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Bunch DO, Lewis SE, Xiao H, Hu P, Jennette JC, Wu EY. Complement as a major mediator of ANCA vasculitis and a target for precision therapy. Expert Rev Clin Immunol 2024. [PMID: 39275806 DOI: 10.1080/1744666x.2024.2405170] [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: 06/04/2024] [Revised: 08/26/2024] [Accepted: 09/12/2024] [Indexed: 09/16/2024]
Abstract
INTRODUCTION Complement was long thought not to be involved in ANCA vasculitis pathogenesis until studies in murine models demonstrated its central role. The current theory is ANCA-activated neutrophils degranulate and release factors that activate complement, which, in turn, recruits more neutrophils and causes an inflammatory amplification loop that results in the vascular inflammation characteristic of disease. Targeting this amplification loop through complement inhibition has proven to be effective in ANCA vasculitis treatment. AREAS COVERED A PubMed search was conducted using key terms 'ANCA vasculitis' AND 'complement system.' We review findings from experimental mouse models, in vitro studies, and human ANCA vasculitis that support a role for complement activation in disease pathogenesis. We also summarize results from pivotal clinical studies demonstrating the safety and efficacy of complement inhibition in ANCA vasculitis treatment. EXPERT OPINION While complement activation is undoubtedly involved in ANCA vasculitis pathogenesis, less clear is whether measuring complement activation markers can reliably assess disease activity, predict those who will benefit from complement-targeting therapy, or identify patients in stable remission and able to stop therapy. Better understanding the clinical implications of complement activation will shed more light on the utility of complement inhibition and facilitate precision medicine in ANCA vasculitis.
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Affiliation(s)
- Donna O Bunch
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, USA
| | - Sarah E Lewis
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, USA
| | - Hong Xiao
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Peiqi Hu
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - J Charles Jennette
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Eveline Y Wu
- Division of Rheumatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
- Division of Allergy/Immunology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
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2
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Bays A, Gardner GC. Newer Therapies in Rheumatology. Med Clin North Am 2024; 108:829-842. [PMID: 39084836 DOI: 10.1016/j.mcna.2024.02.004] [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] [Indexed: 08/02/2024]
Abstract
Seven of the 11 newer medications recently or soon to be approved to treat rheumatologic diseases discussed in this article are biologic agents and reflect the current ability of science to target specific components of the immune system. The other agents are molecules that are directed against specific immune pathway targets as well. All have shown superiority to placebo and in some cases have been compared to currently accepted therapies. Safety issues are generally centered around infections due to the immune-interrupting nature of these therapies.
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Affiliation(s)
- Alison Bays
- Division of Rheumatology, University of Washington, 1959 Pacific Street, Box 356428, Seattle, WA 98195, USA
| | - Gregory C Gardner
- Division of Rheumatology, University of Washington, 1959 Pacific Street, Box 356428, Seattle, WA 98195, USA.
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3
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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024; 106:369-391. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [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: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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Chalkia A, Flossmann O, Jones R, Nair JR, Simpson T, Smith R, Willcocks L, Jayne D. Avacopan for ANCA-associated vasculitis with hypoxic pulmonary haemorrhage. Nephrol Dial Transplant 2024; 39:1473-1482. [PMID: 38268434 PMCID: PMC11361805 DOI: 10.1093/ndt/gfae020] [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: 11/11/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Pulmonary haemorrhage with hypoxia caused by anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has a high early mortality. Avacopan, an oral C5a receptor antagonist, is an approved treatment for AAV, but patients with pulmonary haemorrhage requiring invasive pulmonary ventilation support were excluded from the Avacopan for the Treatment of ANCA-Associated Vasculitis (ADVOCATE) Trial. METHODS A retrospective, observational, multicentre case series of AAV patients with hypoxic pulmonary haemorrhage, requiring oxygen support or mechanical ventilation, who received avacopan. RESULTS Eight patients (62.5% female), median age 64 years (range 17-80), seven with kidney involvement, median estimated glomerular filtration rate (eGFR) 11 (range 5-99) mL/min/1.73 m2, were followed for a median of 6 months from presentation. Seven were newly diagnosed (87.5%), five were myeloperoxidase-ANCA and three proteinase 3-ANCA positive. All had hypoxia, four requiring mechanical ventilation (three invasive and one non-invasive). Intensive care unit (ICU) stay for the four patients lasted a median of 9 days (range 6-60). Four received rituximab and cyclophosphamide combination, three rituximab and one cyclophosphamide. Four underwent plasma exchange and one received 2 months of daily extracorporeal membrane oxygenation therapy. Following the initiation of avacopan after a median of 10 days (range 2-40), pulmonary haemorrhage resolved in all patients, even the two who had 1 month of refractory pulmonary haemorrhage prior to avacopan. Additionally, after 1 month, the median prednisolone dose was 5 mg/day (range 0-50), with three patients successfully discontinuing steroid use. Two patients suffered serious infections, two discontinued avacopan, one permanently due to a rash and one temporarily after 3 months due to neutropenia. All patients survived and no re-hospitalization occurred. CONCLUSION We report the use of avacopan as a component of the treatment for pulmonary haemorrhage with hypoxia in AAV. Despite the life-threatening presentations all patients recovered, but attribution of the positive outcomes to avacopan is limited by the concomitant therapies and retrospective observational design.
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Affiliation(s)
- Aglaia Chalkia
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Rachel Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
- Vasculitis & Lupus Clinic, Addenbrooke's Hospital Cambridge, Cambridge, UK
| | | | - Thomas Simpson
- Department of Respiratory Medicine, Lewisham Hospital, London, UK
| | - Rona Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
- Vasculitis & Lupus Clinic, Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Lisa Willcocks
- Vasculitis & Lupus Clinic, Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
- Vasculitis & Lupus Clinic, Addenbrooke's Hospital Cambridge, Cambridge, UK
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Ketteler M. [Kidney diseases: News from the KDIGO guidelines]. Dtsch Med Wochenschr 2024; 149:1039-1044. [PMID: 39146752 DOI: 10.1055/a-2145-7564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
The KDIGO Update 2024 was supplemented by new "Clinical Practice Points", which were derived from the current evidence but are not necessarily comprehensively proven by prospective controlled studies. The most significant change in the Update 2024 for Lupus nephritis concerns the recommendations for induction therapy for lupus nephritis classes III and IV. The basis is still high-dose glucocorticoid treatment and the use of hydroxychloroquine. The 2 new developments in the 2024 Update concerning ANCA-associated nephritis are based on the studies on the use of the C5a receptor inhibitor Avacopan and the increasing data on induction protocols with reduced glucocorticoid dosage. Due to the inconsistency and variability of the conditions under which blood pressure measurements are carried out in practice, an international consensus statement was issued which defines 4 steps to achieve sufficient validity of the measurement results. CKD-MBD Controversies Conference 2023: The update for CKD-MBD, which was discussed in the Controversies Conference 2023, is in progress and has not been released yet. However, there were no serious contradictions between the 2023 data and the 2017 guidelines - the risk assessment regarding calcium-containing phosphate binders may have been put into perspective.
