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Tang L, Marcell L, Kottilil S. Systemic manifestations of hepatitis C infection. Infect Agent Cancer 2016; 11:29. [PMID: 27222662 PMCID: PMC4878040 DOI: 10.1186/s13027-016-0076-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/10/2016] [Indexed: 12/19/2022] Open
Abstract
Chronic hepatitis C (HCV) is a common infection affecting 185 million people worldwide. The most common manifestation of chronic HCV is progressive liver fibrosis, cirrhosis, liver failure and hepatocellular carcinoma. However, several systemic manifestations of HCV have been recognized and reported in the literature. The purpose of this review is to assimilate published literature based on evidence to categorize these extrahepatic manifestations with the likelihood of a causal association with HCV. Exciting recent developments have resulted in simple all oral interferon-free highly effective therapy for HCV. However, this treatment is also expensive and less accessible to most affected individuals as treatment recommendations are based on stage of liver fibrosis. Expanding the scope of HCV therapy to those with extrahepatic manifestations beyond what is currently recommended will significantly reduce the morbidity and mortality in this aging population.
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Affiliation(s)
- Lydia Tang
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Room S222, Baltimore, MD USA
| | - Lauren Marcell
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Room S222, Baltimore, MD USA
| | - Shyam Kottilil
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Room S222, Baltimore, MD USA
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153
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Mathew S, Faheem M, Ibrahim SM, Iqbal W, Rauff B, Fatima K, Qadri I. Hepatitis C virus and neurological damage. World J Hepatol 2016; 8:545-556. [PMID: 27134702 PMCID: PMC4840160 DOI: 10.4254/wjh.v8.i12.545] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/16/2015] [Accepted: 04/11/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis C virus (HCV) infection exhibits a wide range of extrahepatic complications, affecting various organs in the human body. Numerous HCV patients suffer neurological manifestations, ranging from cognitive impairment to peripheral neuropathy. Overexpression of the host immune response leads to the production of immune complexes, cryoglobulins, as well as autoantibodies, which is a major pathogenic mechanism responsible for nervous system dysfunction. Alternatively circulating inflammatory cytokines and chemokines and HCV replication in neurons is another factor that severely affects the nervous system. Furthermore, HCV infection causes both sensory and motor peripheral neuropathy in the mixed cryoglobulinemia as well as known as an important risk aspect for stroke. These extrahepatic manifestations are the reason behind underlying hepatic encephalopathy and chronic liver disease. The brain is an apt location for HCV replication, where the HCV virus may directly wield neurotoxicity. Other mechanisms that takes place by chronic HCV infection due the pathogenesis of neuropsychiatric disorders includes derangement of metabolic pathways of infected cells, autoimmune disorders, systemic or cerebral inflammation and alterations in neurotransmitter circuits. HCV and its pathogenic role is suggested by enhancement of psychiatric and neurological symptoms in patients attaining a sustained virologic response followed by treatment with interferon; however, further studies are required to fully assess the impact of HCV infection and its specific antiviral targets associated with neuropsychiatric disorders.
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154
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Management of Vasculitic Glomerulonephritis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016. [DOI: 10.1007/s40674-016-0049-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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155
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Otsuka T, Sakai Y, Ohno D, Tsuruoka S. A Case of Cryoglobulinemic Membranoproliferative Glomerulonephritis Induced by Hepatitis C Virus. J NIPPON MED SCH 2016; 82:193-201. [PMID: 26328796 DOI: 10.1272/jnms.82.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 61-year-old man with bilateral purpura of the lower limbs and subsequent edema, was hospitalization after renal dysfunction developed. The presence of hepatitis C virus (HCV) RNA and cryoglobulin and the finding of membranoproliferative glomerulonephritis on renal biopsy led to a diagnosis of HCV-related glomerulonephritis due to cryoglobulinemia. Because of the pre-existence of nephrotic syndrome and the continuously increasing serum level of creatinine, treatment with cryofiltration, interferon, and steroids was started. After 5 cryofiltration sessions, the cryocrit level had decreased to 1% and the levels of serum creatinine and proteinuria had also decreased. However, 3 weeks after the start of treatment, nephrotic syndrome developed again and was accompanied by lower-extremity mononeuropathy and renal dysfunction. Thereafter, the patient showed disorientation, an affective disorder, and delirium, and his condition gradually deteriorated. Radiological examination of the head and examination of the cerebrospinal fluid showed no abnormalities. Despite the withdrawal of the interferon therapy and the reduction of the steroid dose, the patient's conditions remained unchanged, and the level of consciousness deteriorated. Although cryofiltration had beneficial effects and plasma exchange was continuously performed, the patient died on the 74th hospital day. Because of the significant changes due to ventilatory support and hemorrhage associated with disseminated intravascular coagulation, the autopsy findings did not allow us to definitively determine whether the symptoms had been caused by the HCV-related membranoproliferative glomerulonephritis or the interferon therapy or both. We have reported this case to provide insight into whether interferon therapy should be administered for HCV-related membranoproliferative glomerulonephritis with marked neurological symptoms due to cryoglobulinemia.
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Affiliation(s)
- Tomoyuki Otsuka
- Department of Nephrology, Nippon Medical School Musashi Kosugi Hospital
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157
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Martín-Gómez MA, Caba Molina M, Cruz Caparros G, Muñoz Vico J, Gómez Morales M. Sjogren syndrom and mixed nephropathy. Significance of early kidney biopsy. Nefrologia 2016; 36:451-3. [PMID: 27006328 DOI: 10.1016/j.nefro.2016.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/28/2015] [Accepted: 02/15/2016] [Indexed: 10/22/2022] Open
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Cacoub P, Comarmond C, Domont F, Savey L, Desbois AC, Saadoun D. Extrahepatic manifestations of chronic hepatitis C virus infection. Ther Adv Infect Dis 2016; 3:3-14. [PMID: 26862398 DOI: 10.1177/2049936115585942] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
During hepatitis C virus (HCV) chronic infection, extrahepatic manifestations are frequent and polymorphous. This article reports on a large cohort of patients with HCV-related autoimmune or lymphoproliferative disorders, from mixed cryoglobulinemia vasculitis to frank lymphomas. The relationship between HCV infection and such immune-related diseases has been formally demonstrated by epidemiological, clinical, immunological and pathological data, and results of therapeutic trials. More recently, other nonliver-related HCV disorders have been reported, including cardiovascular (i.e. stroke, ischemic heart disease), renal, metabolic and central nervous system diseases. For these manifestations, most evidence comes from large epidemiological studies; there is a need for mechanistic studies and therapeutic trials for confirmation. Beyond the risk of developing liver complications, that is, cirrhosis and liver cancer, patients with HCV infection have an increased risk of morbidity and mortality related to nonliver diseases. HCV chronic infection should be analyzed as a systemic disease in which extrahepatic consequences increase the weight of its pathological burden. The need for effective viral eradication measures is underlined.
