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Kidoguchi G, Yoshida Y, Watanabe H, Sugimoto T, Mokuda S, Kida T, Yajima N, Omura S, Nakagomi D, Abe Y, Kadoya M, Takizawa N, Nomura A, Kukida Y, Kondo N, Yamano Y, Yanagida T, Endo K, Matsui K, Takeuchi T, Ichinose K, Kato M, Yanai R, Matsuo Y, Shimojima Y, Nishioka R, Okazaki R, Takata T, Ito T, Moriyama M, Takatani A, Miyawaki Y, Ito-Ihara T, Kawaguchi T, Kawahito Y, Hirata S. Effectiveness and safety of rituximab in severely relapsed antineutrophil cytoplasmic antibody-associated vasculitis: a retrospective analysis of a Japanese multicentre cohort from the J-CANVAS. Clin Rheumatol 2024; 43:3195-3204. [PMID: 39134873 PMCID: PMC11442524 DOI: 10.1007/s10067-024-07096-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: 03/05/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 10/01/2024]
Abstract
We aimed to clarify the long-term safety and efficacy of rituximab (RTX) as a remission induction therapy following severe relapse in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We retrospectively collected the data of patients with severely relapsed AAV from a Japanese multicentre cohort. The primary exposure was RTX use; the primary outcome was complete remission (CR) proportions at week 24. Baseline characteristics were compared between the RTX and non-RTX groups. We performed multivariate logistic regression analysis and one-to-one propensity score matching analysis as a sensitivity analysis. Totally, 100 patients were enrolled: 52 in the RTX group and 48 in the non-RTX group. Baseline characteristics were comparable between the two groups, except for age, AAV subtype and ANCA serotype. The median age was 71 vs. 75 years, and the PR3-ANCA positivity rate was 44.2% vs. 18.8% in the RTX and non-RTX groups, respectively. No significant difference was observed in CR proportions at week 24 between the two groups (79.2% vs. 68.1%, p = 0.321), with an adjusted odds ratio of 1.27 (95% confidence interval [CI] 0.47-3.51). At week 48, CR proportions were significantly higher in the RTX group (91.7% vs. 64.9%, p = 0.005), with an adjusted odds ratio of 2.95 (95% CI 0.97-9.91). Serious infection rates were lower in the RTX group than in the non-RTX group, with no statistically significant difference. RTX was not superior to conventional immunosuppressive therapies at week 24 but showed significantly favourable results at week 48 for severely relapsed AAV.
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Affiliation(s)
- Genki Kidoguchi
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan.
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Watanabe
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Takashi Kida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Omura
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University, Tokyo, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Aichi, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Naoya Kondo
- Department of Nephrology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan
| | - Takuya Yanagida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Hematology and Rheumatology, Kagoshima University Hospital, Kagoshima, Japan
| | - Koji Endo
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Japan
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Kiyoshi Matsui
- Department of Diabetes, Endocrinology and Clinical Immunology, School of Medicine, Hyogo Medical University, Hyogo, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Rheumatology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, Hokkaido, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Matsuo
- Department of Rheumatology, Tokyo Kyosai Hospital, Tokyo, Japan
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
| | - Ryota Okazaki
- Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Tomoaki Takata
- Division of Gastroenterology and Nephrology, Tottori University, Tottori, Japan
| | - Takafumi Ito
- Division of Nephrology, Department of Internal Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Mayuko Moriyama
- Department of Rheumatology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Ayuko Takatani
- Rheumatic Disease Center, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
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Mescia F, Salviani C, Tonoli M, Affatato S, Moratto D, Tedesco M, Guerini A, Gemmo A, Camoni M, Delbarba E, Zubani R, Garrafa E, Chiarini M, Gregorini G, Scolari F, Alberici F. Sustained post-rituximab B-cell depletion is common in ANCA-associated vasculitis and is affected by sex and renal function. Nephrol Dial Transplant 2024; 39:683-693. [PMID: 37673675 DOI: 10.1093/ndt/gfad197] [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: 05/16/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE Despite the increasing use of rituximab in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), it remains unclear what the optimal dosing is, especially for maintenance of remission. A deeper understanding of post-rituximab B-cell repopulation patterns may aid better-tailored treatment. METHODS This is a monocentric, retrospective study including ANCA-positive AAV patients receiving a single course of rituximab induction. CD19+ B cells were longitudinally monitored with flow cytometry. B-cell repopulation was defined as CD19+ >10 cells/μL. RESULTS Seventy-one patients were included, the majority with microscopic polyangiitis (75%), myeloperoxidase-ANCA positivity (75%) and with renal involvement (79%). During a median follow-up of 54 months since the first rituximab infusion, 44 patients (62%) repopulated B cells, with a median time to repopulation of 39 months (range 7-102). Patients experiencing B-cell depletion lasting longer than the overall median time to repopulation (39 months) exhibited a lower risk of flare and higher risk of serious infection. In multivariate Cox regression, higher estimated glomerular filtration rate (eGFR) [hazard ratio (HR) 1.84, 95% confidence interval (CI) 1.13-2.98 per 30 mL/min/1.73 m2 eGFR] and female sex (HR 2.70, 95% CI 1.37-5.31) were independent predictors of increased rate of B-cell repopulation. CONCLUSION A subset of AAV patients develop sustained post-rituximab B-cell depletion, which associates with reduced risk of flare and increased risk of serious infection in the long term. Preserved renal function and female sex are associated with faster B-cell repopulation. These observations further highlight the need to personalize immunosuppression to improve clinical outcomes.
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Affiliation(s)
- Federica Mescia
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Chiara Salviani
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mattia Tonoli
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Stefania Affatato
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Daniele Moratto
- Flow Cytometry Laboratory, Department of Laboratory Diagnostics, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Martina Tedesco
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Alice Guerini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Alessia Gemmo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Marta Camoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Elisa Delbarba
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Roberto Zubani
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Emirena Garrafa
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Laboratory Diagnostics, ASST Spedali Civili, Brescia, Italy
| | - Marco Chiarini
- Flow Cytometry Laboratory, Department of Laboratory Diagnostics, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
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Hajishah H, Amini MJ, Chadeganipour AS, Salehi SA, Kazemi D. Efficacy of Rituximab on Refractory Organ Involvements in Granulomatosis with Polyangiitis: A Systematic Review of Case Reports. Curr Rheumatol Rev 2024; 20:270-283. [PMID: 37907486 DOI: 10.2174/0115733971263964231020072640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is a type of Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) characterized by necrotizing vasculitis affecting small and medium-sized blood vessels. GPA affects various organs, with respiratory tract, vasculitis and glomerulonephritis being the most common triad. Remission induction and maintenance therapy for GPA traditionally involves corticosteroids and cyclophosphamide. However, treatment with rituximab, a monoclonal antibody that depletes B-cells involved in autoimmune disease, has been successful in inducing remission in several studies. The purpose of this systematic review was to investigate the efficacy of rituximab in treating various clinical manifestations of GPA. METHODS In adherence to PRISMA guidelines for systematic reviews and meta-analyses, we carried out a comprehensive review to investigate the effectiveness of rituximab on particular organ involvement in GPA. We searched three databases (PubMed, Scopus, and Embase) up until November 6, 2022, for case reports on the topic. To ensure all relevant studies were included, we manually screened the first 50 pages of Google Scholar's search results. RESULTS The review identified a total of 64 case reports and a case series of 113 cases, highlighting the effectiveness of rituximab in treating refractory organ involvement in GPA. The review also analyzed the effectiveness of rituximab in treating ocular, CNS, cardiac, pulmonary, cutaneous, gastrointestinal, renal, and other organ involvements in GPA. CONCLUSIONS Our results indicated that rituximab can be a promising therapy for treating specific clinical manifestations of several organ involvements. However, more research is needed to determine the long-term efficacy of rituximab in treating GPA.
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Affiliation(s)
- Hamed Hajishah
- Student Research Committee, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Javad Amini
- Student Research Committee, Medical School, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Seyyed Amirhossein Salehi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Danial Kazemi
- Student Research Committee, Isfahan University of Medical Sciences, Hezar Jerib Street, Isfahan, Iran
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Sorin B, Iudici M, Guerry MJ, Samson M, Bielefeld P, Maillet T, Nouvier M, Karras A, Meyer L, Lavigne C, Régent A, Durel CA, Fabre M, Charles P, Raimbourg Q, Lanteri A, Pugnet G, Rivière F, Pineton de Chambrun M, Cacoub P, Le Guenno G, Jourdain P, Mekinian A, Paule R, Dion J, Legendre P, Cohen P, Guillevin L, Puéchal X, Terrier B. Induction failure in granulomatosis with polyangiitis: a nationwide case-control study of risk factors and outcomes. Rheumatology (Oxford) 2023; 62:3662-3671. [PMID: 36847447 DOI: 10.1093/rheumatology/kead098] [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: 11/22/2022] [Revised: 02/08/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE To identify characteristics of granulomatosis with polyangiitis (GPA) associated with induction failure, describe salvage therapies and their efficacy. METHODS We conducted a nationwide retrospective case-control study of GPA with induction failure between 2006 and 2021. Each patient with induction failure was randomly paired to three controls matched for age, sex and induction treatment. RESULTS We included 51 patients with GPA and induction failure (29 men and 22 women). At induction therapy, median age was 49 years. Twenty-seven patients received intravenous cyclophosphamide (ivCYC) and 24 rituximab (RTX) as induction therapy. Patients with ivCYC induction failure more frequently had PR3-ANCA (93% vs 70%, P = 0.02), relapsing disease (41% vs 7%, P < 0.001) and orbital mass (15% vs 0%, P < 0.01) compared with controls. Patients with disease progression despite RTX induction therapy more frequently had renal involvement (67% vs 25%, P = 0.02) with renal failure (serum creatinine >100 µmol/l in 42% vs 8%, P = 0.02) compared with controls. After salvage therapy, remission was achieved at 6 months in 35 (69%) patients. The most frequent salvage therapy was switching from ivCYC to RTX (or vice versa), showing an efficacy in 21/29 (72%). Remission was achieved in nine (50%) patients with inappropriate response to ivCYC, while in patients with progression after RTX induction, remission was achieved in four (100%) who received ivCYC (with or without immunomodulatory therapy), but only in three (50%) after adding immunomodulatory therapy alone. CONCLUSION In patients with induction failure, characteristics of GPA, salvage therapies and their efficacy vary according to induction therapy and failure modality.
