond C, Garrido M, Pol S, Desbois AC, Costopoulos M, Le Garff-Tavernier M, Si Ahmed SN, Alric L, Fontaine H, Bellier B, Maciejewski A, Rosenzwajg M, Klatzmann D, Musset L, Poynard T, Cacoub P, Saadoun D. Direct-Acting Antiviral Therapy Restores Immune Tolerance to Patients With Hepatitis C Virus-Induced Cryoglobulinemia Vasculitis. Gastroenterology 2017; 152:2052-2062.e2. [PMID: 28274850 DOI: 10.1053/j.gastro.2017.02.037] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 02/25/2017] [Accepted: 02/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Interferon-free direct-acting antiviral (DAA) therapies are effective in patients with hepatitis C virus-induced cryoglobulinemia vasculitis (HCV-CV). We analyzed blood samples from patients with HCV-CV before and after DAA therapy to determine mechanisms of these drugs and their effects on cellular immunity. METHODS We performed a prospective study of 27 consecutive patients with HCV-CV (median age, 59 y) treated with DAA therapy (21 patients received sofosbuvir plus ribavirin for 24 weeks, 4 patients received sofosbuvir plus daclatasvir for 12 weeks, and 2 patients received sofosbuvir plus simeprevir for 12 weeks) in Paris, France. Blood samples were collected from these patients before and after DAA therapy, and also from 12 healthy donors and 12 individuals with HCV infection without CV. HCV load, cryoglobulins, and cytokines were quantified by flow cytometry, cytokine multiplex assays, and enzyme-linked immunosorbent assay. RESULTS Twenty-four patients (88.9%) had a complete clinical response of CV to DAA therapy at week 24, defined by improvement of all the affected organs and the absence of relapse. Compared with healthy donors and patients with HCV infection without CV, patients with HCV-CV, before DAA therapy, had a lower percentage of CD4+CD25hiFoxP3+ regulatory T cells (P < .01), but higher proportions of IgM+CD21-/low memory B cells (P < .05), CD4+IFNγ+ cells (P < .01), CD4+IL17A+ cells (P < .01), and CD4+CXCR5+interleukin 21+ follicular T-helper (Tfh) cells (P < .01). In patients with HCV-CV, there was a negative correlation between numbers of IgM+CD21-/low memory B cells and T-regulatory cells (P = .03), and positive correlations with numbers of Tfh cells (P = .03) and serum levels of cryoglobulin (P = .01). DAA therapy increased patients' numbers of T-regulatory cells (1.5% ± 0.18% before therapy vs 2.1% ± 0.18% after therapy), decreased percentages of IgM+CD21-/low memory B cells (35.7% ± 6.1% before therapy vs 14.9% ± 3.8% after therapy), and decreased numbers of Tfh cells (12% ± 1.3% before therapy vs 8% ± 0.9% after therapy). Expression levels of B lymphocyte stimulator receptor 3 and programmed cell death 1 on B cells increased in patients with HCV-CV after DAA-based therapy (mean fluorescence units, 37 ± 2.4 before therapy vs 47 ± 2.6 after therapy, P < .01; and 29 ± 7.3 before therapy vs 48 ± 9.3 after therapy, P < .05, respectively). CONCLUSIONS In a prospective clinical trial of patients with HCV-CV, DAA-based therapy restored disturbances in peripheral B- and T-cell homeostasis.
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Affiliation(s)
- Cloé Comarmond
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France; Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - Marlène Garrido
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France
| | - Stanislas Pol
- Department of Hepatology, assistance publique des hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Anne-Claire Desbois
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France; Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - Myrto Costopoulos
- Biological Hematology, Groupe Hospitalier Pitié-Salpétrière, Paris, France
| | | | | | - Laurent Alric
- Department of Internal Medicine and Digestive Diseases, Centre Hospitalier Universitaire Purpan, unité mixte de recherche 152, institut de recherche pour le développement Toulouse 3 University, Toulouse, France
| | - Hélène Fontaine
- Department of Hepatology, assistance publique des hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Bertrand Bellier
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France
| | - Anna Maciejewski
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France
| | - Michelle Rosenzwajg
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France
| | - David Klatzmann
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France
| | - Lucile Musset
- Department of Immunology, unité fonctionnelle d'Immunochimie et d'Autoimmunité, Groupe Hospitalier Pitié-Salpétrière, Paris, France
| | - Thierry Poynard
- Department of Hepatology, unité mixte de recherche_S 938, Institute of Cardiometabolism and Nutrition, assistance publique des hôpitaux de Paris, Groupe Hospitalier Pitié-Salpétrière, Paris, France
| | - Patrice Cacoub
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France; Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - David Saadoun
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (département hospitalo-unniversitaire i2B), Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, unité mixte de recherche 7211, Paris, France; INSERM, unité mixte de recherche_S 959, Paris, France; centre national de recherche et de santé, FRE3632, Paris, France; Département de Médecine Interne et Immunologie Clinique, Paris, France.
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Ramos-Casals M, Zignego AL, Ferri C, Brito-Zerón P, Retamozo S, Casato M, Lamprecht P, Mangia A, Saadoun D, Tzioufas AG, Younossi ZM, Cacoub P. Evidence-based recommendations on the management of extrahepatic manifestations of chronic hepatitis C virus infection. J Hepatol 2017; 66:1282-1299. [PMID: 28219772 DOI: 10.1016/j.jhep.2017.02.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Barcelona, Spain; Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Anna Linda Zignego
- Interdepartmental Center MASVE, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Clodoveo Ferri
- Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Barcelona, Spain; Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain; Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Barcelona, Spain; Rheumatology Department, Hospital Privado Universitario de Córdoba, INSTITUTO DE INVESTIGACIONES EN CIENCIAS DE LA SALUD (INICSA), National Scientific and Technical Research Council, CONICET - CORDOBA - Argentina
| | - Milvia Casato
- Department of Clinical Immunology, Sapienza University of Rome, Italy
| | - Peter Lamprecht
- Department of Rheumatology & Vasculitis Center, University of Lübeck, Germany
| | - Alessandra Mangia
- Liver Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - David Saadoun
- Sorbonne Universités, UPMC Université Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France; CNRS, FRE3632, F-75005 Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013 Paris, France
| | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Zobair M Younossi
- Chairman, Department of Medicine, Inova Fairfax Medical Campus, Vice President for Research, Inova Health System, Professor of Medicine, VCU-Inova Campus, The Claude Moore Health Education and Research Center, Beatty Center for Integrated Research, Falls Church, VA, USA
| | - Patrice Cacoub
- Sorbonne Universités, UPMC Université Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France; CNRS, FRE3632, F-75005 Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013 Paris, France
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Túlio M, Carvalho L, Bana E Costa T, Chagas C. Mixed cryoglobulinemia: a diagnostic and therapeutic challenge. BMJ Case Rep 2017; 2017:bcr-2017-219768. [PMID: 28490478 DOI: 10.1136/bcr-2017-219768] [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: 11/03/2022] Open
Abstract
Mixed cryoglobulinemia is frequently secondary to hepatitis C virus infection. Diagnosis and therapeutic management are challenging, depending on the spectrum and severity of manifestations, as well as on the presence of comorbidities. We describe a case of a 79-year-old woman with a non-cirrhotic hepatitis C virus infection presenting with weakness, arthralgias, purpuric rash with left leg ulcerative lesions, bilateral peripheral sensorimotor polyneuropathy, renal impairment and cardiac failure. The investigation was compatible with a severe type II mixed cryoglobulinemia with multisystemic involvement, including a low-grade B cell lymphoma and concomitant intestinal tuberculosis. Initial management with immunosuppressive therapy with glucocorticoids to control symptoms and simultaneous tuberculosis treatment was required. Unavailability of adequate antiviral treatment led to the need to control the severity of systemic manifestations with rituximab, before the effective aetiological treatment with sofosbuvir and ledipasvir was possible, allowing the definitive resolution of the disease.
