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Abstract
Human marginal zone (MZ) B cells are, in a sense, a new entity. Although they share many properties with their mouse counterpart, they also display striking differences, such as the capacity to recirculate and the presence of somatic mutations in their B cell receptor. These differences are the reason they are often not considered a separate, rodent-like B cell lineage, but rather are considered IgM memory B cells. We review here our present knowledge concerning this subset and the arguments in favor of the proposition that humans have evolved for their MZ B cell compartment a separate B cell population that develops and diversifies its Ig receptor during ontogeny outside T-dependent or T-independent immune responses.
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Affiliation(s)
- Jean-Claude Weill
- INSERM U783, Développement du Système Immunitaire, Université Paris Descartes, Faculté de Médecine, Site Necker-Enfants Malades, 75730 Paris Cedex 15, France.
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202
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Palanichamy A, Barnard J, Zheng B, Owen T, Quach T, Wei C, Looney RJ, Sanz I, Anolik JH. Novel human transitional B cell populations revealed by B cell depletion therapy. THE JOURNAL OF IMMUNOLOGY 2009; 182:5982-93. [PMID: 19414749 DOI: 10.4049/jimmunol.0801859] [Citation(s) in RCA: 205] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Transitional cells represent a crucial step in the differentiation and selection of the mature B cell compartment. Human transitional B cells have previously been variably identified based on the high level of expression of CD10, CD24, and CD38 relative to mature B cell populations and are expanded in the peripheral blood following rituximab-induced B cell-depletion at reconstitution. In this study, we take advantage of the gradual acquisition of the ABCB1 transporter during B cell maturation to delineate refined subsets of transitional B cells, including a late transitional B cell subset with a phenotype intermediate between T2 and mature naive. This late transitional subset appears temporally following the T1 and T2 populations in the peripheral compartment after rituximab-induced B cell reconstitution (and is thus termed T3) and is more abundant in normal peripheral blood than T1 and T2 cells. The identity of this subset as a developmental intermediate between early transitional and mature naive B cells was further supported by its ability to differentiate to naive during in vitro culture. Later transitional B cells, including T2 and T3, are found at comparatively increased frequencies in cord blood and spleen but were relatively rare in bone marrow. Additional studies demonstrate that transitional B cells mature across a developmental continuum with gradual up-regulation of mature markers, concomitant loss of immature markers, and increased responsiveness to BCR cross-linking in terms of proliferation, calcium flux, and survival. The characterization of multiple transitional B cell subpopulations provides important insights into human B cell development.
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Affiliation(s)
- Arumugam Palanichamy
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
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203
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Reconstitution of Peripheral Allospecific CD19+ B-Cell Subsets After B-Lymphocyte Depletion Therapy in Renal Transplant Patients. Transplantation 2009; 87:1394-401. [DOI: 10.1097/tp.0b013e3181a27683] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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204
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Möller B, Aeberli D, Eggli S, Fuhrer M, Vajtai I, Vögelin E, Ziswiler HR, Dahinden CA, Villiger PM. Class-switched B cells display response to therapeutic B-cell depletion in rheumatoid arthritis. Arthritis Res Ther 2009; 11:R62. [PMID: 19419560 PMCID: PMC2714106 DOI: 10.1186/ar2686] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Revised: 03/10/2009] [Accepted: 05/06/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Reconstitution of peripheral blood (PB) B cells after therapeutic depletion with the chimeric anti-CD20 antibody rituximab (RTX) mimics lymphatic ontogeny. In this situation, the repletion kinetics and migratory properties of distinct developmental B-cell stages and their correlation to disease activity might facilitate our understanding of innate and adaptive B-cell functions in rheumatoid arthritis (RA). METHODS Thirty-five 'RTX-naïve' RA patients with active arthritis were treated after failure of tumour necrosis factor blockade in an open-label study with two infusions of 1,000 mg RTX. Prednisone dose was tapered according to clinical improvement from a median of 10 mg at baseline to 5 mg at 9 and 12 months. Conventional disease-modifying antirheumatic drugs were kept stable. Subsets of CD19+ B cells were assessed by flow cytometry according to their IgD and CD27 surface expression. Their absolute number and relative frequency in PB were followed every 3 months and were determined in parallel in synovial tissue (n = 3) or synovial fluid (n = 3) in the case of florid arthritis. RESULTS Six of 35 patients fulfilled the European League Against Rheumatism criteria for moderate clinical response, and 19 others for good clinical response. All PB B-cell fractions decreased significantly in number (P < 0.001) after the first infusion. Disease activity developed independently of the total B-cell number. B-cell repopulation was dominated in quantity by CD27-IgD+ 'naïve' B cells. The low number of CD27+IgD- class-switched memory B cells (MemB) in the blood, together with sustained reduction of rheumatoid factor serum concentrations, correlated with good clinical response. Class-switched MemB were found accumulated in flaring joints. CONCLUSIONS The present data support the hypothesis that control of adaptive immune processes involving germinal centre-derived, antigen, and T-cell-dependently matured B cells is essential for successful RTX treatment.
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Affiliation(s)
- Burkhard Möller
- Clinic for Rheumatology, Clinical Immunology, and Allergology, Inselspital - University Hospital of Bern, Freiburgstrasse, Bern 3010, Switzerland.
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205
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Abstract
The basic understanding of inflammatory dermatoses and autoimmune-mediated skin disorders has greatly advanced and broadened our understanding of underlying immune mechanisms that shape the complex network of chronic inflammation and autoimmunity. The new treatment options for psoriasis exemplify how new insights into (auto)immune responses, especially the role and function of various immune cells and proinflammatory cytokines, may lead to new therapeutic strategies. The concept of targeting B cells in autoimmune-mediated disorders is closely related to the discovery of autoantibodies and their cellular origin. However, the appreciation of B cells in autoimmunity has significantly changed and is not limited to their role as progenitors of autoantibody secreting plasma cells. Recent investigations of various inflammatory skin diseases, that is, autoimmune blistering disorders, collagen vascular diseases, and atopic dermatitis, actually support the concept that B cells might be as important as T cells in the etiopathogenesis of these disorders. The striking clinical improvement seen in patients with rheumatoid arthritis following B-cell depletion with the anti-CD20 mAb rituximab has tremendously catalyzed the interest in B-cell-targeted therapies in different autoimmune diseases. Future translational and clinical investigations are mandatory to precisely define the role and the contribution of impaired B-cell function in (auto)immune-mediated skin diseases.