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Affiliation(s)
- Boris Sorin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Michele Iudici
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Division of Rheumatology, Department of Internal Medicine and Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Mary-Jane Guerry
- Department of Nephrology, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Philip Bielefeld
- Department of Nephrology and Systemic Diseases, Hôpital François Mitterrand, Dijon, France
| | - Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Mathilde Nouvier
- Department of Nephrology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Lara Meyer
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Christian Lavigne
- Department of Internal Medicine-Clinical Immunology, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marc Fabre
- Department of Internal Medicine, Centre Hospitalier Pierre Oudot, Bourgouin, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Quentin Raimbourg
- Department of Nephrology, Hôpital Bichat Claude Bernard, Paris, France
| | - Aurélia Lanteri
- Department of Internal Medicine-Infectious Diseases, Centre Hospitalier d'Antibes, Antibes, France
| | - Grégory Pugnet
- Department of Internal Medicine and Clinical Immunology, Hôpital Rangueil, Toulouse, France
| | - Frédéric Rivière
- Department of Pneumology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | | | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, Hôpital Pitié Salpêtrière, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Hôpital d'Estaing, Clermont-Ferrand, France
| | - Pierre Jourdain
- Department of Nephrology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Arsène Mekinian
- Department of Internal Medicine, Hôpital Saint-Antoine, Paris, France
| | - Romain Paule
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Jérémie Dion
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Paul Legendre
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Department of Clinical Immunology, Centre Hospitalier du Mans, Le Mans, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
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McClure ME, Gopaluni S, Wason J, Henderson RB, Van Maurik A, Savage CCO, Pusey CD, Salama AD, Lyons PA, Lee J, Mynard K, Jayne DR, Jones RB. A randomised study of rituximab and belimumab sequential therapy in PR3 ANCA-associated vasculitis (COMBIVAS): design of the study protocol. Trials 2023; 24:180. [PMID: 36906660 PMCID: PMC10007661 DOI: 10.1186/s13063-023-07218-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/03/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Sequential B cell-targeted immunotherapy with BAFF antagonism (belimumab) and B cell depletion (rituximab) may enhance B cell targeting in ANCA-associated vasculitis (AAV) through several mechanisms. METHODS Study design: COMBIVAS is a randomised, double-blind, placebo-controlled trial designed to assess the mechanistic effects of sequential therapy of belimumab and rituximab in patients with active PR3 AAV. The recruitment target is 30 patients who meet the criteria for inclusion in the per-protocol analysis. Thirty-six participants have been randomised to one of the two treatment groups in a 1:1 ratio: either rituximab plus belimumab or rituximab plus placebo (both groups with the same tapering corticosteroid regimen), and recruitment is now closed (final patient enrolled April 2021). For each patient, the trial will last for 2 years comprising a 12-month treatment period followed by a 12-month follow-up period. PARTICIPANTS Participants have been recruited from five of seven UK trial sites. Eligibility criteria were age ≥ 18 years and a diagnosis of AAV with active disease (newly diagnosed or relapsing disease), along with a concurrent positive test for PR3 ANCA by ELISA. INTERVENTIONS Rituximab 1000 mg was administered by intravenous infusions on day 8 and day 22. Weekly subcutaneous injections of 200 mg belimumab or placebo were initiated a week before rituximab on day 1 and then weekly through to week 51. All participants received a relatively low prednisolone (20 mg/day) starting dose from day 1 followed by a protocol-specified corticosteroid taper aiming for complete cessation by 3 months. OUTCOMES The primary endpoint of this study is time to PR3 ANCA negativity. Key secondary outcomes include change from baseline in naïve, transitional, memory, plasmablast B cell subsets (by flow cytometry) in the blood at months 3, 12, 18 and 24; time to clinical remission; time to relapse; and incidence of serious adverse events. Exploratory biomarker assessments include assessment of B cell receptor clonality, B cell and T cell functional assays, whole blood transcriptomic analysis and urinary lymphocyte and proteomic analysis. Inguinal lymph node and nasal mucosal biopsies have been performed on a subgroup of patients at baseline and month 3. DISCUSSION This experimental medicine study provides a unique opportunity to gain detailed insights into the immunological mechanisms of belimumab-rituximab sequential therapy across multiple body compartments in the setting of AAV. TRIAL REGISTRATION ClinicalTrials.gov NCT03967925. Registered on May 30, 2019.
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Affiliation(s)
- Mark E McClure
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK.
- Department of Medicine, University of Cambridge, Cambridge, UK.
| | - Seerapani Gopaluni
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | | | | | | | - Charles D Pusey
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Alan D Salama
- UCL Centre for Nephrology, Royal Free Hospital, London, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
| | - Jacinta Lee
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Kim Mynard
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - David R Jayne
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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6
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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7
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Seth I, Bhagavata Srinivasan SP, Bulloch G, Yi DS, Frankel A, Hsu K, Passam F, Garsia R, Corte TJ. Diffuse alveolar haemorrhage as a rare complication of antiphospholipid syndrome. Respirol Case Rep 2022; 10:e0948. [PMID: 35414937 PMCID: PMC8980908 DOI: 10.1002/rcr2.948] [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: 10/19/2021] [Revised: 03/01/2022] [Accepted: 03/25/2022] [Indexed: 12/24/2022] Open
Abstract
Diffuse alveolar haemorrhage (DAH) is a rare complication of antiphospholipid syndrome. With a mortality rate of 46%, early diagnosis and management remain an ongoing challenge. Case reports are limited, and management guidelines are not yet definitive. In this case report, we present a 43-year-old male with DAH who required high-dose oral steroids, intravenous methylprednisolone cyclophosphamide and rituximab over 18 months to control life-threatening episodes of pulmonary bleeding.
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Affiliation(s)
- Ishith Seth
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | | | - Gabriella Bulloch
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | - Dong Seok Yi
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | - Anthony Frankel
- Bankstown Lidcombe HospitalSouth Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Kelvin Hsu
- Bankstown Lidcombe HospitalSouth Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Freda Passam
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Roger Garsia
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Tamera J. Corte
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
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8
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Néel A, Degauque N, Bruneau S, Braudeau C, Bucchia M, Caristan A, De Mornac D, Genin V, Glemain A, Oriot C, Rimbert M, Brouard S, Josien R, Hamidou M. [Pathogenesis of ANCA-associated vasculitides in 2021: An update]. Rev Med Interne 2022; 43:89-97. [PMID: 35033384 DOI: 10.1016/j.revmed.2021.11.002] [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: 05/07/2021] [Revised: 10/22/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022]
Abstract
Anticytoplasmic neutrophil antibodies (ANCA)-associated vasculitis (AAV) are rare systemic immune-mediated diseases characterized by small vessel necrotizing vasculitis and/or respiratory tract inflammation. Over the last 2 decades, anti-MPO vasculitis mouse model has enlightened the role of ANCA, neutrophils, complement activation, T helper cells (Th1, Th17) and microbial agents. In humans, CD4T cells have been extensively studied, while the dramatic efficacy of rituximab demonstrated the key role of B cells. Many areas of uncertainty remain, such as the driving force of GPA extra-vascular granulomatous inflammation and the relapse risk of anti-PR3 AAV pathogenesis. Animal models eventually led to identify complement activation as a promising therapeutic target. New investigation tools, which permit in depth immune profiling of human blood and tissues, may open a new era for the studying of AAV pathogenesis.
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Affiliation(s)
- A Néel
- Service de médecine interne, CHU de Nantes, Nantes, France; Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France; Centre de référence maladies auto-immunes systémiques Rares, hôpital Cochin, AP-HP, Paris, France.
| | - N Degauque
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
| | - S Bruneau
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
| | - C Braudeau
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France; Laboratoire d'immunologie, CHU de Nantes, Nantes, France
| | - M Bucchia
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France; Service de pédiatrie, CHU de Nantes, Nantes, France
| | - A Caristan
- Service de médecine interne, CHD Vendée, La-Roche-Sur-Yon, France
| | - D De Mornac
- Service de médecine interne, CHU de Nantes, Nantes, France; Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
| | - V Genin
- Service de médecine interne, CHU de Nantes, Nantes, France; Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
| | - A Glemain
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
| | - C Oriot
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France; Service de pédiatrie, CHU de Nantes, Nantes, France
| | - M Rimbert
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France; Laboratoire d'immunologie, CHU de Nantes, Nantes, France
| | - S Brouard
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
| | - R Josien
- Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France; Laboratoire d'immunologie, CHU de Nantes, Nantes, France
| | - M Hamidou
- Service de médecine interne, CHU de Nantes, Nantes, France; Inserm, centre de recherche en transplantation et immunologie, UMR 1064, université de Nantes, Nantes, France
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9
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Duarte I, Oliveira J, Outerelo C, Godinho I, Pereira M, Fernandes P, Jorge S, Gameiro J. Rituximab in glomerular diseases: a case series and narrative review. J Bras Nefrol 2021; 44:187-195. [PMID: 34874051 PMCID: PMC9269185 DOI: 10.1590/2175-8239-jbn-2021-0120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/27/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The use of Rituximab (RTX) in glomerular diseases (GD) has increased in the past years, although it is still only used in a small fraction of patients. METHODS A single center retrospective study of adult patients with membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), lupus nephritis (LN), and vasculitis treated with RTX as first or second-line therapy was conducted at our center from 2010 to 2020. RESULTS We identified 19 patients; 36.8% had MN and 25.0% each had FSGS, LN, and vasculitis. RTX was first-line therapy in 26.3% of patients and in 73.7% it was second-line therapy. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had complete remission (CR), 2 patients (28.6%) had partial remission (PR), and 3 patients (42.9%) had no response (NR). In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response, and 1 patient had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response, and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Infusion reactions were present in 2 patients (10.5%) and one patient had multiple infectious complications. CONCLUSIONS The efficacy of RTX in treating different types of immune-mediated GD has been demonstrated with different response rates, but an overall safe profile. In our case series, the results are also encouraging. Longitudinal studies are needed to better understand the effect of RTX in GD.