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Affiliation(s)
- Maria Túlio
- Department of Gastroenterology, Hospital de Egas Moniz, Lisboa, Portugal
| | - Liliana Carvalho
- Department of Gastroenterology, Hospital de Egas Moniz, Lisboa, Portugal
| | - Tiago Bana E Costa
- Department of Gastroenterology, Hospital de Egas Moniz, Lisboa, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Hospital de Egas Moniz, Lisboa, Portugal
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Rituximab for Treatment of Membranoproliferative Glomerulonephritis and C3 Glomerulopathies. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2180508. [PMID: 28573137 PMCID: PMC5440792 DOI: 10.1155/2017/2180508] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 01/18/2023]
Abstract
Membranoproliferative glomerulonephritis (MPGN) is a histological pattern of injury resulting from predominantly subendothelial and mesangial deposition of immunoglobulins or complement factors with subsequent inflammation and proliferation particularly of the glomerular basement membrane. Recent classification of MPGN is based on pathogenesis dividing MPGN into immunoglobulin-associated MPGN and complement-mediated C3 glomerulonephritis (C3GN) and dense deposit disease (DDD). Current guidelines suggest treatment with steroids, cytotoxic agents with or without plasmapheresis only for subjects with progressive disease, that is, nephrotic range proteinuria and decline of renal function. Rituximab, a chimeric B-cell depleting anti-CD20 antibody, has emerged in the last decade as a treatment option for patients with primary glomerular diseases such as minimal change disease, focal-segmental glomerulosclerosis, or idiopathic membranous nephropathy. However, data on the use of rituximab in MPGN, C3GN, and DDD are limited to case reports and retrospective case series. Patients with immunoglobulin-associated and idiopathic MPGN who were treated with rituximab showed partial and complete responses in the majorities of cases. However, rituximab was not effective in few cases of C3GN and DDD. Despite promising results in immunoglobulin-associated and idiopathic MPGN, current evidence on this treatment remains weak, and controlled and prospective data are urgently needed.
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Shah R, Segal MS, Wilkowski MJ. Case Report of Spontaneous Remission of Biopsy-Proven Idiopathic Immune Complex-Mediated Membranoproliferative Glomerulonephritis. Case Rep Nephrol Dial 2017; 7:81-90. [PMID: 28868298 PMCID: PMC5566695 DOI: 10.1159/000477660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/21/2017] [Indexed: 01/24/2023] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is a histopathologic diagnosis causing microscopic hematuria, nephrotic range proteinuria, and chronic renal failure. Current understanding divides pathogenesis into two broad categories: immune complex mediated and complement mediated (now termed C3 glomerulopathy). The term idiopathic immune complex-mediated MPGN would apply to a patient without an identifiable source of immune complex production and no evidence of C3 glomerulopathy. Presented is a patient with idiopathic immune complex mediated MPGN and her clinical course. The patient opted for conservative therapy with losartan, carvedilol, chlorthalidone, and atorvastatin. Nephrotic range proteinuria of 8.7 g per day resolved over 5 months, with improvement of serum from 3.3 to 1.2 mg/dL. Remission continues at follow-up 21 months after biopsy. For idiopathic immune complex-mediated MPGN, resorting to empiric immunosuppression therapy may not be the best option. As this patient demonstrates, a conservative approach of blood pressure control with anti-renin-angiotensin agents, control of lipids, and watchful follow-up can be successful.
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Affiliation(s)
- Rehan Shah
- Tift Regional Medical Center, Tifton, Georgia, USA
| | - Mark S Segal
- Division of Nephrology, University of Florida School of Medicine, Gainesville, Florida, USA
| | - Michael J Wilkowski
- Mercer University School of Medicine - Savannah Campus, Savannah, Georgia, USA
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Lauletta G, Russi S, Pavone F, Vacca A, Dammacco F. Direct-acting antiviral agents in the therapy of hepatitis C virus-related mixed cryoglobulinaemia: a single-centre experience. Arthritis Res Ther 2017; 19:74. [PMID: 28388935 PMCID: PMC5385046 DOI: 10.1186/s13075-017-1280-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/09/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The efficacy and safety of direct-acting antiviral agents (DAAs) were evaluated in a cohort of prospectively enrolled patients with hepatitis C virus (HCV)-related mixed cryoglobulinaemia (MC), an immune complex-mediated vasculitis of small and medium vessels in which the pathogenetic role of HCV has been clearly established. METHODS Twenty-two patients received DAAs. Clinical and laboratory features were recorded at baseline, every 4 weeks until the end of treatment (EoT), and 12 weeks afterwards. Primary efficacy endpoints were (a) sustained virological response 12 weeks after therapy completion (SVR12), (b) regression of symptomatology (clinical response) and (c) cryoglobulin disappearance or cryocrit reduction ≥50% (immunological response). Complete response (CR) was defined as the occurrence of all three primary endpoints; partial response (PR) was defined as the occurrence of SVR12, with or without either immunological or clinical response; and no response was defined as missing the achievement of all three endpoints. RESULTS All patients reached SVR12. Compared with basal values, mean cryocrit values were significantly decreased at EoT and SVR12. A significant reduction of alanine transaminase and a parallel increase of complement component C4 levels were also detected. Rheumatoid factor activity was significantly reduced at EoT but not at SVR12. At SVR12, a CR was established in 14 patients (63.7%) and a PR in 8 patients (36.3%). In one patient with small lymphocytic lymphoma, the tumour progressed despite viral clearance. Mild adverse events were recorded in nine patients (40.9%). CONCLUSIONS The response rates induced by the use of DAAs in patients with MC were remarkably higher than those previously achieved with pegylated interferon-α/ribavirin, with or without rituximab. A much longer follow-up is desirable to achieve useful information in terms of persistent viral clearance and clinical response.
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Affiliation(s)
- Gianfranco Lauletta
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Sabino Russi
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Fabio Pavone
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
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71
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Mitchell T, Chakera A, Jeffrey GP, Adams LA, Garas G, Jones T, MacQuillan G. Reversal of end-stage renal failure using direct-acting antiviral agents for chronic hepatitis C. Med J Aust 2017; 205:205-6. [PMID: 27581262 DOI: 10.5694/mja16.00207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022]
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72
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Wiznia LE, Laird ME, Franks AG. Hepatitis C virus and its cutaneous manifestations: treatment in the direct-acting antiviral era. J Eur Acad Dermatol Venereol 2017; 31:1260-1270. [PMID: 28252812 DOI: 10.1111/jdv.14186] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/16/2017] [Indexed: 12/21/2022]
Abstract
New all-oral direct-acting antivirals (DAA) have changed the hepatitis C virus (HCV) treatment landscape. Given that dermatologists frequently encounter HCV-infected patients, knowledge of the current treatment options and their utility in treating HCV-associated dermatologic disorders is important. In addition to highlighting the new treatment options, we review four classically HCV-associated dermatologic disorders - mixed cryoglobulinaemia (MC), lichen planus (LP), porphyria cutanea tarda (PCT) and necrolytic acral erythema (NAE) - and examine the role for all-oral direct-acting antiviral (DAA) regimens in their treatment. A literature search of English-language publications was conducted of the PubMed and EMBASE databases using search terms including 'hepatitis C', 'direct acting antivirals', 'cutaneous', 'mixed cryoglobulinemia', 'necrolytic acral erythema', 'lichen planus', 'porphyria cutanea tarda', 'rash', as well as specific drug names, related terms and abbreviations. Currently, limited data exist on the use of DAAs in HCV-infected patients with cutaneous side-effects, although treatment of the underlying HCV is now recommended for nearly all patients, with the new drugs offering much-improved dosage schedules and side-effect profiles. The most data exist for MC, in which several studies suggest that DAAs and achievement of sustained virologic response (SVR) improve cutaneous symptoms. Studies of both older and newer regimens are limited by their small size, retrospective nature, lack of appropriate controls and wide variability in study protocols. Given the strong association, screening for HCV should be considered in patients with MC, LP, PCT and NAE.