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Affiliation(s)
- Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, and Inflammation Immunopathology Biotherapy Department (DHU i2B), Paris, France
| | | | | | - Léa Savey
- Sorbonne Universités, UPMC Univ Paris 06, and Inflammation Immunopathology Biotherapy Department (DHU i2B), Paris, France
| | | | - David Saadoun
- Sorbonne Universités, UPMC Univ Paris 06, and Inflammation Immunopathology Biotherapy Department (DHU i2B), Paris, France
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159
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Hasegawa J, Hayami N, Hoshino J, Suwabe T, Sumida K, Mise K, Ueno T, Yamanouchi M, Sawa N, Ohashi K, Fujii T, Takaichi K, Ubara Y. Cryoglobulinemic vasculitis with primary Sjögren’s syndrome: A case report. Mod Rheumatol 2016; 28:570-574. [DOI: 10.3109/14397595.2015.1128870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jumpei Hasegawa
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
- Department of Nephrology, Ohkubo Hospital, Tokyo, Japan,
| | - Noriko Hayami
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Junichi Hoshino
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Tatsuya Suwabe
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Keiichi Sumida
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Koki Mise
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Toshiharu Ueno
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Masayuki Yamanouchi
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Naoki Sawa
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan, and
| | - Takeshi Fujii
- Department of Pathology, Toranomon Hospital, Tokyo, Japan, and
| | - Kenmei Takaichi
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Yoshifumi Ubara
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan,
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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160
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161
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162
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Corouge M, Vallet-Pichard A, Pol S. HCV and the kidney. Liver Int 2016; 36 Suppl 1:28-33. [PMID: 26725894 DOI: 10.1111/liv.13022] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 12/18/2022]
Abstract
Chronic hepatitis C (CHC) is significantly associated with a risk of renal deterioration over time. Renal impairment, especially stage 4-5 chronic kidney disease, increases the risk of: (i) the prevalence and incidence (in dialysis/transplantation) of hepatitis C virus (HCV) infection; (ii) liver deterioration during kidney transplantation and (iii) allograft failure and patient mortality. HCV-infected dialysis patients have a higher mortality than non-infected dialysis patients and than HCV-infected kidney recipients. The harmful impact of HCV emphasizes the need for oral antiviral therapies in patients with chronic kidney disease. Symptomatic cryoglobulinemic vasculitis and extensive liver fibrosis are already approved indications for early access to oral antiviral treatment. Patients with stage 4-5 chronic kidney disease should also be given priority: dialysis patients (whatever the stage of fibrosis and whether or not they are candidates for kidney transplantation) as well as all kidney recipients. The results of treatment of HCV with direct-acting antiviral (DAAs) drugs in patients with late chronic kidney disease are excellent, similar to those in the general population, although additional clinical trials are definitely needed, particularly to optimize adjustment of treatment to kidney function and determine the risk of drug-drug interactions.
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Affiliation(s)
- Marion Corouge
- Hepatology Department, Université Paris Descartes, Cochin Hospital, APHP, Paris, France.,INSERM U818 and UMS-20, Institut Pasteur, Paris, France
| | - Anaïs Vallet-Pichard
- Hepatology Department, Université Paris Descartes, Cochin Hospital, APHP, Paris, France.,INSERM U818 and UMS-20, Institut Pasteur, Paris, France
| | - Stanislas Pol
- Hepatology Department, Université Paris Descartes, Cochin Hospital, APHP, Paris, France.,INSERM U818 and UMS-20, Institut Pasteur, Paris, France
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163
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Abstract
Patients with chronic hepatitis C virus (HCV) infection frequently present with extrahepatic manifestations covering a large spectrum, involving different organ systems leading to the concept of systemic HCV infection. These manifestations include autoimmune phenomena and frank autoimmune and/or rheumatic diseases and may dominate the course of chronic HCV infection. Chronic HCV infection causes liver inflammation affecting the development of hepatic diseases. HCV is also a lymphotropic virus that triggers B cells and promotes favorable conditions for B lymphocyte proliferation, including mixed cryoglobulinemia (MC) and MC vasculitis, which is the most prominent extrahepatic manifestation of chronic HCV infection. HCV may also promote a low-grade chronic systemic inflammation that may affect the development of some extrahepatic manifestations, particularly cardiovascular and cerebral vascular diseases. Recognition of extrahepatic symptoms of HCV infection could facilitate early diagnosis and treatment. The development of direct-acting antiviral agents (DDAs) has revolutionized HCV treatment. DDAs, as well as new B-cell-depleting or B-cell-modulating monoclonal antibodies, will expand the panorama of treatment options for HCV-related extrahepatic manifestations including cryoglobulinemic vasculitis. In this context, a proactive, integrated approach to HCV therapy should maximize the benefits of HCV therapy, even when liver disease is mild.
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Affiliation(s)
- E Rosenthal
- Service de Médecine Interne, Hôpital de l'Archet, CHU de Nice, Nice; Université de Nice-Sophia Antipolis, Nice, France COREVIH PACA EST, CHU de Nice, France
| | - P Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France INSERM, UMR_S 959, Paris, France CNRS, FRE3632, Paris, France AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
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164
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Abstract
B cells play a central role in the immunopathogenesis of glomerulonephritides and transplant rejection. B cells secrete antibodies that contribute to tissue injury via multiple mechanisms. In addition, B cells contribute to disease pathogenesis in autoimmunity and alloimmunity by presenting antigens as well as providing costimulation and cytokines to T cells. B cells also play an immunomodulatory role in regulating the immune response by secreting cytokines that inhibit disease onset and/or progression. B cell-targeted approaches for treating immune diseases of the kidney and other organs have gained significant momentum. However, much remains to be understood about B-cell biology in order to determine the timing, duration, and context of optimal therapeutic response to B cell-targeted approaches. In this review, we discuss the multifaceted roles of B cells as enhancers and regulators of immunity with relevance to kidney disease and transplantation.
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Affiliation(s)
| | - Fadi G Lakkis
- Departments of Medicine (Renal-Electrolyte), Surgery, and Immunology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Geetha Chalasani
- Departments of Medicine (Renal-Electrolyte), Surgery, and Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Renal Section, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
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165
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Abstract
Chronic infection with the hepatitis C virus (HCV) is a major cause of liver disease worldwide and is also responsible for extrahepatic manifestations (EHMs) involving the skin, kidneys, salivary glands, eyes, thyroid, and immune system. Mixed cryoglobulinemia is the prototype EHM related to HCV infection. Although these HCV-related EHMs may contribute to significant rates of morbidity affecting patient's quality of life and survival, most of these complications can reverse after HCV eradication by interferon therapy. This notwithstanding, individual patients may have an irreversible injury in various organs that is not reversed by a cure of the HCV infection.
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Affiliation(s)
- Mauro Viganò
- Hepatology Division, Ospedale San Giuseppe, Università degli Studi di Milano, Via San Vittore 12, Milan 20122, Italy
| | - Massimo Colombo
- Division of Gastroenterology and Hepatology, "A. M. and A. Migliavacca" Center for Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, Milan 20122, Italy.
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166
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Reynaud Q, Killian M, Robles A, Mounsef F, Camdessanché JP, Mariat C, Cathébras P. Le rituximab dans la vraie vie : revue d’utilisation du rituximab de 2010 à 2013 au CHU de Saint-Étienne. Rev Med Interne 2015; 36:800-12. [DOI: 10.1016/j.revmed.2015.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 05/03/2015] [Accepted: 06/05/2015] [Indexed: 12/13/2022]
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167
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Garcovich S, Garcovich M, Capizzi R, Gasbarrini A, Zocco MA. Cutaneous manifestations of hepatitis C in the era of new antiviral agents. World J Hepatol 2015; 7:2740-2748. [PMID: 26644817 PMCID: PMC4663393 DOI: 10.4254/wjh.v7.i27.2740] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/23/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
The association of chronic hepatitis C virus (HCV) infection with a wide spectrum of cutaneous manifestations has been widely reported in the literature, with varying strength of epidemiological association. Skin diseases which are certainly related with chronic HCV infection due to a strong epidemiological and pathogenetic association are mixed cryoglobulinemia, lichen planus and porphyria cutanea tarda. Chronic pruritus and necrolytic acral erythema are conditions that may share a possible association with HCV infection, while several immune-mediated inflammatory skin conditions, such as psoriasis, chronic urticaria and vitiligo, have been only anecdotally reported in the setting of chronic HCV infection. Traditional interferon-based treatment regimens for HCV infection are associated with substantial toxicity and a high-risk of immune-related adverse events, while the advent of new direct-acting antivirals with sustained virological response and improved tolerability will open the door for all-oral, interferon-free regimens. In the new era of these direct acting antivirals there will be hopefully a renewed interest in extra-hepatic manifestations of HCV infection. The aim of the present paper is to review the main cutaneous HCV-related disorders - mixed cryoglobulinemia, lichen planus, porphyria cutanea tarda and chronic pruritus - and to discuss the potential impact of new antiviral treatments on the course of these extra-hepatic manifestations of chronic HCV infection.