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206
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Palanichamy A, Roll P, Theiss R, Dörner T, Tony HP. Modulation of molecular imprints in the antigen-experienced B cell repertoire by rituximab. ACTA ACUST UNITED AC 2009; 58:3665-74. [PMID: 19035487 DOI: 10.1002/art.24141] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Transient B cell depletion by rituximab has recently gained more importance in the treatment of rheumatic disorders. Nevertheless, little is known about the reemerging B cells. We analyzed dynamic changes in the repopulating B cells, particularly the postswitch B cells, and studied the mutational patterns of Ig genes in antigen-experienced B cells. METHODS Five patients with active rheumatoid arthritis (RA) were treated with rituximab. In 3 patients, B cell receptor (BCR) gene analysis was performed before treatment and during B cell recovery using genomic DNA. In 2 patients, B cell subsets were studied during the early recovery phase using single-cell technology. For comparison, immunophenotyping of B cell subsets was performed. RESULTS Early B cell recovery was marked by a relatively expanded population of highly mutated B cells, which were correlated with B cells with a plasmablast phenotype on comparative immunophenotyping. Analysis of the mutational pattern in these cells revealed increased RGYW/WRCY (where R = A/G, Y = C/T, and W = A/T) hotspot targeting (44% before rituximab versus 59% after) and elevated ratios of replacement to silent mutations within the complementarity-determining regions in Ig genes (1.87 before rituximab versus 2.67 after; P < or = 0.0025). CONCLUSION Our findings show that rituximab leads to qualitative changes in the imprints of highly mutated, antigen-experienced BCRs, representing the result of selection, whereas molecular processes such as Ig V rearrangements are not affected by this treatment.
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207
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Singh N, Pirsch J, Samaniego M. Antibody-mediated rejection: treatment alternatives and outcomes. Transplant Rev (Orlando) 2009; 23:34-46. [PMID: 19027615 DOI: 10.1016/j.trre.2008.08.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Over the past 10 years, thanks to the development of sensitive methods of antibody detection and markers of antibody injury such as C4d staining, the role of anti-human leukocyte antigen (HLA) and non-HLA alloantibodies as effectors of acute and chronic immune allograft injury has been revisited. Antibody-mediated rejection (AMR) defines all allograft rejection caused by antibodies directed against donor-specific HLA molecules, blood group antigen (ABO)-isoagglutinins, or endothelial cell antigens. Antibody-mediated rejection can be a recalcitrant process, resistant to therapy and carries an ominous prognosis to the graft. In concordance with these views, treatment protocols for AMR use permutations of a multiple-prong approach that include (1) the suppression of the T-cell dependent antibody response, (2) the removal of donor reactive antibody, (3) the blockade of the residual alloantibody, and (4) the depletion of naive and memory B-cells. Although all published protocols report a variable rate of success, a major weakness of all current protocols is the lack of effective anti-plasma cell agents. In comparison to acute AMR, the treatment for chronic AMR (CAMR) is not well characterized. Although in acute AMR large titers of pre-existent alloantibodies result in massive activation of the complement system and lytic injury of the graft endothelium, thereby requiring aggressive and fast removal of the offending agents, in CAMR, complement activation results in sublytic endothelial cell injury and activation. Although this type of injury results in chronic graft failure, its slow progression likely renders it amenable of suppression by heightening of maintenance immunosuppression and anti-idiotypic blockade of the circulating alloantibody without the need of plasma exchange. In this review, we will discuss the rationale behind the design of treatment protocols for acute AMR and CAMR as well as their reported results and complications.
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Affiliation(s)
- Neeraj Singh
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53713, USA
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208
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Feuchtenberger M, Kneitz C, Roll P, Kleinert S, Tony HP. Sustained Remission After Combination Therapy with Rituximab and Etanercept in Two Patients with Rheumatoid Arthritis After TNF Failure: Case Report. Open Rheumatol J 2009; 3:9-13. [PMID: 19479056 PMCID: PMC2684711 DOI: 10.2174/1874312900903010009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 01/05/2009] [Accepted: 01/08/2009] [Indexed: 01/04/2023] Open
Abstract
Objectives: Approximately up to 40% of patients with rheumatoid arthritis (RA) fail to respond to tumor necrosis factor (TNF) inhibitors, lose response over time or are unable to tolerate treatment. Materials and Methodology: We report two female patients suffering from active, refractory rheumatoid arthritis despite TNF blocking agents who have been treated with rituximab added to ongoing therapy with etanercept. Results: Combination therapy was tolerated without any acute side effects. Both patients improved with a significant, long lasting reduction of disease activity (DAS28, CRP). Evaluation of the immunological parameters showed the expected B-cell depletion and a transient reduction of immunoglobulin-levels. One patient developed four serious infections requiring antibiotic treatment (1 pneumonia, 3 exacerbations of her pre-existing chronic bronchitis) within follow up of 45 months. Conclusion: Combination therapy of rituximab and etanercept lead to a significant improvement of clinical disease activity and inflammatory parameters in two RA patients refractory to anti-TNF treatment.