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Affiliation(s)
- Inês Duarte
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - João Oliveira
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Cristina Outerelo
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Iolanda Godinho
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Marta Pereira
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Paulo Fernandes
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Sofia Jorge
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
| | - Joana Gameiro
- Centro Hospitalar Universitário Lisboa Norte, Serviço de Nefrologia e Transplantação Renal, Lisboa, Portugal
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10
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Wang CR, Tsai YS, Tsai HW, Lee CH. B-Cell-Depleting Therapy Improves Myocarditis in Seronegative Eosinophilic Granulomatosis with Polyangiitis. J Clin Med 2021; 10:jcm10194577. [PMID: 34640595 PMCID: PMC8509673 DOI: 10.3390/jcm10194577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac involvement is a major mortality cause in eosinophilic granulomatosis with polyangiitis (EGPA), requiring novel therapeutics to spare the use of cyclophosphamide with known cardiotoxicity. Despite the observed efficacy of B-cell-depleting therapy in myocarditis of seropositive microscopic polyangiitis, it remains to be elucidated in seronegative EGPA. A retrospective study was performed in 21 hospitalized active patients aged 20 to 70 years with five-factor score 1 or 2, eosinophil counts 10,034 ± 6641/μL and vasculitis scores 27 ± 6. Overt myocarditis was identified in 10 cases, at disease onset in 6 and relapse in 4, with endomyocarditis in 4 and myopericarditis in 4. Five seronegative and one seropositive patient received rituximab with an induction regimen 375 mg/m2 weekly × 4 for refractory or relapse disease, and the same regimen for annual maintenance therapy. All cases had lower eosinophil counts, improved cardiac dysfunction and clinical remission with a relapse-free follow-up, 48 ± 15 months after the induction treatment. One seronegative endomyocarditis patient had eosinophilia and disease relapse with asthma attack and worsening cardiac insufficiency 24 months after induction, achieving clinical remission under anti-IL-5 therapy. Our findings suggest the suppression of IL-5-mediated eosinophilia as an action mechanism of B-cell-depleting therapy in seronegative EGPA myocarditis.
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Affiliation(s)
- Chrong-Reen Wang
- Division of Rheumatology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
- Correspondence:
| | - Yi-Shan Tsai
- Department of Medical Imaging, National Cheng Kung University Hospital, Tainan 70403, Taiwan;
| | - Hung-Wen Tsai
- Department of Pathology, National Cheng Kung University Hospital, Tainan 70403, Taiwan;
| | - Cheng-Han Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan;
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11
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Granulomatosis with Polyangiitis in Adolescence: Two Distinct Presentations. Case Rep Rheumatol 2021; 2021:6642910. [PMID: 34239753 PMCID: PMC8235959 DOI: 10.1155/2021/6642910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/10/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction. Granulomatosis with polyangiitis (GPA) is a rare disease in pediatric age. We report two cases with distinct presentations. Case Reports. A seventeen-year-old male with prolonged febrile syndrome, cough, and constitutional symptoms. CT-scan showed cavitated lesions of the lung and bronchial biopsy a necrotizing inflammatory process. The remaining investigation revealed hematoproteinuria and positive C-ANCA and anti-PR3. Complications: Bilateral acute pulmonary thromboembolism, splenic infarction, and extensive popliteal and superficial femoral deep vein thrombosis. He was treated with corticosteroids, immunoglobulin, rituximab, and anticoagulation. Rituximab was maintained every six months during the first two years. Control angio-CT was performed with almost complete resolution of previous findings. In a twelve-year-old female with inflammatory signs of the limbs, investigation showed myositis of the thigh and tenosynovitis of the wrist, normocytic normochromic anemia (Hg 9.4 g/dL), mild elevation of inflammatory markers, and high creatine kinase. During hospitalization, she presented an extensive alveolar hemorrhage associated with severe anemia and positive C-ANCA and anti-PR3. Clinical deterioration prompted intravenous methylprednisolone pulses and plasmapheresis. Induction therapy with rituximab and prednisolone showed good results. Rituximab was maintained every six months, for 18 months, with gradual tapering of corticoids. Discussion. GPA is a systemic disease with variable clinical presentation and severity. Pediatric patients have similar clinical manifestations to adults but different frequencies of organ involvement; constitutional symptoms are also more common. We highlight the different presentation of these two cases, as well as the need for an individualized approach. Rituximab has been used for both induction-remission and maintenance therapy, with good results, particularly in young patients.
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12
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Cheema K, Cox A, Coles A, Scott K, Willcocks L, Jones RB. Deciphering neurological symptoms in ANCA-associated vasculitis, uncontrolled disease or a complication of therapy. Rheumatology (Oxford) 2021; 60:iii67-iii69. [PMID: 34137879 DOI: 10.1093/rheumatology/keab103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kim Cheema
- Cummings School of Medicine, University of Calgary, Alberta, Canada
| | | | | | | | - Lisa Willcocks
- Vasculitis and Lupus Clinic, Department of Medicine, Cambridge University Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Department of Medicine, Cambridge University Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, UK
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13
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Bénard V, Farhat C, Zarandi-Nowroozi M, Durand M, Charles P, Puéchal X, Guillevin L, Pagnoux C, Makhzoum JP. Comparison of Two Rituximab Induction Regimens for Antineutrophil Cytoplasm Antibody-Associated Vasculitis: Systematic Review and Meta-Analysis. ACR Open Rheumatol 2021; 3:484-494. [PMID: 34114739 PMCID: PMC8280814 DOI: 10.1002/acr2.11274] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022] Open
Abstract
Objective The objective of this study was to compare the efficacy and safety of two rituximab (RTX) regimens for the induction of remission in severe antineutrophil cytoplasm antibody–associated vasculitis (AAV): the four‐dose (375 mg/m2 intravenously weekly) versus the two‐dose (1000 mg intravenously biweekly) regimen. Methods A systematic review was performed to identify studies using the four‐ and/or two‐dose RTX regimens for induction of remission in severe AAV. Disease status 6 months after RTX infusion was required for inclusion. Patients were excluded if they received concomitant cyclophosphamide or plasma exchange. The primary end point was the proportion of patients in complete remission at 6 months. The pooled estimate was obtained by using meta‐analysis methods for proportions with random effects. Secondary end points included antineutrophil cytoplasm antibody status, number of patients with B‐cell depletion, mean prednisone dose, infections, and death. Results A total of 27 studies and 506 patients were included for analysis: 361 patients received the four‐dose regimen, and 145 patients received the two‐dose regimen. Most patients had relapsing disease at inclusion (83% and 92% of patients, respectively). There was no significant difference between the four‐ and two‐dose regimens, with a complete remission achieved in 85% (95% confidence interval [CI]: 70‐96) and 91% (95% CI: 79‐99) of patients, respectively. At 6 months, both regimens were associated with a similar mean daily prednisone dose (8.1 mg), infections (12% in both), and death (1% vs 0%, respectively). Conclusion No difference was found in terms of efficacy or safety between the four‐ and two‐dose RTX regimens for induction of remission in severe AAV.
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Affiliation(s)
- Valérie Bénard
- Canadian Network for Research on Vasculitides, Hôpital Sacré-Coeur de Montréal, and University of Montreal, Montreal, Quebec, Canada
| | | | | | - Madeleine Durand
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Charles
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, and Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, and Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Loic Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, and Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christian Pagnoux
- Canadian Network for Research on Vasculitides, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Jean-Paul Makhzoum
- Canadian Network for Research on Vasculitides, Hôpital Sacré-Coeur de Montréal, and University of Montreal, Montreal, Quebec, Canada
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14
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Segelmark L, Flores-Suárez LF, Mohammad AJ. Severe infections in patients with ANCA associated vasculitis treated with rituximab. Rheumatology (Oxford) 2021; 61:205-212. [PMID: 33757116 DOI: 10.1093/rheumatology/keab293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab (RTX) is an anti-CD20 antibody that selectively depletes B-cells and has emerged as a therapy for ANCA-associated vasculitis (AAV) during the past decade. This study sought to quantify, and determine potential risk factors for, severe infections in AAV patients treated with RTX at rheumatology clinics in Mexico City, Mexico and Lund, Sweden. METHODS The study consisted of a retrospective case-record review (2005-2015) with standardized data collection related to the occurrence of severe infection in 46 patients with AAV in Mexico City (n = 20) and Lund (n = 26) treated with RTX during their disease course. Median duration of follow-up from first RTX dose to death or end of study was 26 months. RESULTS Eleven (24%) patients suffered a total of 18 severe infections (infection rate of 11.5/100 patient-years). Thirteen of the 18 infections (72%) occurred within the first year of treatment. Risk factors for severe infection were older age at RTX initiation and absence of ENT-involvement at diagnosis. In multivariate analyses, age at RTX infusion was the only independent factor predicting severe infection. Four patients (9%) died during follow-up, all as a result of infection. CONCLUSIONS Severe infections are common following RTX treatment, and mortality due to infection is a major concern. Most severe infections occur within the first year of RTX treatment. The negative correlation of ENT involvement with severe infection might reflect GPA phenotype heterogeneity. Older age at time of RTX treatment independently predicts severe infections.
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Affiliation(s)
- Leo Segelmark
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - L F Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden.,Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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15
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Morishita KA, Wagner-Weiner L, Yen EY, Sivaraman V, James KE, Gerstbacher D, Szymanski AM, O'Neil KM, Cabral DA. Consensus Treatment Plans for Severe Pediatric Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2021; 74:1550-1558. [PMID: 33675161 DOI: 10.1002/acr.24590] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE There is no standardized approach to the treatment of pediatric antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (ped-AAV). Because of the rarity of ped-AAV, randomized trials have not been feasible. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed consensus treatment plans (CTPs) for severe ped-AAV to enable the future study of comparative effectiveness and safety. METHODS A workgroup of CARRA members (rheumatologists and nephrologists) formed the AAV working group. This group performed a literature review on existing evidence-based treatments and guidelines for the management of AAV. They determined that the target population for CTP development was patients <18 years with new-onset granulomatosis with polyangiitis (GPA), microscopic polyangiitis, or renal-limited AAV (eosinophilic-GPA was excluded) with presentation confined to those with severe disease i.e. organ- or life-threatening. Face-to-face consensus conferences employed nominal group techniques to identify treatment strategies for remission-induction and remission-maintenance, data elements to be systematically collected, and outcomes to be measured over time. RESULTS The ped-AAV workgroup developed two CTPs for each of the remission-induction and remission-maintenance of severe AAV. A corticosteroid-weaning regimen for induction and maintenance, a core dataset, and outcome measures were also defined. A random sample of CARRA membership voted acceptance of the CTPs for remission-induction and remission-maintenance with a 94% (75/80) and 98% (78/80) approval rate respectively. CONCLUSION Consensus methodology established standardized CTPs for treating severe ped-AAV. These CTPs were in principle accepted by CARRA-wide membership for pragmatic comparative effectiveness evaluation in a long-term registry.