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Affiliation(s)
- Markus Ketteler
- Allg. Innere Medizin u. Nephrologie, Robert-Bosch-Krankenhaus, Stuttgart, Deutschland
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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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Falde SD, Lal A, Cartin-Ceba R, Mertz LE, Fervenza FC, Zand L, Koster MJ, Warrington KJ, Lee AS, Aslam N, Abril A, Specks U. Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Diffuse Alveolar Hemorrhage With Avacopan. ACR Open Rheumatol 2024. [PMID: 39077977 DOI: 10.1002/acr2.11726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/10/2024] [Accepted: 06/30/2024] [Indexed: 07/31/2024] Open
Abstract
OBJECTIVE Avacopan, an activated complement factor 5 receptor antagonist, has been approved as adjunct therapy for severe active antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Current evidence supports the management of AAV presenting with diffuse alveolar hemorrhage (DAH) by administering glucocorticoids combined with either rituximab or cyclophosphamide in addition to supportive care. The role of avacopan in patients with DAH as a primary severe disease manifestation of AAV has not been well established. Furthermore, concerns remain regarding timely access to avacopan, the best glucocorticoid tapering regimen, and long-term efficacy and safety of the drug. We sought to identify clinical features and outcomes of patients presenting with DAH secondary to AAV who received avacopan in addition to glucocorticoids and rituximab or cyclophosphamide. METHODS We performed a retrospective cohort study of all consecutive patients presenting with DAH as part of active severe granulomatosis with polyangiitis or microscopic polyangiitis. Demographic and clinical characteristics were collected at presentation and follow-up. RESULTS Fifteen patients met inclusion criteria and were observed for a median time of 17 weeks (interquartile range [IQR] 6-37 weeks) after initiation of avacopan. Patients were predominantly female and White, had never smoked, and were a median age of 66 years (IQR 52-72 years) at diagnosis. The majority had newly diagnosed severe AAV with renal involvement. Three patients progressed to respiratory failure. The timing of avacopan introduction and patterns of glucocorticoid tapers varied widely in this cohort. Two serious adverse events related to infection were observed, including one opportunistic infection leading to the patient's death, although neither was directly attributed to avacopan administration. CONCLUSION We describe the clinical course of patients who presented with the severe AAV disease manifestation of DAH and received avacopan as adjunct therapy. Most patients achieved remission during follow-up, and adverse events, including infection, were observed.
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Affiliation(s)
| | - Amos Lal
- Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | | | | | - Andy Abril
- Mayo Clinic Jacksonville, Jacksonville, Florida
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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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Fouka E, Drakopanagiotakis F, Steiropoulos P. Pathogenesis of Pulmonary Manifestations in ANCA-Associated Vasculitis and Goodpasture Syndrome. Int J Mol Sci 2024; 25:5278. [PMID: 38791316 PMCID: PMC11121030 DOI: 10.3390/ijms25105278] [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: 03/06/2024] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Pulmonary manifestations of vasculitis are associated with significant morbidity and mortality in affected individuals. They result from a complex interplay between immune dysregulation, which leads to vascular inflammation and tissue damage. This review explored the underlying pathogenesis of pulmonary involvement in vasculitis, encompassing various forms such as granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), and anti-GBM disease. Mechanisms involving ANCA and anti-GBM autoantibodies, neutrophil activation, and neutrophil extracellular trap (NETs) formation are discussed, along with the role of the complement system in inducing pulmonary injury. Furthermore, the impact of genetic predisposition and environmental factors on disease susceptibility and severity was considered, and the current treatment options were presented. Understanding the mechanisms involved in the pathogenesis of pulmonary vasculitis is crucial for developing targeted therapies and improving clinical outcomes in affected individuals.
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Affiliation(s)
- Evangelia Fouka
- Department of Respiratory Medicine, General Hospital G. Papanikolaou, Medical School, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece;
| | - Fotios Drakopanagiotakis
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
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Antonucci L, Thurman JM, Vivarelli M. Complement inhibitors in pediatric kidney diseases: new therapeutic opportunities. Pediatr Nephrol 2024; 39:1387-1404. [PMID: 37733095 DOI: 10.1007/s00467-023-06120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 09/22/2023]
Abstract
Historically, the complement system (classical, lectin, alternative, and terminal pathways) is known to play a crucial role in the etiopathogenesis of many kidney diseases. Direct or indirect activation in these settings is revealed by consumption of complement proteins at the serum level and kidney tissue deposition seen by immunofluorescence and electron microscopy. The advent of eculizumab has shown that complement inhibitors may improve the natural history of certain kidney diseases. Since then, the number of available therapeutic molecules and experimental studies on complement inhibition has increased exponentially. In our narrative review, we give a summary of the main complement inhibitors that have completed phase II and phase III studies or are currently used in adult and pediatric nephrology. The relevant full-text works, abstracts, and ongoing trials (clinicaltrials.gov site) are discussed. Data and key clinical features are reported for eculizumab, ravulizumab, crovalimab, avacopan, danicopan, iptacopan, pegcetacoplan, and narsoplimab. Many of these molecules have been shown to be effective in reducing proteinuria and stabilizing kidney function in different complement-mediated kidney diseases. Thanks to their efficacy and target specificity, these novel drugs may radically improve the outcome of complement-mediated kidney diseases, contributing to an improvement in our understanding of their underlying pathophysiology.
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Affiliation(s)
- Luca Antonucci
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
- Ph.D. Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
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Miao S, Bekker P, Armas D, Lor M, Han Y, Webster K, Trivedi A. Pharmacokinetic Evaluation of the CYP3A4 and CYP2C9 Drug-Drug Interaction of Avacopan in 2 Open-Label Studies in Healthy Participants. Clin Pharmacol Drug Dev 2024; 13:517-533. [PMID: 38423992 DOI: 10.1002/cpdd.1389] [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: 10/02/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024]
Abstract
Avacopan, a complement 5a receptor (C5aR) antagonist approved for treating severe active antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis, was evaluated in 2 clinical drug-drug interaction studies. The studies assessed the impact of avacopan on the pharmacokinetics (PK) of CYP3A4 substrates midazolam and simvastatin and CYP2C9 substrate celecoxib, and the influence of CYP3A4 inhibitor itraconazole and inducer rifampin on the PKs of avacopan. The results indicated that twice-daily oral administration of 30 mg of avacopan increased the area under the curve (AUC) of midazolam by 1.81-fold and celecoxib by 1.15-fold when administered without food, and twice-daily oral administration of 30 or 60 mg of avacopan increased the AUC of simvastatin by approximately 2.6-3.5-fold and the AUC of the active metabolite β-hydroxy-simvastatin acid by approximately 1.4-1.7-fold when co-administered with food. Furthermore, the AUC of avacopan increased by approximately 2.19-fold when co-administered with itraconazole and decreased by approximately 13.5-fold when co-administered with rifampin. These findings provide critical insights into the potential drug-drug interactions involving avacopan, which could have significant implications for patient care and treatment planning. (NCT06207682).
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Peterson CG, Jackson RL. Successful use of eculizumab in immediate ANCA vasculitis recurrence in a pediatric kidney transplant. Pediatr Transplant 2024; 28:e14760. [PMID: 38623882 DOI: 10.1111/petr.14760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Kidney transplantation is an acceptable therapy end-stage kidney disease secondary to antineutrophil cytoplasmic antibody-associated vasculitis with risk of disease recurrence ranging from 3% to 17%. Standard posttransplant immunosuppression is the mainstay of therapy after recurrence. Recently, new medications focused on complement regulation and avoidance of steroids have been shown to be effective in treating antineutrophil cytoplasmic antibody (ANCA) vasculitis with no studies in the pediatric population. METHODS We report a 5-year-old patient with immediate recurrence of positive myeloperoxidase (MPO)-ANCA vasculitis after deceased donor kidney transplant and the novel use of eculizumab to salvage the graft. RESULTS Eculizumab and transition to ravulizumab has been successful in improving graft function and maintenance of disease remission after immediate MPO-ANCA vasculitis recurrence posttransplant. CONCLUSIONS Complement inhibitors may be used in addition to standard immunosuppression postkidney transplant in a pediatric patient with MPO-ANCA vasculitis recurrence without higher rates of infections.