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168
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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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169
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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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170
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Abstract
BACKGROUND Renal vasculitis presents as rapidly progressive glomerulonephritis which comprises of a group of conditions characterised by acute kidney injury (AKI), haematuria and proteinuria. Treatment of these conditions comprises steroid and non-steroid agents in combination with plasma exchange. Although immunosuppression overall has been very successful in treatment of these conditions, many questions remain unanswered in terms of dose and duration of therapy, the use of plasma exchange and the role of new therapies. This an update of a review first published in 2008. OBJECTIVES To evaluate the benefits and harms of any intervention used for the treatment of renal vasculitis in adults. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 27 July 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials investigating any intervention for the treatment of renal vasculitis in adults. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes or mean difference (MD) for continuous outcomes. MAIN RESULTS Thirty one studies (2217 patients) were included. Studies conducted earlier tended to have a higher risk of bias due to poor (or poorly reported) study design, broad inclusion criteria, less well developed disease definitions and low patient numbers. Later studies tend to have improved in all areas of quality, aided by the development of large transnational study groups.Plasma exchange as adjunctive therapy significantly reduces the risk of end-stage kidney disease at three months (2 studies: RR 0.43, 95% CI 0.23 to 0.78) and 12 months (6 studies: RR 0.45, 95% CI 0.29 to 0.72). Four studies (300 patients) compared the use of pulse and continuous administration of cyclophosphamide. Remission rates were equivalent but pulse treatment causes an increased risk of relapse (4 studies: RR 1.79, 95% CI 1.11 to 2.87) compared with continuous cyclophosphamide. Azathioprine has equivalent efficacy as a maintenance agent to cyclophosphamide with fewer episodes of leucopenia. Mycophenolate mofetil may be equivalent to cyclophosphamide as an induction agent but resulted in a higher relapse rate when tested against azathioprine in remission maintenance. Rituximab is an effective remission induction agent. Methotrexate or leflunomide are potential choices in remission maintenance therapy. Oral co-trimoxazole did not reduce relapses significantly in granulomatosis with polyangiitis. AUTHORS' CONCLUSIONS Plasma exchange was effective in patients with severe AKI secondary to vasculitis. Pulse cyclophosphamide results in an increased risk of relapse when compared to continuous oral use but a reduced total dose. Whilst cyclophosphamide is standard induction treatment, rituximab and mycophenolate mofetil were also effective. Azathioprine, methotrexate and leflunomide were effective as maintenance therapy. Further studies are required to more clearly delineate the appropriate place of newer agents within an evidence-based therapeutic strategy.
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Affiliation(s)
- Giles Walters
- Department of Renal Medicine, The Canberra Hospital, Yamba Drive, Garran, ACT, Australia, 2605
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Basile U, Gragnani L, Piluso A, Gulli F, Urraro T, Dell'Abate MT, Torti E, Stasi C, Monti M, Rapaccini GL, Zignego AL. Assessment of free light chains in HCV-positive patients with mixed cryoglobulinaemia vasculitis undergoing rituximab treatment. Liver Int 2015; 35:2100-7. [PMID: 25800731 DOI: 10.1111/liv.12829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Mixed cryoglobulinaemia (MC) is an HCV-related lymphoproliferative disorder characterized by the presence of circulating immune complexes called cryoglobulins. Treatment with anti-CD20 monoclonal antibody rituximab is proved to be very useful, especially in patients ineligible to interferon-based antiviral therapy. Recently, free light chain (FLC) κ/λ ratio and FLC patterns were associated with MC. The aim of this study was to evaluate changes in FLC-κ, FCL-λ, FLC ratio following rituximab treatment in patients with HCV-related MC and to correlate FLC-κ, FCL-λ and FLC ratio values with therapy response. PATIENTS AND METHODS We retrospectively enrolled 46 patients with HCV infection (26 females, 20 males), including 10 patients without signs/symptoms of MC-related vasculitis, 36 with MC vasculitis. Clinical and biological data were recorded at baseline and 6 months after RTX treatment. Nephelometric measurement of serum FLCs was taken. RESULTS The mean serum FLC-κ level and FLC ratio were significantly higher in patients with MC, compared to HCV patients without MC and to blood donors. An abnormal FLC ratio at baseline correlated with the presence of cryoglobulins, C4 consumption, higher RF level and higher vasculitis rate. To evaluate the predictive value of FLCs, patients with MC were divided into two groups according to RTX therapy outcome (responders and no/partial responders). Abnormal baseline FLC ratio was significantly associated with no/partial response. CONCLUSIONS RTX treatment in HCV-related MC induces a reduction in FLC-κ and RF levels. Moreover, pretreatment FLC ratio, which can be easily assessed by a routine test, may be useful to predict response to this expensive treatment for patients with HCV-related MC ineligible to IFN-based therapy.
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Affiliation(s)
- Umberto Basile
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessia Piluso
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesca Gulli
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Teresa Urraro
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria T Dell'Abate
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Eleonora Torti
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Cristina Stasi
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Monica Monti
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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172
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Cacoub P, Comarmond C, Domont F, Savey L, Saadoun D. Cryoglobulinemia Vasculitis. Am J Med 2015; 128:950-5. [PMID: 25837517 DOI: 10.1016/j.amjmed.2015.02.017] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 02/24/2015] [Accepted: 02/24/2015] [Indexed: 12/12/2022]
Abstract
Cryoglobulinemic vasculitis (CryoVas) is a small-vessel vasculitis involving mainly the skin, the joints, the peripheral nervous system, and the kidneys. Type I CryoVas is single monoclonal immunoglobulins related to an underlying B-cell lymphoproliferative disorder. Type II and III cryoglobulins, often referred to as mixed cryoglobulinemia, consist of polyclonal immunoglobulin (Ig)G with or without monoclonal IgM with rheumatoid factor activity. Hepatitis C virus (HCV) infection represents the main cause of mixed CryoVas. The 10-year survival rates are 63%, 65%, and 87% in HCV-positive mixed CryoVas, HCV-negative mixed CryoVas, and type I CryoVas patients, respectively. In HCV-positive patients, baseline poor prognostic factors include the presence of severe liver fibrosis, and central nervous system, kidney, and heart involvement. Treatment with antivirals is associated with a good prognosis, whereas use of immunosuppressants (including corticosteroids) is associated with a poor outcome. In HCV-negative patients, pulmonary and gastrointestinal involvement, renal insufficiency, and age > 65 years are independently associated with death. Increased risk of lymphoma also should be underlined. Treatment of type I CryoVas is that of the hemopathy; specific treatment also includes plasma exchange, corticosteroids, rituximab, and ilomedine. In HCV-CryoVas with mild-to-moderate disease, an optimal antiviral treatment should be given. For HCV-CryoVas with severe vasculitis (ie, worsening of renal function, mononeuritis multiplex, extensive skin disease, intestinal ischemia…) control of disease with rituximab, with or without plasmapheresis, is required before initiation of antiviral therapy. Other immunosuppressants should be given only in case of refractory forms of CryoVas, frequently associated with underlying B-cell lymphoma.
