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Tumba MC, Silva RL, Arevalo AB, Sattui SE. Current perspective on infections and mitigation strategies in primary systemic vasculitis. Curr Rheumatol Rep 2024; 26:279-289. [PMID: 38668813 DOI: 10.1007/s11926-024-01149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize and evaluate most recent evidence on the epidemiology of infections and associated risk factors in patients with primary systemic vasculitides (PSV), as well as discuss mitigation strategies including the risk of antibiotic prophylaxis. RECENT FINDINGS Infections remain one of the leading causes of mortality in patients with PSV, with rates of severe infection ranging from 16 to 40% in different cohorts. Older age, frailty, renal and pulmonary involvement, and higher burden of comorbidities have been recognized as important patient-associated risk factors. Treatments including higher cumulative doses of glucocorticoids are associated with an increased risk of infections, and recent studies show the potential benefit of interventions such as reduced-dose glucocorticoid regimens. Existing mitigation strategies include screening, vaccination, and infection prophylaxis. The latter remains particularly important for Pneumocystis jirovecii pneumonia; however, the benefit-risk ratio seems to be less clear outside of induction phase (i.e., high dose of glucocorticoids) and optimal treatment duration remains less clear. Patients with PSV are at increased risk of infections, due to disease itself, comorbidities, and treatment side effects. Awareness of the timing and types of infection, as well as mitigation strategies are imperative to ensure treatment success and survival for patients.
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Affiliation(s)
- Manuel Carpio Tumba
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raisa Lomanto Silva
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ana B Arevalo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Massachusetts, Boston, MA, USA
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
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Reggiani F, Stella M, Calatroni M, Sinico RA. Treatment strategies for ANCA-associated vasculitides: from standard protocols to future horizons. Expert Rev Clin Immunol 2024; 20:765-780. [PMID: 38445642 DOI: 10.1080/1744666x.2024.2326628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION ANCA-associated vasculitides (AAV), classified into granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis represent a group of disorders characterized by necrotizing vasculitis of small vessels, endothelial injury and tissue damage. The outcomes and prognosis of AAV have undergone significant changes with the introduction of glucocorticoids (GCs) and other immunosuppressants (cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil). The enhanced understanding of pathogenesis has subsequently led to the incorporation into clinical practice of drugs targeting specific therapeutic targets. AREAS COVERED After an extensive literature search of Pubmed, Medline, Embase of the most recent evidence, we provide an overview of available treatments, highlighting how newer drugs have integrated into standard protocols. Our review also explores potential new therapeutic targets, including B cell depletion and inhibition, T cell inhibition, complement inhibition, and IL-5 and IgE inhibition. EXPERT OPINION There is hope that the new treatment targets currently under study in AAV may enable a faster and more lasting clinical response, ensuring the reduction of possible side effects from therapies. Moreover, numerous aspects necessitate further exploration in the future, such as tailoring of GCs, integration of GCs-sparing agents, efficacy of combination therapy, optimal maintenance therapy, to reduce organ-damage and improve quality of life.
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Affiliation(s)
- Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matteo Stella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
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3
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Konda R, Rajasekaran A, Rizk DV. Antineutrophil cytoplasmic antibody-associated vasculitis. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00167. [PMID: 38785128 DOI: 10.1097/mnh.0000000000001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW This review focuses on latest developments in managing antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV), a systemic autoimmune condition characterized by inflammation and necrosis of small blood vessels due to circulating autoantibodies that target neutrophilic granules. RECENT FINDINGS Our understanding of AAV pathogenesis has evolved in the past decades highlighting the central pathogenic roles of autoantibodies and complement activation. In parallel, the appreciation for glucocorticoid toxicity has led the research on crucial steroid-sparing therapeutic alternatives. Complement inhibitors (like avacopan) that have emerged are associated with better preservation of kidney function in AAV patients with severe kidney impairment. The role of plasma-exchange (PLEX) was revisited in updated guidelines that recommended its potential use in the context of diffuse alveolar hemorrhage associated hypoxia and severe kidney involvement, particularly with a serum creatinine level above 3.4 mg/dl. The ANCA Kidney Risk Score risk prediction and Glucocorticoid Toxicity Index score aid in identifying high-risk patients and individualizing management plans. SUMMARY Kidney involvement in AAV requires prompt diagnosis and initiation of immunosuppression to prevent irreversible nephron loss. Newer therapeutic targets are on the horizon and offer hope for personalized treatment strategies.