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Affiliation(s)
- Martin Feuchtenberger
- University of Würzburg, Dept. of Medicine II, Rheumatology and Clinical Immunology, Germany; Department of Medicine II, Klinikum Südstadt Rostock, Germany
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209
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Blank N, Max R, Schiller M, Briem S, Lorenz HM. Safety of combination therapy with rituximab and etanercept for patients with rheumatoid arthritis. Rheumatology (Oxford) 2009; 48:440-1. [DOI: 10.1093/rheumatology/ken491] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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210
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Feuchtenberger M, Müller S, Roll P, Waschbisch A, Schäfer A, Kneitz C, Wiendl H, Tony HP. Frequency of regulatory T cells is not affected by transient B cell depletion using anti-CD20 antibodies in rheumatoid arthritis. Open Rheumatol J 2008; 2:81-8. [PMID: 19156222 PMCID: PMC2627533 DOI: 10.2174/1874312900802010081] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 11/10/2008] [Accepted: 11/12/2008] [Indexed: 12/13/2022] Open
Abstract
Objectives Transient B cell depletion with the monoclonal anti-CD20 antibody rituximab has shown favourable clinical responses in patients with rheumatoid arthritis (RA). Recently a characteristic regeneration pattern of B cell subpopulations has been reported. However, little is known about the impact of B-cell depletion on peripheral T cells in particular regulatory T cells. Materials and Methodology 17 patients with RA having failed anti-TNF were treated with rituximab. Four colour staining was performed using CD19, CD3, CD4, CD8, CD16, CD56, CD25, HLA-DR, HLA-G and intracellular Foxp3 at five time points spanning up to 12 months after rituximab. In addition, quantification of the soluble form of the HLA class I molecule HLA-G by ELISA has been performed. Results Peripheral B cell depletion lasted 6 to 9 months. The absolute number of CD3+, CD4+ and CD8+ lymphocytes showed no significant changes up to 1 year after B-cell depletion compared to before therapy. Only the relative frequency for CD3 and CD4 showed a significant increase (p < 0.05). In particular, CD4+CD25++ and Foxp3 positive regulatory T cells remained constant. The percentage of HLA-G positive cells in the CD4+ or CD8+ population did not change significantly either. The amount of sHLA-G remained without significant changes. Conclusion Absolute T cell counts showed no significant changes after rituximab compared to the time point before therapy.In particular, the frequency of regulatory T cells with a CD4+CD25++ phenotype as well as positive Foxp3 expression were numerically stable. Additionally, HLA-G positive regulatory T cells and soluble levels of HLA-G showed no significant changes.
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Affiliation(s)
- Martin Feuchtenberger
- University of Würzburg, Department of Medicine II, Rheumatology and Clinical Immunology, Germany.
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211
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B-Cell Depletion Immunotherapy in Pemphigus: Effects on Cellular and Humoral Immune Responses. J Invest Dermatol 2008; 128:2859-69. [DOI: 10.1038/jid.2008.178] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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212
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Zarkhin V, Li L, Kambham N, Sigdel T, Salvatierra O, Sarwal MM. A randomized, prospective trial of rituximab for acute rejection in pediatric renal transplantation. Am J Transplant 2008; 8:2607-17. [PMID: 18808404 DOI: 10.1111/j.1600-6143.2008.02411.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report 1-year outcomes of a randomized study of Rituximab versus standard-of-care immunosuppression (Thymoglobulin and/or pulse steroids) for treatment of biopsy confirmed, acute transplant rejection with B-cell infiltrates, in 20 consecutive recipients (2-23 years). Graft biopsies, with Banff and CADI scores, CD20 and C4d stains, were performed at rejection and 1 and 6 months later. Peripheral blood CMV, EBV and BK viral loads, graft function, DSA, immunoglobulins, serum humanized antichimeric antibody (HACA) and Rituximab, and lymphocyte counts were monitored until 1 year posttreatment. Rituximab infusions were given with a high index of safety without HACA development and increased infections complications. Rituximab therapy resulted in complete tissue B-cell depletion and rapid peripheral B-cell depletion. Peripheral CD19 cells recovered at a mean time of approximately 12 months. There were some benefits for the recovery of graft function (p = 0.026) and improvement of biopsy rejection scores at both the 1- (p = 0.0003) and 6-month (p < 0.0001) follow-up biopsies. Reappearance of C4d deposition was not seen on follow-up biopsies after Rituximab therapy, but was seen in 30% of control patients. There was no change in DSA in either group, independent of rejection resolution. This study reports safety and suggests further investigation of Rituximab as an adjunctive treatment for B-cell-mediated graft rejection.
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Affiliation(s)
- V Zarkhin
- Department of Pediatrics, Stanford University Medical Center, Stanford, CA, USA
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213
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Harvey BP, Quan TE, Rudenga BJ, Roman RM, Craft J, Mamula MJ. Editing antigen presentation: antigen transfer between human B lymphocytes and macrophages mediated by class A scavenger receptors. THE JOURNAL OF IMMUNOLOGY 2008; 181:4043-51. [PMID: 18768860 DOI: 10.4049/jimmunol.181.6.4043] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
B lymphocytes can function independently as efficient APCs. However, our previous studies demonstrate that both dendritic cells and macrophages are necessary to propagate immune responses initiated by B cell APCs. This finding led us to identify a process in mice whereby Ag-specific B cells transfer Ag to other APCs. In this study, we report the ability and mechanism by which human B lymphocytes can transfer BCR-captured Ag to macrophages. The transfer of Ag involves direct contact between the two cells followed by the capture of B cell-derived membrane and/or intracellular components by the macrophage. These events are abrogated by blocking scavenger receptor A, a receptor involved in the exchange of membrane between APCs. Macrophages acquire greater amounts of Ag in the presence of specific B cells than in their absence. This mechanism allows B cells to amplify or edit the immune response to specific Ag by transferring BCR-captured Ag to other professional APCs, thereby increasing the frequency of its presentation. Ag transfer may perpetuate chronic autoimmune responses to specific self-proteins and help explain the efficacy of B cell-directed therapies in human disease.
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Affiliation(s)
- Bohdan P Harvey
- Section of Rheumatology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
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214
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Martinez-Gamboa L, Mei H, Loddenkemper C, Ballmer B, Hansen A, Lipsky PE, Emmerich F, Radbruch A, Salama A, Dörner T. Role of the spleen in peripheral memory B-cell homeostasis in patients with autoimmune thrombocytopenia purpura. Clin Immunol 2008; 130:199-212. [PMID: 18977183 DOI: 10.1016/j.clim.2008.09.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 09/02/2008] [Accepted: 09/02/2008] [Indexed: 12/27/2022]
Abstract
The effect of splenectomy on circulating memory B cells in autoimmune thrombocytopenia purpura (AITP) patients has not yet been addressed. We therefore analyzed the distribution and phenotypic characteristics of B-cell subsets in non-splenectomized and splenectomized AITP patients and controls, as well as CD95 expression after B cell activation. Decreased frequencies of memory B cells in splenectomized individuals were observed, with a rapid decline of CD27+IgD+ and a slower decrease of CD27+IgD- and CD27-/IgD- cells. Similar results were noted following splenectomy in healthy donors (HD). CD95+ B cells were substantially increased in all subsets in patients with active AITP, indicating their enhanced activation status. After splenectomy, the percentage of CD95+ B cells were further increased in the CD27+IgD- post-switch memory population in AITP, but not in HD. CD95+CD27+ memory B cells largely reside in the region in the human spleen analogous to the murine marginal zone. Thus, the spleen plays a fundamental role in controlling peripheral memory B cell homeostasis in both AITP and HD and regulates activated CD95+ B cells in patients with AITP.