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Affiliation(s)
- Patrice Cacoub
- Sorbonne Universités, University Pierre and Marie Curie (UPMC), UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; Institute National de la Santé et de la Recherche Medicalé (INSERM), UMR_S 959, Paris, France; Centre National de la Recherche Scientifique (CNRS), FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
| | - Cloe Comarmond
- Sorbonne Universités, University Pierre and Marie Curie (UPMC), UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; Institute National de la Santé et de la Recherche Medicalé (INSERM), UMR_S 959, Paris, France; Centre National de la Recherche Scientifique (CNRS), FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Fanny Domont
- Sorbonne Universités, University Pierre and Marie Curie (UPMC), UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Léa Savey
- Sorbonne Universités, University Pierre and Marie Curie (UPMC), UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - David Saadoun
- Sorbonne Universités, University Pierre and Marie Curie (UPMC), UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; Institute National de la Santé et de la Recherche Medicalé (INSERM), UMR_S 959, Paris, France; Centre National de la Recherche Scientifique (CNRS), FRE3632, Paris, France; Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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173
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Quartuccio L, Zuliani F, Corazza L, Scaini P, Zani R, Lenzi M, Tavoni A, Sebastiani M, Baldovino S, Urraro T, Saccardo F, Sbreglia C, Mazzaro C, Pioltelli P, Fraticelli P, Filippini D, Gabrielli A, Perrella O, Scarpato S, Roccatello D, Zignego AL, Ferri C, Bombardieri S, Pietrogrande M, Monti G, Galli M, De Vita S. Retreatment regimen of rituximab monotherapy given at the relapse of severe HCV-related cryoglobulinemic vasculitis: Long-term follow up data of a randomized controlled multicentre study. J Autoimmun 2015; 63:88-93. [DOI: 10.1016/j.jaut.2015.07.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 07/17/2015] [Accepted: 07/23/2015] [Indexed: 11/25/2022]
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174
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Zignego AL, Gragnani L, Piluso A, Sebastiani M, Giuggioli D, Fallahi P, Antonelli A, Ferri C. Virus-driven autoimmunity and lymphoproliferation: the example of HCV infection. Expert Rev Clin Immunol 2015; 11:15-31. [PMID: 25534977 DOI: 10.1586/1744666x.2015.997214] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
HCV chronic infection is characterized by possible development of both hepatic and extrahepatic manifestations. The infection by this both hepatotropic and lymphotropic virus is responsible for polyoligoclonal B-lymphocyte expansion, leading to several immune-mediated disorders. Mixed cryoglobulinemia syndrome that in some cases may evolve to frank B-cell non-Hodgkin's lymphoma is the prototype of HCV-driven autoimmune and lymphoproliferative disorders. The HCV oncogenic potential has been suggested by several clinicoepidemiological and laboratory studies; it includes hepatocellular carcinoma, B-cell non-Hodgkin's lymphoma and papillary thyroid cancer. The definition HCV syndrome refers to the complex of HCV-driven diseases; these latter are characterized by heterogeneous geographical distribution, suggesting a role of other important genetic and/or environmental cofactors. The natural history of HCV syndrome is the result of a multifactorial and multistep pathogenetic process, which may evolve from mild manifestations to systemic autoimmune disorders, and less frequently to malignant neoplasias. The present updated review analyzes the clinical and pathogenetic aspects of the main HCV-associated diseases.
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Affiliation(s)
- Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MASVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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175
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Fabrizi F, Cresseri D, Fogazzi GB, Moroni G, Passerini P, Martin P, Messa P. Rituximab therapy for primary glomerulonephritis: Report on two cases. World J Clin Cases 2015; 3:736-742. [PMID: 26301235 PMCID: PMC4539414 DOI: 10.12998/wjcc.v3.i8.736] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 12/30/2014] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
The evidence in the medical literature on the efficacy and safety of rituximab therapy for primary glomerulonephritis is limited and controversial. We describe two male Caucasian patients with rapidly progressive kidney failure due to primary proliferative glomerulonephritis. Both of them received high-dose intravenous corticosteroids and oral cyclophosphamide with limited benefit. The first patient (hepatitis C virus-negative mixed cryoglobulinemia) underwent plasma-exchange with intravenous immunoglobulins; he showed significant benefit on kidney function (he became dialysis independent with serum creatinine going back to 1.6 mg/dL) after one rituximab pulse even if urinary abnormalities were still present. No improvement in renal function or urinary changes occurred in the second patient. Both these individuals developed sepsis over the follow-up, the first patient died two months after rituximab therapy. This report is in keeping with the occurrence of severe infections after rituximab therapy in patients with renal impairment at baseline and concomitant high-dose steroids.
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176
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De Vita S, Quartuccio L, Seror R, Salvin S, Ravaud P, Fabris M, Nocturne G, Gandolfo S, Isola M, Mariette X. Efficacy and safety of belimumab given for 12 months in primary Sjögren's syndrome: the BELISS open-label phase II study. Rheumatology (Oxford) 2015; 54:2249-56. [PMID: 26242856 DOI: 10.1093/rheumatology/kev257] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To report the efficacy and safety of long-term treatment of SS with belimumab, targeting the B-cell-activating factor. METHODS Patients with primary SS were included in the BELISS open-label phase II study, a 1-year open-label trial, if they were positive for anti-SSA or anti-SSB antibodies and had systemic complications or persistent salivary gland enlargement or early disease or biomarkers of B-cell activation. They received belimumab, 10 mg/kg i.v., at weeks 0, 2 and 4 and then every 4 weeks; if response was observed at week 28, or if the clinician and the patient agreed to continue the study in the absence of side effects, treatment was continued for 1 year. Efficacy and safety were analysed during the 1-year period of treatment. RESULTS Among the 30 patients recruited, 28 were evaluated at week 28 as already reported. Nineteen terminated the 52-week study, 15 of them being responders and 4 non-responders at week 28. Thirteen of the 15 responders at week 28 also responded at week 52 (86.7%). The improvement in the EULAR Sjögren's Syndrome Disease Activity Index and EULAR Sjögren's Syndrome Patient Reported Index scores observed at week 28 showed a trend to further improvement at week 52, and the amelioration of peculiar EULAR Sjögren's Syndrome Disease Activity Index domains (glandular, lymphadenopathy, articular) appeared of particular relevance. The decrease in biomarkers of B-cell activation observed at week 28 persisted unchanged until week 52, with RF decreasing further. Salivary flow, Schirmer's test and the focus score of salivary biopsy did not change. Safety of treatment was good. CONCLUSION Long-term treatment with belimumab may be beneficial in SS. Randomized, double-blind, controlled studies in larger populations are encouraged.
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Affiliation(s)
- Salvatore De Vita
- Clinic of Rheumatology, Department of Medical and Biological Sciences, Udine University, Udine, Italy,
| | - Luca Quartuccio
- Clinic of Rheumatology, Department of Medical and Biological Sciences, Udine University, Udine, Italy
| | - Raphaèle Seror
- Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, INSERM U1012, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Hôtel Dieu Hospital, Centre of Clinical Epidemiology, INSERM, U738, University of Paris Descartes, Faculty of Medicine, Paris, France
| | - Sara Salvin
- Clinic of Rheumatology, Department of Medical and Biological Sciences, Udine University, Udine, Italy
| | - Philippe Ravaud
- Assistance Publique-Hôpitaux de Paris, Hôtel Dieu Hospital, Centre of Clinical Epidemiology, INSERM, U738, University of Paris Descartes, Faculty of Medicine, Paris, France
| | - Martina Fabris
- Clinic of Rheumatology, Department of Medical and Biological Sciences, Udine University, Udine, Italy, Institute of Clinical Pathology and
| | - Gaétane Nocturne
- Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, INSERM U1012, Le Kremlin Bicêtre
| | - Saviana Gandolfo
- Clinic of Rheumatology, Department of Medical and Biological Sciences, Udine University, Udine, Italy
| | - Miriam Isola
- Institute of Statistics, Department of Medical and Biological Sciences, Udine University, Udine, Italy
| | - Xavier Mariette
- Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, INSERM U1012, Le Kremlin Bicêtre
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177
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Damoiseaux J, Cohen Tervaert JW. Diagnostics and treatment of cryoglobulinaemia: it takes two to tango. Clin Rev Allergy Immunol 2015; 47:299-310. [PMID: 24068540 DOI: 10.1007/s12016-013-8390-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Cryoglobulins are immunoglobulins that reversibly precipitate in the cold. They come in different flavours and, as such, are differentially associated with lymphoproliferative diseases (type I), or systemic autoimmune diseases, and/or infectious diseases (type II/III). The clinical manifestations of cryoglobulinaemia result from either hyper-viscosity or small vessel vasculitis. Hepatitis C virus (HCV) is a well-known factor in the aetiology of cryoglobulinaemia, but substantial geographical differences exist in the association between cryoglobulins and HCV. In the absence of any underlying disease, cryoglobulinaemia is referred to as 'idiopathic' or 'essential'. Detection of cryoglobulins in the laboratory is hampered by several pitfalls, in particular in the pre-analytical stage as well as in the quantification. In addition, our personal experience reveals that the detection of rheumatoid factor, most often present in high concentrations in patients with mixed cryoglobulinaemia, relies on the choice of the test system. Hence, interpretation of the laboratory results in relation to the clinical manifestations requires a partnership between the clinician and the laboratory specialist in order to make a correct diagnosis. Treatment options are primarily directed by identification of underlying diseases, i.e. infections or systemic autoimmune diseases. Idiopathic cryoglobulinaemia is treated with corticosteroids and immunosuppression, or B cell depleting anti-CD20 biologicals. In this overview, the recent literature on current laboratory and clinical practice of cryoglobulinaemia is discussed from a personal perspective.