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Affiliation(s)
- L E Wiznia
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
| | - M E Laird
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
| | - A G Franks
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
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73
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Ali MA, Kayani WZ, Linzie BM, Punjabi GV, Wetmore JB. Myopericarditis in a patient with hepatitis C and cryoglobulinemic renal disease. Clin Case Rep 2017; 5:616-620. [PMID: 28469862 PMCID: PMC5412876 DOI: 10.1002/ccr3.788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 10/05/2016] [Accepted: 11/22/2016] [Indexed: 12/12/2022] Open
Abstract
Although cryoglobulinemia is a well‐appreciated complication of hepatitis C (HC), myopericarditis with resulting pericardial effusion is extremely rare, especially in the absence of a liver transplant. In patients with HC, pericardial effusion with impending tamponade can be a florid and potentially life‐threatening manifestation of multiorgan cryoglobulinemic disease.
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Affiliation(s)
- Mohamoud A Ali
- Department of Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Waqas Z Kayani
- Department of Family & Community Medicine UND School of Medicine and Health Sciences Minot North Dakota USA
| | - Bradley M Linzie
- Department of Pathology Hennepin County Medical Center Minneapolis Minnesota USA
| | - Gopal V Punjabi
- Department of Radiology Hennepin County Medical Center Minneapolis Minnesota USA
| | - James B Wetmore
- Division of Nephrology Hennepin County Medical Center Minneapolis Minnesota USA.,Chronic Disease Research Group Minneapolis Minnesota USA
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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75
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Voma CB, Levinson SS. Analysis, detection and quantitation of mixed cryoglobulins in HCV infection: brief review and case examples. Clin Chem Lab Med 2017; 54:1853-1859. [PMID: 27049619 DOI: 10.1515/cclm-2015-1143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 03/01/2016] [Indexed: 11/15/2022]
Abstract
Considering the high incidence of cryoglobulins in hepatitis C virus (HCV) infection together with the high worldwide prevalence of HCV infection, identification of clinically apparent mixed cryoglobulinemia syndrome is increasingly important as most patients who are identified can now be successfully treated. Different approaches for the detection, analysis and reporting of cryoglobulins have been described and there is a wide variation in results reported, ranging from a qualitative "negative" or "positive", to a quantitative report including cryoglobulin type and the total protein. Protein and immunofixation (IFE) electrophoresis are generally used to identify and characterize cryoglobulins, as these methods quantify and phenotype. Here, we present a brief review of the literature and demonstrate a case oriented approach for identifying mixed cryoglobulinemia from the preanalytical phase, leading up to and including the analytical phase with characterization by IFE. Most patients with mixed cryoglobulinemia can now be treated with success. Nevertheless, the high cost may limit treatment of those with symptoms unless there is laboratory evidence for mixed cryoglubulinemia. Low levels of cryoglobulins can be associated with severe symptoms; as a result, accurate identification of cryoglobulins may be of increasing importance since clear identification may be a good reason to initiate treatment.
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76
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Barsoum RS, William EA, Khalil SS. Hepatitis C and kidney disease: A narrative review. J Adv Res 2017; 8:113-130. [PMID: 28149647 PMCID: PMC5272932 DOI: 10.1016/j.jare.2016.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/07/2016] [Accepted: 07/17/2016] [Indexed: 02/07/2023] Open
Abstract
Hepatitis-C (HCV) infection can induce kidney injury, mostly due to formation of immune-complexes and cryoglobulins, and possibly to a direct cytopathic effect. It may cause acute kidney injury (AKI) as a part of systemic vasculitis, and augments the risk of AKI due to other etiologies. It is responsible for mesangiocapillary or membranous glomerulonephritis, and accelerates the progression of chronic kidney disease due to other causes. HCV infection increases cardiovascular and liver-related mortality in patients on regular dialysis. HCV-infected patients are at increased risk of acute post-transplant complications. Long-term graft survival is compromised by recurrent or de novo glomerulonephritis, or chronic transplant glomerulopathy. Patient survival is challenged by increased incidence of diabetes, sepsis, post-transplant lymphoproliferative disease, and liver failure. Effective and safe directly acting antiviral agents (DAAs) are currently available for treatment at different stages of kidney disease. However, the relative shortage of DAAs in countries where HCV is highly endemic imposes a need for treatment-prioritization, for which a scoring system is proposed in this review. It is concluded that the thoughtful use of DAAs, will result in a significant change in the epidemiology and clinical profiles of kidney disease, as well as improvement of dialysis and transplant outcomes, in endemic areas.
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Affiliation(s)
- Rashad S. Barsoum
- Kasr-El-Aini Medical School, Cairo University, Cairo, Egypt
- The Cairo Kidney Center, Cairo, Egypt
| | - Emad A. William
- The Cairo Kidney Center, Cairo, Egypt
- National Research Centre, Cairo, Egypt
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Successful Treatment With Bosentan for Digital Ulcers Related to Mixed Cryoglobulinemia: A Case Report. Am J Ther 2017; 23:e1942-e1943. [PMID: 26785421 DOI: 10.1097/mjt.0000000000000384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 49-year-old man diagnosed with genotype 1 hepatitis C, CD5-positive marginal zone lymphoma, and mixed cryoglobulinemia type II developed skin ulcers and necrosis in his right foot. He was treated with amlodipine, corticosteroids, plasmapheresis, alprostadil, rituximab, and cyclophosphamide without a satisfactory response. For this reason, he required a partial amputation of the second, third, and fifth fingers of the right foot. To prevent ulcer deterioration of the first finger, bosentan was initiated. After 10 months of treatment, the ulcer completely healed and no adverse effects were experienced by the patient.
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78
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Thrift AP, El-Serag HB, Kanwal F. Global epidemiology and burden of HCV infection and HCV-related disease. Nat Rev Gastroenterol Hepatol 2017; 14:122-132. [PMID: 27924080 DOI: 10.1038/nrgastro.2016.176] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chronic HCV infection is a global health problem that affects >184 million people worldwide. HCV is associated with several hepatic and extrahepatic disorders, including several malignancies. The burden of HCV-related disorders is influenced by the number of new and existing cases, number of existing cases and the natural history of the infection. The natural history of HCV is affected by several demographic, virological, clinical and lifestyle factors. Major variations exist in the burden of HCV among different populations and geographical regions, as well as over time. With the advent of new and efficacious antiviral treatments, it is important to learn the determinants of HCV burden to design appropriate strategies for detection, prognostication and treatment. Furthermore, with the expected growth of patients cured of HCV, it is essential to learn about the possible change in natural history and burden of disease in these patients. In this Review, we will discuss the global epidemiology and burden of HCV and its complications, as well as the natural history and clinical course of chronic and cured HCV infection.