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Affiliation(s)
- Raghunandan Konda
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Liu W, Tian G, Chen C, Zhang M, Chen Z, Chen T, Lin Z, Wu W, Wu Y, Wu K, Liu Q. Application of biological agents in the treatment of anti-neutrophil cytoplasmic antibody-associated vasculitis. Front Pharmacol 2024; 15:1378384. [PMID: 38831887 PMCID: PMC11144864 DOI: 10.3389/fphar.2024.1378384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/19/2024] [Indexed: 06/05/2024] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been traditionally treated using glucocorticoids and immunosuppressants. However, these treatment modes are associated with high recurrence AAV rates and adverse reactions. Therefore, treatment strategies for AAV need to be urgently optimized. The efficacy and safety of biological agents in the treatment of vasculitis have been clinically validated. This review comprehensively summarizes the evidence-based support for the clinical use of existing biological agents in AAV. The findings reveal that multiple biological agents not only effectively reduce the adverse reactions associated with glucocorticoids and immunosuppressants but also demonstrate significant therapeutic efficacy. Notably, rituximab, an anti-CD20 antibody, has emerged as a first-line treatment option for AAV. Mepolizumab has shown promising results in relapsed and refractory eosinophilic granulomatosis with polyangiitis. Other biological agents targeting cytokines, complement, and other pathways have also demonstrated clinical benefits in recent studies. The widespread application of biological agents provides new insights into the treatment of AAV and is expected to drive further clinical research. These advancements not only improve patient outcomes but also offer more possibilities and hope in the field of AAV treatment.
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Affiliation(s)
- Weijun Liu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Guanyuan Tian
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Chao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Mingying Zhang
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Zhanmao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Tietao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Zhibin Lin
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Wuzhong Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Yiqaing Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Kefei Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Qinghua Liu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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Stefanski AL, Dörner T, Kneitz C. [Influence of underlying disease and immunosuppression on the immunocompetence in inflammatory rheumatic diseases]. Z Rheumatol 2024; 83:87-97. [PMID: 37644129 DOI: 10.1007/s00393-023-01408-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 08/31/2023]
Abstract
Patients with inflammatory rheumatic diseases have a higher risk of infections in comparison to the general population. For this patient group, in addition to cardiovascular diseases, infections play an important role with respect to morbidity and mortality. Even if it is difficult to make concrete statements with respect to individual diseases, it can be assumed that there is a lower risk of infections in inflammatory joint diseases in comparison to connective tissue diseases and vasculitides. The increased risk of infections is determined by multiple factors, whereby the underlying factors are classified into three main categories: patient-related factors (age, comorbidities, lifestyle), disease-related factors (immunological dysfunction as part of the disease pathophysiology) and drug-related factors (type and dosage of the immunosuppression and/or immunomodulation). An improved understanding of the complexity of these associations enables the optimization of treatment and disease control taking the individual risk factors into account, with the aim of a significant reduction in the risk of infections.
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Affiliation(s)
- A-L Stefanski
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Deutschland.
| | - T Dörner
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Deutschland
| | - C Kneitz
- Rheumatologische Schwerpunktpraxis Schwerin, Schwerin, Deutschland
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Mahrhofer H. [Should patients with ANCA-associated vasculitis undergoing maintenance therapy with rituximab receive cotrimoxazole prophylaxis?]. Z Rheumatol 2024; 83:122-124. [PMID: 38272971 DOI: 10.1007/s00393-023-01469-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Hartmut Mahrhofer
- Klinik für Innere Medizin, Rheumatologie, Pneumologie Nephrologie und Diabetologie. Rheumazentrum (GBA) des Landes Baden-Württemberg Europäisches Vaskulitis-Referenzzentrum (ERN-RITA), medius Klinik Kirchheim, Eugenstr. 3, 73230, Kirchheim-Teck, Deutschland.