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Affiliation(s)
- Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands,
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178
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Fabrizi F, Martin P, Cacoub P, Messa P, Donato FM. Treatment of hepatitis C-related kidney disease. Expert Opin Pharmacother 2015; 16:1815-27. [DOI: 10.1517/14656566.2015.1066333] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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179
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180
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Teng GG, Chatham WW. Vasculitis related to viral and other microbial agents. Best Pract Res Clin Rheumatol 2015; 29:226-43. [PMID: 26362741 DOI: 10.1016/j.berh.2015.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/08/2015] [Indexed: 12/11/2022]
Abstract
Vasculitis due to infection may occur as a consequence of the inflammation of vessel walls due to direct or contiguous infection, type II or immune complex-mediated reaction, cell-mediated hypersensitivity, or inflammation due to immune dysregulation triggered by bacterial toxin and/or superantigen production. As immunosuppressive therapy administered in the absence of antimicrobial therapy may increase morbidity and fail to effect the resolution of infection-associated vascular inflammation, it is important to consider infectious entities as potential inciting factors in vasculitis syndromes. The causality between infection and vasculitis has been established in hepatitis B-associated polyarteritis nodosa (HBV-PAN) and hepatitis C-associated (cryoglobulinemic) vasculitis (HCV-CV). The review summarizes the recent literature on the pathophysiological mechanisms and the approaches to the management of HBV-PAN and HCV-CV. Roles of other viral and microbial infections, which either manifest as vasculitic syndromes or are implicated in the pathogenesis of primary vasculitides, are also discussed.
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Affiliation(s)
- Gim Gee Teng
- Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
| | - W Winn Chatham
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA.
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181
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Retamozo S, Brito-Zerón P, Ramos-Casals M. [Treatment of cryoglobulinemic vasculitis associated with hepatitis C virus infection]. Med Clin (Barc) 2015; 144:410-7. [PMID: 24787686 DOI: 10.1016/j.medcli.2014.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 02/13/2014] [Accepted: 02/27/2014] [Indexed: 10/25/2022]
Abstract
Cryoglobulinemia is a heterogeneous systemic autoimmune disease with a wide variety of causes, symptoms and outcomes, and different etiopathogenic pathways involved in the vasculitic organ damage. The discovery of the hepatitis C virus (HCV) in 1989 changed radically the focus of research of the so-called "essential" cryoglobulinemia. Cryoglobulins can be detected in 25-30% of patients with HCV, overwhelmingly representing mixed cryoglobulins. However, only 10-15% of patients present with cryoglobulinemic vasculitis, with a broad spectrum of symptoms including mild or life-threatening manifestations. Consequently, not all patients can be uniformly treated. The key therapeutic points in HCV+ patients with cryoglobulinemic vasculitis cover different aspects. The first is to treat the underlying cause of cryoglobulinemia whenever possible, hence the use of antiviral therapies must always be considered in these patients. An individualized diagnostic approach to assess the number of organs involved and the severity of organ involvement is also essential in the therapeutic planning. This complex clinical scenario leads to an equally complex therapeutic scenario. There are three main treatment strategies for HCV-associated cryoglobulinemic vasculitis: conventional immunosuppression, antiviral treatment and biological therapies. The most recent studies are suggesting a change from the classical therapeutic approach (monotherapeutic regimens) to combination/sequential regimens, including treatments targeting the virus and those directed against the induced autoimmune disease, with the aim of blocking the various etiopathogenic pathways involved.
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Affiliation(s)
- Soledad Retamozo
- Laboratorio de Enfermedades Autoinmunes Josep Font, Centro de Investigación Biomédica CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (CELLEX-IDIBAPS), Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona. España
| | - Pilar Brito-Zerón
- Laboratorio de Enfermedades Autoinmunes Josep Font, Centro de Investigación Biomédica CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (CELLEX-IDIBAPS), Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona. España
| | - Manuel Ramos-Casals
- Laboratorio de Enfermedades Autoinmunes Josep Font, Centro de Investigación Biomédica CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (CELLEX-IDIBAPS), Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona. España.
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Lymphoproliferative disease-related mixed cryoglobulinemia treated with rituximab and prednisolone. CEN Case Rep 2015; 4:6-13. [PMID: 28509274 DOI: 10.1007/s13730-014-0130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/28/2014] [Indexed: 10/23/2022] Open
Abstract
Mixed cryoglobulinemia is often associated with hepatic C virus infection and is less common with hepatitis B virus infection, and it often progresses into lymphoproliferative diseases. Rituximab is known to achieve systemic B-cell depletion and clinical remission of the systemic effects of cryoglobulins in hepatitis C virus-associated cryoglobulinemia. Conversely, there are few reports regarding the use of rituximab in hepatitis B virus-associated cryoglobulinemia. We report here the case of a 65-year-old Japanese female who presented with lymphoproliferative disease-related cryoglobulinemia with hepatitis B virus, including membranoproliferative glomerulonephritis with renal failure. The vasculitis was refractory to conventional and antiviral therapy, but rituximab use led to control the disease. Our case highlights the benefit and efficacy of rituximab in association with antiviral therapy in small vessel vasculitis related to lymphoproliferative disease-related cryoglobulinemia with hepatitis B virus.
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183
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Cryoglobulinemic vasculitis and skin ulcers. Our therapeutic strategy and review of the literature. Semin Arthritis Rheum 2015; 44:518-526. [DOI: 10.1016/j.semarthrit.2014.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 02/06/2023]
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184
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Blaes F. Diagnosis and therapeutic options for peripheral vasculitic neuropathy. Ther Adv Musculoskelet Dis 2015; 7:45-55. [PMID: 25829955 PMCID: PMC4357592 DOI: 10.1177/1759720x14566617] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Vasculitis can affect the peripheral nervous system alone (nonsystemic vasculitic neuropathy) or can be a part of primary or secondary systemic vasculitis. In cases of pre-existing systemic vasculitis, the diagnosis can easily be made, whereas suspected vasculitic neuropathy as initial or only manifestation of vasculitis requires careful clinical, neurophysiological, laboratory and histopathological workout. The typical clinical syndrome is mononeuropathia multiplex or asymmetric neuropathy, but distal-symmetric neuropathy can frequently be seen. Standard treatments include steroids, azathioprine, methotrexate and cyclophosphamide. More recently the B-cell antibody rituximab and intravenous immunoglobulins have shown to be effective in some vasculitic neuropathy types.
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Affiliation(s)
- Franz Blaes
- Department of Neurology, KKH Gummersbach, Wilhelm-Breckow-Allee 20, 51643 Gummersbach, Germany
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185
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Louthrenoo W. Treatment considerations in patients with concomitant viral infection and autoimmune rheumatic diseases. Best Pract Res Clin Rheumatol 2015; 29:319-42. [DOI: 10.1016/j.berh.2015.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 05/08/2015] [Indexed: 12/17/2022]
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Loricera J, Blanco R, Hernández JL, Pina T, González-Vela MC, González-Gay MA. Biologic therapy in ANCA-negative vasculitis. Int Immunopharmacol 2015; 27:213-9. [PMID: 25828585 DOI: 10.1016/j.intimp.2015.03.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 03/10/2015] [Accepted: 03/14/2015] [Indexed: 01/20/2023]
Abstract
Standard therapeutic schemes for vasculitis are usually associated with numerous side effects and uneven clinical response. However, recent advances in understanding of the pathogenesis of these systemic diseases have resulted in the development of a group of biologic agents potentially useful in patients with vasculitis. Thus, anti-tumor necrosis factor-α drugs may be effective in patients with refractory Kawasaki disease but have failed to do so in giant cell arteritis, and their role in Takayasu arteritis is yet unclear. Preliminary reports on the use of the anti-IL6-receptor antibody, tocilizumab, in large-vessel vasculitis have been encouraging. Interferon alpha has showed positive results in hepatitis B virus-associated polyarteritis nodosa, and hepatitis C virus-induced cryoglobulinemia. Early experience with rituximab in several types of vasculitis has been quite promising, but must be confirmed in ongoing randomized clinical trials. The development of new biologic targeted therapies will probably open a hopeful future for patients with vasculitis.