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Affiliation(s)
| | | | | | | | | | | | | | | | - David A Cabral
- British Columbia's Children's Hospital, University of British Columbia
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16
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Krishna R, De Giacomi F, Kumar N, Kalina P, Specks U, Baqir M. Rituximab Versus Cyclophosphamide for Central Nervous System Involvement of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Series. J Clin Rheumatol 2021; 27:64-72. [PMID: 31567753 DOI: 10.1097/rhu.0000000000001169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effectiveness of rituximab (RTX) with cyclophosphamide (CYC) in patients who have central nervous system (CNS) involvement in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS A computer-assisted search was conducted to identify all adults who received a diagnosis of AAV with CNS involvement from January 1, 1997, through July 1, 2017, at our institution. RESULTS Of the 17 patients identified, 11 had received RTX, and 6 had received CYC. Age at diagnosis of CNS involvement was similar in both groups. In the RTX group, 91% of the patients were women; in the CYC group, 33% were women (p = 0.03). At the time of CNS presentation, orbital involvement had occurred in 6 patients in the RTX group and in none of the patients in the CYC group. Initial remission of induction was achieved in all patients (100%) in the CYC group and in 10 patients (91%) in the RTX group. Two patients had no response to RTX: 1 patient when RTX was used for remission induction at the time of diagnosis and the second patient when RTX was used for remission induction after relapse. The median follow-up was 38 months (range, 9-127 months). Central nervous system relapse occurred in 4 patients in the RTX group and in 1 patient in the CYC group. Of the 4 patients in the RTX group with relapse, 3 had marked ocular involvement. Both nonresponder patients in the RTX group had ocular involvement. CONCLUSION Rituximab is as effective as CYC in remission induction in patients with CNS involvement in AAV.
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Affiliation(s)
- Rachana Krishna
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Federica De Giacomi
- Cardio-Thoracic-Vascular Department, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | | | | | - Ulrich Specks
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Misbah Baqir
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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17
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Gill EE, Smith ML, Gibson KM, Morishita KA, Lee AHY, Falsafi R, Graham J, Foell D, Benseler SM, Ross CJ, Luqmani RA, Cabral DA, Hancock REW, Brown KL. Different Disease Endotypes in Phenotypically Similar Vasculitides Affecting Small-to-Medium Sized Blood Vessels. Front Immunol 2021; 12:638571. [PMID: 33692808 PMCID: PMC7937946 DOI: 10.3389/fimmu.2021.638571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/01/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Chronic primary vasculitis describes a group of complex and rare diseases that are characterized by blood vessel inflammation. Classification of vasculitis subtypes is based predominantly on the size of the involved vessels and clinical phenotype. There is a recognized need to improve classification, especially for small-to-medium sized vessel vasculitides, that, ideally, is based on the underlying biology with a view to informing treatment. Methods: We performed RNA-Seq on blood samples from children (n = 41) and from adults (n = 11) with small-to-medium sized vessel vasculitis, and used unsupervised hierarchical clustering of gene expression patterns in combination with clinical metadata to define disease subtypes. Results: Differential gene expression at the time of diagnosis separated patients into two primary endotypes that differed in the expression of ~3,800 genes in children, and ~1,600 genes in adults. These endotypes were also present during disease flares, and both adult and pediatric endotypes could be discriminated based on the expression of just 20 differentially expressed genes. Endotypes were associated with distinct biological processes, namely neutrophil degranulation and T cell receptor signaling. Conclusions: Phenotypically similar subsets of small-to-medium sized vessel vasculitis may have different mechanistic drivers involving innate vs. adaptive immune processes. Discovery of these differentiating immune features provides a mechanistic-based alternative for subclassification of vasculitis.
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Affiliation(s)
- Erin E Gill
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Maren L Smith
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Kristen M Gibson
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Kimberly A Morishita
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital, Vancouver, BC, Canada
| | - Amy H Y Lee
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Reza Falsafi
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Jinko Graham
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, BC, Canada
| | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Hospital Muenster, Muenster, Germany
| | - Susanne M Benseler
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Colin J Ross
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Raashid A Luqmani
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - David A Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital, Vancouver, BC, Canada
| | - Robert E W Hancock
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada.,Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada
| | - Kelly L Brown
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada
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18
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Springer JM, Kalot MA, Husainat NM, Byram KW, Dua AB, James KE, Chang Lin Y, Turgunbaev M, Villa-Forte A, Abril A, Langford C, Maz M, Chung SA, Mustafa RA. Granulomatosis With Polyangiitis and Microscopic Polyangiitis: A Systematic Review and Meta-Analysis of Benefits and Harms of Common Treatments. ACR Open Rheumatol 2021; 3:196-205. [PMID: 33590973 PMCID: PMC7966881 DOI: 10.1002/acr2.11230] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/31/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this systemic review is to compare different treatments for patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) to inform evidence-based recommendations for the American College of Rheumatology (ACR)/Vasculitis Foundation (VF) Vasculitis Management Guidelines. METHODS A systemic review was conducted by searching articles in English using OVID Medline, PubMed, Embase, and the Cochrane Library. Articles were screened for suitability in addressing PICO questions, with studies presenting the highest level of evidence given preference. RESULTS A total of 729 full-text articles addressing GPA and MPA PICO questions were reviewed. For remission induction, rituximab was shown to be noninferior to cyclophosphamide (CYC) (odds ratio [OR]: 1.55, moderate certainty of evidence). The addition of plasma exchange to induction therapy in severe disease did not improve the composite end point of death or end stage renal disease (hazard ratio [HR]: 0.86 [95% confidence interval CI: 0.65, 1.13], moderate certainty of evidence). In nonsevere disease, methotrexate was noninferior to CYC for induction of remission (remission at 6 months of 90% vs. 94%). For maintenance of remission, methotrexate and azathioprine showed no difference in the risk of relapse over a mean follow-up of 29 months (HR: 0.92, [95% CI: 0.52, 1.65]low certainty of evidence). As maintenance therapy, rituximab was superior to a tapering azathioprine strategy in major relapse-free survival at 28 months (HR: 6.61, [95% CI: 1.56, 27.96], moderate certainty of evidence). In two randomized trials, longer-term azathioprine maintenance therapy (>24 months) is associated with fewer relapses without an increase in adverse events. CONCLUSION This comprehensive systematic review synthesizes and evaluates the benefits and toxicities of different treatment options for GPA and MPA.
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Affiliation(s)
| | | | | | - Kevin W Byram
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anisha B Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City, Kansas
| | | | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, Kansas
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19
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Antineutrophil cytoplasmic antibodies (ANCA) - their role in pathogenesis, diagnosis, and treatment monitoring of ANCA-associated vasculitis. Cent Eur J Immunol 2021; 45:218-227. [PMID: 33456335 PMCID: PMC7792441 DOI: 10.5114/ceji.2019.92494] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/23/2020] [Indexed: 12/24/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) constitutes a group of rare diseases characterized by necrotizing inflammation of small blood vessels and the presence of ANCA. Increasing clinical and experimental evidences support their pathogenic role in AAV, but the exact mechanism is not fully understood. Recently, the important role of neutrophil extracellular traps (NETs) in pathogenesis of AAV is underlined. There is an indication that NETs can be a source for the formation of ANCA. The most common ANCA target antigens are myeloperoxidase (MPO) and proteinase 3 (PR3). Though the mechanism of action of ANCA is still under exploration, ANCA serology is being increasingly used for classification of AAV and revealed as kenner in defining various disease subsets associated with different genetic background, clinical features, treatment response, and prognosis. Controversy exists regarding the utility of serial measurements of ANCA in patients with AAV to monitor treatment and predict disease relapse.
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20
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Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci 2021; 22:E793. [PMID: 33466873 PMCID: PMC7830514 DOI: 10.3390/ijms22020793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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21
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van Dam LS, Oskam JM, Kamerling SWA, Arends EJ, Bredewold OW, Berkowska MA, van Dongen JJM, Rabelink TJ, van Kooten C, Teng YKO. Highly Sensitive Flow Cytometric Detection of Residual B-Cells After Rituximab in Anti-Neutrophil Cytoplasmic Antibodies-Associated Vasculitis Patients. Front Immunol 2020; 11:566732. [PMID: 33384685 PMCID: PMC7770159 DOI: 10.3389/fimmu.2020.566732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background B-cell depletion with rituximab (RTX) is an effective treatment for anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) patients. Nevertheless, relapses are frequent after RTX, often preceded by B-cell repopulation suggesting that residual autoreactive B-cells persist despite therapy. Therefore, this study aimed to identify minimal residual autoimmunity (MRA) in the B-cell compartment of AAV patients treated with RTX. Methods EuroFlow-based highly-sensitive flow cytometry (HSFC) was employed to study B-cell and plasma cell (PC) subsets in-depth in AAV patients before and after RTX treatment. Additionally, peripheral blood mononuclear cells (PBMCs) of these RTX-treated AAV patients were cultured and in vitro stimulated with CpG, IL-2, and IL-21 to induce antibody-secreting cells (ASC). (ANCA)-IgG was measured in these supernatants by ELISA. Results By employing EuroFlow-based HSFC, we detected circulating CD19+ B-cells at all timepoints after RTX treatment, in contrast to conventional low-sensitive flow cytometry. Pre-germinal center (Pre-GC) B-cells, memory B-cells and CD20+CD138− plasmablasts (PBs) were rapidly and strongly reduced, while CD20−CD138− PrePC and CD20-CD138+ mature (m)PCs were reduced slower and remained detectable. Both memory B-cells and CD20− PCs remained detectable after RTX. Serum ANCA-IgG decreased significantly upon RTX. Changes in ANCA levels strongly correlated with changes in naive, switched CD27+ and CD27− (double-negative) memory B-cells, but not with plasma cells. Lastly, we demonstrated in vitro ANCA production by AAV PBMCs, 24 and 48 weeks after RTX treatment reflecting MRA in the memory compartment of AAV patients. Conclusion We demonstrated that RTX induced strong reductions in circulating B-cells, but never resulted in complete B-cell depletion. Despite strongly reduced B-cell numbers after RTX, ANCA-specific memory B-cells were still detectable in AAV patients. Thus, MRA is identifiable in AAV and can provide a potential novel approach in personalizing RTX treatment in AAV patients.