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Liu C. Detection of serum interleukin-18 level and neutrophil/lymphocyte ratio in patients with antineutrophil cytoplasmic antibody-associated vasculitis and its clinical significance. Open Life Sci 2024; 19:20220823. [PMID: 38415205 PMCID: PMC10898623 DOI: 10.1515/biol-2022-0823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/23/2023] [Accepted: 12/13/2023] [Indexed: 02/29/2024] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of autoimmune diseases. This study aimed to investigate the clinical significance of changes in interleukin-18 (IL-18) and neutrophil/lymphocyte ratio (NLR) in the pathogenesis of AAV and the impact of NLR on the prognosis of patients. The clinical data of 52 AAV patients (AAV group) who met the conditions of hospitalization, 30 patients with mild mesangial proliferative glomerulonephritis (disease controls), and 30 healthy volunteers (normal controls) in Nephrology Department of Liuzhou People's Hospital from May 2020 to August 2022 were selected. A total of 52 AAV patients were divided into active phase (>15 points) and remission phase (≤15 points) based on the Birmingham vasculitis activity score (BVAS). Serum IL-18 level was detected by enzyme-linked immunosorbent assay in three groups. Pearson product moment correlation analysis was performed to investigate the correlation between serum IL-18 levels and clinical laboratory indicators, and receiver operating characteristic (ROC) curve analysis was performed on serum IL-18, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) levels, and NLR in AAV patients. The levels of serum creatinine, parathyroid hormone, β2-microglobulin (β2-MG), ESR, CRP, and IL-18 in active stage of AAV were significantly higher than those in remission stage of AAV. Moreover, the serum IL-18 level of active AAV patients was significantly higher than that of disease control group (P < 0.05). The levels of eGFR, hemoglobin, and complement C3 were significantly lower than those during the remission (P < 0.05). Pearson product moment correlation analysis showed that serum IL-18 level in AAV patients was positively correlated with BVAS score and ESR level. The area under the curve of serum IL-18, NLR, CRP, ESR levels evaluated by ROC curve was 0.921, 0.899, 0.83, and 0.75, respectively. Kaplan-Meier survival curve showed that the cumulative survival rate of patients in low NLR group was significantly higher than that in high NLR group (68.36 vs 42.89%), with significant difference (Log-Rank = 6.745, P = 0.025 < 0.05). IL-18 may be adopted as one of the important biological markers to judge the disease of AAV, and the cumulative survival rate of patients with high NLR is low, which may be applied as an indicator to evaluate the poor prognosis of patients with AAV.
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Affiliation(s)
- Changning Liu
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou 545006, China
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8
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Aryanian Z, Balighi K, Emadi SN, Hatami P. Rituximab as a maintenance treatment in patients with pemphigus vulgaris: When is the right time for discontinuation? J Cosmet Dermatol 2024; 23:406-408. [PMID: 37916650 DOI: 10.1111/jocd.16030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Naser Emadi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Hatami
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Hajishah H, Amini MJ, Chadeganipour AS, Salehi SA, Kazemi D. Efficacy of Rituximab on Refractory Organ Involvements in Granulomatosis with Polyangiitis: A Systematic Review of Case Reports. Curr Rheumatol Rev 2024; 20:270-283. [PMID: 37907486 DOI: 10.2174/0115733971263964231020072640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is a type of Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) characterized by necrotizing vasculitis affecting small and medium-sized blood vessels. GPA affects various organs, with respiratory tract, vasculitis and glomerulonephritis being the most common triad. Remission induction and maintenance therapy for GPA traditionally involves corticosteroids and cyclophosphamide. However, treatment with rituximab, a monoclonal antibody that depletes B-cells involved in autoimmune disease, has been successful in inducing remission in several studies. The purpose of this systematic review was to investigate the efficacy of rituximab in treating various clinical manifestations of GPA. METHODS In adherence to PRISMA guidelines for systematic reviews and meta-analyses, we carried out a comprehensive review to investigate the effectiveness of rituximab on particular organ involvement in GPA. We searched three databases (PubMed, Scopus, and Embase) up until November 6, 2022, for case reports on the topic. To ensure all relevant studies were included, we manually screened the first 50 pages of Google Scholar's search results. RESULTS The review identified a total of 64 case reports and a case series of 113 cases, highlighting the effectiveness of rituximab in treating refractory organ involvement in GPA. The review also analyzed the effectiveness of rituximab in treating ocular, CNS, cardiac, pulmonary, cutaneous, gastrointestinal, renal, and other organ involvements in GPA. CONCLUSIONS Our results indicated that rituximab can be a promising therapy for treating specific clinical manifestations of several organ involvements. However, more research is needed to determine the long-term efficacy of rituximab in treating GPA.