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Affiliation(s)
- Javier Loricera
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avenida de Valdecilla s/n, 39008 Santander, Spain
| | - Ricardo Blanco
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avenida de Valdecilla s/n, 39008 Santander, Spain
| | - José L Hernández
- Department of Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avenida de Valdecilla s/n, 39008 Santander, Spain
| | - Trinitario Pina
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avenida de Valdecilla s/n, 39008 Santander, Spain
| | - M Carmen González-Vela
- Department of Pathology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avenida de Valdecilla s/n, 39008 Santander, Spain
| | - Miguel A González-Gay
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avenida de Valdecilla s/n, 39008 Santander, Spain.
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187
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Ferri C, Sebastiani M, Giuggioli D, Colaci M, Fallahi P, Piluso A, Antonelli A, Zignego AL. Hepatitis C virus syndrome: A constellation of organ- and non-organ specific autoimmune disorders, B-cell non-Hodgkin's lymphoma, and cancer. World J Hepatol 2015; 7:327-43. [PMID: 25848462 PMCID: PMC4381161 DOI: 10.4254/wjh.v7.i3.327] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/27/2014] [Accepted: 01/09/2015] [Indexed: 02/06/2023] Open
Abstract
The clinical course of chronic hepatitis C virus (HCV) infection is characterized by possible development of both liver and extrahepatic disorders. The tropism of HCV for the lymphoid tissue is responsible for several immune-mediated disorders; a poly-oligoclonal B-lymphocyte expansion, commonly observed in a high proportion of patients with HCV infection, are responsible for the production of different autoantibodies and immune-complexes, such as mixed cryoglobulins. These serological alterations may characterize a variety of autoimmune or neoplastic diseases. Cryoglobulinemic vasculitis due to small-vessel deposition of circulating mixed cryoglobulins is the prototype of HCV-driven immune-mediated and lymphoproliferative disorders; interestingly, in some cases the disease may evolve to frank malignant lymphoma. In addition, HCV shows an oncogenic potential as suggested by several clinico-epidemiological and laboratory studies; in addition to hepatocellular carcinoma that represents the most frequent HCV-related malignancy, a causative role of HCV has been largely demonstrated in a significant percentage of patients with isolated B-cells non-Hodgkin's lymphomas. The same virus may be also involved in the pathogenesis of papillary thyroid cancer, a rare neoplastic condition that may complicate HCV-related thyroid involvement. Patients with HCV infection are frequently asymptomatic or may develop only hepatic alteration, while a limited but clinically relevant number can develop one or more autoimmune and/or neoplastic disorders. Given the large variability of their prevalence among patients' populations from different countries, it is possible to hypothesize a potential role of other co-factors, i.e., genetic and/or environmental, in the pathogenesis of HCV-related extra-hepatic diseases.
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Affiliation(s)
- Clodoveo Ferri
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Marco Sebastiani
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Dilia Giuggioli
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Michele Colaci
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Poupak Fallahi
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Alessia Piluso
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Alessandro Antonelli
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - Anna Linda Zignego
- Clodoveo Ferri, Marco Sebastiani, Dilia Giuggioli, Michele Colaci, Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
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188
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Fanouriakis A, Kougkas N, Vassilopoulos D, Fragouli E, Repa A, Sidiropoulos P. Rituximab for eosinophilic granulomatosis with polyangiitis with severe vasculitic neuropathy: Case report and review of current clinical evidence. Semin Arthritis Rheum 2015; 45:60-6. [PMID: 25908179 DOI: 10.1016/j.semarthrit.2015.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 03/09/2015] [Accepted: 03/17/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Rituximab is approved for the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. Our objective was to review published clinical evidence on the efficacy of rituximab in the treatment of eosinophilic granulomatosis and polyangiitis (EGPA). METHODS We describe a case of refractory EGPA with severe vasculitic neuropathy, which responded impressively to B-cell-depleting therapy. A systematic search of the English literature was also performed to capture all available clinical evidence on the use of rituximab in EGPA. RESULTS We identified a total of 73 EGPA patients who have been treated with rituximab, all data coming from case series or isolated case reports. The majority of patients (85.1%) were treated for refractory or relapsing disease; a mean (SD) of 2.1 (0.9) different immunosuppressive agents were used prior to rituximab administration. Efficacy of RTX therapy was significant in the majority of cases and in a wide variety of disease manifestations; however, a lack of standardized assessment of disease activity before and after treatment was observed in many reports. Overall, 54.0% of patients were treated with a single cycle of rituximab and only 10.8% experienced relapses of the disease. Few significant side effects were observed during a highly variable period of follow-up (3 months to 5 years), mainly severe infections and allergic reactions. CONCLUSIONS RTX seems to be effective in cases of severe EGPA refractory to standard of care immunosuppressive treatment, although support comes from case reports and non-controlled studies.
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Affiliation(s)
- Antonis Fanouriakis
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece.
| | - Nikolaos Kougkas
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine, Hippokration General Hospital, Athens University School of Medicine, Athens, Greece
| | - Eleni Fragouli
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
| | - Argyro Repa
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
| | - Prodromos Sidiropoulos
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
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189
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Combined treatment with antiviral therapy and rituximab in patients with mixed cryoglobulinemia: review of the literature and report of a case using direct antiviral agents-based antihepatitis C virus therapy. Case Reports Immunol 2015; 2015:816424. [PMID: 25815218 PMCID: PMC4359800 DOI: 10.1155/2015/816424] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 01/09/2015] [Accepted: 01/20/2015] [Indexed: 12/15/2022] Open
Abstract
Mixed cryoglobulinemia (MC) is an autoimmune/B-cell lymphoproliferative disorder associated with Hepatitis C Virus (HCV) infection, manifesting as a systemic vasculitis. In the last decade, antiviral treatment (AT) with pegylated interferon (Peg-IFN) plus ribavirin (RBV) was considered the first therapeutic option for HCV-MC. In MC patients ineligible or not responsive to antivirals, the anti-CD20 monoclonal antibody rituximab (RTX) is effective. A combined AT plus RTX was also suggested. Since the introduction of direct acting antivirals (DAAs), few data were published about MC and no data about a combined schedule. Here, we report a complete remission of MC after a sustained virological response following a combined RTX/Peg-IFN+RBV+DAA (boceprevir) treatment and review the literature about the combined RTX/AT.
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190
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Ghetie D, Mehraban N, Sibley CH. Cold Hard Facts of Cryoglobulinemia. Rheum Dis Clin North Am 2015; 41:93-108, viii-ix. [DOI: 10.1016/j.rdc.2014.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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191
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Rossa AD, Tavoni A, Bombardieri S. Cryoglobulinemia. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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192
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Vassilopoulos D, Calabrese LH. Rheumatologic aspects of viral infections. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00110-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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193
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Saadoun D, Resche Rigon M, Pol S, Thibault V, Blanc F, Pialoux G, Karras A, Bazin-Kara D, Cazorla C, Vittecoq D, Musset L, Peltier J, Decaux O, Ziza JM, Lambotte O, Cacoub P. PegIFNα/ribavirin/protease inhibitor combination in severe hepatitis C virus-associated mixed cryoglobulinemia vasculitis. J Hepatol 2015; 62:24-30. [PMID: 25135864 DOI: 10.1016/j.jhep.2014.08.015] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 07/15/2014] [Accepted: 08/09/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS The aim of this study was to analyse the safety and efficacy of the PegIFNα/ribavirin/protease inhibitor combination in severe and/or refractory hepatitis C virus (HCV)-mixed cryoglobulinemia (MC) vasculitis. METHODS This prospective cohort study included 30 patients (median age 59 years [53-66] and 57% of women) with HCV-MC vasculitis. PegIFNα/ribavirin (for 48 weeks) was associated with telaprevir (375 mg three times daily, for 12 weeks, [n = 17]) or boceprevir (800 mg three times daily, for 44 weeks, (n = 13]). RESULTS Twenty three patients (76.7%) were non-responders to previous antiviral therapy. At week 72, twenty patients (66.7%) were complete clinical and sustained virological responders. The cryoglobulin level decreased from 0.45 to 0 g/L (p<0.0001) and the C4 level increased from 0.09 to 0.14 g/L (p = 0.017). Complete clinical responders had a higher frequency of purpura (16/20 [80%] vs. 4/10 [40%], p = 0.045), and a trend towards lower frequency of neuropathy (9/20 (45%) vs. 8/10 [80%], p = 0.12) compared with partial responders. Serious adverse events occurred in 14 patients (46.6%) during the 72 weeks of follow-up. Twenty eight patients (93.3%) received erythropoietin, 14 (46.6%) had red blood cell transfusion and 2 (6.6%) received granulocyte stimulating agent. The baseline factors associated with serious adverse events included liver fibrosis (p = 0.045) and a low platelet count (p = 0.021). CONCLUSIONS The PegIFNα/ribavirin/protease inhibitor combination is highly effective in severe and/or refractory HCV-MC at the cost of frequent side effects. Baseline platelet count and liver fibrosis are useful in guiding treatment decisions.