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Affiliation(s)
| | - Rachel L Jackson
- Intermountain Healthcare, Primary Children's Hospital, Salt Lake City, Utah, USA
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Floege J, Jayne DRW, Sanders JSF, Tesar V, Balk EM, Gordon CE, Adam G, Tonelli MA, Cheung M, Earley A, Rovin BH. Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of ANCA-Associated Vasculitis. Kidney Int 2024; 105:447-449. [PMID: 38388147 DOI: 10.1016/j.kint.2023.10.009] [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: 09/11/2023] [Revised: 10/20/2023] [Accepted: 10/20/2023] [Indexed: 02/24/2024]
Abstract
In 2021, the Kidney Disease: Improving Global Outcomes (KDIGO) Guideline for the Management of Glomerular Diseases was published. KDIGO is committed to providing the nephrology community with periodic updates, based on new developments for each disease. For patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), avacopan received regulatory approval in late 2021, leading to this KDIGO guideline update. In addition, the evidence supporting a lower-dose glucocorticoid induction regimen or even complete replacement of glucocorticoids has become stronger. Herein, an executive summary of the most important guideline changes from the AAV chapter is provided as a quick reference.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology, University Hospital, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany.
| | - David R W Jayne
- Division of Experimental Medicine & Immunotherapeutics, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jan-Stephan F Sanders
- Division of Nephrology, Department of Internal Medicine, University of Groningen, Groningen, The Netherlands
| | - Vladimír Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Ethan M Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Craig E Gordon
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gaelen Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Marcello A Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Brad H Rovin
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Floege J, Jayne DR, Sanders JSF, Tesar V, Rovin BH. KDIGO 2024 Clinical Practice Guideline for the Management of Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. Kidney Int 2024; 105:S71-S116. [PMID: 38388102 DOI: 10.1016/j.kint.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/20/2023] [Indexed: 02/24/2024]
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15
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Roper T, Salama AD. ANCA-Associated Vasculitis: Practical Issues in Management. Indian J Nephrol 2024; 34:6-23. [PMID: 38645911 PMCID: PMC11003588 DOI: 10.4103/ijn.ijn_346_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/20/2023] [Indexed: 04/23/2024] Open
Abstract
ANCA associated vasculitides are multi-system autoimmune diseases which are increasing in prevalence. In this review we will discuss the clinical manifestations and review the management options. We highlight the various trials of induction and maintenance therapy and discuss the areas of unmet need. These include understanding which patients are at highest risk of relapse, clinical adaptation of improved biomarkers of disease activity and tools to discuss long term prognosis.
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Affiliation(s)
- Tayeba Roper
- UCL Department of Renal Medicine, Royal Free Hospital, London NW3 2PF, UK
| | - Alan David Salama
- UCL Department of Renal Medicine, Royal Free Hospital, London NW3 2PF, UK
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16
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Alihosseini C, Kopelman H, Zaino M, Feldman SR. Avacopan for the Treatment of Anti-Neutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. Ann Pharmacother 2023; 57:1449-1454. [PMID: 36975183 DOI: 10.1177/10600280231161592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE To review the safety and efficacy of avacopan for the treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. DATA SOURCES A systematic review of the literature was performed using the terms avacopan OR tavneos OR CCX168 OR ANCA-associated vasculitis in PubMed and Google Scholar. Articles between January 2016 and January 2023 were considered for inclusion. Bibliographies and ClinicalTrials.gov were also searched for completion. STUDY SELECTION AND DATA EXTRACTION Relative English language and human studies related to pharmacology, clinical trials, and safety were included. DATA SYNTHESIS The 52-week ADVOCATE and 12-week CLEAR clinical trials evaluated the safety and efficacy of avacopan. The remission rate was 65.7% and 54.9% in the avacopan and placebo group, respectively, in the ADVOCATE trial. The Birmingham Vasculitis Activity Score improved by ≥50% in 86.4% of avacopan treated patients and 70% of prednisone treated patients in the CLEAR trial. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON WITH EXISTING DRUGS Glucocorticoids in combination with cyclophosphamide, azathioprine, and/or rituximab have been a mainstay of ANCA-associated vasculitis treatment. However, short- and long-term medication-related adverse effects risk negative outcomes for patients. Avacopan may provide equivalent to better treatment with fewer side effects due to a reduction, if not elimination, of glucocorticoids. CONCLUSIONS Avacopan used in isolation or combination is safe and effective for ANCA-associated vasculitis.
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Affiliation(s)
| | - Hannah Kopelman
- Advanced Dermatology and Cosmetic Surgery, Maitland, FL, USA
| | - Mallory Zaino
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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17
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Tang B, Yang X. Clinical advances in immunotherapy for immune-mediated glomerular diseases. Clin Exp Med 2023; 23:4091-4105. [PMID: 37889398 PMCID: PMC10725396 DOI: 10.1007/s10238-023-01218-7] [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: 08/25/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Due to the suboptimal therapeutic efficacy and potential adverse effects associated with traditional immunosuppressive medications, there has been an increasing emphasis on the development and utilization of immunotherapies. This paper aims to provide clinicians with valuable insights for selecting appropriate therapeutic approaches and contribute to the development of novel immunotherapeutic drugs. MAIN BODY This paper categorizes the immunotherapeutic drugs that are used for the treatment of immune-mediated glomerular diseases into three groups: immunotherapies targeting antigen-presenting cells (anti-CD80), immunotherapies targeting T/B cells (anti-CD20, anti-CD22, BAFF and APRIL inhibitors, CD40-CD40L inhibitors, proteasome inhibitors, Syk inhibitors, and Btk inhibitors), and immunotherapies targeting the complement system (C5 inhibitors, C5a/C5aR inhibitors, C3 inhibitors, MASP2 inhibitors, factor B inhibitors, and factor D inhibitors). The article then provides a comprehensive overview of advances related to these immunotherapeutic drugs in clinical research. CONCLUSION Certain immunotherapeutic drugs, such as rituximab, belimumab, and eculizumab, have exhibited notable efficacy in treating specific immune-mediated glomerular diseases, thereby providing novel therapeutic approaches for patients. Nonetheless, the efficacy of numerous immunotherapeutic drugs remains to be substantiated.
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Affiliation(s)
- Bihui Tang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Xiao Yang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
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18
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Wooden B, Tarragon B, Navarro-Torres M, Bomback AS. Complement inhibitors for kidney disease. Nephrol Dial Transplant 2023; 38:ii29-ii39. [PMID: 37218685 DOI: 10.1093/ndt/gfad079] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Indexed: 05/24/2023] Open
Abstract
A refined understanding of the role of complement in the pathogenesis of glomerular and other kidney diseases has, over the past two decades, been matched by the development of novel, complement-targeting therapies. As we increasingly recognize the important role that complement activation across all three pathways-classical, lectin and alternative-plays in glomerular lesions both rare (e.g. C3 glomerulopathy) and common (e.g. immunoglobulin A nephropathy), we can identify avenues for precise, targeted approaches to modifying the natural history of these kidney diseases. In this review, we survey the evidence on using complement inhibition from the earliest, small-scale studies focusing on C5-targeting agents to more recent, large, multicenter, randomized trials utilizing complement blockade higher up in the complement pathway at the level of C3. We conclude by examining where the field of complement targeting therapy may be headed in light of these studies.
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Affiliation(s)
- Benjamin Wooden
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Blanca Tarragon
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariela Navarro-Torres
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
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19
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Alvarez L, Kambham N, Su R. Renal improvement and remission in a patient with refractory ANCA-associated vasculitis treated with avacopan. J Nephrol 2023; 36:2365-2370. [PMID: 37036661 PMCID: PMC10638159 DOI: 10.1007/s40620-023-01614-y] [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: 10/23/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023]
Abstract
Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is associated with end-organ damage resulting in significant morbidity and mortality. Most recently, avacopan, an orally administered selective antagonist of the C5a receptor, was approved by the US Food and Drug Administration as an adjunctive treatment of adult patients with severe, active ANCA-associated vasculitis (granulomatosis with polyangiitis and microscopic polyangiitis) in combination with standard therapy including glucocorticoids. This case study describes a 58-year-old Asian female with severe ANCA-associated vasculitis and acute renal failure who responded to adjunctive therapy with avacopan despite being refractory to rituximab and glucocorticoid therapy.