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Affiliation(s)
- Aaron P Thrift
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Suite 10C, Houston, Texas, USA
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Suite 10C, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Suite 10C, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Colantuono S, Mitrevski M, Yang B, Tola J, Carlesimo M, De Sanctis GM, Fiorilli M, Casato M, Visentini M. Efficacy and safety of long-term treatment with low-dose rituximab for relapsing mixed cryoglobulinemia vasculitis. Clin Rheumatol 2017; 36:617-623. [PMID: 28111716 DOI: 10.1007/s10067-017-3552-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/16/2017] [Accepted: 01/16/2017] [Indexed: 12/23/2022]
Abstract
This study aims to evaluate the efficacy and safety of repeated treatments with low-dose rituximab for relapsing mixed cryoglobulinemia vasculitis. Thirty-seven patients with mixed cryoglobulinemia vasculitis refractory to standard of care treatment, 34 of which were HCV-positive, were treated with rituximab at the reduced dosage of 250 mg/m2 given twice 1 week apart per cycle. Thirty patients (81%) achieved a clinical response; 5 of them remain in remission, 3 were lost to follow-up or died, and 22 relapsed after a mean of 15.7 months. Eleven relapsers were retreated with one (6 patients), 2 (3 patients), or 3 (2 patients) additional rituximab cycles given at each relapse. Clinical and laboratory efficacy and side effects of long-term treatment were evaluated. Clinical response to retreatment was 91% (10/11) at the first relapse, 80% (4/5) at the second relapse, and 100% (2/2) at the third relapse. The mean (±SD) time to relapse was 17.1 ± 14.1 months in 30 patients who were treated with only one cycle (from first cycle to the first relapse) and 45.7 ± 30.6 months (from first cycle to the last observed relapse) in 11 patients treated with 2 or more cycles (p = 0.0037). Severe adverse reactions occurred in 3 patients, in 2 of whom at the first cycle. Our results suggest that repeated treatment of relapsing mixed cryoglobulinemia with a low-dose rituximab regimen is efficacious, safe, and cost-effective for the long-term management of this disorder.
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Affiliation(s)
- Stefania Colantuono
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Milica Mitrevski
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Baoran Yang
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Julia Tola
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Maurizio Carlesimo
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | | | - Massimo Fiorilli
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Milvia Casato
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Marcella Visentini
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy.
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Vasculitic and autoimmune wounds. J Vasc Surg Venous Lymphat Disord 2016; 5:280-292. [PMID: 28214498 DOI: 10.1016/j.jvsv.2016.09.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/01/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Chronic wounds are a major cause of morbidity and mortality. Approximately 20% to 23% of nonhealing wounds that are refractory to vascular intervention have other causes, including vasculitis, pyoderma gangrenosum, and other autoimmune diseases. The purpose of this article was to review the literature across medical and surgical specialties with regard to refractory chronic wounds associated with vasculitis and autoimmune diseases and to delineate clinical outcomes of these wounds in response to vascular and other interventions. METHODS An electronic search encompassing MEDLINE, PubMed, Cochrane Library, and Scopus was completed using the following search terms: rheumatoid arthritis; systemic sclerosis; systemic lupus erythematosus; antineutrophil cytoplasmic antibody-associated vasculitis; mixed connective tissue disease; antiphospholipid syndrome; pyoderma gangrenosum; thromboangiitis obliterans; cryoglobulinemia; hydroxyurea; sickle cell; atrophie blanche; livedoid vasculitis; cholesterol emboli; calciphylaxis; antiphospholipid antibodies; prothrombotic; combined with the terms: chronic wound and leg ulcer. Full-text articles published in English up to March 1, 2016, that investigated the clinical outcomes of chronic wounds associated with autoimmune diseases were included. Review articles and evaluations of management of chronic wounds were also reviewed. Primary outcomes included in the review were amputation, ulcer healing, reduction in wound size, overall survival, and freedom from reintervention. Owing to the heterogeneity of data reporting among articles, qualitative analysis is also reported. RESULTS Vasculitis and autoimmune diseases play a role in 20% to 23% of patients with chronic lower extremity ulcers. Furthermore, patients with autoimmune disease have a significantly high rate of split thickness skin graft failure (50% compared to 97% in patients without autoimmune disease; P = .0002). The management of leg ulcers associated with autoimmune diseases is discussed. CONCLUSIONS Autoimmune and vasculitic causes should be considered in patients with chronic wounds who do not respond to appropriate vascular intervention and standard local wound care. A multidisciplinary approach with the involvement of rheumatologists allows investigation for underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Ryu A, Shimamura Y, Hasegawa K, Moniwa N, Takizawa H, Kang JH, Sakai H, Ogawa Y. [Case Report; Hepatitis B virus-associated cryoglobulinemia with membranoproliferative glomerulonephritis]. ACTA ACUST UNITED AC 2016; 103:2807-9. [PMID: 27522822 DOI: 10.2169/naika.103.2807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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82
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Gomis A, Díaz M, de Lorenzo A, Ruiz-Roso G, Liaño F. Precaución con el uso de los nuevos antivirales de acción directa para el tratamiento del virus de la hepatitis C en pacientes con enfermedad renal asociada. Nefrologia 2016; 36:713-715. [DOI: 10.1016/j.nefro.2016.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022] Open
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83
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Gragnani L, Visentini M, Fognani E, Urraro T, De Santis A, Petraccia L, Perez M, Ceccotti G, Colantuono S, Mitrevski M, Stasi C, Del Padre M, Monti M, Gianni E, Pulsoni A, Fiorilli M, Casato M, Zignego AL. Prospective study of guideline-tailored therapy with direct-acting antivirals for hepatitis C virus-associated mixed cryoglobulinemia. Hepatology 2016; 64:1473-1482. [PMID: 27483451 DOI: 10.1002/hep.28753] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 07/15/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Hepatitis C virus (HCV)-associated mixed cryoglobulinemia (MC) vasculitis commonly regresses upon virus eradication, but conventional therapy with pegylated interferon and ribavirin yields approximately 40% sustained virologic responses (SVR). We prospectively evaluated the efficacy and safety of sofosbuvir-based direct-acting antiviral therapy, individually tailored according to the latest guidelines, in a cohort of 44 consecutive patients with HCV-associated MC. In two patients MC had evolved into an indolent lymphoma with monoclonal B-cell lymphocytosis. All patients had negative HCV viremia at week 12 (SVR12) and at week 24 (SVR24) posttreatment, at which time all had a clinical response of vasculitis. The mean (±standard deviation) Birmingham Vasculitis Activity Score decreased from 5.41 (±3.53) at baseline to 2.35 (±2.25) (P < 0.001) at week 4 on treatment to 1.39 (±1.48) (P < 0.001) at SVR12 and to 1.27 (±1.68) (P < 0.001) at SVR24. The mean cryocrit value fell from 7.2 (±15.4)% at baseline to 2.9 (±7.4)% (P < 0.01) at SVR12 and to 1.8 (±5.1)% (P < 0.001) at SVR24. Intriguingly, in the 2 patients with MC and lymphoma there was a partial clinical response of vasculitis and ∼50% decrease of cryocrit, although none experienced a significant decrease of monoclonal B-cell lymphocytosis. Adverse events occurred in 59% of patients and were generally mild, with the exception of 1 patient with ribavirin-related anemia requiring blood transfusion. CONCLUSION Interferon-free, guideline-tailored therapy with direct-acting antivirals is highly effective and safe for HCV-associated MC patients; the overall 100% rate of clinical response of vasculitis, on an intention-to-treat basis, opens the perspective for curing the large majority of these so far difficult-to-treat patients. (Hepatology 2016;64:1473-1482).