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Affiliation(s)
- David Saadoun
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital Pitié-Salpétrière, DHU I2B, Immunopathology, Inflammation, Biotherapy, Paris, France; Université Pierre et Marie Curie, Paris VI, UMR CNRS 7211, INSERM U959, Hôpital Pitié-Salpétrière, Paris, France.
| | | | - Stanislas Pol
- Department of Hepatology, Hôpital Necker, Paris, France
| | - Vincent Thibault
- Department of Virology, Hôpital Pitié-Salpétrière, Paris, France
| | - François Blanc
- Department of Internal Medicine, Hôpital Lapeyronie, Montpellier, France
| | - Gilles Pialoux
- Department of Infectious Diseases, Hôpital Tenon, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen George Pompidou, Paris, France
| | | | - Cécile Cazorla
- Department of Internal Medicine, Centre Hospitalier de Nouvelle Calédonie, Nouméa, France
| | - Daniel Vittecoq
- Department of Infectious Diseases, Hôpital Paul Brousse, Villejuif, France
| | - Lucile Musset
- Laboratory of Immunochemistry, Hôpital Pitié-Salpétrière, Paris, France
| | - Julie Peltier
- Department of Nephrology, Hôpital Tenon, Paris, France
| | - Olivier Decaux
- Department of Internal Medicine, Hôpital Sud, Rennes, France
| | - Jean-Marc Ziza
- Department of Internal Medicine, Hôpital Croix Saint Simon, Paris, France
| | - Olivier Lambotte
- Department of Internal Medicine, Hôpital Bicêtre, Kremlin Bicêtre, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital Pitié-Salpétrière, DHU I2B, Immunopathology, Inflammation, Biotherapy, Paris, France; Université Pierre et Marie Curie, Paris VI, UMR CNRS 7211, INSERM U959, Hôpital Pitié-Salpétrière, Paris, France.
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194
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Alix JJ, Hadjivassiliou M, Ali R, Slater D, Messenger AG, Rao DG. Sensory ganglionopathy with livedoid vasculopathy controlled by immunotherapy. Muscle Nerve 2014; 51:296-301. [DOI: 10.1002/mus.24452] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2014] [Indexed: 12/26/2022]
Affiliation(s)
- James J.P. Alix
- Department of Clinical Neurophysiology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield S10 2JF
| | - Marios Hadjivassiliou
- Department of Neurology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - Rokiahmah Ali
- Department of Histopathology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - David Slater
- Department of Histopathology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - Andrew G. Messenger
- Department of Dermatology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - D. Ganesh Rao
- Department of Clinical Neurophysiology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield S10 2JF
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195
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Benstead TJ, Chalk CH, Parks NE. Treatment for cryoglobulinemic and non-cryoglobulinemic peripheral neuropathy associated with hepatitis C virus infection. Cochrane Database Syst Rev 2014; 2014:CD010404. [PMID: 25525951 PMCID: PMC11232532 DOI: 10.1002/14651858.cd010404.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Peripheral neuropathy is the most common neurologic complication of hepatitis C virus (HCV) infection. The pathophysiology of the neuropathy associated with HCV is not definitively known; however, proposed mechanisms include cryoglobulin deposition in the vasa nervorum and HCV-mediated vasculitis. The optimal treatment for HCV-related peripheral neuropathy has not been established. OBJECTIVES To assess the effects of interventions (including interferon alfa, interferon alfa plus ribavirin, corticosteroids, cyclophosphamide, plasma exchange, and rituximab) for cryoglobulinemic or non-cryoglobulinemic peripheral neuropathy associated with HCV infection. SEARCH METHODS On 26 August 2014, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We also searched two trials registers, the Networked Digital Library of Theses and Dissertations (NDLTD) (October 2014), and three other databases. We checked references in identified trials and requested information from trial authors to identify any additional published or unpublished data. SELECTION CRITERIA We included all randomized controlled trials (RCTs) and quasi-RCTs involving participants with cryoglobulinemic or non-cryoglobulinemic peripheral neuropathy associated with HCV infection. We considered any intervention (including interferon alfa, interferon alfa plus ribavirin, corticosteroids, cyclophosphamide, plasma exchange, and rituximab) alone or in combination versus placebo or another intervention ('head-to-head' comparison study design) evaluated after a minimum interval to follow-up of at least six months. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. The planned primary outcome was change in sensory impairment (using any validated sensory neuropathy scale or quantitative sensory testing) at the end of the follow-up period. Other planned outcomes were: change in impairment (any validated combined sensory and motor neuropathy scale), change in disability (any validated disability scale), electrodiagnostic measures, number of participants with improved symptoms of neuropathy (global impression of change), and severe adverse events. MAIN RESULTS Four trials of HCV-related cryoglobulinemia fulfiled selection criteria and the review authors included three in quantitative synthesis. All studies were at high risk of bias. No trial addressed the primary outcome of change in sensory impairment. No trial addressed secondary outcomes of change in combined sensory and motor impairment, disability, or electrodiagnostic measures. A single trial of HCV-related mixed cryoglobulinemia treated with pegylated interferon alfa (peginterferon alfa), ribavirin, and rituximab versus peginterferon alfa and ribavirin did not show a significant difference in the number of participants with improvement in neuropathy at 36 months post treatment (risk ratio (RR) 4.00, 95% confidence interval (CI) 0.27 to 59.31, n = 9). One study of interferon alfa (n = 22) and two studies of rituximab (n = 61) provided adverse event data. Severe adverse events were no more common with interferon alfa (RR 7.00, 95% CI 0.38 to 128.02) or rituximab (RR 3.00, 95% CI 0.13 to 67.06) compared to the control group. AUTHORS' CONCLUSIONS There is a lack of RCTs and quasi-RCTs addressing the effects of interventions for peripheral neuropathy associated with HCV infection. At present, there is insufficient evidence from RCTs and quasi-RCTs to make evidence-based decisions about treatment.
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Affiliation(s)
- Tim J Benstead
- Department ofMedicine,Division ofNeurology,DalhousieUniversity, Room3828Halifax Infirmary, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada.
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196
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Cacoub P, Gragnani L, Comarmond C, Zignego AL. Extrahepatic manifestations of chronic hepatitis C virus infection. Dig Liver Dis 2014; 46 Suppl 5:S165-73. [PMID: 25458776 DOI: 10.1016/j.dld.2014.10.005] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/03/2014] [Indexed: 02/09/2023]
Abstract
Hepatitis C virus (HCV) infected patients are known to be at risk of developing liver complications i.e. cirrhosis and liver cancer. However, the risks of morbidity and mortality are underestimated because they do not take into account non-liver consequences of chronic hepatitis C virus infection. Numerous extrahepatic manifestations have been reported in up to 74% of patients, from perceived to disabling conditions. The majority of data concern hepatitis C virus-related autoimmune and/or lymphoproliferative disorders, from mixed cryoglobulinaemia vasculitis to frank lymphomas. More recently, other hepatitis C virus-associated disorders have been reported including cardiovascular, renal, metabolic, and central nervous system diseases. This review aims to outline most of the extrahepatic manifestations that are currently being investigated, including some of autoimmune and/or lymphoproliferative nature, and others in which the role of immune mechanisms appears less clear. Beyond the liver, hepatitis C virus chronic infection should be analyzed as a multifaceted systemic disease leading to heavy direct and indirect costs. The accurate consideration of extrahepatic consequences of such a systemic infection significantly increases the weight of its pathological burden. The need for effective viral eradication measures is underlined.