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Affiliation(s)
- Luis Alvarez
- Division of Nephrology, Department of Medicine and Nephrology, Palo Alto Medical Foundation, Palo Alto, CA, USA.
| | - Neeraja Kambham
- Division of Renal Pathology, Stanford University, Stanford, CA, USA
| | - Robert Su
- Division of Rheumatology, Sutter Health System, Fremont, CA, USA
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20
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Granath A, Pettersson S, Gunnarsson I, Welin E, Dahlberg K. How is the patient perspective captured in ANCA-associated vasculitis research? An integrative review. Rheumatol Adv Pract 2023; 7:rkad092. [PMID: 37954916 PMCID: PMC10637867 DOI: 10.1093/rap/rkad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/02/2023] [Indexed: 11/14/2023] Open
Abstract
Objective The aim was to describe how the patient perspective is captured in clinical research on ANCA-associated vasculitis (AAV). Methods This integrative review included 2149 publications found in four different databases and manual searches. After screening, 156 articles remained. All articles were sorted and categorized, and 77 original articles were analysed further. Results The patient perspective was captured with patient-reported outcome measures (PROMs), single-item questionnaires, project-specific questionnaires and interviews. The most common aspects measured were health-related quality of life, anxiety and depression, and fatigue, and the least common were lifestyle habits, relationships and self-management. Conclusion The patient perspective was captured predominantly with generic PROMs and occasionally with a qualitative approach. AVV is a lifelong disease, and the results from this review show that not all aspects of importance to patients are covered with the PROMs used in research. Future studies should include the areas that are the most important for patients.
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Affiliation(s)
- Annika Granath
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
- Centre for Innovation, Research and Education, Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Susanne Pettersson
- Rheumatology Unit, Inflammation and Ageing Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Iva Gunnarsson
- Rheumatology Unit, Inflammation and Ageing Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Elisabet Welin
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Karuna Dahlberg
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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21
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Kareem S, Jacob A, Mathew J, Quigg RJ, Alexander JJ. Complement: Functions, location and implications. Immunology 2023; 170:180-192. [PMID: 37222083 PMCID: PMC10524990 DOI: 10.1111/imm.13663] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/09/2023] [Indexed: 05/25/2023] Open
Abstract
The complement system, an arm of the innate immune system plays a critical role in both health and disease. The complement system is highly complex with dual possibilities, helping or hurting the host, depending on the location and local microenvironment. The traditionally known functions of complement include surveillance, pathogen recognition, immune complex trafficking, processing and pathogen elimination. The noncanonical functions of the complement system include their roles in development, differentiation, local homeostasis and other cellular functions. Complement proteins are present in both, the plasma and on the membranes. Complement activation occurs both extra- and intracellularly, which leads to considerable pleiotropy in their activity. In order to design more desirable and effective therapies, it is important to understand the different functions of complement, and its location-based and tissue-specific responses. This manuscript will provide a brief overview into the complex nature of the complement cascade, outlining some of their complement-independent functions, their effects at different locale, and their implication in disease settings.
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Affiliation(s)
- Samer Kareem
- Department of Medicine, University at Buffalo, Buffalo, New York, United States
| | - Alexander Jacob
- Department of Medicine, University at Buffalo, Buffalo, New York, United States
| | - John Mathew
- Department of Rheumatology, Christian Medical College, Vellore, India
| | - Richard J Quigg
- Department of Medicine, University at Buffalo, Buffalo, New York, United States
| | - Jessy J Alexander
- Department of Medicine, University at Buffalo, Buffalo, New York, United States
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22
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Heras Benito M. [Complement in vasculitis associated with anti-neutrophil cytoplasm antibodies with renal involvement: pathogenic, prognostic and therapeutic implications]. Med Clin (Barc) 2023; 161:160-165. [PMID: 37236835 DOI: 10.1016/j.medcli.2023.04.007] [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: 02/20/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023]
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitides are primary vasculitides that affect small vessels in various organs, including the kidney. Renal involvement is characterized by the presence of glomerulonephritis with crescents and necrosis in light microscopy and a pauci-immune pattern in immunofluorescence. The participation of complement in the pathogenesis of these entities has been valued in recent years, initially in animal models and later in studies in humans, by demonstrating the presence of fragments of the alternative complement pathway, in plasma and urine, together with complement deposits in glomeruli and small vessels of patients affected by antineutrophil cytoplasmic antibody vasculitis. The presence of complement in these entities confers a worse general and renal prognosis.
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Affiliation(s)
- Manuel Heras Benito
- Servicio de Nefrología, Hospital Universitario de Salamanca, Salamanca, España.
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23
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Nguyen ID, Sinnathamby ES, Mason J, Urban B, Neuchat EE, Wenger DM, Ahmadzadeh S, Shekoohi S, Kaye AD. Avacopan, a Novel Competitive C5a Receptor Antagonist, for Severe Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis. Clin Drug Investig 2023; 43:595-603. [PMID: 37596445 DOI: 10.1007/s40261-023-01298-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 08/20/2023]
Abstract
Avacopan is a relatively novel drug with complement antagonizing properties, and it has demonstrated promising outcomes in treating antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis. This review article seeks to investigate the current standard of care for ANCA vasculitis with the combination of avacopan. The current standard therapy involves the usage of daily corticosteroids in addition to either cyclophosphamide or rituximab; however, prolonged use of corticosteroids is known to be associated with various adverse effects. Avacopan was introduced as a possible substitution to alleviate high-corticosteroid dosages. It functions through competitive inhibition of the C5a receptor in the complement system and results in the reduction of neutrophil activation and migration to sites of inflammation. Clinical trials have observed the efficacy of avacopan both in conjunction with standard therapy with corticosteroids and without corticosteroids. The use of avacopan was able to achieve disease remission and improve renal function in patients with ANCA-associated vasculitis. Additionally, the novel treatment did not increase the risk of adverse events during treatment, while also lowering the toxic effects associated with corticosteroid usage. In summary, current evidence supports the success and safety of administering avacopan to treat patients with ANCA-associated vasculitis. Additional clinical trials are warranted to identify optimal dosage and method in using avacopan in the clinical setting.
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Affiliation(s)
- Ivan D Nguyen
- School of Medicine, LSU Health Sciences Center New Orleans, 1901 Gravier Street, New Orleans, LA, 70112, USA
| | - Evan S Sinnathamby
- School of Medicine, LSU Health Sciences Center New Orleans, 1901 Gravier Street, New Orleans, LA, 70112, USA
| | - Joseph Mason
- School of Medicine, LSU Health Sciences Center New Orleans, 1901 Gravier Street, New Orleans, LA, 70112, USA
| | - Bretton Urban
- School of Medicine, LSU Health Sciences Center New Orleans, 1901 Gravier Street, New Orleans, LA, 70112, USA
| | - Elisa E Neuchat
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Danielle M Wenger
- University of Arizona College of Medicine-Phoenix, 475 N 5th St, Phoenix, AZ, 85004, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
- Department of Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
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24
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Berti A, Cornec D, Dua AB. Treatment Approaches to Granulomatosis with Polyangiitis and Microscopic Polyangiitis. Rheum Dis Clin North Am 2023; 49:545-561. [PMID: 37331732 DOI: 10.1016/j.rdc.2023.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
We have made significant headway in our ability to induce and maintain remission in patients with granulomatosis with polyangiitis and microscopic polyangiitis. With increased understanding of the pathogenesis of antineutrophilic cytoplasmic antibody-associated vasculitides (AAV), therapeutic targets have been identified and studied in clinical trials. From initial induction strategies including glucocorticoids and cyclophosphamide, we have discovered effective induction regimens with rituximab and complement inhibition that can significantly decrease the glucocorticoid cumulative doses in patients with AAV. There are many trials underway evaluating management strategies for refractory patients and exploring new and old therapies that may help to continuously improve outcomes for patients with AAV.