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Affiliation(s)
- Laura Gragnani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marcella Visentini
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Elisa Fognani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Teresa Urraro
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Adriano De Santis
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Luisa Petraccia
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marie Perez
- Istituto Dermopatico Dell'Immacolata IRCCS, Rome, Italy
| | - Giorgia Ceccotti
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Milica Mitrevski
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Stasi
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Martina Del Padre
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Monica Monti
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Gianni
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro Pulsoni
- Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Massimo Fiorilli
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Milvia Casato
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Anna Linda Zignego
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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Abstract
Cryoglobulinemia is a distinct entity characterized by the presence of cryoglobulins in the serum. Cryoglobulins differ in their composition, which has an impact on the clinical presentation and the underlying disease that triggers cryoglobulin formation. Cryoglobulinemia is categorized into two main subgroups: type I, which is seen exclusively in clonal hematologic diseases, and type II/III, which is called mixed cryoglobulinemia and is seen in hepatitis C virus infection and systemic diseases such as B-cell lineage hematologic malignancies and connective tissue disorders. Clinical presentation is broad and varies between types but includes arthralgia, purpura, skin ulcers, glomerulonephritis, and peripheral neuropathy. Life-threatening manifestations can develop in a small proportion of patients. A full evaluation for the underlying cause is required, because each type requires a different kind of treatment, which should be tailored on the basis of disease severity, underlying disease, and prior therapies. Relapses can be frequent and can result in significant morbidity and cumulative organ impairment. We explore the spectrum of this heterogeneous disease by discussing the disease characteristics of 5 different patients.
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85
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Rey D, Muret P, Piroth L. Optimum combination therapy regimens for HIV/HCV infection. Expert Rev Anti Infect Ther 2016; 14:299-309. [PMID: 26822803 DOI: 10.1586/14787210.2016.1147952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
HIV-HCV co-infection mostly affects intravenous drug users, in whom prevalence has tended to decrease in recent years, while it has increased in men who have sex with men, with occurrence of acute hepatitis C. Hepatitis C has a poorer prognosis in patients co-infected with HIV, as clinical progression is faster and degree of hepatic fibrosis is greater. However, optimized ARV treatment is clearly associated with slower progression to hepatic complications. Interactions between HCV and HIV drugs are numerous, which underlines the importance of pharmacological advice for HIV-treated patients before they start HCV treatment. In HIV-HCV co-infection, treatment of hepatitis C has to be offered as in mono-infected patients (US and European countries) or to all patients (French guidelines). In most patients, HCV eradication is achieved with different DAA associations, the choice and duration being driven by HCV genotype, hepatic fibrosis stage, and whether patients have been previously treated or not.
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Affiliation(s)
- David Rey
- a Le Trait d'Union, Center for HIV Care, NHC , Hôpitaux Universitaires , Strasbourg , France
| | - Patrice Muret
- b Laboratoire de Pharmacologie Clinique , INSERM U1098 , CHRU Besançon , France
| | - Lionel Piroth
- c Infectious Diseases Department, Centre Hospitalier Universitaire and UMR 1347 , Université de Bourgogne , Dijon , France
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86
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Ooka K, Lim JK. Treatment of Hepatitis C in Patients Undergoing Immunosuppressive Drug Therapy. J Clin Transl Hepatol 2016; 4:206-227. [PMID: 27777889 PMCID: PMC5075004 DOI: 10.14218/jcth.2016.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/22/2016] [Accepted: 07/12/2016] [Indexed: 12/09/2022] Open
Abstract
With 185 million people chronically infected globally, hepatitis C is a leading bloodborne infection. All-oral regimens of direct acting agents have superior efficacy compared to the historical interferon-based regimens and are significantly more tolerable. However, trials of both types of regimens have often excluded patients on immunosuppressive medications for reasons other than organ transplantation. Yet, these patients-most often suffering from malignancy or autoimmune diseases-could stand to benefit from these treatments. In this study, we systematically review the literature on the treatment of hepatitis C in these neglected populations. Research on patients with organ transplants is more robust and this literature is reviewed here non-systematically. Our systematic review produced 2273 unique works, of which 56 met our inclusion criteria and were used in our review. The quality of data was low; only 3 of the 56 studies were randomized controlled trials. Sustained virologic response was reported sporadically. Interferon-containing regimens achieved this end-point at rates comparable to that in immunocompetent individuals. Severe adverse effects and death were rare. Data on all-oral regimens were sparse, but in the most robust study, rates of sustained virologic response were again comparable to immunocompetent individuals (40/41). Efficacy and safety of interferon-containing regimens and all-oral regimens were similar to rates in immunocompetent individuals; however, there were few interventional trials. The large number of case reports and case series makes conclusions vulnerable to publication bias. While firm conclusions are challenging, given the dearth of high-quality studies, our results demonstrate that antiviral therapy can be safe and effective. The advent of all-oral regimens offers patients and clinicians greatly increased chances of cure and fewer side effects. Preliminary data reveal that these regimens may confer such benefits in immunosuppressed individuals as well. More prospective interventional trials would greatly benefit the many patients with chronic hepatitis C on immunosuppressive therapies.
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Affiliation(s)
- Kohtaro Ooka
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph K. Lim
- Yale Liver Center, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
- *Correspondence to: Joseph K. Lim, Yale Liver Center, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520-8019, USA. Tel: +1-203-737-6063, Fax: +1-203-785-7273, E-mail:
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87
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Shanmugam VK. Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing In Chronic Wounds. CURRENT DERMATOLOGY REPORTS 2016; 5:270-277. [PMID: 27833788 DOI: 10.1007/s13671-016-0157-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Autoimmune diseases are a common cause of delayed wound healing and should be considered in patients with chronic wounds who do not respond to local wound care or who fail skin grafting in the absence of infection. RECENT FINDINGS Epidemiologic studies have shown that, of patients with chronic wounds evaluated in specialized wound healing clinics, 20-23% have autoimmune etiologies for their wounds including vasculitis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, pyoderma gangrenosum and other autoimmune diseases. SUMMARY In this article autoimmune diseases known to be associated with chronic wounds and delayed wound healing are reviewed and the importance of a multidisciplinary approach for patients with chronic wounds, with involvement of rheumatology and dermatology is highlighted. This approach allows for investigation of underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, The George Washington University, School of Medicine and Health Sciences, 701 Ross Hall, 2300 Eye Street, NW, Washington, DC 20037
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88
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Kawano S, Torisu T, Esaki M. A Rare Cause of Gastrointestinal Ulcers. Gastroenterology 2016; 151:403-4. [PMID: 27485652 DOI: 10.1053/j.gastro.2016.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/07/2016] [Accepted: 06/03/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Shinichi Kawano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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89
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Berera S, Gomez A, Dholaria K, Arosemena LR, Ladino-Avellaneda MA, Barisoni L, Bhamidimarri KR. A Rare Case of Hepatitis C-Associated Cryoglobulinemic Duodenal Vasculitis. ACG Case Rep J 2016; 3:e134. [PMID: 27807586 PMCID: PMC5062685 DOI: 10.14309/crj.2016.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 02/29/2016] [Indexed: 11/17/2022] Open
Abstract
Intestinal involvement of cryoglobulinemia is an uncommon manifestation and marker of severe vasculitis. We describe the case of a woman admitted to our service for management of acute renal failure and progressive gastrointestinal symptoms after initiating hepatitis C virus treatment with ribavirin and sofosbuvir 4 weeks prior. With an undetectable hepatitis C viral load and persistent symptoms despite hepatitis C virus therapy cessation, an upper endoscopy revealed duodenal sloughing, erythema, and bleeding, sparking suspicion for recurrence of cryoglobulinemic vasculitis.