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Affiliation(s)
- Laura S van Dam
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Jelle M Oskam
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Sylvia W A Kamerling
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Eline J Arends
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - O W Bredewold
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Magdalena A Berkowska
- Immunomonitoring group, Department of Immunohematology and Bloodtransfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Jacques J M van Dongen
- Immunomonitoring group, Department of Immunohematology and Bloodtransfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Ton J Rabelink
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Cees van Kooten
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, section Nephrology, Leiden University Medical Center, Leiden, Netherlands
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22
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Sasaki H, Hotta K, Mitsuke A, Fukasawa Y, Tanabe T, Higuchi H, Takada Y, Harada H. Long-Term Outcome of ABO-Incompatible Kidney Transplantation in Patients Treated With Low-Dose Rituximab Regimen. Transplant Proc 2020; 53:989-994. [PMID: 33272650 DOI: 10.1016/j.transproceed.2020.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/07/2020] [Accepted: 10/01/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Introduction of rituximab in the desensitization protocols for ABO-incompatible (ABOI) kidney transplantation (KTX) has afforded excellent results. However, the acceptability of minimal dosage of rituximab in these protocols remains to be defined. METHODS Sixty-three patients who underwent ABOI KTX were included in this study. The desensitization protocol consisted of plasmapheresis, tacrolimus, mycophenolate mofetil, methylprednisolone, intravenous immunoglobulin, basiliximab, and low-dose rituximab (100 mg/body). We evaluated the efficacy, safety, and long-term outcome of this protocol (group R, n = 39) and compared them with those of patients who underwent splenectomy (group S, n = 24). RESULTS Graft and patient survival at 10 years after KTX were comparable between the groups (94.4% [group R] vs 95.4% [group S] and 94.6% [group R] vs 95.8% [group S], respectively). The incidence of acute antibody-mediated rejection (AAMR) was similar in the 2 groups (10.2% vs 12.5%). There were no significant differences in the incidence of chronic active antibody-mediated rejection. Of the patients, 7 developed AAMR and 3 of these patients (1 in group R and 2 in group S) lost their grafts. There were no significant differences in the incidence of chronic active antibody-mediated rejection. The incidence of postoperative cytomegalovirus infection in group R was significantly lower than that in group S. Furthermore, the incidence of postoperative late-onset neutropenia was low in group R. CONCLUSIONS A low-dose rituximab regimen for ABOI KTX is acceptable for preventing AAMR with a low incidence of delayed adverse events.
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Affiliation(s)
- Hajime Sasaki
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan.
| | - Akihiko Mitsuke
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Yuichiro Fukasawa
- Department of Surgical Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Tatsu Tanabe
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Haruka Higuchi
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Yusuke Takada
- Department of Urology, Sapporo City General Hospital, Sapporo, Japan
| | - Hiroshi Harada
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
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23
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Smith RM, Jones RB, Specks U, Bond S, Nodale M, Aljayyousi R, Andrews J, Bruchfeld A, Camilleri B, Carette S, Cheung CK, Derebail V, Doulton T, Forbess L, Fujimoto S, Furuta S, Gewurz-Singer O, Harper L, Ito-Ihara T, Khalidi N, Klocke R, Koening C, Komagata Y, Langford C, Lanyon P, Luqmani RA, Makino H, McAlear CA, Monach P, Moreland LW, Mynard K, Nachman P, Pagnoux C, Pearce F, Peh CA, Pusey C, Ranganathan D, Rhee RL, Spiera R, Sreih AG, Tesar V, Walters G, Weisman MH, Wroe C, Merkel PA, Jayne D. Rituximab as therapy to induce remission after relapse in ANCA-associated vasculitis. Ann Rheum Dis 2020; 79:1243-1249. [PMID: 32581088 PMCID: PMC7456549 DOI: 10.1136/annrheumdis-2019-216863] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/15/2020] [Accepted: 04/29/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Evaluation of rituximab and glucocorticoids as therapy to induce remission after relapse in ANCA-associated vasculitis (AAV) in a prospective observational cohort of patients enrolled into the induction phase of the RITAZAREM trial. METHODS Patients relapsing with granulomatosis with polyangiitis or microscopic polyangiitis were prospectively enrolled and received remission-induction therapy with rituximab (4×375 mg/m2) and a higher or lower dose glucocorticoid regimen, depending on physician choice: reducing from either 1 mg/kg/day or 0.5 mg/kg/day to 10 mg/day by 4 months. Patients in this cohort achieving remission were subsequently randomised to receive one of two regimens to prevent relapse. RESULTS 188 patients were studied: 95/188 (51%) men, median age 59 years (range 19-89), prior disease duration 5.0 years (range 0.4-34.5). 149/188 (79%) had previously received cyclophosphamide and 67/188 (36%) rituximab. 119/188 (63%) of relapses had at least one major disease activity item, and 54/188 (29%) received the higher dose glucocorticoid regimen. 171/188 (90%) patients achieved remission by 4 months. Only six patients (3.2% of the study population) did not achieve disease control at month 4. Four patients died in the induction phase due to pneumonia (2), cerebrovascular accident (1), and active vasculitis (1). 41 severe adverse events occurred in 27 patients, including 13 severe infections. CONCLUSIONS This large prospective cohort of patients with relapsing AAV treated with rituximab in conjunction with glucocorticoids demonstrated a high level of efficacy for the reinduction of remission in patients with AAV who have relapsed, with a similar safety profile to previous studies.
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Affiliation(s)
- Rona M Smith
- University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Marianna Nodale
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Reem Aljayyousi
- University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
| | - Jacqueline Andrews
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Annette Bruchfeld
- Department of Renal Medicine, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | | | | | | | - Vimal Derebail
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tim Doulton
- East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
| | - Lindsy Forbess
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | | | | | | | | | - Rainer Klocke
- Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
| | - Curry Koening
- University of Utah Vasculitis Center, Salt Lake City, Utah, USA
| | | | | | - Peter Lanyon
- Rheumatology, Nottingham University Hospital, Nottingham, UK
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | | | - Carole A McAlear
- Division of Rheumatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Paul Monach
- Division of Rheumatology, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | | | - Kim Mynard
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick Nachman
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christian Pagnoux
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fiona Pearce
- Nottingham University Hospitals NHS Trust, Nottingham, Nottingham, UK
| | - Chen Au Peh
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | | | - Rennie L Rhee
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Antoine G Sreih
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Vladimir Tesar
- Department of Nephrology, Charles University, Prague, Czech Republic
| | - Giles Walters
- Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | | | - Caroline Wroe
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, Middlesbrough, UK
| | - Peter A Merkel
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Jayne
- University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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24
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ANCA-associated vasculitides: Recommendations of the French Vasculitis Study Group on the use of immunosuppressants and biotherapies for remission induction and maintenance. Presse Med 2020; 49:104031. [PMID: 32645418 DOI: 10.1016/j.lpm.2020.104031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/21/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment of vasculitides associated with anti-neutrophil cytoplasm antibodies (ANCA) (AAVs) has evolved dramatically in recent years, particularly since the demonstration of rituximab efficacy as remission induction and maintenance therapy for granulomatosis with polyangiitis and microscopic polyangiitis. In 2013, the French Vasculitis Study Group (FVSG) published recommendations for its use by clinicians. Since then, new data have made it possible to better specify and codify prescription of rituximab to treat AAVs. Herein, the FVSG Recommendations Committee, an expert panel comprised of physicians with extensive experience in the treatment and management of vasculitides, presents its consensus guidelines based on literature analysis, the results of prospective therapeutic trials and personal experience.
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25
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Abstract
Granulomatosis with polyangiitis (GPA) (Wegener) is a necrotizing vasculitis combining inflammation of the vascular wall and peri- and extravascular granulomatosis. Clinically, GPA is characterized in its full form by ENT signs, lung, and kidney involvement. One of the key features of GPA is the presence of ANCAs-cytoplasmic in approximately 90% of systemic forms and in 50% of localized forms-directed against proteinase 3 in most cases. PR3-ANCAs are highly specific to GPA and therefore have a high diagnostic value. Treatment of GPA is based on a combination of corticosteroids and cyclophosphamide or rituximab, which allows remission to be achieved in more than 80% of cases. Azathioprine was the most widely used maintenance treatment, but low-dose semi-annual rituximab maintenance infusions further decrease relapses with acceptable safety. Nevertheless, relapses occur in more than 50% of cases. One of the biggest treatment challenges is the occurrence of side effects, the severity and frequency of which are often linked to the prolonged treatment course, which is difficult to avoid.
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Affiliation(s)
- Xavier Puéchal
- Centre de Référence des Maladies Systémiques Auto-immunes rares, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris, France.
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26
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Moller D, Tan J, Gauiran DTV, Medvedev N, Hudoba M, Carruthers MN, Dehghan N, Berghe J, Bruyère H, Chen LY. Causes of hypereosinophilia in 100 consecutive patients. Eur J Haematol 2020; 105:292-301. [DOI: 10.1111/ejh.13437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Daniel Moller
- Department of Medicine University of British Columbia Vancouver BC Canada
| | - Julia Tan
- Department of Medicine University of British Columbia Vancouver BC Canada
| | | | - Nadia Medvedev
- Division of Hematopathology University of British Columbia Vancouver BC Canada
| | - Monika Hudoba
- Division of Hematopathology University of British Columbia Vancouver BC Canada
| | | | - Natasha Dehghan
- Division of Rheumatology University of British Columbia Vancouver BC Canada
| | - Janette Berghe
- Department of Pathology and Laboratory Medicine University of British Columbia and Cytogenomics LaboratoryVancouver General Hospital Vancouver BC Canada
| | - Helene Bruyère
- Department of Pathology and Laboratory Medicine University of British Columbia and Cytogenomics LaboratoryVancouver General Hospital Vancouver BC Canada
| | - Luke Y.C. Chen
- Division of Hematology University of British Columbia Vancouver BC Canada
- Centre for Health Education Scholarship University of British Columbia Vancouver BC Canada
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27
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Karras A, Lazareth H, Chauvet S. B-cell treatment in ANCA-associated vasculitis. Rheumatology (Oxford) 2020; 59:iii68-iii73. [PMID: 32348514 DOI: 10.1093/rheumatology/kez605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/04/2019] [Indexed: 11/14/2022] Open
Abstract
The pivotal role of B-cells in ANCA-associated vasculitis has been suggested by experimental data that demonstrate the direct pathogenicity of ANCAs. Rituximab (RTX), an anti-CD20 monoclonal antibody that targets B-cells, has proven its efficacy for induction of remission in severe ANCA vasculitis. RTX is equivalent to CYC for induction of remission, and is probably superior in relapsing patients. Long-term B cell depletion by prolonged RTX treatment has been shown to significantly reduce the relapse rate, when compared with AZA maintenance therapy. Biomarkers, such as B-cell subpopulations or ANCA monitoring, may help the clinician to determine the optimal dose and duration of RTX therapy.