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Affiliation(s)
- Alvise Berti
- Center for Medical Sciences (CISMed), Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, and Division of Rheumatology, Santa Chiara Hospital, APSS Trento, Italy
| | - Divi Cornec
- Rheumatology Department, INSERM UMR1227 LBAI, Lymphocytes B, Autoimmunité et Immunothérapies, University of Brest, National Reference Center for Rare Systemic Autoimmune Diseases CERAINO, CHRU Brest, Brest, France.
| | - Anisha B Dua
- Division of Rheumatology, Northwestern University Feinberg School of Medicine, 675 North Saint Clair Street, Suite 14-100, Chicago, IL 60611, USA
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25
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Schirmer JH, Sanchez-Alamo B, Hellmich B, Jayne D, Monti S, Luqmani RA, Tomasson G. Systematic literature review informing the 2022 update of the EULAR recommendations for the management of ANCA-associated vasculitis (AAV): part 1-treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:e003082. [PMID: 37479496 PMCID: PMC10364171 DOI: 10.1136/rmdopen-2023-003082] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/16/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To summarise and update evidence to inform the 2022 update of the EULAR recommendations for the management of antineutrophil cytoplasm antibody-associated vasculitis (AAV). METHODS A systematic literature review (SLR) was performed to identify current evidence regarding treatment of AAV. PubMed, EMBASE and the Cochrane library were searched from 1 February 2015 to 25 February 2022. The evidence presented here is focused on the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RESULTS 3517 articles were screened and 175 assessed by full-text review. Ninety articles were included in the final evidence synthesis. Cyclophosphamide and rituximab (RTX) show similar efficacy for remission induction (level of evidence (LoE) 1a) but RTX is more effective in relapsing disease (LoE 1b). Glucocorticoid (GC) protocols with faster tapering result in similar remission rates but lower rates of serious infections (LoE 1b). Avacopan can be used to rapidly taper and replace GC (LoE 1b). Data on plasma exchange are inconsistent depending on the analysed trial populations but meta-analyses based on randomised controlled trials demonstrate a reduction of the risk of end-stage kidney disease at 1 year but not during long-term follow-up (LoE 1a). Use of RTX for maintenance of remission is associated with lower relapse rates compared with azathioprine (AZA, LoE 1b). Prolonged maintenance treatment results in lower relapse rates for both, AZA (LoE 1b) and RTX (LoE 1b). CONCLUSION This SLR provides current evidence to inform the 2022 update of the EULAR recommendations for the management of AAV.
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Affiliation(s)
- Jan Henrik Schirmer
- Clinic for Internal Medicine I, Rheumatology and Clinical Immunology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Beatriz Sanchez-Alamo
- Nephrology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
- Nephrology, Skåne University Hospital, Lund, Sweden
| | - Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken Kirchheim/Teck, University Tübingen, Kirchheim-Teck, Germany
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, University of Pavia; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raashid Ahmed Luqmani
- Oxford NIHR Biomedical Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gunnar Tomasson
- Faculty of Medicine, University of Iceland, Landspitali University Hospital, Reykjavik, Iceland
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Osman M, Cohen Tervaert JW, Pagnoux C. Avacopan for the treatment of ANCA-associated vasculitis: an update. Expert Rev Clin Immunol 2023; 19:461-471. [PMID: 36545762 DOI: 10.1080/1744666x.2023.2162041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids (GC) have been part of the standard treatment of anti-neutrophil cytoplasm autoantibodies (ANCA)-associated vasculitides (AAV) for more than 60 years. Various therapeutic advances have occurred over the past 2 decades and led to a significant reduction of GC exposure, but most patients still have to suffer from complications of GC, including infections, metabolic abnormalities, and cardiovascular morbidity. In 2007, activation of the complement pathway was demonstrated to play a role in the pathogenesis of AAV. Avacopan, an oral competitive inhibitor of the C5a receptor (C5aR1, CD88), was then developed, with an additional aim to decrease the use of GC. AREAS COVERED In this article, we briefly summarize the rationale for targeting the complement pathway in AAV, and review relevant findings from pre-clinical, phase I, II, and III studies, subsequent and more recent case reports and series on the efficacy and safety of avacopan. EXPERT OPINION Based on the results of these studies, avacopan was approved in most countries since late 2021, as an adjunctive induction treatment for patients with AAV. Several newer questions now are pending answers, including as to how avacopan should be used in real-world practice, beyond how it was given in the original clinical trials.
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Affiliation(s)
- Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Christian Pagnoux
- Vasculitis clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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27
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Levien TL, Baker DE. Avacopan. Hosp Pharm 2023; 58:134-142. [PMID: 36890951 PMCID: PMC9986577 DOI: 10.1177/00185787221087187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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28
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Paroli M, Gioia C, Accapezzato D. New Insights into Pathogenesis and Treatment of ANCA-Associated Vasculitis: Autoantibodies and Beyond. Antibodies (Basel) 2023; 12:antib12010025. [PMID: 36975372 PMCID: PMC10045085 DOI: 10.3390/antib12010025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a group of rare systemic diseases affecting small-caliber vessels. The damage caused by AAV mainly involves the lung and kidneys. AAV includes three different types: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Although the different phenotypic forms of AAV share common features, recent studies have shown that there are significant differences in terms of pathogenetic mechanisms involving both the adaptive and innate immune systems. Advances in our understanding of pathogenesis have enabled the development of immuno-targeted therapies. This review illustrates the characteristics of the various forms of AAV and the new therapies available for this disease that can have lethal consequences if left untreated.
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Affiliation(s)
- Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Morris A, Geetha D. Advances in remission induction therapy for ANCA-associated vasculitis. Best Pract Res Clin Rheumatol 2023; 37:101828. [PMID: 37244804 DOI: 10.1016/j.berh.2023.101828] [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: 03/29/2023] [Revised: 04/09/2023] [Accepted: 04/23/2023] [Indexed: 05/29/2023]
Abstract
Since its first description 40 years ago, huge strides have been made in the management of ANCA-associated vasculitis with improved patient outcomes. The use of cyclophosphamide and/or B-cell depleting therapy alongside glucocorticoids remains the cornerstone of therapy in organ or life-threatening disease, but recent trials have re-evaluated existing treatment strategies, alongside the development of new treatment targets. This has led to refinement of the role of plasma exchange, the use of reduced dosing of oral glucocorticoids with improved patient outcomes, as well as other treatment adjuvants/options of steroid minimization including C5a receptor antagonism and IL-5 inhibition. In this review we examine developments in remission induction therapy for ANCA-associated vasculitis.
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Affiliation(s)
- Adam Morris
- Renal Medicine, Royal Preston Hospital, Preston, UK
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Terrier B, Karras A. Inhibiting C5a/C5aR to treat ANCA-associated vasculitides. Joint Bone Spine 2023; 90:105472. [PMID: 36273796 DOI: 10.1016/j.jbspin.2022.105472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/02/2022] [Accepted: 10/11/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic diseases, French Vasculitis Study Group, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, 27, rue du Faubourg Saint-Jacques, 75679 Paris cedex 14, France.
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, France
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van Leeuwen JR, Popov T, Obergfell A, Rabelink TJ, Teng YKO. Preliminary Assessment of Safety and Tolerability of Avacopan During the Early Access Program for ANCA-Associated Vasculitis. Biologics 2023; 17:11-14. [PMID: 36721867 PMCID: PMC9884459 DOI: 10.2147/btt.s394843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Jolijn R van Leeuwen
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine - Nephrology Section, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Ton J Rabelink
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine - Nephrology Section, Leiden University Medical Center, Leiden, the Netherlands
| | - Y K Onno Teng
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine - Nephrology Section, Leiden University Medical Center, Leiden, the Netherlands,Correspondence: YK Onno Teng, Department of Nephrology, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC, Leiden, the Netherlands, Tel +31-071-5262148, Fax +31-071-5266868, Email
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Kemper C, Ferreira VP, Paz JT, Holers VM, Lionakis MS, Alexander JJ. Complement: The Road Less Traveled. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 210:119-125. [PMID: 36596217 PMCID: PMC10038130 DOI: 10.4049/jimmunol.2200540] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/11/2022] [Indexed: 01/04/2023]
Abstract
The complement field has recently experienced a strong resurgence of interest because of the unexpected discovery of new complement functions extending complement's role beyond immunity and pathogen clearance, a growing list of diseases in which complement plays a role, and the proliferation of complement therapeutics. Importantly, although the majority of complement components in the circulation are generated by the liver and activated extracellularly, complement activation unexpectedly also occurs intracellularly across a broad range of cells. Such cell-autonomous complement activation can engage intracellular complement receptors, which then drive noncanonical cell-specific effector functions. Thus, much remains to be discovered about complement biology. In this brief review, we focus on novel noncanonical activities of complement in its "classic areas of operation" (kidney and brain biology, infection, and autoimmunity), with an outlook on the next generation of complement-targeted therapeutics.