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Affiliation(s)
- Lorena Martinez-Gamboa
- Charité Center 14 for Tumor Medicine, Institute for Transfusion Medicine and Immune Hematology, Charité University Hospital, Berlin, Germany
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215
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[B-cell-depleting antibodies in skin diseases]. Hautarzt 2008; 59:793-805. [PMID: 18779943 DOI: 10.1007/s00105-008-1538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Basic insight into immune mechanisms, particularly the role and function of various immune cells and proinflammatory cytokines in the etiopathogenesis of inflammatory dermatoses and autoimmune skin disorders, has made possible the development of novel therapeutic strategies. Because of their properties as antigen presenting cells and progenitors of autoantibody-secreting plasma cells, B cells have a major impact in different autoimmune diseases and represent an important therapeutic target. The remarkable clinical improvement seen in patients with rheumatoid arthritis after treatment with the monoclonal anti-CD20 antibody, rituximab, has strongly augmented the interest in B-cell-targeted therapies in different autoimmune diseases. Future clinical and immunological investigations are mandatory to precisely define the contribution of impaired B-cell function in development and progression of autoimmune mediated skin disorders.
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216
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Scheeren FA, Nagasawa M, Weijer K, Cupedo T, Kirberg J, Legrand N, Spits H. T cell-independent development and induction of somatic hypermutation in human IgM+ IgD+ CD27+ B cells. ACTA ACUST UNITED AC 2008; 205:2033-42. [PMID: 18695003 PMCID: PMC2526198 DOI: 10.1084/jem.20070447] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
IgM+IgD+CD27+ B cells from peripheral blood have been described as circulating marginal zone B cells. It is still unknown when and where these cells develop. These IgM+IgD+CD27+ B cells exhibit somatic hypermutations (SHMs) in their B cell receptors, but the exact nature of the signals leading to induction of these SHMs remains elusive. Here, we show that IgM+IgD+CD27+ B cells carrying SHMs are observed during human fetal development. To examine the role of T cells in human IgM+IgD+CD27+ B cell development we used an in vivo model in which Rag2−/−γC−/− mice were repopulated with human hematopoietic stem cells. Using Rag2−/−γC−/− mice on a Nude background, we demonstrated that development and induction of SHMs of human IgM+IgD+CD27+ B cells can occur in a T cell–independent manner.
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Affiliation(s)
- Ferenc A Scheeren
- Department of Cell Biology and Histology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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217
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Hennigan S, Channick RN, Silverman GJ. Rituximab treatment of pulmonary arterial hypertension associated with systemic lupus erythematosus: a case report. Lupus 2008; 17:754-6. [DOI: 10.1177/0961203307087610] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract Pulmonary hypertension is a common but underdiagnosed complication of systemic lupus erythematosus, which can be associated with significant morbidity and early mortality. Although often associated with anti-phospholipid antibodies, the etiology remains poorly understood. In case reports and small open trials, the anti-CD20, B-cell targeted therapeutic antibody, rituximab, has been reported to provide benefits for systemic lupus erythematosus patients with glomerulonephritis, anti-phospholipid antibody syndrome, vasculitis, arthritis, and refractory skin disease. However, the outcome of rituximab treatment of pulmonary arterial hypertension associated with systemic lupus erythematosus has not been described. We, therefore, present a case of a young systemic lupus erythematosus patient with early onset of pulmonary arterial hypertension during the disease course, refractory to multiple treatment modalities, who had significant improvement with rituximab therapy.
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Affiliation(s)
- S Hennigan
- Department of Medicine, University of California, San Diego, California, USA
| | - RN Channick
- Department of Medicine, University of California, San Diego, California, USA
| | - GJ Silverman
- Department of Medicine, University of California, San Diego, California, USA,
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218
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Roll P, Dörner T, Tony HP. Anti-CD20 therapy in patients with rheumatoid arthritis: predictors of response and B cell subset regeneration after repeated treatment. ACTA ACUST UNITED AC 2008; 58:1566-75. [PMID: 18512772 DOI: 10.1002/art.23473] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE B cell depletion with the anti-CD20 antibody rituximab has proven efficacy in patients with rheumatoid arthritis (RA). The effects on B cell homeostasis after repeated treatments and the relationship of certain B cell subsets to clinical response or relapse are currently not known. METHODS In this open-label study, 17 patients with RA refractory to standard therapy were treated with 1 cycle of rituximab. Of these 17 patients, 11 received a second cycle of rituximab therapy. Immunophenotyping was performed before therapy and during B cell recovery. RESULTS Twelve of 17 patients showed a good European League Against Rheumatism response after receiving 1 cycle of rituximab therapy. At the time of B cell recovery, the IgD+,CD27+ memory B cell subset was significantly larger (P = 0.019) in the nonresponder group. Within the group of 12 responders, 6 patients, whose disease was characterized by a significantly higher proportion of overall CD27+ memory B cells before therapy, experienced an early relapse (weeks 24-40 posttreatment). Eleven patients were re-treated, again resulting in a good clinical response. B cell reconstitution followed a similar pattern after each cycle. The early reconstitution phase was characterized by immature CD38++,IgD+,CD10+ B cells, whereas the number of naive B cells increased continuously thereafter. The number of memory B cells was still reduced at the time of the second depletion but recovered to levels similar to those following the first cycle of therapy. CONCLUSION Data derived from repeated B lymphocyte depletion with rituximab in patients with RA suggest that analysis of certain memory B cell subsets provides information on efficacy, response, and late as well as early relapse, consistent with the conclusion that targeting memory B cells is a key to its mechanism of action.