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Affiliation(s)
- Hamed Hajishah
- Student Research Committee, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Javad Amini
- Student Research Committee, Medical School, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Seyyed Amirhossein Salehi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Danial Kazemi
- Student Research Committee, Isfahan University of Medical Sciences, Hezar Jerib Street, Isfahan, Iran
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Higashida-Konishi M, Akiyama M, Hama S, Oshige T, Izumi K, Oshima H, Okano Y. Successful treatment of PR3-ANCA-positive interstitial pneumonia with a moderate dose of glucocorticoid and rituximab. Mod Rheumatol Case Rep 2023; 8:137-140. [PMID: 37225939 DOI: 10.1093/mrcr/rxad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-positive interstitial pneumonia (IP) is reported as IP that is ANCA-positive and does not involve organ damage associated with vasculitis other than the lungs. While the combination of glucocorticoid and rituximab is effective in ANCA-associated vasculitis, the treatment strategy for ANCA-positive IP has not been established. Here, we report the first case of successful treatment of proteinase 3 (PR3)-ANCA-positive IP with a moderate dose of glucocorticoid and rituximab. The patient was an 80-year-old male who presented with subacute dry cough and dyspnoea. Blood tests revealed elevated levels of C-reactive protein, Krebs von den Lungen 6 (KL-6), and PR3-ANCA. Chest computed tomography (CT) showed interstitial shadows and infiltrates around honeycomb cysts. 18F-fluorodeoxyglucose (FDG) positron emission tomography CT revealed an uptake of FDG in the IP area. After starting treatment with a moderate dose of prednisolone and rituximab, the patient's clinical symptoms disappeared, C-reactive protein and KL-6 turned to be normal, and infiltrates around the cysts of honeycomb lungs disappeared. Prednisolone was gradually decreased to 2 mg, and no relapse or adverse events were observed during the course of treatment. Our case suggests that early treatment with a moderate dose of glucocorticoid and rituximab is effective for PR3-ANCA-positive IP.
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Affiliation(s)
- Misako Higashida-Konishi
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Hama
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Tatsuhiro Oshige
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Izumi
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hisaji Oshima
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yutaka Okano
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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Guo Y, Zhao H, Ren M, Wang Y, Wang L, Tang L. Efficacy and safety of rituximab in elderly patients with membranous nephropathy. Front Pharmacol 2023; 14:1323334. [PMID: 38186651 PMCID: PMC10771833 DOI: 10.3389/fphar.2023.1323334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Objectives: Advancing age is a risk factor for treatment-related side effects and mortality in membranous nephropathy (MN) patients treated with traditional immunosuppressive regimens. This study aimed to determine the efficacy and safety of rituximab (RTX) in the treatment of elderly patients with MN. Methods: We performed a single center retrospective review of 37 consecutive MN patients aged 70 and older at the time of RTX infusion. We also enrolled 76 young patients (<70 years old) with MN as the control group. We assessed clinical and laboratory indices, remission rates, and adverse events at RTX infusion, 3 months, and last visit. Results: A total of 37 elderly patients with MN were included, with a median follow-up period of 15.50 (10.00, 24.40) months. Of the 37 patients, 75.68% were male, and mean age was 71.89 ± 2.47 years. At last visit, 7 (18.92%) patients achieved complete remission, and 26 (70.27%) patients achieved complete or partial remission. There were no differences in the complete remission rate and complete or partial remission rate at last visit compared to young patients (26.32% vs. 18.92%, p = 0.387; 85.53% vs. 70.27%, p = 0.055). After RTX treatment, three of 6 elderly patients with pneumonia died due to ineffective treatment of the infection in RTX therapy courses. The results of multivariant regression analysis showed that elderly patients have an increased risk of serious infection, compared with patients younger than 70 years (OR = 32.874, 95% CI 1.300-831.490, p = 0.034). For each increase of 1 g/L in serum albumin, the risk of serious infection would decrease by 43.2% (OR = 0.568, 95% CI 0.334-0.969, p = 0.038). Conclusion: This study demonstrates that RTX is effective in the treatment of elderly patients with MN. However, we also observed a high incidence of infectious complications. Our experience was limited by its retrospective design and relatively small sample size, and further randomized controlled studies with large sample size are needed to confirm our preliminary findings.