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Affiliation(s)
- Claudia Kemper
- Complement and Inflammation Research Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine, Toledo, OH
| | - Jeanne T Paz
- Gladstone Institute of Neurological Disease, Gladstone Institutes, San Francisco CA
- Department of Neurology, University of California, San Francisco, San Francisco, CA
- Neurosciences Graduate Program, University of California, San Francisco, San Francisco, CA
| | - V Michael Holers
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; and
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Mazzariol M, Manenti L, Vaglio A. The complement system in antineutrophil cytoplasmic antibody-associated vasculitis: pathogenic player and therapeutic target. Curr Opin Rheumatol 2023; 35:31-36. [PMID: 36301247 DOI: 10.1097/bor.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the role of the complement system in the pathogenesis of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) as well as the employment of complement inhibitors in AAV treatment. RECENT FINDINGS AAV has traditionally been considered a pauci-immune disease until recent findings demonstrated the pathogenic role of the complement system. The complement alternative pathway is crucial in AAV, and C5a seems to be a key molecule for AAV to develop. Avacopan, a C5a-receptor (C5aR) antagonist, proved effective in achieving AAV remission and ameliorating kidney function. SUMMARY The increased circulating levels of some complement components - as well as the consumption of others - in patients with AAV suggested a systemic activation of the complement system. Low C3 levels correlate with a more aggressive disease and a worse renal prognosis. In ANCA-associated glomerulonephritis, renal deposits of C3d and properdin, suggestive of local alternative pathway activation, correlate with glomerular crescents and proteinuria. The interaction between C5a and neutrophil triggers alternative pathway activation, suggesting the central role of C5a in AAV pathogenesis. Avacopan, a C5aR inhibitor, showed beneficial effects in AAV and represents a promising therapy to achieve sustained remission and to spare glucocorticoids.
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Affiliation(s)
- Martina Mazzariol
- Department of Medical Sciences, University of Torino, Torino
- Nephrology and Dialysis Unit, Department of Pediatrics, Meyer Children's Hospital, Firenze
| | | | - Augusto Vaglio
- Nephrology and Dialysis Unit, Department of Pediatrics, Meyer Children's Hospital, Firenze
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio," University of Firenze, Firenze, Italy
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Avacopan in granulomatosis with polyangiitis and microscopic polyangiitis: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00974-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Scurt FG, Bose K, Hammoud B, Brandt S, Bernhardt A, Gross C, Mertens PR, Chatzikyrkou C. Old known and possible new biomarkers of ANCA-associated vasculitis. J Autoimmun 2022; 133:102953. [PMID: 36410262 DOI: 10.1016/j.jaut.2022.102953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/06/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises a group of multisystem disorders involving severe, systemic, small-vessel vasculitis with short- and long term serious and life-threating complications. Despite the simplification of treatment, fundamental aspects concerning assessment of its efficacy and its adaptation to encountered complications or to the relapsing/remitting/subclinical disease course remain still unknown. The pathogenesis of AAV is complex and unique, and despite the progress achieved in the last years, much has not to be learnt. Foremost, there is still no accurate marker enabling us to monitoring disease and guide therapy. Therefore, the disease management relays often on clinical judgment and follows a" trial and error approach". In the recent years, an increasing number of new molecules s have been explored and used for this purpose including genomics, B- and T-cell subpopulations, complement system factors, cytokines, metabolomics, biospectroscopy and components of our microbiome. The aim of this review is to discuss both the role of known historical and clinically established biomarkers of AAV, as well as to highlight potential new ones, which could be used for timely diagnosis and monitoring of this devastating disease, with the goal to improve the effectiveness and ameliorate the complications of its demanding therapy.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany.
| | - K Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - S Brandt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - A Bernhardt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - C Gross
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Peter R Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
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Casal Moura M, Branco C, Martins-Martinho J, Ferraro JL, Berti A, Nogueira E, Ponte C. A glance into the future of anti-neutrophil cytoplasmic antibody-associated vasculitis. Ther Adv Musculoskelet Dis 2022; 14:1759720X221125979. [PMID: 36353270 PMCID: PMC9638684 DOI: 10.1177/1759720x221125979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
In the past decade, unprecedented progress has been made in understanding the pathogenesis, diagnosis, assessment, and treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). International collaborations and input from several fields (e.g. immunology, rheumatology, and nephrology) have been critical for analyzing demographics, disease manifestations, and outcomes in clinical research studies. Such efforts opened new avenues for generating novel questions and rationale to design better clinical trials. In addition, clinical research has been a source of several biological discoveries and the starting point for knowledge seeking on the pathophysiology of AAV. Interestingly, the blending of clinical and basic research provides a platform for personalized medicine. Despite recent revisions on AAV classification, the incorporation of new findings on disease genetics and immunologic responses may soon result in changes in clinical practice. These advances will enhance the selection of more specific and targeted therapies. However, current unmet needs in the management of AAV are still sizable and heavily impact long-term survival. Especially, frequent relapses, damage accrual, and high morbidity contribute to poor outcomes. Finally, the lack of defined biomarkers for disease activity and the prognosis is a permanent challenge in AAV research. Our work provides an overview of the current state of the art in AAV literature and suggests bridges for the remaining knowledge gaps. It offers potential future directions for the clinical assessment, management, and research in the field toward a more personalized medicine approach.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo
Clinic College of Medicine and Science, 200 First Street, Rochester, MN
55905-0002, USA
- Department of Medicine, Faculty of Medicine,
Porto University, Porto, Portugal
| | - Carolina Branco
- Renal Transplant and Nephrology Department,
Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte,
Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa
Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de
Medicina de Lisboa, Lisbon, Portugal
| | - José Luís Ferraro
- Rheumatology Department, Hospital de Santa
Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de
Medicina de Lisboa, Lisbon, Portugal
| | - Alvise Berti
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo
Clinic College of Medicine and Science, Rochester, MN, USA
- Rheumatology Department, Santa Chiara Hospital
and Department of Cellular, Computational and Integrative Biology (CIBIO),
University of Trento, Trento, Italy
| | - Estela Nogueira
- Renal Transplant and Nephrology Department,
Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte,
Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa
Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de
Medicina de Lisboa, Lisbon, Portugal
- Unidade de Investigação em Reumatologia,
Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de
Lisboa, Lisbon, Portugal
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Sim TM, Mak A, Tay SH. Insights into the role of neutrophils in neuropsychiatric systemic lupus erythematosus: Current understanding and future directions. Front Immunol 2022; 13:957303. [PMID: 36016935 PMCID: PMC9396336 DOI: 10.3389/fimmu.2022.957303] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 12/12/2022] Open
Abstract
Central nervous system (CNS) involvement of systemic lupus erythematosus (SLE), termed neuropsychiatric SLE (NPSLE), is a major and debilitating manifestation of the disease. While patients with SLE mostly complain of common neuropsychological symptoms such headache and mild mood disorders that may not even be technically attributed to SLE, many SLE patients present with life-threatening NPSLE syndromes such as cerebrovascular disease, seizures and psychosis that are equally challenging in terms of early diagnosis and therapy. While we are just beginning to unravel some mysteries behind the immunologic basis of NPSLE, advancements in the mechanistic understanding of the complex pathogenic processes of NPSLE have been emerging through recent murine and human studies. The pathogenic pathways implicated in NPSLE are multifarious and various immune effectors such as cell-mediated inflammation, autoantibodies and cytokines including type I interferons have been found to act in concert with the disruption of the blood-brain barrier (BBB) and other neurovascular interfaces. Beyond antimicrobial functions, neutrophils are emerging as decision-shapers during innate and adaptive immune responses. Activated neutrophils have been recognized to be involved in ischemic and infective processes in the CNS by releasing neutrophil extracellular traps (NETs), matrix metalloproteinase-9 and proinflammatory cytokines. In the context of NPSLE, these mechanisms contribute to BBB disruption, neuroinflammation and externalization of modified proteins on NETs that serve as autoantigens. Neutrophils that sediment within the peripheral blood mononuclear cell fraction after density centrifugation of blood are generally defined as low-density neutrophils (LDNs) or low-density granulocytes. LDNs are a proinflammatory subset of neutrophils that are increased with SLE disease activity and are primed to undergo NETosis and release cytokines such as interferon-α and tumor necrosis factor. This review discusses the immunopathogenesis of NPSLE with a focus on neutrophils as a core mediator of the disease and potential target for translational research in NPSLE.