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Affiliation(s)
- Petra Roll
- University of Würzburg, Wurzburg, Germany
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219
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Abstract
The therapy of rheumatoid arthritis has been revolutionised by advances in the understanding of disease at a cellular and molecular level accompanied by the technology to target specific mediators of disease. Proposed therapeutic targets from in vitro and animal models however have frequently resulted in unexpected outcomes in clinical trials. These have included have included cytokines, chemokines, the T cell receptor trimolecular complex, T cells and B cells. The most successful strategies have resulted from a close dialogue between clinical and laboratory work. The key stages in the development of these agents and remaining unanswered questions are reviewed.
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Affiliation(s)
- Edward M Vital
- Academic Section of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, LS7 4SA, UK
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221
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Lorenzi AR, Clarke AM, Wooldridge T, Waldmann H, Hale G, Symmons D, Hazleman BL, Isaacs JD. Morbidity and mortality in rheumatoid arthritis patients with prolonged therapy-induced lymphopenia: twelve-year outcomes. ACTA ACUST UNITED AC 2008; 58:370-5. [PMID: 18240243 DOI: 10.1002/art.23122] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess immunologically relevant outcomes in a cohort of rheumatoid arthritis (RA) patients with prolonged therapy-induced lymphopenia. METHODS Morbidity (infection or malignancy) and mortality were assessed in 53 RA patients who were treated with the lymphocytotoxic monoclonal antibody alemtuzumab between 1991 and 1994. Data were obtained by interview, medical record review, and Office for National Statistics mortality monitoring. Lymphocyte subsets were enumerated by flow cytometry. A retrospective, matched-cohort study of mortality was performed with 102 control subjects selected from the European League Against Rheumatism database of patients with rheumatic disorders. RESULTS Lymphopenia persisted in the patients: median CD3+CD4+, CD3+CD8+, CD19+, and CD56+ lymphocyte counts measured at a median followup of 11.8 years from the first administration of alemtuzumab were 0.50 x 10(9)/liter, 0.26 x 10(9)/liter, 0.11 x 10(9)/liter, and 0.09 x 10(9)/liter, respectively. Twenty-seven of 51 cases and 46 of 101 controls with available data had died, yielding a mortality rate ratio of 1.20 (95% confidence interval 0.72-1.98). Causes of death were similar to those that would be expected in a hospital-based RA cohort. No opportunistic infections were noted, and only 3 infections were documented following 36 elective orthopedic procedures. CONCLUSION Despite continued lymphopenia 11.8 years after therapy, our patient cohort did not exhibit excess mortality or unusual infection-related morbidity, and surgery was well tolerated. These data should be reassuring for clinicians and patients who are considering lymphocytotoxic or other immunomodulatory therapy for RA.
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Fleischmann RM. Safety of biologic therapy in rheumatoid arthritis and other autoimmune diseases: focus on rituximab. Semin Arthritis Rheum 2008; 38:265-80. [PMID: 18336874 DOI: 10.1016/j.semarthrit.2008.01.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 11/21/2007] [Accepted: 01/05/2008] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To review the safety of biologic agents used to treat rheumatoid arthritis (RA) and other autoimmune diseases, with a focus on rituximab. METHODS Information was gathered from a search of the PubMed database and from major congress abstract listings through June 2007. RESULTS Rituximab is approved for treating RA in patients with an inadequate response to TNF inhibitors and is under study in other indications for RA and other autoimmune disorders. The current safety profile of rituximab in RA is known from Phase II and III studies conducted preapproval, treating approximately 750 patients, as well as from long-term extension studies with repeated therapy. Clinical trials have established that the most common adverse events are infusion-associated reactions, seen in 29 to 40% of patients, most of which are mild to moderate and occur following the first rituximab infusion, with incidence and severity decreasing with subsequent infusions. Rates of infections and serious infections to date are within the range expected for RA patients treated with other biologic agents, but the longer term effects of B-cell depletion and the effects of repeated treatment on the risk of infections are uncertain. Information is limited for rituximab safety in other autoimmune disorders but current data do not suggest that there is a significant difference in adverse events from that previously reported. CONCLUSIONS Rituximab is an important addition to the rheumatologist's armamentarium for the treatment of difficult RA and ongoing trials will determine its utility in other indications for RA and other autoimmune conditions. The true safety profile of rituximab will emerge as larger numbers of patients are treated in routine clinical practice.
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Affiliation(s)
- Roy M Fleischmann
- University of Texas Southwestern Medical Center, and Metroplex Clinical Research Center, Dallas, TX 75235-5360, USA.
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Nakayama M, Kamei K, Nozu K, Matsuoka K, Nakagawa A, Sako M, Iijima K. Rituximab for refractory focal segmental glomerulosclerosis. Pediatr Nephrol 2008; 23:481-5. [PMID: 17973121 DOI: 10.1007/s00467-007-0640-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Revised: 08/19/2007] [Accepted: 09/11/2007] [Indexed: 11/24/2022]
Abstract
We present the cases of two children with steroid-resistant nephrotic syndrome (SRNS) who were treated with rituximab (anti-CD20 monoclonal antibody). Both were resistant to conventional therapy, and renal biopsy showed focal segmental glomerulosclerosis (FSGS). Combination therapy with methylprednisolone pulse therapy and plasmapheresis was the only way to decrease proteinuria. However, the patients suffered severe reactions to steroid treatment. We therefore treated them with rituximab in a single dose of 375 mg/m(2), which resulted in the rapid clearing of circulating CD19-positive B cells. One month after rituximab treatment, both achieved partial remission; one patient has maintained complete remission for 8 months, and the other relapsed 8 months after the first rituximab treatment with the recovery of peripheral B-cell counts and received a second rituximab treatment. She achieved complete remission 5 months after the second course and has maintained the remission for 2 months. We conclude that rituximab may be an effective treatment for refractory SRNS with FSGS.
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Affiliation(s)
- Makiko Nakayama
- Department of Nephrology, National Children's Medical Center, National Center for Child Health and Development, 10-1, Okura 2 chome, Setagaya-ku, Tokyo 157-8535, Japan
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Abstract
This article focuses on the initial results achieved with the more selective immunosuppressive approach of B-lymphocyte depletion in patients who fail cyclophosphamide or have contraindications for its use in the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This novel approach has sparked hope for patients and physicians in their search for effective, well-tolerated therapy for AAV. B-cell depletion is now undergoing rigorous investigation in randomized clinical trials.