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Affiliation(s)
- Yanhong Guo
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Huayan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Mingjing Ren
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yulin Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Liuwei Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lin Tang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Wallace ZS, Fu X, Cook C, Ahola C, Williams Z, Doliner B, Hanberg JS, Stone JH, Zhang Y, Choi HK. Comparative Effectiveness of Rituximab- Versus Cyclophosphamide-Based Remission Induction Strategies in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis for the Risk of Kidney Failure and Mortality. Arthritis Rheumatol 2023; 75:1599-1607. [PMID: 37011036 PMCID: PMC10523845 DOI: 10.1002/art.42515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/23/2023] [Accepted: 03/31/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE To compare rituximab- versus cyclophosphamide-based remission induction strategies for the long-term risks of kidney failure and death in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in a real-world cohort. METHODS We performed a cohort study using the Mass General Brigham AAV Cohort, which includes proteinase 3-ANCA+ and myeloperoxidase (MPO)-ANCA+ AAV patients diagnosed from January 1, 2002 to December 31, 2019. We included cases in which the initial remission induction strategy was based either on rituximab or cyclophosphamide. The primary outcome was the composite outcome of kidney failure or death. We used multivariable Cox proportional hazards models and propensity score-matched analyses to assess the association of rituximab- versus cyclophosphamide-based treatment strategies with the composite outcome of kidney failure or death. RESULTS Of 595 included patients, 352 patients (~60%) received rituximab-based and 243 patients (~40%) received cyclophosphamide-based regimens. The mean age was 61 years, 58% of patients were female, 70% of patients were MPO-ANCA+, and 69% of patients had renal involvement (median estimated glomerular filtration rate 37.3 ml/minute/1.73 m2 ). There were 133 events at 5 years, and the incidence rates in rituximab- and cyclophosphamide-based regimens were 6.8 and 6.1 per 100 person-years, respectively. The risk of kidney failure or death was similar in both groups in multivariable-adjusted analyses (hazard ratio [HR] 1.03 [95% confidence interval (95% CI) 0.55-1.93]) and in propensity score-matched analyses (HR 1.05 [95% CI 0.55-1.99]) at 5 years. Our findings were similar when outcomes were assessed at 1 and 2 years as well as in subgroups stratified according to renal involvement and severity as well as major organ involvement. CONCLUSION Rituximab- and cyclophosphamide-based remission induction strategies for AAV are associated with similar risks of kidney failure and death.