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Affiliation(s)
- Shivali Berera
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Alexandra Gomez
- Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Kevin Dholaria
- Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Leopoldo R. Arosemena
- Division of Hepatology, Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Marco A. Ladino-Avellaneda
- Divison of Nephrology, Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Laura Barisoni
- Department of Pathology, Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Kalyan R. Bhamidimarri
- Division of Hepatology, Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
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90
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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91
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El-Fishawy H, Saadi G, Hassaballa M, Hussein M, Doss W, Ragab G, Barsoum R. Antiviral treatment prioritization in HCV-infected patients with extrahepatic manifestations - An Egyptian perspective. J Adv Res 2016; 7:391-402. [PMID: 27222744 PMCID: PMC4856830 DOI: 10.1016/j.jare.2016.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 02/07/2023] Open
Abstract
Egypt, the single country with highest incidence of HCV infection in the world, has embarked on a government-sponsored mass treatment program using several combinations of DAAs. Recognizing the importance of extrahepatic manifestations, independently of the hepatic, a subcommittee was assigned to develop national guidelines for respective prioritizing indications and protocols. It evaluated the benefit of treating patients with different extrahepatic manifestations, and reviewed relevant clinical trials and guidelines concerning DAA combinations available in Egypt. The latter included Sofosbuvir plus either peg-interferon, Simeprevir, Ledipasvir or daclatasvir, and the Viekera family comprising paritaprevir/ritonavir + ombitasvir with (GT-1) or without (GT-4) Dasabuvir. Any of these protocols may be used with or without Ribavirin according to indication. A blueprint was subjected to peer debate in dedicated workshops in two national meetings and subsequently to an online professional review, eventually leading to a final report that was adopted by the health authorities. Seven compelling and 10 optional indications were identified for treating patients with predominantly extrahepatic manifestations. The former include kidney disease at different stages, cryoglobulinemic vasculitis and non-Hodgkin lymphoma. Selected treatment protocols, were encoded and their use was prioritized on the basis of evidence of efficacy and safety. We concluded that any of the studied protocols may be used, preferably with ribavirin, for 12-week treatment in all patients with extrahepatic manifestations without cirrhosis and with eGFR above 30 ml/min/1.73 sqm. Ribavirin should be included in protocols for treating patients with compensated cirrhosis. Daclatasvir-based protocols are recommended for decompensated cirrhosis, while the Viekera family is recommended in patients with eGFR < 30 ml/min/1.73 sqm, including those on dialysis. In kidney-transplanted patents, caution is due to avoidance of the pharmacokinetic interaction with the Cytochrome-P450 enzyme system, in-between immunosuppressive agents and most DAAs, particularly the Viekera family.
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Affiliation(s)
| | - Gamal Saadi
- Kasr-El-Aini Nephrology and Dialysis Center, Cairo University, Egypt
| | - May Hassaballa
- Kasr-El-Aini Nephrology and Dialysis Center, Cairo University, Egypt
| | - Mohamed Hussein
- Rheumatology Unit, Department of Internal Medicine, Cairo University, Egypt
| | - Wahid Doss
- Department of Tropical Medicine, Cairo University, Egypt
| | - Gaafar Ragab
- Rheumatology Unit, Department of Internal Medicine, Cairo University, Egypt
| | - Rashad Barsoum
- Kasr-El-Aini Nephrology and Dialysis Center, Cairo University, Egypt
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93
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The expanding spectrum of HCV-related cryoglobulinemic vasculitis: a narrative review. Clin Exp Med 2016; 16:233-42. [PMID: 26935415 DOI: 10.1007/s10238-016-0410-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/10/2016] [Indexed: 02/06/2023]
Abstract
Cryoglobulinemic vasculitis (CV) is a small-to-medium-vessel vasculitis that appears in 10-15 % of patients chronically infected with hepatitis C virus (HCV). The classic symptom triad of CV, purpura/asthenia/arthralgia, is accompanied by clinical features that include glomerulonephritis, neuropathy, interstitial pneumonitis, and cardiomyopathy, ranging in their severity from mild to life threatening. The risk of developing non-Hodgkin lymphoma is also higher. The cumulative 10-year survival rate of CV patients is significantly lower than in the age- and sex-matched general population, with death typically caused by nephropathy, malignancies, liver involvement, and severe infections. Unfailing serological stigmata include both a cryoglobulin IgM fraction with rheumatoid factor activity and decreased complement C4 levels. On peripheral B cells, the expression of the CD81 B cell receptor is reduced while that of the CD19 receptor is increased. A monoclonal B cell lymphocytosis develops in almost one-third of patients. HCV-related proteins (but not HCV-RNA genomic sequences) can be detected on biopsy samples by immunofluorescence and immunohistochemistry and involve the vessel lumen, vessel walls, and the perivascular spaces of the skin, kidney, and peripheral nerves, supporting the pathogenetic role of HCV in the onset of a widespread microvasculitis. Based on the demonstration of HCV infection in the large majority of CV patients, a therapeutic regimen consisting of once-weekly pegylated interferon-α and the daily administration of ribavirin results in a sustained virologic response in ~50 % of patients. In those with refractory and relapsing disease, addition of the anti-CD20 monoclonal antibody rituximab has significantly increased the overall response rates. The extension to CV of latest-generation direct-acting antivirals, strikingly successful in non-CV HCV-positive patients, has yielded high complete response rates according to the few studies published thus far.
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94
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Takada S, Uchida-Kobayashi S, Iida-Ueno A, Teranishi Y, Motoyama H, Kozuka R, Kawamura E, Hagihara A, Ishizu H, Morikawa H, Enomoto M, Murakami Y, Tamori A, Kawada N. A case of hepatitis C virus-associated mixed cryoglobulinemic vasculitis treated with daclatasvir and asunaprevir. KANZO 2016; 57:328-333. [DOI: 10.2957/kanzo.57.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Affiliation(s)
- Sayuri Takada
- Department of Gastoroenterology, Kashiwara Municipal Hospital
| | | | - Ayako Iida-Ueno
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Yuga Teranishi
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Hiroyuki Motoyama
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Ritsuzo Kozuka
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Etsushi Kawamura
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Atsushi Hagihara
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Hirotaka Ishizu
- Department of Gastoroenterology, Kashiwara Municipal Hospital
| | - Hiroyasu Morikawa
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Masaru Enomoto
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Yoshiki Murakami
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Akihiro Tamori
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University
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95
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Calvaruso V, Craxì A. Why do I treat my patients with mild hepatitis C? Liver Int 2016; 36 Suppl 1:7-12. [PMID: 26725891 DOI: 10.1111/liv.13011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 12/12/2022]
Abstract
The major advances achieved in the treatment of HCV by the development of new direct-acting antiviral agents (DAAs) allow treatment of almost the entire spectrum of patients with chornic infection. As a result of the exceedingly high cost of DAAs in many countries, IFN-free DAA regimens are mostly reserved to patients with advanced fibrosis or cirrhosis. Hence, treatment of patients with milder liver disease is often deferred. This could ultimately result in an increased burden of advanced liver disease and in increased long-term costs of management. Moreover, studies performed during the 'interferon era' and the early data on interferon-free regimens show that patients without severe fibrosis achieve higher rates of sustained virological response with less treatment-related adverse events. Unfortunately, there is no univocal way to predict the progression of liver fibrosis and therefore to identify the patients with early disease who would require urgent HCV treatment. Many studies have also demonstrated that treatment-induced HCV clearance reduces all-cause mortality regardless of the stage of liver fibrosis, pointing to an effect on extrahepatic manifestations of HCV infection. Last but not least, pharmacoeconomic studies show that DAA treatment of patients with mild HCV disease is cost-effective even at high prices of drugs, thus suggesting the opprtunity to treat regardless of the stage of liver disease.