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38
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Jackson H, Jaki T. An alternative to traditional sample size determination for small patient populations. Stat Biopharm Res 2022. [DOI: 10.1080/19466315.2022.2107565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Holly Jackson
- Department of Mathematics and Statistics, Lancaster University, Lancaster, U.K
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, U.K
- MRC Biostatistics Unit, University of Cambridge, Cambridge, U.K
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Carvalho K, Schartz ND, Balderrama-Gutierrez G, Liang HY, Chu SH, Selvan P, Gomez-Arboledas A, Petrisko TJ, Fonseca MI, Mortazavi A, Tenner AJ. Modulation of C5a-C5aR1 signaling alters the dynamics of AD progression. J Neuroinflammation 2022; 19:178. [PMID: 35820938 PMCID: PMC9277945 DOI: 10.1186/s12974-022-02539-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The complement system is part of the innate immune system that clears pathogens and cellular debris. In the healthy brain, complement influences neurodevelopment and neurogenesis, synaptic pruning, clearance of neuronal blebs, recruitment of phagocytes, and protects from pathogens. However, excessive downstream complement activation that leads to generation of C5a, and C5a engagement with its receptor C5aR1, instigates a feed-forward loop of inflammation, injury, and neuronal death, making C5aR1 a potential therapeutic target for neuroinflammatory disorders. C5aR1 ablation in the Arctic (Arc) model of Alzheimer's disease protects against cognitive decline and neuronal injury without altering amyloid plaque accumulation. METHODS To elucidate the effects of C5a-C5aR1 signaling on AD pathology, we crossed Arc mice with a C5a-overexpressing mouse (ArcC5a+) and tested hippocampal memory. RNA-seq was performed on hippocampus and cortex from Arc, ArcC5aR1KO, and ArcC5a+ mice at 2.7-10 months and age-matched controls to assess mechanisms involved in each system. Immunohistochemistry was used to probe for protein markers of microglia and astrocytes activation states. RESULTS ArcC5a+ mice had accelerated cognitive decline compared to Arc. Deletion of C5ar1 delayed or prevented the expression of some, but not all, AD-associated genes in the hippocampus and a subset of pan-reactive and A1 reactive astrocyte genes, indicating a separation between genes induced by amyloid plaques alone and those influenced by C5a-C5aR1 signaling. Biological processes associated with AD and AD mouse models, including inflammatory signaling, microglial cell activation, and astrocyte migration, were delayed in the ArcC5aR1KO hippocampus. Interestingly, C5a overexpression also delayed the increase of some AD-, complement-, and astrocyte-associated genes, suggesting the possible involvement of neuroprotective C5aR2. However, these pathways were enhanced in older ArcC5a+ mice compared to Arc. Immunohistochemistry confirmed that C5a-C5aR1 modulation in Arc mice delayed the increase in CD11c-positive microglia, while not affecting other pan-reactive microglial or astrocyte markers. CONCLUSION C5a-C5aR1 signaling in AD largely exerts its effects by enhancing microglial activation pathways that accelerate disease progression. While C5a may have neuroprotective effects via C5aR2, engagement of C5a with C5aR1 is detrimental in AD models. These data support specific pharmacological inhibition of C5aR1 as a potential therapeutic strategy to treat AD.
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Affiliation(s)
- Klebea Carvalho
- Department of Developmental & Cell Biology, University of California, Irvine, Irvine, CA 92697 USA
| | - Nicole D. Schartz
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
| | | | - Heidi Y. Liang
- Department of Developmental & Cell Biology, University of California, Irvine, Irvine, CA 92697 USA
| | - Shu-Hui Chu
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
| | - Purnika Selvan
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
| | - Angela Gomez-Arboledas
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
| | - Tiffany J. Petrisko
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
| | - Maria I. Fonseca
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
| | - Ali Mortazavi
- Department of Developmental & Cell Biology, University of California, Irvine, Irvine, CA 92697 USA
| | - Andrea J. Tenner
- Department of Molecular Biology & Biochemistry, University of California, Irvine, 3205 McGaugh Hall, Irvine, CA 92697-3900 USA
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA USA
- Department of Pathology and Laboratory Medicine, University of California, Irvine, School of Medicine, Irvine, CA USA
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Tesar V, Hruskova Z. Complement Inhibition in ANCA-Associated Vasculitis. Front Immunol 2022; 13:888816. [PMID: 35880179 PMCID: PMC9307875 DOI: 10.3389/fimmu.2022.888816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Efficacy of immunosuppressive treatment of Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is complicated by its toxicity. With the replacement of cyclophosphamide with rituximab, serious adverse events seem to be associated especially with high-dose corticosteroids. Activation of alternative complement pathway plays an important role in the pathogenesis of AAV. Avacopan (C5a receptor inhibitor) was demonstrated to have at least similar efficacy and better safety (in terms of corticosteroid-related adverse events) compared with high-dose corticosteroids in the induction treatment of AAV. Other modes of the inhibition of alternative complement pathway are currently tested in AAV or could be considered on the basis of the experience in other glomerular diseases.
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Fernandez-Ruiz R, Belmont HM. The role of anticomplement therapy in lupus nephritis. Transl Res 2022; 245:1-17. [PMID: 35158097 DOI: 10.1016/j.trsl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
The complement system plays crucial roles in homeostasis and host defense against microbes. Deficiency of early complement cascade components has been associated with increased susceptibility to systemic lupus erythematosus (SLE), whereas excessive complement consumption is a hallmark of this disease. Although enhanced classical pathway activation by immune complexes was initially thought to be the main contributor to lupus nephritis (LN) pathogenesis, an increasing body of evidence has suggested the alternative and the lectin pathways are also involved. Therapeutic agents targeting complement activation have been used in LN patients and clinical trials are ongoing. We review the mechanisms by which complement system dysregulation contributes to renal injury in SLE and summarize the latest evidence on the use of anticomplement agents to manage this condition.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, NYU Grossman School of Medicine, New York, New York
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Kimoto Y, Horiuchi T. The Complement System and ANCA Associated Vasculitis in the Era of Anti-Complement Drugs. Front Immunol 2022; 13:926044. [PMID: 35812453 PMCID: PMC9260009 DOI: 10.3389/fimmu.2022.926044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
ANCA (anti-neutrophil cytoplasmic antibody)-associated vasculitis (AAV) is the condition in which ANCA, as an autoantibody, is associated with the pathogenesis of vasculitis in small blood vessels, mainly in the ear, nose, throat, kidney, lung, and nerves. These diseases are important because they can be fatal due to renal failure and pulmonary hemorrhage if not promptly and appropriately treated. Recently accumulated evidence has shown that C5a produced by the complement alternative pathway primes neutrophils, which in turn activate the complement alternative pathway, leading to the pathogenesis of AAV. Avacopan (CCX168), a C5aR antagonist was shown to be effective against AAV, and it has been a novel therapeutic option, becoming a novel anti-complement drug to modulate inflammatory diseases.
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Werion A, Rondeau E. Application of C5 inhibitors in glomerular diseases in 2021. Kidney Res Clin Pract 2022; 41:412-421. [PMID: 35354244 PMCID: PMC9346396 DOI: 10.23876/j.krcp.21.248] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 11/04/2022] Open
Abstract
The complement pathway is an essential mechanism in innate immunity, but it is also involved in multiple pathologies. For kidney diseases, strong evidence of a dysregulation in the alternative pathway in atypical hemolytic uremic syndrome (aHUS) led to the use of eculizumab, the first anti-C5 inhibitor available in clinical practice. Intensive fundamental research resulted in the development of subsequent new drugs, such as long-acting C5 inhibitors, oral medications, or antagonists of C5aR, the receptor for C5a. New data in the domain of C5-inhibition in glomerular diseases are still limited and mainly focus on 1) the efficacy of ravulizumab, a long-acting C5 inhibitor in aHUS, and 2) the use of avacopan, a C5aR antagonist, in antineutrophil cytoplasmic antibody vasculitis. Several new studies ongoing or planned for the next few years will evaluate the efficacy of C5 inhibition in secondary thrombotic microangiopathy, C3 glomerulopathy, membranous nephropathy, or immunoglobulin A nephropathy.