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Affiliation(s)
- Zachary S Wallace
- Rheumatology Unit, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Claire Cook
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Catherine Ahola
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Zachary Williams
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Brett Doliner
- Department of Medicine, Massachusetts General Hospital, Boston
| | | | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
| | - Yuqing Zhang
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Mongan Institute, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
| | - Hyon K Choi
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Mongan Institute, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
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13
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Aqeel F, Xu L, Salas A, Wen Y, Eid SM, Geetha D. Outcomes of remission induction therapy for ANCA-associated vasculitis in the elderly. Clin Rheumatol 2023; 42:2427-2435. [PMID: 37225927 PMCID: PMC11128295 DOI: 10.1007/s10067-023-06644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Treatment regimens combining glucocorticoids with cyclophosphamide or rituximab or both are used to induce remission in ANCA-associated glomerulonephritis (ANCA-GN). There is a paucity of data on the efficacy and safety of these regimens in elderly patients with ANCA-GN. This study aimed to examine outcomes and adverse events in elderly AAV patients with three induction regimens: cyclophosphamide (CYC), cyclophosphamide and rituximab (CYC + RTX), and rituximab (RTX). METHODS This single-center retrospective cohort study included patients 60 years and older diagnosed with ANCA-GN. Baseline characteristics and outcomes across several clinical parameters were recorded and compared for significance using Kruskal-Wallis test, Chi-squared test, Fisher exact test, univariate, and multivariate logistic regression as appropriate. Cox proportional hazard regression model was used for survival analysis. RESULTS Seventy-five patients were included. The mean (SD) age at diagnosis was 70 (± 6) years. The mean (SD) follow-up duration was 5.17 (± 3.47) years. Remission induction therapy with glucocorticoids plus CYC was used in 25 patients, glucocorticoids plus CYC and RTX in 12 patients, and glucocorticoids plus RTX in 38 patients. RTX-treated patients had a higher baseline estimated glomerular filtration ratio (eGFR) (p = 0.00009). High remission rates were achieved in all groups (100% vs. 100% vs. 94.6% respectively, p = 0.368). The incidence of end-stage renal disease (ESRD) at one year was 8% among all groups (p = 0.999). There was no difference in the number of infections requiring hospitalization (p = 0.822), but a statistical difference in leukopenia was noted (32% vs. 25% vs. 3% respectively, p = 0.005). The use of RTX only was associated with reduced leukopenia (aOR = 0.1, 95% CI = 0.005-0.8) after adjusting for other variables. CONCLUSIONS CYC, CYC + RTX, and RTX are equally effective for remission induction in elderly patients with ANCA-GN. Induction therapy with RTX only was associated with a lower risk of leukopenia compared to CYC-containing regimens. Infections requiring hospitalization were similar among all groups. End-stage kidney disease at one year was comparable among the 3 groups. Key Points • Cyclophosphamide, Rituximab, and Cyclophosphamide+Rituximab are equally effective in remission induction in elderly patients with ANCA glomerulonephritis. • The use of Rituximab only was associated with a lower risk of bone marrow suppression compared to Cyclophosphamide only. • More information is needed on the comparative safety of induction therapy strategies in elderly ANCA glomerulonephritis patients.
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Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Lillian Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio Salas
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yumeng Wen
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaker M Eid
- Department of Internal Medicine, Division of Hospitalist Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Singh H, Kumar U, Senapati S. Translational implications of humoral and cellular immune dysfunction in granulomatosis with polyangiitis. Cytokine 2023; 164:156154. [PMID: 36812668 DOI: 10.1016/j.cyto.2023.156154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/11/2023] [Indexed: 02/22/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is a rare systemic ANCA (Anti-neutrophil cytoplasmic antibodies) associated vasculitis (AAV). In the last couple of decades, GPA has emerged as a disease of concern due to rapid increase in the prevalence and incidence especially in developing countries. Unknown aetiology and rapid progression have made GPA a critical disease. Thus, establishing specific tools to facilitate early and faster disease diagnosis and efficient disease management has immense importance. GPA may develop in genetically predisposed individuals on receiving the external stimulus (i.e. microbial pathogen, pollutant etc.) that triggers the immune response. B-cell activating factor (BAFF) produced by the neutrophils, promotes the B-cell maturation and survival which leads to increased ANCA production. Abnormal B-cell and T-cell proliferation and their cytokine response plays a major role in disease pathogenesis and granuloma formation. ANCA interacts with neutrophils and induces the neutrophil extracellular traps (NETs) formation and reactive oxygen species (ROS) production which leads to the endothelial cell injury. This review article summarizes the critical pathological events and how cytokines and immune cells shape the GPA pathogenesis. Decoding this complex network would facilitate in developing tools for diagnosis, prognosis and disease management. Recently developed specific monoclonal antibodies (MAbs) targeting cytokines and immune cells are being used for safer treatment and achieving longer remission.