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Affiliation(s)
- Vincenza Calvaruso
- Sezione di Gastroenterologia & Epatologia, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Antonio Craxì
- Sezione di Gastroenterologia & Epatologia, DIBIMIS, Università di Palermo, Palermo, Italy
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Uruha A, Noguchi S, Hayashi YK, Tsuburaya RS, Yonekawa T, Nonaka I, Nishino I. Hepatitis C virus infection in inclusion body myositis: A case-control study. Neurology 2015; 86:211-7. [PMID: 26683644 DOI: 10.1212/wnl.0000000000002291] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/06/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To clarify whether there is any association between inclusion body myositis (IBM) and hepatitis C virus (HCV) infection. METHODS We assessed the prevalence of HCV infection in 114 patients with IBM whose muscle biopsies were analyzed pathologically for diagnostic purpose from 2002 to 2012 and in 44 age-matched patients with polymyositis diagnosed in the same period as a control by administering a questionnaire survey to the physicians in charge. We also compared clinicopathologic features including the duration from onset to development of representative symptoms of IBM and the extent of representative pathologic changes between patients with IBM with and without HCV infection. RESULTS A significantly higher number of patients with IBM (28%) had anti-HCV antibodies as compared with patients with polymyositis (4.5%; odds ratio 8.2, 95% confidence interval 1.9-36) and the general Japanese population in their 60s (3.4%). Furthermore, between patients with IBM with and without HCV infection, we did not find any significant difference in the clinicopathologic features, indicating that the 2 groups have essentially the same disease regardless of HCV infection. CONCLUSION Our results provide the statistical evidence for an association between IBM and HCV infection, suggesting a possible pathomechanistic link between the 2 conditions.
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Affiliation(s)
- Akinori Uruha
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Satoru Noguchi
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Yukiko K Hayashi
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Rie S Tsuburaya
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Takahiro Yonekawa
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Ikuya Nonaka
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Ichizo Nishino
- From the Department of Genome Medicine Development, Medical Genome Center (A.U., S.N., Y.K.H., I. Nishino), and the Department of Neuromuscular Research, National Institute of Neuroscience (A.U., S.N., Y.K.H., R.S.T., T.Y., I. Nonaka, I. Nishino), National Center of Neurology and Psychiatry (NCNP), Ogawahigashi-cho, Kodaira; and the Department of Pathophysiology (Y.K.H.), Tokyo Medical University, Shinjuku, Shinjuku-ku, Tokyo, Japan.
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97
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Monaco S, Mariotto S, Ferrari S, Calabrese M, Zanusso G, Gajofatto A, Sansonno D, Dammacco F. Hepatitis C virus-associated neurocognitive and neuropsychiatric disorders: Advances in 2015. World J Gastroenterol 2015; 21:11974-11983. [PMID: 26576086 PMCID: PMC4641119 DOI: 10.3748/wjg.v21.i42.11974] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/11/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Since its identification in 1989, hepatitis C virus (HCV) has emerged as a worldwide health problem with roughly 185 million chronic infections, representing individuals at high risk of developing cirrhosis and liver cancer. In addition to being a frequent cause of morbidity and mortality due to liver disease, HCV has emerged as an important trigger of lymphoproliferative disorders, owing to its lymphotropism, and of a wide spectrum of extra-hepatic manifestations (HCV-EHMs) affecting different organ systems. The most frequently observed HCV-EHMs include mixed cryoglobulinemia and cryoglobulinemic vasculitis, B-cell non-Hodgkin’s lymphoma, nephropathies, thyreopathies, type 2 diabetes mellitus, cardiovascular diseases, and several neurological conditions. In addition, neuropsychiatric disorders and neurocognitive dysfunction are reported in nearly 50% of patients with chronic HCV infection, which are independent of the severity of liver disease or HCV replication rates. Fatigue, sleep disturbance, depression and reduced quality of life are commonly associated with neurocognitive alterations in patients with non-cirrhotic chronic HCV infection, regardless of the stage of liver fibrosis and the infecting genotype. These manifestations, which are the topic of this review, typically occur in the absence of structural brain damage or signal abnormalities on conventional brain magnetic resonance imaging (MRI), although metabolic and microstructural changes can be detected by in vivo proton magnetic resonance spectroscopy, perfusion-weighted and diffusion tensor MRI, and neurophysiological tests of cognitive processing. Several lines of evidence, including comparative and longitudinal neuropsychological assessments in patients achieving spontaneous or treatment-induced viral clearance, support a major pathogenic role for HCV in neuropsychiatric and neurocognitive disorders.
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98
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Saadoun D, Thibault V, Si Ahmed SN, Alric L, Mallet M, Guillaud C, Izzedine H, Plaisier A, Fontaine H, Costopoulos M, Le Garff-Tavernier M, Hezode C, Pol S, Musset L, Poynard T, Cacoub P. Sofosbuvir plus ribavirin for hepatitis C virus-associated cryoglobulinaemia vasculitis: VASCUVALDIC study. Ann Rheum Dis 2015; 75:1777-82. [PMID: 26567178 DOI: 10.1136/annrheumdis-2015-208339] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/26/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) is the aetiological agent for most cases of cryoglobulinaemia vasculitis. Interferon-containing regimens are associated with important side effects and may exacerbate the vasculitis. OBJECTIVE To evaluate safety and efficacy of an oral interferon-free regimen, sofosbuvir plus ribavirin, in HCV-cryoglobulinaemia vasculitis. PATIENTS AND METHODS We enrolled 24 consecutive patients (median age of 56.5 years and 46% of women) with HCV-cryoglobulinaemia vasculitis. Sofosbuvir (400 mg/day) was associated with ribavirin (200-1400 mg/day), for 24 weeks. The primary efficacy end point was a complete clinical response of the vasculitis at the end of treatment (week 24). RESULTS Main features of HCV-cryoglobulinaemia vasculitis included purpura and peripheral neuropathy (67%), arthralgia (58%), glomerulonephritis (21%) and skin ulcers (12%). Twenty-one patients (87.5%) were complete clinical response at week 24. Complete clinical response was achieved in six (25%) patients at week 4, four (16.6%) at week 8, seven (29.2%) at week 12, three (12.5%) at week 16 and one (4.2%) at week 20. The cryoglobulin level decreased from 0.35 (0.16-0.83) at baseline to 0.15 (0.05-0.45) g/L at week 24. The C4 serum level increased from 0.10 (0.07-0.19) to 0.17 (0.09-0.23) g/L at week 24. Seventy-four per cent of patients had a sustained virological response at week 12 post treatment. The most common side effects were fatigue, insomnia and anaemia. Two serious adverse events were observed. CONCLUSIONS Sofosbuvir plus ribavirin combination was associated with a high rate of complete clinical response and a low rate of serious adverse events in HCV-cryoglobulinaemia vasculitis.