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Affiliation(s)
- Patrice Cacoub
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR_S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.
| | - Laura Gragnani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Cloe Comarmond
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR_S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - 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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197
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Montero N, Barrios C, Rodriguez E, Pascual J, Soler MJ. Treatment for hepatitis C virus-associated cryoglobulinaemic vasculitis. Hippokratia 2014. [DOI: 10.1002/14651858.cd011403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nuria Montero
- Hospital Universitari de Bellvitge; Department of Nephrology; Feixa LLarga s/n Barcelona Spain 08907
| | - Clara Barrios
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Eva Rodriguez
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Julio Pascual
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Maria Jose Soler
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
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198
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Zignego AL, Wojcik GL, Cacoub P, Visentini M, Casato M, Mangia A, Latanich R, Charles E, Gragnani L, Terrier B, Piazzola V, Dustin LB, Khakoo SI, Busch MP, Lauer GM, Kim AY, Alric L, Thomas DL, Duggal P. Genome-wide association study of hepatitis C virus- and cryoglobulin-related vasculitis. Genes Immun 2014; 15:500-5. [PMID: 25030430 PMCID: PMC4208981 DOI: 10.1038/gene.2014.41] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 01/12/2023]
Abstract
The host genetic basis of mixed cryoglobulin vasculitis is not well understood and has not been studied in large cohorts. A genome-wide association study was conducted among 356 hepatitis C virus (HCV) RNA-positive individuals with cryoglobulin-related vasculitis and 447 ethnically matched, HCV RNA-positive controls. All cases had both serum cryoglobulins and a vasculitis syndrome. A total of 899 641 markers from the Illumina HumanOmni1-Quad chip were analyzed using logistic regression adjusted for sex, as well as genetically determined ancestry. Replication of select single-nucleotide polymorphisms (SNPs) was conducted using 91 cases and 180 controls, adjusting for sex and country of origin. The most significant associations were identified on chromosome 6 near the NOTCH4 and MHC class II genes. A genome-wide significant association was detected on chromosome 6 at SNP rs9461776 (odds ratio=2.16, P=1.16E-07) between HLA-DRB1 and DQA1: this association was further replicated in additional independent samples (meta-analysis P=7.1 × 10(-9)). A genome-wide significant association with cryoglobulin-related vasculitis was identified with SNPs near NOTCH4 and MHC Class II genes. The two regions are correlated and it is difficult to disentangle which gene is responsible for the association with mixed cryoglobulinemia vasculitis in this extended major histocompatibility complex region.
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Affiliation(s)
| | - Genevieve L. Wojcik
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD, United States
| | | | | | | | - Alessandra Mangia
- Liver Unity, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Rachel Latanich
- Department of Medicine, Johns Hopkins Medical Institution, Baltimore MD, United States
| | - Edgar Charles
- Rockefeller University, New York City NY, United States
| | | | | | - Valeria Piazzola
- Liver Unity, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | - Salim I. Khakoo
- University of Southampton, Southampton, England, United Kingdom
| | - Michael P. Busch
- Blood Systems Research Institute, San Francisco CA, United States
| | - George M. Lauer
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Arthur Y. Kim
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Laurent Alric
- Toulouse III University, CHU Purpan Hospital, Toulouse, France
| | - David L. Thomas
- Department of Medicine, Johns Hopkins Medical Institution, Baltimore MD, United States
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD, United States
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199
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Visco C, Finotto S. Hepatitis C virus and diffuse large B-cell lymphoma: Pathogenesis, behavior and treatment. World J Gastroenterol 2014; 20:11054-11061. [PMID: 25170194 PMCID: PMC4145748 DOI: 10.3748/wjg.v20.i32.11054] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/25/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
A significant association between hepatitis C virus (HCV) infection and B-cell lymphoma has been reported by epidemiological studies, most of them describing a strong relationship between indolent lymphomas and HCV. Furthermore, the curative potential of antiviral therapy on HCV related indolent lymphomas supports a specific role for the virus in lymphomagenesis. These observations are reinforced by numerous laboratory experiments that led to several hypothetical models of B-cell transformation by HCV. Diffuse large B-cell lymphoma (DLBCL), the most common lymphoma subtype in the western countries, has been associated to HCV infection despite its aggressive nature. This association seems particularly prominent in some geographical areas. Clinical presentation of HCV-associated DLBCL has consistently been reported to differ from the HCV-negative counterpart. Nevertheless, histopathology, tolerance to standard-of-care chemo-immunotherapy (R-CHOP or CHOP-like regimens) and final outcome of HCV-positive DLBCL patients is still matter of debate. Addition of rituximab has been described to enhance viral replication but the probability of severe hepatic complications remains low, with some exceptions (i.e., hepatitis B virus or immune immunodeficiency virus co-infected patients, presence of grade > 2 transaminases elevation, cirrhosis or hepatocarcinoma). HCV viral load in this setting is not necessarily directly associated with liver damage. Overall, treatment of HCV associated DLBCL should be performed in an interdisciplinary approach with hepatologists and hematologists with close monitoring of liver function. Available reports reveal that the final outcome of HCV-positive DLBCL that receive standard immunochemotherapy is not inferior to their HCV-negative counterpart. This review summarizes data on epidemiology, pathogenesis and therapeutic approach on HCV-associated DLBCL. Several issues that are matter of debate like clinical management of patients with transaminase elevation, criteria for discontinuing or starting immuno-chemotherapy, as well as the exact role of monoclonal antibodies will be analyzed.
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MESH Headings
- Animals
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antiviral Agents/therapeutic use
- Cell Transformation, Viral
- Drug Resistance, Neoplasm
- Hepacivirus/drug effects
- Hepacivirus/pathogenicity
- Hepatitis C/diagnosis
- Hepatitis C/drug therapy
- Hepatitis C/epidemiology
- Hepatitis C/virology
- Humans
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/epidemiology
- Lymphoma, Large B-Cell, Diffuse/virology
- Treatment Outcome
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200
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Palazzi C, D'Amico E, D'Angelo S, Gilio M, Leccese P, Olivieri I. An update on the management of hepatitis C virus-related arthritis. Expert Opin Pharmacother 2014; 15:2039-45. [PMID: 25146875 DOI: 10.1517/14656566.2014.946404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV)-related arthritis is an uncommon disease belonging to the autoimmune disorders due to the chronic stimulus exerted by the virus on the immune system. It shows two clinical subsets: a symmetrical polyarthritis resembling rheumatoid arthritis but less aggressive and an intermittent mono-oligoarthritis involving the lower limbs. AREAS COVERED We extensively review the current literature using the largest electronic databases (MEDLINE, EMBASE and COCHRANE) with regard to HCV-related arthritis (HCVrA) and studies focusing on the co-existence of HCV and other kinds of arthritides. EXPERT OPINION The therapeutic approach to HCVrA remains largely empirical, because few studies have been published on this topic. Mainstream treatment based on the administration of hydroxychloroquine and low doses of corticosteroid is still largely preferred. Cyclosporine represents a useful alternative due to its antiviral properties. Anti-TNF agents are safe, but their hypothetic use appears excessive for a mild disorder such as HCVrA. IFN-α (and more recently pegylated IFN-α) when administered as a component of the combined (IFN-α + ribavirin) anti-HCV therapy can promote the appearance or the worsening of several autoimmune HCV-related disorders, including arthritis. New and forthcoming antiviral molecules will be used in the near future for a revolutionary IFN-free treatment.
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Affiliation(s)
- Carlo Palazzi
- San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Rheumatology Department of Lucania , Potenza , Italy
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