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225
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Sutter JA, Kwan-Morley J, Dunham J, Du YZ, Kamoun M, Albert D, Eisenberg RA, Luning Prak ET. A longitudinal analysis of SLE patients treated with rituximab (anti-CD20): factors associated with B lymphocyte recovery. Clin Immunol 2008; 126:282-90. [PMID: 18226586 DOI: 10.1016/j.clim.2007.11.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 11/07/2007] [Accepted: 11/13/2007] [Indexed: 10/22/2022]
Abstract
Identifying factors associated with B lymphocyte depletion and recovery may aid the development of individualized treatment regimens, optimizing therapy for patients with autoimmune disease. In this study, 12 patients with active SLE were monitored at baseline and monthly following treatment with rituximab. The number and phenotype of peripheral blood B lymphocytes, T lymphocytes and natural killer cells were correlated with the extent and longevity of B lymphocyte depletion. This analysis generated three candidate biomarkers for lymphocyte monitoring in patients with autoimmune disease who are treated with rituximab: circulating transitional B cells, the kappa:lambda ratio and natural killer cells. Further refinement of these potential biomarkers may lead to a better understanding of the role of B cells in disease pathogenesis and a more rational use of B cell depletion therapies.
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Affiliation(s)
- Jennifer A Sutter
- Department of Pathology and Laboratory Medicine, School of Medicine, University of Pennsylvania, 405B Stellar Chance Labs, 422 Curie Boulevard, Philadelphia, PA 19104, USA
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Abstract
A revolution in the treatment of rheumatoid arthritis has occurred in recent years. This holds particularly true for B-cell-directed therapies for rheumatoid arthritis. The approval of rituximab for the treatment of rheumatoid arthritis has not only expanded the armamentarium of therapies for rheumatologists, but it has also led the way to better understanding of the biologic sequelae of these treatments as well as the potential to better understand the etiology of autoimmune diseases. This review updates the latest B-cell therapies in rheumatoid arthritis.
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Affiliation(s)
- Jennifer Kwan-Morley
- Division of Rheumatology, Dartmouth Hitchcock Medical Center, One Medical Drive, Lebanon, NH 03755, USA
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227
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Levesque MC, St Clair EW. B cell–directed therapies for autoimmune disease and correlates of disease response and relapse. J Allergy Clin Immunol 2008; 121:13-21; quiz 22-3. [PMID: 18206502 DOI: 10.1016/j.jaci.2007.11.030] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 11/30/2007] [Accepted: 11/30/2007] [Indexed: 11/18/2022]
Affiliation(s)
- Marc C Levesque
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC 27710, USA.
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228
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Abstract
Rheumatoid arthritis is characterised by pain, swelling, and destruction of joints, with resultant disability. Only disease-modifying antirheumatic drugs can interfere with the disease process. In the past few years, biological agents, especially inhibitors of tumour necrosis factor, have allowed for hitherto unseen therapeutic benefit, although even with these drugs the frequency and degree of responses are restricted. Therefore, new agents are needed, and three novel biological compounds for treatment of rheumatoid arthritis have already been used in practice or are on the horizon: rituximab (anti-CD20), abatacept (cytotoxic T-lymphocyte antigen 4 immunoglobulin), and tocilizumab (anti-interleukin 6 receptor). We discuss the targets of these drugs, the roles of these targets in the pathogenesis of rheumatoid arthritis, and the efficacy and adverse effects of these agents from clinical trial data. Novel therapeutic strategies in conjunction with optimised disease assessment for better treatment of rheumatoid arthritis and an outlook into potential future targets are also presented.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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229
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Anolik JH, Barnard J, Owen T, Zheng B, Kemshetti S, Looney RJ, Sanz I. Delayed memory B cell recovery in peripheral blood and lymphoid tissue in systemic lupus erythematosus after B cell depletion therapy. ACTA ACUST UNITED AC 2007; 56:3044-56. [PMID: 17763423 DOI: 10.1002/art.22810] [Citation(s) in RCA: 231] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Recent data suggest that the reconstituting peripheral B cell compartment after B cell depletion therapy may be functionally immature, with a preponderance of transitional B cells and a paucity of memory B cells. This study was undertaken to determine the magnitude, duration, and cause of these defects in rituximab-treated systemic lupus erythematosus (SLE) patients. METHODS Fifteen patients with SLE previously treated with rituximab as part of a phase I/II dose-escalation study were evaluated during a long-term followup (mean followup period 41 months). B cells from peripheral blood and tonsils were assessed using multicolor flow cytometry, and their developmental pathway was classified based on the expression of defined surface markers. RESULTS Reconstitution of peripheral blood CD27+ memory B cells was delayed for several years after B cell depletion therapy in a subset of patients with prolonged clinical responses and autoantibody normalization. This delay correlated with the degree of expansion of B cells of a transitional phenotype during the B cell reconstitution phase (P = 0.005) and the absence of baseline autoantibodies directed against extractable nuclear antigens (RNP, Sm, Ro antigen, La antigen). Despite the paucity of peripheral blood memory cells and the prolonged expansion of functionally immature transitional B cells, tonsil biopsy tissues revealed active germinal center (GC) reactions, but with decreased Fc receptor homolog 4-positive memory B cells. CONCLUSION These results suggest heterogeneity in the B cell depletion and reconstitution process that impacts clinical and immunologic outcomes in SLE. The presence of GC reactions, but with altered memory B cell subpopulations in tonsils, suggests that peripheral blood memory cell reconstitution lags behind a slow secondary lymphoid tissue recovery, with important implications for immunologic competence and tolerance.