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Affiliation(s)
- David Saadoun
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, Paris, France INSERM, UMR_S 959, Paris, France CNRS, FRE3632, Paris, France Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, AP-HP, Paris, France
| | - Vincent Thibault
- Groupe Hospitalier Pitié-Salpétrière, Department of Virology, APHP, Paris, France
| | | | - Laurent Alric
- Department of Internal Medicine-Digestive, Centre hospitalier universitaire Purpan, UMR 152 Toulouse 3 University, Toulouse, France
| | - Maxime Mallet
- Groupe Hospitalier Pitié-Salpétrière, Department of Hepatology, AP-HP, Paris, France
| | | | - Hassane Izzedine
- Groupe Hospitalier Pitié-Salpétrière, Department of Nephrology, APHP, Paris, France
| | | | - Hélène Fontaine
- Department of Hepatology, APHP, Hôpital Cochin, Paris, France
| | - Myrto Costopoulos
- Groupe Hospitalier Pitié-Salpétrière, Biological Hematology, APHP, Paris, France
| | | | - Christophe Hezode
- Department of Hepatology, APHP, Hôpital Henri Mondor, Créteil, France
| | - Stanislas Pol
- Department of Hepatology, APHP, Hôpital Cochin, Paris, France
| | - Lucile Musset
- Groupe Hospitalier Pitié-Salpétrière, Department of Immunology, UF d'Immunochimie et d'autoimmunité, APHP, Paris, France
| | - Thierry Poynard
- Groupe Hospitalier Pitié-Salpétrière, Department of Hepatology, AP-HP, Paris, France
| | - Patrice Cacoub
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, Paris, France INSERM, UMR_S 959, Paris, France CNRS, FRE3632, Paris, France Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, AP-HP, Paris, France
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99
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Negro F, Forton D, Craxì A, Sulkowski MS, Feld JJ, Manns MP. Extrahepatic morbidity and mortality of chronic hepatitis C. Gastroenterology 2015; 149:1345-60. [PMID: 26319013 DOI: 10.1053/j.gastro.2015.08.035] [Citation(s) in RCA: 262] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 08/14/2015] [Accepted: 08/17/2015] [Indexed: 12/17/2022]
Abstract
Chronic hepatitis C virus (HCV) infection is associated with several extrahepatic manifestations. Patients with HCV may develop mixed cryoglobulinemia and its sequelae, ranging from cutaneous and visceral vasculitis to glomerulonephritis and B-cell non-Hodgkin lymphoma. HCV-infected patients have increased rates of insulin resistance, diabetes, and atherosclerosis, which may lead to increased cardiovascular morbidity and mortality. Neurological manifestations of HCV infection include fatigue and cognitive impairment. The mechanisms causing the extrahepatic effects of HCV infection are likely multifactorial and may include endocrine effects, HCV replication in extrahepatic cells, or a heightened immune reaction with systemic effects. Successful eradication of HCV with interferon alfa and ribavirin was shown to improve some of these extrahepatic effects; sustained virological response is associated with resolution of complications of cryoglobulinemia, reduced levels of insulin resistance, reduced incidence of diabetes and stroke, and improved fatigue and cognitive functioning. The availability of new interferon-free, well-tolerated anti-HCV treatment regimens is broadening the spectrum of patients available for therapy, including those in whom interferon was contraindicated, and will likely result in greater improvements in the extrahepatic manifestations of HCV. If these regimens are shown to confer significant benefit in the metabolic, cardiovascular, or neuropsychiatric conditions associated with HCV infection, extrahepatic manifestations of HCV may become a major indication for treatment even in the absence of liver disease.
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Affiliation(s)
- Francesco Negro
- Division of Gastroenterology and Hepatology and Division of Clinical Pathology, University Hospital, Geneva, Switzerland
| | - Daniel Forton
- Department of Gastroenterology and Hepatology, St George's Hospital, London, England
| | - Antonio Craxì
- Gastroenterology and Internal Medicine, University of Palermo, Palermo, Italy
| | - Mark S Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Ontario, Canada
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School of Hannover, Hannover, Germany.
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100
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Visentini M, Tinelli C, Colantuono S, Monti M, Ludovisi S, Gragnani L, Mitrevski M, Ranieri J, Fognani E, Piluso A, Granata M, De Silvestri A, Scotti V, Mondelli MU, Zignego AL, Fiorilli M, Casato M. Efficacy of low-dose rituximab for the treatment of mixed cryoglobulinemia vasculitis: Phase II clinical trial and systematic review. Autoimmun Rev 2015; 14:889-96. [PMID: 26031898 DOI: 10.1016/j.autrev.2015.05.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 05/24/2015] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate whether rituximab at a low dose of 250 mg/m(2) × 2 may be as effective as at higher dosages, most commonly 375 mg/m(2)×4, used in previous studies on the treatment of patients with refractory mixed cryoglobulinemia (MC) vasculitis associated with hepatitis C virus (HCV) infection. METHODS We conducted a phase 2, single-arm two-stage trial (EUDRACT n. 2008-000086-38) of low-dose rituximab in 52 patients with HCV-associated MC who were ineligible/intolerant or non-responder to antiviral therapy. The primary outcomes were response of vasculitis evaluated by the Birmingham Vasculitis Activity Score (BVAS) at months 3, 6 and 12, rate of relapses and time to relapse, and rate of adverse events. Our data were compared with those reported in 19 published studies selected among 291 reviewed in a literature search. RESULTS The cumulative response rate (complete and partial) at month 3 was 81% in our patients, and 86% in 208 patients from studies using high-dose rituximab. The relapse rate and median time to relapse were, respectively, 41% and 6 months in our study, and 32% and 7 months in high-dose studies. Treatment-related adverse events were 11.5% in our study and 19.9% in high-dose studies. None of these differences was statistically significant. CONCLUSION Rituximab at a low dosage of 250 mg/m(2) × 2 is as effective as at higher dosages for treating MC vasculitis. This low-dose regimen may improve the cost/benefit profile of rituximab therapy for MC.
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Affiliation(s)
- Marcella Visentini
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy.
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | | | - Monica Monti
- Research Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Firenze, Firenze, Italy
| | - Serena Ludovisi
- Infectious Diseases Research Laboratories, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Laura Gragnani
- Research Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Firenze, Firenze, Italy
| | - Milica Mitrevski
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Jessica Ranieri
- Research Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Firenze, Firenze, Italy
| | - Elisa Fognani
- Research Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Firenze, Firenze, Italy
| | - Alessia Piluso
- Research Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Firenze, Firenze, Italy
| | - Massimo Granata
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometric Unit, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Valeria Scotti
- Clinical Epidemiology and Biometric Unit, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Mario U Mondelli
- Infectious Diseases Research Laboratories, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Anna Linda Zignego
- Research Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Firenze, Firenze, Italy
| | - Massimo Fiorilli
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Milvia Casato
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
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