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Affiliation(s)
- Alexandre Karras
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris.,Univesité Paris Descartes.,INSERM U970, Paris Cardiovascular Centre (PARCC)
| | - Hélène Lazareth
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris.,Univesité Paris Descartes.,INSERM U970, Paris Cardiovascular Centre (PARCC)
| | - Sophie Chauvet
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris.,Univesité Paris Descartes.,INSERM UMRS 1138, Cordeliers Research Center, Complement and Diseases team, Paris, France
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28
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Post-rituximab immunoglobulin M (IgM) hypogammaglobulinemia. Autoimmun Rev 2020; 19:102466. [PMID: 31917267 DOI: 10.1016/j.autrev.2020.102466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody that targets the B cell-specific cell surface antigen CD20 and is currently used to treat several autoimmune diseases. The elimination of mature CD20-positive B lymphocytes committed to differentiate into autoantibody-producing plasma cells is considered to be the major effect of rituximab, that makes it a beneficial biological agent in treating autoimmune diseases. Hypogammaglobulinemia has been reported after rituximab therapy in patients with lymphoma and rheumatoid arthritis. Similar data are scarce for other autoimmune diseases. Low immunoglobulin G (IgG) or hypogammaglobulinemia has attracted the most attention because of its significant role in protective immunity. However, the incidence and clinical implications of low immunoglobulin M (IgM) or hypogammaglobulinemia have not been studied in detail. This review will focus on the frequency and the clinical concerns of low IgM levels that result as a consequence of the administration of rituximab. The etiopathogenic mechanisms underlying post-rituximab IgM hypogammaglobulinemia and its implications are presented. The long-term consequences, if any, are not known or documented. Multiple factors may be involved in whether IgG or IgM decreases secondary to rituximab therapy. It is possible that the autoimmune disease itself may be one of the important factors. The dose, frequency and number of infusions appear to be important variables. Post-rituximab therapy immunoglobulin levels return to normal. During this process. IgM levels take a longer time to return to normal levels when compared to IgG or other immunoglobulins. IgM deficiency persists after B cell repopulation to normal levels has occurred. Laboratory animals and humans deficient in IgM can have multiple infections. Specific pharmacologic agents or biologic therapy that address and resolve IgM deficiency are currently unavailable. If the clinical situation so warrants, then prophylactic antibiotics may be indicated and perhaps helpful. Research in this iatrogenic phenomenon will provide a better understanding of not only the biology of IgM, but also the factor(s) that control its production and regulation, besides its influence if any, on rituximab therapy.
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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Asthma control in eosinophilic granulomatosis with polyangiitis treated with rituximab. Clin Rheumatol 2020; 39:1581-1590. [PMID: 31897956 DOI: 10.1007/s10067-019-04891-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/03/2019] [Accepted: 12/11/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Rituximab (RTX) treatment is used for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, but its benefits in eosinophilic granulomatosis with polyangiitis (EGPA) are unclear. Our aim was to characterize asthma control and glucocorticoid (GC) sparing after RTX treatment. METHODS A retrospective, computer-assisted search was performed to identify patients with EGPA and GC-dependent asthma diagnosed between 2000 and 2017 who received RTX for remission induction. Demographic and clinical features were analyzed. RESULTS Of the 17 patients included, the majority were myeloperoxidase-ANCA positive (n = 13, 76.5%). Uncontrolled asthma symptoms and atopy were present in 13 patients (76.5%). RTX was used for initial remission induction in patients with new onset of severe disease (n = 5, 29.4%) and after failed remission induction with other immunosuppression (n = 12, 70.6%). It was used for remission maintenance in nine patients (52.9%). GCs were used for maintenance at a median dose of 25 mg/day (interquartile range, 16.25-37.5). At the end of follow-up, 13 patients (76.5%) had non-severe or controlled asthma, and remission was achieved in 12 (70.6%). Median serum eosinophil and C-reactive protein values decreased (1.06 vs 0.10 × 109/L [P = .012] and 27.0 vs 5.0 mg/dL [P = .001], respectively), whereas pulmonary function test results remained unchanged. Median GC dose was significantly reduced at 6, 12, 18, and 24 months (P < .0001). Patients receiving RTX for maintenance required less than 10 mg of GCs for asthma control. CONCLUSION RTX seems to be safe and have GC-sparing efficacy for asthma control in EGPA. Randomized controlled trials are needed for detailed study of RTX for treating EGPA.Key Points• In this retrospective study we have concluded that rituximab (RTX) might be considered for the control of severe corticosteroid-dependent asthma in eosinophilic granulomatosis polyangiitis (EGPA) patients especially when myeloperoxidase antibodies are positive.• Rituximab has not been studied particularly for asthma control in EGPA patients.• The most noticeable effect of RTX was the decrease in the use of corticosteroids for the control of asthma.
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McAdoo SP, Medjeral-Thomas N, Gopaluni S, Tanna A, Mansfield N, Galliford J, Griffith M, Levy J, Cairns TD, Jayne D, Salama AD, Pusey CD. Long-term follow-up of a combined rituximab and cyclophosphamide regimen in renal anti-neutrophil cytoplasm antibody-associated vasculitis. Nephrol Dial Transplant 2019; 34:63-73. [PMID: 29462348 PMCID: PMC6322443 DOI: 10.1093/ndt/gfx378] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/18/2017] [Indexed: 01/29/2023] Open
Abstract
Background Current guidelines advise that rituximab or cyclophosphamide should be used for the treatment of organ-threatening disease in anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV), although few studies have examined the efficacy and safety of these agents in combination. Methods We conducted a single-centre cohort study of 66 patients treated with a combination of oral corticosteroids, rituximab and low-dose pulsed intravenous cyclophosphamide followed by a maintenance regimen of azathioprine and tapered steroid for the treatment of biopsy-proven renal involvement in AAV. Patients were followed for a median of 56 months. Case–control analysis with 198 propensity-matched cases from European Vasculitis Study Group (EUVAS) trials compared long-term differences in relapse-free, renal and patient survival. Results At entry, the median Birmingham Vasculitis Activity Score (BVAS) was 19 and estimated glomerular filtration rate was 25 mL/min. Cumulative doses of rituximab, cyclophosphamide and corticosteroids were 2, 3 and 4.2 g, respectively, at 6 months. A total of 94% of patients achieved disease remission by 6 months (BVAS < 0) and patient and renal survival were 84 and 95%, respectively, at 5 years. A total of 84% achieved ANCA-negative status and 57% remained B cell deplete at 2 years, which was associated with low rates of major relapse (15% at 5 years). The serious infection rate during long-term follow-up was 1.24 per 10 patient-years. Treatment with this regimen was associated with a reduced risk of death {hazard ratio [HR] 0.29 [95% confidence interval (CI) 0.125–0.675], P = 0.004}, progression to end-stage renal disease (ESRD) [HR 0.20 (95% CI 0.06–0.65), P = 0.007] and relapse [HR 0.49 (95% CI 0.25–0.97), P = 0.04] compared with propensity-matched patients enrolled in EUVAS trials. Conclusions This regimen is potentially superior to current standards of care, and controlled studies are warranted to establish the utility of combination drug approaches in the treatment of AAV.
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Affiliation(s)
- Stephen P McAdoo
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Anisha Tanna
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | | | - Jack Galliford
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Megan Griffith
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy Levy
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Thomas D Cairns
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Alan D Salama
- Centre for Nephrology, University College London, London, UK
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
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Abstract
A role for the alternative complement pathway has emerged in the understanding of ANCA vasculitis pathogenesis. Current therapies of ANCA vasculitis are limited by partial efficacy and toxicity and many patients pursue a relapsing course. Improved therapies are needed. Inhibition of the alternative complement pathway component C5a is attractive due to its role in neutrophil activation and migration, and engagement of other inflammatory and thrombotic mechanisms. Two inhibitors of C5a are in clinical development for ANCA vasculitis: avacopan, an oral C5a receptor inhibitor has demonstrated efficacy, safety and steroid sparing in two Phase II trials; and IFX-1, a monoclonal antibody to C5a which is entering Phase II development. Complement inhibition has the potential to contribute to remission induction protocols achieving a higher quality of remission as well as replacing steroids. Confirmation of safety, especially infective risk, and the potential to replace steroids depends on further studies and a role in relapse prevention needs to be explored.