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230
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Dörner T, Lipsky PE. B-cell targeting: a novel approach to immune intervention today and tomorrow. Expert Opin Biol Ther 2007; 7:1287-99. [PMID: 17727320 DOI: 10.1517/14712598.7.9.1287] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
B cells and their products, antibodies, play an important role in the diagnosis and, in some instances, in the pathogenesis of many autoimmune diseases. Specific B-cell directed therapies are of recent interest as their impact on B-cell activity can influence a variety of autoimmune diseases. The development and introduction of rituximab, a depleting antibody targeting CD20+ B cells, and previously CD52-directed treatment with Campath-1h for the treatment of B-cell malignancies as well as rheumatoid arthritis have pioneered this therapeutic field. Other non-depleting strategies employ CD22 or B-cell activating factor/B lymphocyte stimulator and apoptosis-inducing ligand as targets and are under clinical investigation at present. Abnormalities of B-cell subsets have been identified by a number of independent groups which often represent characteristic patterns of disturbances of the human B-cell repertoire. However, the clinical value of specific B-cell subset targeting/depletion has not been addressed extensively. As such an approach may afford the possibility to avoid unnecessary adverse events related to depletion of non-pathogenic B-cell populations, B-cell subset targeting may have the capacity to enhance the benefit/risk ratio of B-cell immune intervention.
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Affiliation(s)
- Thomas Dörner
- Charite University Hospital Berlin and Deutsche Rheumaforschungszentrum, Chariteplatz 01, 10098 Berlin, Germany.
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231
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Abstract
PURPOSE OF REVIEW The introduction of rituximab (MabThera, Rituxan) maintenance treatment has initiated a new era in the management of low-grade non-Hodgkin's lymphomas. RECENT FINDINGS Five randomized trials have recently reported on rituximab maintenance in the treatment of indolent non-Hodgkin's lymphomas. These trials enrolled patients with follicular, mantle cell and small lymphocytic non-Hodgkin's lymphomas, mostly in relapse. Patients responding to either rituximab monotherapy, chemotherapy alone or rituximab associated with chemotherapy were randomly assigned between observation and rituximab maintenance. Maintenance treatment significantly improved progression-free survival and response duration, and resulted in increased overall survival in two patients. In one trial, rituximab maintenance therapy produced significantly longer progression-free survival compared with rituximab retreatment at disease progression. SUMMARY Rituximab maintenance therapy has demonstrated an impact on survival in patients with follicular lymphoma. These data justify recommending rituximab maintenance for patients with relapsed follicular lymphoma. Further trials are needed to determine its efficacy in first-line follicular lymphoma and other histological subtypes. The optimal schedule of maintenance therapy has not been established. Although these trials did not report severe adverse drug reactions, information concerning long-term toxicity is scarce, and careful monitoring of patients is therefore recommended.
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Affiliation(s)
- Guillaume Cartron
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire (CHU) de Montpellier, France.
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232
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Mackay F, Groom JR, Tangye SG. An important role for B-cell activation factor and B cells in the pathogenesis of Sjögren's syndrome. Curr Opin Rheumatol 2007; 19:406-13. [PMID: 17762603 DOI: 10.1097/bor.0b013e328277ef4c] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review provides an update on the specific, strong association between dysregulated production of the cytokine B-cell activation factor and Sjögren's syndrome, and offers new perspectives on potential pathogenic mechanisms. RECENT FINDINGS Excess B-cell activation factor in mice triggers Sjögren's syndrome-like symptoms, and elevated serum B-cell activation factor in humans correlates with Sjögren's syndrome. B-cell activation factor is produced locally by activated monocytes, T cells and dendritic cells, and by epithelial cells and infiltrating B cells. Moreover, recent data in humans suggest that the innate immune system plays a role as an initiator of immune disorders in inflamed tissues. SUMMARY Recent data have demonstrated the critical role of B-cell activation factor and B cells in the pathogenesis of Sjögren's syndrome, and its association with B lymphomas. Moreover, B-cell depleting treatments have confirmed the critical role of B cells in Sjögren's syndrome. Excess B-cell activation factor possibly corrupts B-cell tolerance and allows the emergence of self-reactive B cells that efficiently present antigen to T cells. In addition, B-cell activation factor may stimulate T-cell independent activation of B cells via Toll-like receptors; this recently identified mechanism could also play a separate, detrimental role in autoimmunity.
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Affiliation(s)
- Fabienne Mackay
- The Autoimmunity Research Unit, The Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, NSW 2010, Australia.
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233
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Visentini M, Granata M, Veneziano ML, Borghese F, Carlesimo M, Pimpinelli F, Fiorilli M, Casato M. Efficacy of low-dose rituximab for mixed cryoglobulinemia. Clin Immunol 2007; 125:30-3. [PMID: 17692572 DOI: 10.1016/j.clim.2007.06.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 05/21/2007] [Accepted: 06/25/2007] [Indexed: 10/23/2022]
Abstract
Rituximab at 375 mg/m(2) x 4 is effective for refractory HCV-related mixed cryoglobulinemia. We conducted a pilot study to assess the efficacy of a lower dosage, 250 mg/m(2) x 2. Six consecutive patients with mixed cryoglobulinemia were treated. All patients had severe or life-threatening disease manifestations, including necrotizing skin ulcers, renal disease, hyperviscosity or intestinal vasculitis. Four of five evaluable patients (excluding one early death) had >80% decrease of cryocrit and remission of vasculitis at the end of a 22- to 55-week (median 40) follow-up. The non-responder failed to respond to additional rituximab treatment, suggesting intrinsic resistance rather than insufficient dosage as the cause of treatment failure. No sustained increase of HCV viremia after rituximab was observed. Rituximab at 250 mg/m(2) x 2 may be as effective as at 375 mg/m(2) x 4 for treating mixed cryoglobulinemia. Larger studies are required to assess the efficacy of low-dose rituximab.
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Affiliation(s)
- Marcella Visentini
- Department of Clinical Immunology, University of Rome La Sapienza, Viale dell'Università 37, 00185, Rome, Italy
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234
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Silverman GJ, Khanna S. B cell modulation in rheumatology. Curr Opin Pharmacol 2007; 7:426-33. [PMID: 17625968 PMCID: PMC2693398 DOI: 10.1016/j.coph.2007.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 05/24/2007] [Accepted: 05/24/2007] [Indexed: 12/31/2022]
Abstract
While evidence of dysregulation of the B cell compartment was first demonstrated with the identification of autoantibodies, other functional roles of B lymphocytes in autoimmune pathogenesis have generally been underappreciated or completely overlooked. With the recent approval of the first B cell targeting agent in rheumatoid arthritis, new strategies are being developed to target B cells through a range of membrane-associated lineage-specific molecules and also by interfering with B-cell-specific pro-survival signals. B-cell-directed agents therefore provide an effective new mechanistic approach to treatment and also enable new perspectives from the dissection of the contributions of B cells in physiologic and pathologic immune responses.