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Affiliation(s)
- Harinder Singh
- Immunogenomics Laboratory, Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda, India.
| | - Uma Kumar
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Sabyasachi Senapati
- Immunogenomics Laboratory, Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda, India.
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15
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Samson M, Devilliers H, Thietart S, Charles P, Pagnoux C, Cohen P, Karras A, Mouthon L, Terrier B, Puéchal X, Guillevin L. Score to assess the probability of relapse in granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:rmdopen-2022-002953. [PMID: 36972927 PMCID: PMC10069598 DOI: 10.1136/rmdopen-2022-002953] [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: 12/22/2022] [Accepted: 03/12/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE To develop a score assessing the probability of relapse in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). METHODS Long-term follow-up data from GPA and MPA patients included in five consecutive randomised controlled trials were pooled. Patient characteristics at diagnosis were entered into a competing-risks model, with relapse as the event of interest and death the competing event. Univariate and multivariate analyses were computed to identify variables associated with relapse and build a score, which was then validated in an independent cohort of GPA or MPA patients. RESULTS Data collected from 427 patients (203 GPA, 224 MPA) at diagnosis were included. Mean±SD follow-up was 80.6±51.3 months; 207 (48.5%) patients experienced ≥1 relapse. Relapse risk was associated with proteinase 3 (PR3) positivity (HR=1.81 (95% CI 1.28 to 2.57); p<0.001), age ≤75 years (HR=1.89 (95% CI 1.15 to 3.13); p=0.012) and estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m² (HR=1.67 (95% CI 1.18 to 2.33); p=0.004) at diagnosis. A score, the French Vasculitis Study Group Relapse Score (FRS), from 0 to 3 points was modelised: 1 point each for PR3-antineutrophil cytoplasmic antibody positivity, eGFR ≥30 mL/min/1.73 m² and age ≤75 years. In the validation cohort of 209 patients, the 5-year relapse risk was 8% for a FRS of 0, 30% for 1, 48% for 2 and 76% for 3. CONCLUSION The FRS can be used at diagnosis to assess the relapse risk in patients with GPA or MPA. Its value for tailoring the duration of maintenance therapy should be evaluated in future prospective trials.
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Affiliation(s)
- Maxime Samson
- Department of Internal Medicine and Clinical Immunology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Hervé Devilliers
- INSERM, CIC 1432, Clinical Epidemiology Unit, University of Burgundy, Dijon, France
| | - Sara Thietart
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Pascal Cohen
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Alexandre Karras
- Department of Nephrology, AP-HP, Hopital Europeen Georges Pompidou, Paris, France
- Universite Paris Descartes, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loic Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
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16
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Quartuccio L, Treppo E, Urso L, Del Frate G, Mescia F, Alberici F, Vaglio A, Emmi G. Unmet needs in ANCA-associated vasculitis: Physicians' and patients' perspectives. Front Immunol 2023; 14:1112899. [PMID: 36911748 PMCID: PMC9995379 DOI: 10.3389/fimmu.2023.1112899] [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: 11/30/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
In recent years, clinical research has increased significantly and therapies for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis have improved. However, there are still unanswered questions and unmet needs about AAV patients. The purpose of this review is to examine the frontiers of research related to emerging biomarkers eventually predicting relapse, and new therapeutic approaches, not to mention new quality of life assessment tools. Identifying predictors of relapse may help optimize therapeutic strategies, minimize disease recurrence, and reduce treatment-related side effects. In addition, it is important to recognize that patients may suffer long-term consequences of the disease and its treatment, which, although life-saving, is often associated with significant side effects. Our goal, therefore, is to highlight what has been achieved, the pitfalls, and what still needs to be done, comparing the views of physicians and patients.
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Affiliation(s)
- Luca Quartuccio
- Division of Rheumatology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Elena Treppo
- Division of Rheumatology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Livio Urso
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giulia Del Frate
- Division of Rheumatology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Federica Mescia
- Nephrology Unit, University of Brescia, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Federico Alberici
- Nephrology Unit, University of Brescia, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
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17
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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