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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Fijolek J, Wiatr E, Petroniec V, Augustynowicz-Kopec E, Bednarek M, Gawryluk D, Roszkowski-Sliz K. Antineutrophil cytoplasmic antibodies and their relationship with disease activity and presence of staphylococcal superantigens in nasal swabs in patients having granulomatosis with polyangiitis: results of a study involving 115 patients from a single center. Clin Rheumatol 2019; 38:3297-3305. [PMID: 31338700 DOI: 10.1007/s10067-019-04693-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/05/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Antineutrophil cytoplasmic antibodies (ANCAs) are considered a risk factor for granulomatosis with polyangiitis (GPA) exacerbation, especially when staphylococcal superantigens (SAgs) are present in nasal swabs. Their role in monitoring disease activity remains controversial. This study determined the relationship of ANCAs with disease activity and presence of SAgs in GPA patients. METHODS Among a total of 115 GPA patients hospitalized in the period 2009-2016, we investigated the presence of SAgs and ANCA concentration. Blood samples and nasal swabs were taken at each visit (referred further to as episodes). Disease activity was assessed using the Birmingham Vasculitis Activity Score (BVAS). RESULTS We analyzed 362 episodes. ANCAs were detected in 215 (59.4%), while SAgs were detected in 126 (34.8%) episodes. We found a significant correlation between the presence of ANCAs and disease activity (p = 0.0032), as well as between their level and GPA severity (r = 0.25363, p = 0.000001). We also determined that an ANCA values ≥ 138 Ru/ml were an indicator of active disease with high specificity and low sensitivity (84.4% and 37.3%, respectively). The relationship between ANCA presence and the presence of SAgs was not confirmed; however, when SAgs were analyzed based on the different types, ANCA levels were found to be significantly higher in the group with SAg type B (p = 0.031). CONCLUSIONS There was no detectable evidence for the association between ANCA level and the presence of SAgs. Although monitoring ANCA levels as a marker of disease activity may be clinically relevant, GPA management cannot proceed on the basis of ANCA levels alone. Key Points • ANCA concentration usually correlates with GPA activity, although in half of patients, ANCAs persist despite effective treatment and clinical remission. • ANCA values of 138 Ru/ml seem to be an indicator of active disease with high specificity, but low sensitivity. • Although there is a relevance for ANCA monitoring as a marker of disease activity, GPA management cannot be based on ANCA levels alone. • The suspected clinical correlation between ANCA formation and SAg presence in nasal swabs is not obvious and requires further investigations.
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Affiliation(s)
- Justyna Fijolek
- The Third Department of Pneumonology, National Tuberculosis and Lung Diseases Research Institute, Plocka St 26, 01-138, Warsaw, Poland.
| | - E Wiatr
- The Third Department of Pneumonology, National Tuberculosis and Lung Diseases Research Institute, Plocka St 26, 01-138, Warsaw, Poland
| | - V Petroniec
- Department of Microbiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - E Augustynowicz-Kopec
- Department of Microbiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - M Bednarek
- The Second Department of Pneumonology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - D Gawryluk
- The Third Department of Pneumonology, National Tuberculosis and Lung Diseases Research Institute, Plocka St 26, 01-138, Warsaw, Poland
| | - K Roszkowski-Sliz
- The Third Department of Pneumonology, National Tuberculosis and Lung Diseases Research Institute, Plocka St 26, 01-138, Warsaw, Poland
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Teixeira V, Mohammad AJ, Jones RB, Smith R, Jayne D. Efficacy and safety of rituximab in the treatment of eosinophilic granulomatosis with polyangiitis. RMD Open 2019; 5:e000905. [PMID: 31245051 PMCID: PMC6560673 DOI: 10.1136/rmdopen-2019-000905] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/06/2019] [Accepted: 05/15/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Eosinophilic granulomatosis with polyangiitis (EGPA) is a subset of antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis with distinct pathophysiological mechanisms, clinical features and treatment responses. Rituximab is a licensed therapy for granulomatosis with polyangiitis and microscopic polyangiitis but there is limited experience of rituximab in EGPA. Methods EGPA patients from a tertiary centre who received rituximab for mostly refractory EGPA or in whom cyclophosphamide was contra indicated were studied. A standardised dataset was collected at time of initial treatment and every 3 months for 24 months. Response was defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 and partial response as ≥50% reduction in BVAS from baseline. Remission was defined as a BVAS of 0 on prednisolone dose ≤5 mg. Results Sixty-nine patients (44 female) received rituximab between 2003 and 2017. Improvement (response and partial response) was observed in 76.8% of patients at 6 months, 82.8% at 12 months and in 93.2% by 24 months, while relapses occurred in 54% by 24 months, with asthma being the most frequent manifestation. The median BVAS decreased from 6 at baseline to 1 at 6 months, and 0 at 12 and 24 months. Prednisolone dose (mg/day, median) decreased from 12.5 to 7, 7.5 and 5 at 6, 12 and 24 months, respectively. ANCA positive patients had a longer asthma/ear, nose and throat (ENT) relapse-free survival time and a shorter time to remission. Discussion Rituximab demonstrated some efficacy in EGPA and led to a reduction in prednisolone requirement, but asthma and ENT relapse rates were high despite continued treatment. The ANCA positive subset appeared to have a more sustained response on isolated asthma/ENT exacerbations.
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Affiliation(s)
- Vítor Teixeira
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Aladdin J Mohammad
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Clinical Sciences, Rheumatology, Lund University, Lund, Skåne, Sweden
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - Rona Smith
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - David Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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Terrier B. Traitement des vascularites à ANCA : certitudes et controverses. Nephrol Ther 2019; 15 Suppl 1:S7-S12. [DOI: 10.1016/j.nephro.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
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Durel CA, Hot A, Trefond L, Aumaitre O, Pugnet G, Samson M, Abad S, Belot A, Blanchard-Delaunay C, Cohen P, Cohen-Aubard F, Cottin V, Crestani B, Moreuil CD, Durupt S, Garzaro M, Girszyn N, Godeau B, Hachulla E, Jamilloux Y, Jego P, Killian M, Lazaro E, Le Gallou T, Liozon E, Martin T, Papo T, Perlat A, Pillet P, Guillevin L, Terrier B. Orbital mass in ANCA-associated vasculitides: data on clinical, biological, radiological and histological presentation, therapeutic management, and outcome from 59 patients. Rheumatology (Oxford) 2019; 58:1565-1573. [DOI: 10.1093/rheumatology/kez071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Objective
Orbital mass is a rare and sight-threatening manifestation of ANCA-associated vasculitides, which remains a therapeutic challenge. We aimed to describe the presentation, therapeutic management and outcome of ANCA-associated vasculitides-related orbital mass.
Methods
We conducted a French nationwide retrospective study of patients with orbital mass in the setting of ANCA-associated vasculitides according to ACR criteria and/or Chapel Hill Consensus Conference definitions.
Results
Fifty-nine patients [33 women, median age 46 (range 7–90) years] were included. Fifty-six (95%) patients had granulomatosis with polyangiitis, two eosinophilic granulomatosis with polyangiitis and one microscopic polyangiitis. Orbital mass was unilateral in 47 (80%) cases, and seemed to develop from ENT involvement in most cases. Orbital mass biopsy was available in 32 (54%) patients, showing lymphoplasmacytic infiltration in 65%, fibrosis in 55%, granulomas in 48% and vasculitis in 36%. All patients but one received glucocorticoids as first-line therapy associated with immunosuppressive agents in 82%, mainly cyclophosphamide. Response to therapy was noted in 52% of patients treated with cyclophosphamide compared with 91% of those treated with rituximab. Twenty-seven (46%) patients required a second-line therapy because of relapse (59%) or refractory course (41%). Sequelae included visual impairment in 28%, with definitive blindness in 17%. Refractory course was associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
Conclusion
Orbital mass is associated with refractory course and high frequency of sequelae, especially blindness. Refractory course is associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
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Affiliation(s)
| | - Arnaud Hot
- Department of Internal Medicine, Hôpital Edouard Herriot, Lyon
| | - Ludovic Trefond
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Olivier Aumaitre
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Gregory Pugnet
- Department of Internal Medicine, Hôpital Purpan, Toulouse
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon
| | - Sébastien Abad
- AP-HP, Hôpital Avicennes, Department of Internal Medicine, Université Paris 13, Sorbonne, Paris Cité, Faculté de Médecine Bobigny, Paris
| | - Alexandre Belot
- Department of Pediatric Nephrology, Rheumatology, Dermatology, National Referral Center for Inflammatory Rheumatism and Autoimmune Diseases, Hôpital Femme Mère Enfant, Bron
| | | | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris
| | - Fleur Cohen-Aubard
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Center for Rare Pulmonary Diseases, Lyon
| | | | - Claire De Moreuil
- Department of Internal Medicine, Hôpital de la Cavale Blanche, Brest
| | - Stéphane Durupt
- Department of Internal Medicine, Centre Hospitalier Lyon Sud, Lyon
| | | | - Nicolas Girszyn
- Department of Internal Medicine, Hôpital Charles Nicolle, Rouen
| | - Bertrand Godeau
- Department of Internal Medicine, Referral Center for Adult Autoimmune Cytopenias, Hôpital Henri Mondor, Créteil
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, National Referral Center for Systemic Autoimmune Diseases North and North-West of France, Université de Lille, Lille
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Lyon
| | - Patrick Jego
- Department of Internal Medicine, Hôpital Sud, Rennes
| | - Martin Killian
- Department of Internal Medicine, Hôpital Nord, Saint-Etienne
| | - Estibaliz Lazaro
- Department of Internal Medicine, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac
| | | | - Eric Liozon
- Department of Internal Medicine, Hôpital de Limoges, Limoges
| | - Thierry Martin
- Department of Clinical Immunology, HIV, and Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases RESO, Nouvel Hôpital Civil, Strasbourg
| | - Thomas Papo
- Department of Internal Medicine, Hôpital Bichat, Paris
| | | | - Pascal Pillet
- Department of Medical Pediatrics, CHU de Bordeaux – GH Pellegrin, Bordeaux
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
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Lazzari G, Briatico Vangosa A, Assunta De Cillis M, Buccoliero G, Silvano G. Lower cranial nerve palsy during radiotherapy for glottic cancer in a patient with Wegener's granulomatosis: An interesting case report. Mol Clin Oncol 2019; 10:147-152. [PMID: 30680194 PMCID: PMC6315903 DOI: 10.3892/mco.2018.1748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/15/2018] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to report an unusual case of multiple lower cranial nerve palsies in a patient with Wegener's granulomatosis (WG) during radiotherapy for glottic cancer. WG is an autoimmune disease characterized by necrotizing granulomas mainly in the upper and lower respiratory tract or kidneys; however, the involvement of cranial nerves is not uncommon. Prior to the use of cyclophosphamide (CYC) the 1-year mortality rate was ~82%; the introduction of rituximab (RTX) has revolutionized the course of the WG, with remission rates comparable to those of CYC and superior effectiveness in relapsing patients. Hypogammaglobulinemia and B-cell depletion are the best known monitored side effects affecting survival due to secondary infections. Immunodepression and relapse with lower cranial nerve palsy have a negative impact on prognosis. We herein present the case of a heavily pre-treated GPA patient with secondary immunosuppression, who underwent radiotherapy for glottic cancer and developed multiple low cranial nerve palsies during treatment, which was interrupted at 60 Gy. The possible related causes and the association between previous immunosuppressive treatments and radiotherapy were also analyzed to elucidate the cause of this complication.