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Affiliation(s)
- Gregg J Silverman
- Rheumatic Diseases Core Center, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0663, USA.
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235
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Tanaka Y, Yamamoto K, Takeuchi T, Nishimoto N, Miyasaka N, Sumida T, Shima Y, Takada K, Matsumoto I, Saito K, Koike T. A multicenter phase I/II trial of rituximab for refractory systemic lupus erythematosus. Mod Rheumatol 2007; 17:191-7. [PMID: 17564773 DOI: 10.1007/s10165-007-0565-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 02/26/2007] [Indexed: 10/23/2022]
Abstract
Although corticosteroids and immunosuppressants are widely used for the treatments of systemic lupus erythematosus (SLE), safer and more effective therapies are prerequisite. We and others have reported that anti-CD20 antibody rituximab targeting B cells are effective for refractory SLE and, therefore, safety and clinical efficacy of rituximab in SLE was evaluated by a multicenter phase I/II clinical trial. An open-label, multicenter study of 15 patients with active and refractory SLE (total British Isles Lupus Assessment Group [BILAG] score 8 to 17) was conducted. Rituximab was administered to 5 SLE patients as 4 infusions of 500 mg/body every week and to 10 SLE patients as 2 infusions of 1000 mg/body every other week. Assessment of safety, infusion reactions and adverse effects was used as the primary outcome for clinical tolerability and was evaluated by 28 weeks. Rituximab was well tolerated, with most experiencing no significant adverse effects. B cells rapidly reduced in all patients and remained low until 6 months post-treatment. Four patients developed human antichimeric antibodies without affecting efficacy of rituximab. Changes in routine safety laboratory tests clearly related to rituximab were not observed. Nine among 14 evaluable patients achieved the major or partial clinical response of BILAG score and prednisolone dose significantly decreased at the 28 weeks. Rituximab therapy appears to be safe for the treatment of active SLE patients and holds significant therapeutic promise, at least for the majority of patients experiencing profound B-cell depletion.
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Affiliation(s)
- Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahata-nishi, Kitakyushu 807-8555, Japan.
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237
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Atzeni F, Doria A, Turiel M, Maurizio T, Sarzi-Puttini P. What is the role of rituximab in the treatment of rheumatoid arthritis? Autoimmun Rev 2007; 6:553-8. [PMID: 17854748 DOI: 10.1016/j.autrev.2007.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 02/09/2007] [Indexed: 12/25/2022]
Abstract
Rituximab is a monoclonal antibody against CD20 that was developed for the treatment of relapsed or refractory B-cell non-Hodgkin's lymphoma (NHL). Recent controlled trials have shown that B cell-targeted therapy with rituximab is effective in RA (which suggest that B lymphocytes may be critical in its pathogenesis of RA) and early exposure data suggest that the tolerability and safety profile of rituximab may be even better in RA than in NHL patients. Rituximab is generally well tolerated, with a low incidence of serious adverse events, including serious infections. Available evidence suggests that its clinical benefits depend on effective B cell depletion, and the fact that its novel mode of action leads to the depletion of B cells makes it distinct from other biological therapies for RA that target T cells and their related cytokines. Although complete peripheral B cell depletion is regularly seen in RA and other autoimmune diseases, especially systemic lupus erythematosus (SLE), incomplete depletion has been reported in a subset of patients, even after full dosing with rituximab.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, L. Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy.
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238
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Strand V, Kimberly R, Isaacs JD. Biologic therapies in rheumatology: lessons learned, future directions. Nat Rev Drug Discov 2007; 6:75-92. [PMID: 17195034 DOI: 10.1038/nrd2196] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
During the past decade biologic therapies such as monoclonal antibodies and fusion proteins have revolutionized the management of rheumatic disease. By targeting key cytokines and immune cells biologics have provided more specific therapeutic interventions with less immunosuppression. Clinical use, however, has revealed that their theoretical simplicity hides a more complex reality. Efficacy, toxicity and even pharmacodynamic effects can deviate from those predicted, as poignantly illustrated by the catastrophic effects witnessed during the first-into-human administration of TGN1412. This review summarizes lessons gleaned from practical experience and discusses how these can inform future discovery and development of new biologic therapies for rheumatology.
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Affiliation(s)
- Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, 306 Ramona Road, Portola Valley, California 94028, USA
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239
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Anolik JH, Friedberg JW, Zheng B, Barnard J, Owen T, Cushing E, Kelly J, Milner ECB, Fisher RI, Sanz I. B cell reconstitution after rituximab treatment of lymphoma recapitulates B cell ontogeny. Clin Immunol 2006; 122:139-45. [PMID: 17008130 DOI: 10.1016/j.clim.2006.08.009] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Revised: 08/11/2006] [Accepted: 08/16/2006] [Indexed: 12/13/2022]
Abstract
The long-term immunologic effects of B cell depletion with rituximab and the characteristics of the reconstituting B cell pool in lymphoma patients are not well defined, despite the widespread usage of this therapy. Here we report that during the B cell reconstitution phase a majority of the peripheral blood B cells have an immature transitional phenotype (47.8%+/-25.2% vs. 4.4%+/-2.4% for normal controls, p<0.0001), similar to what has been described during the original ontogeny of the immune system and following bone marrow transplantation. Moreover, the recovery of the CD27+ memory B cell pool was delayed compared to normal B cell ontogeny, remaining below normal controls at 1 year post-rituximab (4.4%+/-3% vs. 31%+/-7%, p<0.0001). Expansion of functionally immature B cells and decreased memory B cells may contribute to an immunodeficient state in patients recovering from rituximab mediated B cell depletion, particularly with repeated treatment.
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Affiliation(s)
- Jennifer H Anolik
- Department of Medicine, Division of Clinical Immunology and Rheumatology, James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Silverman GJ. Therapeutic B cell depletion and regeneration in rheumatoid arthritis: emerging patterns and paradigms. ACTA ACUST UNITED AC 2006; 54:2356-67. [PMID: 16868991 DOI: 10.1002/art.22020] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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