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Affiliation(s)
- Alexis Werion
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
- Correspondence: Eric Rondeau Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Rue de la Chine 4, 75020 Paris, France. E-mail:
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van Leeuwen JR, Bredewold OW, van Dam LS, Werkman SL, Jonker JT, Geelhoed M, Langeveld AP, Remmelts HH, van den Broecke MM, Ray A, Rabelink TJ, Teng YO. Compassionate Use of Avacopan in Difficult-to-Treat Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Kidney Int Rep 2022; 7:624-628. [PMID: 35257076 PMCID: PMC8897689 DOI: 10.1016/j.ekir.2021.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jolijn R. van Leeuwen
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Obbo W. Bredewold
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Laura S. van Dam
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Stella L. Werkman
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacqueline T. Jonker
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Alrijne Ziekenhuis, Leiden, The Netherlands
| | - Miranda Geelhoed
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antonius P.M. Langeveld
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department Otorhinolaryngology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hilde H.F. Remmelts
- Department of Nephrology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Maud M. van den Broecke
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Argho Ray
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton J. Rabelink
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Y.K. Onno Teng
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic diseases (LuVaCs), Department of Internal Medicine—Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
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d’Alessandro M, Conticini E, Bergantini L, Cameli P, Cantarini L, Frediani B, Bargagli E. Neutrophil Extracellular Traps in ANCA-Associated Vasculitis and Interstitial Lung Disease: A Scoping Review. Life (Basel) 2022; 12:life12020317. [PMID: 35207604 PMCID: PMC8877891 DOI: 10.3390/life12020317] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Deregulated neutrophil extracellular traps (NETs) formation is implicated in various diseases, including ANCA-associated vasculitis and pulmonary fibrosis (PF). Lung involvement is frequent in AAV, and interstitial lung diseases (ILDs) are strongly related to MPO-ANCA positivity and mainly reported in microscopic polyangiitis. The association between AAV and ILD is a strong indicator of poor prognosis and limited survival. Neutrophils, ANCA and NET interplay in PF development in AAV. This study aimed to review the literature concerning the implications of NET in lung fibrogenesis specifically focused on AAV associated with ILD, and the potential of NET as a theranostic marker. Methods: Through scoping review methodology, we used a descriptive thematic analysis to understand the pathogenic role of NETs in patients with AAV and pulmonary fibrosis and their further role as a theranostic marker of this disease. Results: The implications of NET in the pathogenesis of AAV and ILD, as well as an association between these two diseases, have been identified, but the underlying pathophysiological mechanisms are still unknown. The pharmacological or genetic inhibition of NET release reduces disease severity in multiple inflammatory disease models, indicating that NETs are potential therapeutic targets. In this regard, despite the lack of clinical data, we may hypothesise that an optimal management of AAV-ILD patients would require not only B-cells targeted therapy, but also NETs inhibition. Conclusion: Preliminary findings seem to display a lack of efficacy of traditional immunosuppressants, such as Rituximab, in this subset of patients, while to date no patients suffering from a definite ILD have been enrolled in clinical trials. Further insights would be provided by their employment, as a combination treatment, in common clinical practice. Although we can imagine that the inhibition of NETs in patients with AAV-ILD could reduce severity and mortality, we still lack the scientific basis that could improve our understanding of the disease from a molecular point of view.
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Affiliation(s)
- Miriana d’Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
- Correspondence:
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
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Comparison of Complement Pathway Activation in Autoimmune Glomerulonephritis. Kidney Int Rep 2022; 7:1027-1036. [PMID: 35571000 PMCID: PMC9091805 DOI: 10.1016/j.ekir.2022.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 12/11/2022] Open
Abstract
Introduction Methods Results Conclusion
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Mandell MJ, Gheriani GA, Lenert A, Lenert PS. Avacopan: An Oral Complement 5a Inhibitor for ANCA-associated Vasculitis. Rheumatology (Oxford) 2022. [DOI: 10.17925/rmd.2022.1.1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The oral complement 5a receptor antagonist, avacopan, was recently studied in phase II and III clinical trials in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This article summarizes the study findings and considers the implications for future care of patients with AAV. Avacopan was proven to be safe and noninferior to glucocorticoids for AAV in a study where patients with severe newly diagnosed or relapsing AAV were initially treated with either rituximab or cyclophosphamide. Greater improvement in the glomerular filtration rate, reduced numbers of relapses and better health-related quality of life were observed in the avacopan group compared with the prednisone group. Patients in the avacopan group also had fewer glucocorticoid-associated adverse events and, despite complement inhibition, there were no cases of Neisseria meningitidis infection reported in either group. Future studies should address the long-term safety of avacopan and whether it can completely replace glucocorticoids in AAV-induction protocols and for the management of minor disease relapses.
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Adeeb F, Malik H, Sitram R, Mahmood W, Bhutta S. Steroid-free management and recent advances in antineutrophil cytoplasmic antibody-associated vasculitis. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_87_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Avacopan (TAVNEOS™) is a complement 5a receptor (C5aR) antagonist developed by ChemoCentryx for the treatment of autoimmune diseases including anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis. The therapeutic effects of avacopan are attributed to the inhibition of C5aR activity on neutrophils, however, the exact mechanism of therapeutic efficacy in patients with ANCA-associated vasculitis has not been established. In September 2021, avacopan received its first approval in Japan for the treatment of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA), the two most common forms of ANCA-associated vasculitis, where it is being commercialized by Kissei Pharmaceutical through a partnership with Vifor Pharma. In October 2021, avacopan was approved in the USA as an adjunctive treatment in adults for severe active ANCA-associated vasculitis (specifically MPA and GPA) in combination with standard therapy including glucocorticoids (avacopan does not eliminate glucocorticoid use). Avacopan has received a positive opinion in the EU, and is also undergoing regulatory review in Switzerland and Canada. Avacopan is being investigated for the treatment of complement component 3 glomerulopathy, hidradenitis suppurativa, lupus nephritis and IgA nephropathy. This article summarizes the milestones in the development of avacopan leading to these first approvals in Japan and the USA.
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Affiliation(s)
- Arnold Lee
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Freiwald T, Afzali B. Renal diseases and the role of complement: Linking complement to immune effector pathways and therapeutics. Adv Immunol 2021; 152:1-81. [PMID: 34844708 PMCID: PMC8905641 DOI: 10.1016/bs.ai.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complement system is an ancient and phylogenetically conserved key danger sensing system that is critical for host defense against pathogens. Activation of the complement system is a vital component of innate immunity required for the detection and removal of pathogens. It is also a central orchestrator of adaptive immune responses and a constituent of normal tissue homeostasis. Once complement activation occurs, this system deposits indiscriminately on any cell surface in the vicinity and has the potential to cause unwanted and excessive tissue injury. Deposition of complement components is recognized as a hallmark of a variety of kidney diseases, where it is indeed associated with damage to the self. The provenance and the pathophysiological role(s) played by complement in each kidney disease is not fully understood. However, in recent years there has been a renaissance in the study of complement, with greater appreciation of its intracellular roles as a cell-intrinsic system and its interplay with immune effector pathways. This has been paired with a profusion of novel therapeutic agents antagonizing complement components, including approved inhibitors against complement components (C)1, C3, C5 and C5aR1. A number of clinical trials have investigated the use of these more targeted approaches for the management of kidney diseases. In this review we present and summarize the evidence for the roles of complement in kidney diseases and discuss the available clinical evidence for complement inhibition.
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Affiliation(s)
- Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States; Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Behdad Afzali
- Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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