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Affiliation(s)
- Grazia Lazzari
- Department of Radiation Oncology, S. Giuseppe Moscati Hospital, I-74100 Taranto, Italy
| | | | | | - Giovanni Buccoliero
- Department of Infectious Diseases, S. Giuseppe Moscati Hospital, I-74100 Taranto, Italy
| | - Giovanni Silvano
- Department of Radiation Oncology, S. Giuseppe Moscati Hospital, I-74100 Taranto, Italy
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Oda K, Ishikawa E, Ito T, Mizoguchi S, Hirabayashi Y, Suzuki Y, Haruki A, Fujimoto M, Murata T, Katayama K, Onishi T, Ito M. Improvement of Alveolar Hemorrhaging in an Elderly and Renally Impaired Patient with Relapsing Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis by Single Infusion of Rituximab. Intern Med 2018; 57:3267-3270. [PMID: 29984747 PMCID: PMC6287994 DOI: 10.2169/internalmedicine.0936-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rituximab (RTX) has become a therapeutic option for inducing remission of anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV). However, the optimum dosage of RTX to induce remission of AAV and reduce adverse events, such as infection, remains unclear. We herein report an elderly and renally impaired patient with alveolar hemorrhaging due to refractory AAV who was successfully treated with single infusion of RTX. Single infusion of RTX may be a therapeutic option in refractory AAV patients who are vulnerable to infections.
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Affiliation(s)
- Keiko Oda
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Eiji Ishikawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Takayasu Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Shoko Mizoguchi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Yosuke Hirabayashi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Yasuo Suzuki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Ayumi Haruki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Mika Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Tomohiro Murata
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Kan Katayama
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | | | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
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41
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Zonozi R, Niles JL, Cortazar FB. Renal Involvement in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Rheum Dis Clin North Am 2018; 44:525-543. [PMID: 30274621 DOI: 10.1016/j.rdc.2018.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is the most common cause of rapidly progressive glomerulonephritis. ANCAs play an important role in the pathogenesis and diagnosis of AAV. The classic renal lesion in AAV is a pauci-immune necrotizing and crescentic glomerulonephritis. Treatment is divided into 2 phases: (1) induction of remission to eliminate disease activity and (2) maintenance of remission to prevent disease relapse. AAV patients with end-stage renal disease require modification of immunosuppressive strategies and consideration for kidney transplantation. An improved understanding of disease pathogenesis has led to new treatment strategies being tested in clinical trials.
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Affiliation(s)
- Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA
| | - John L Niles
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA
| | - Frank B Cortazar
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA.
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42
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B cell therapy in ANCA-associated vasculitis: current and emerging treatment options. Nat Rev Rheumatol 2018; 14:580-591. [DOI: 10.1038/s41584-018-0065-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/10/2018] [Indexed: 12/19/2022]
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43
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Fujita Y, Fukui S, Endo Y, Tsuji S, Takatani A, Shimizu T, Umeda M, Nishino A, Koga T, Kawashiri SY, Iwamoto N, Ichinose K, Tamai M, Nakamura H, Origuchi T, Ueki R, Uematsu M, Ishida K, Abe K, Kawakami A. Peripheral Ulcerative Keratitis Associated with Granulomatosis with Polyangiitis Emerging Despite Cyclophosphamide, Successfully Treated with Rituximab. Intern Med 2018; 57:1783-1788. [PMID: 29321417 PMCID: PMC6047997 DOI: 10.2169/internalmedicine.0215-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 67-year-old Japanese man was diagnosed with granulomatosis with polyangiitis based on the presence of right maxillary sinusitis, proteinase 3 antineutrophil cytoplasmic antibody positivity, and right scleritis. A conjunctival biopsy specimen showed neutrophil-predominant infiltration around the vessels without granuloma. Because there was a risk of blindness, pulsed methylprednisolone and intravenous cyclophosphamide pulse therapy (IVCY) were started. However, it was ineffective, and peripheral ulcerative keratitis newly emerged. We promptly switched the treatment from IVCY to rituximab, and ophthalmologists performed amniotic membrane transplantation, which avoided blindness. The close and effective working relationship between physicians and ophthalmologists improved our patient's ocular prognosis.
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Affiliation(s)
- Yuya Fujita
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shoichi Fukui
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of Community Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yushiro Endo
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Sosuke Tsuji
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Ayuko Takatani
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Masataka Umeda
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Medical Education Development Center, Nagasaki University Hospital, Japan
| | - Ayako Nishino
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Center for Comprehensive Community Care Education Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shin-Ya Kawashiri
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of Community Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Naoki Iwamoto
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mami Tamai
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hideki Nakamura
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomoki Origuchi
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Ryotaro Ueki
- Department of Ophthalmology and Visual Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Masafumi Uematsu
- Department of Ophthalmology and Visual Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kaori Ishida
- Department of Pathology, Nagasaki University Hospital, Japan
| | - Kuniko Abe
- Department of Pathology, Nagasaki University Hospital, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
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44
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Hamilton P, Kanigicherla D, Venning M, Brenchley P, Meads D. Rituximab versus the modified Ponticelli regimen in the treatment of primary membranous nephropathy: a Health Economic Model. Nephrol Dial Transplant 2018; 33:2145-2155. [DOI: 10.1093/ndt/gfy049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 01/28/2018] [Indexed: 01/15/2023] Open
Affiliation(s)
- Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Durga Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Michael Venning
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Paul Brenchley
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, Leeds, UK
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45
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Abstract
Objective: To explore clinical and laboratory features, therapy and outcome of antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis (AAV) patients from our tertiary care center. Methods: This study of AAV patients seen in Rheumatology clinics at King Khalid University hospital (KKUH), King Saud University, Riyadh during the period 1990-2014 was carried out retrospectively. Demographic, clinical, haematological and immunological parameters along with therapy, complications and outcome were retrieved from patients' medical charts. Different characteristics were compared between the three groups of AAV; GPA (Granulomatosis with polyangiitis), MPA (Microscopic polyangiitis) and EGPA (Eosinophilic granulomatosis with polyangiitis). Results: We identified 34 AAV patients (21 males: 13 females; 31 Saudis: 3 non-Saudis) comprising of 23 GPA, 2 MPA and 9 EGPA cases. The mean age of onset was 42.1±17.6 years (range 11-75) and mean duration of disease was 8.7± 5.1 years (range 1-20). The most frequently affected system was pulmonary in all AAV (73.5%), GPA (65.2%) and EGPA (100%) while it was renal in MPA (100%) patients. Ophthalmological and upper airways involvement was higher in GPA. Neurological involvement was higher in EGPA (p<0.05). ANCA were detected in 79.4% of AAV patients, of them c-ANCA were 77.8% and p-ANCA 22.2%. ANCA was positive in 91.3% GPA, 100% MPA and 44.4% EGPA patients. In GPA c-ANCA were detected in 80.9% and p-ANCA in 17.4%, in MPA, c-ANCA were detected in 50% and p-ANCA in 50%, in EGPA, c-ANCA were observed in 75% and p-ANCA in 25%. GPA patients had PR3 specificity in 93.3%, and MPO in 6.7%, PR3 was present in all MPA patients (100%), while EGPA patients had MPO (100%). Therapy administered were corticosteroids (100%), intravenous cyclophosphamide (58.8%), azathioprine (50%) and rituximab (11.8%). Infections were noted in 29.4%. Conclusions: The 10-year survival in our AAV patients was 95%. ANCA pattern was similar to Caucasian AAV patients and different from Japanese and Chinese AAV patients.
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Affiliation(s)
- Abdurhman Saud Al Arfaj
- Prof. Abdurhman Saud Al Arfaj, FRCP©, FACP, Division of Rheumatology, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Najma Khalil
- Najma Khalil, M.Sc., M.Phil, Division of Rheumatology, College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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46
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Schrezenmeier E, Jayne D, Dörner T. Targeting B Cells and Plasma Cells in Glomerular Diseases: Translational Perspectives. J Am Soc Nephrol 2018; 29:741-758. [PMID: 29326157 DOI: 10.1681/asn.2017040367] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The unique contributions of memory B cells and plasma cells in kidney diseases remain unclear. In this review, we evaluate the clinical experience with treatments directed at B cells, such as rituximab, and at plasma cells, such as proteasome inhibition, to shed light on the role of these two B lineage compartments in glomerular diseases. Specifically, analysis of these targeted interventions in diseases such as ANCA-associated vasculitis, SLE, and antibody-mediated transplant rejection permits insight into the pathogenetic effect of these cells. Notwithstanding the limitations of preclinical models and clinical studies (heterogeneous populations, among others), the data suggest that memory B and plasma cells represent two engines of autoimmunity, with variable involvement in these diseases. Whereas memory B cells and plasma cells appear to be key in ANCA-associated vasculitis and antibody-mediated transplant rejection, respectively, SLE seems likely to be driven by both autoimmune compartments. These conclusions have implications for the future development of targeted therapeutics in immune-mediated renal disease.
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Affiliation(s)
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Thomas Dörner
- Rheumatology and Clinical Immunology, Department of Medicine, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany; and
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47
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Rituximab for anti-neutrophil cytoplasmic antibodies-associated vasculitis: experience of a single center and systematic review of non-randomized studies. Rheumatol Int 2018; 38:607-622. [PMID: 29322343 DOI: 10.1007/s00296-018-3928-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/02/2018] [Indexed: 10/27/2022]
Abstract
Rituximab (RTX) is becoming a standard treatment for patients with anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) but heterogeneity exists regarding its use. We present our uncontrolled experience with RTX in patients with refractory AAV and also the results of a systematic review of non-randomized studies on RTX in AAV patients. We retrospectively reviewed the records of AAV patients treated with RTX following an inadequate response to immunosuppressives between 2011 and 2015. The systematic review covered all English articles listed in PubMed until June 2017. There were 25 AAV patients (21 GPA, four unclassified) treated with RTX (median 2, IQR 1-3 courses; median follow-up 24, IQR 17-50 months). The kidney and the lung were the most commonly affected organs, observed in 14 and 16 patients, respectively. Complete remission rate was 72% at month 6 and 88% at month 12. Two patients had died and three serious adverse events occurred. The systematic review included 56 studies on 1422 patients with the majority being on refractory or relapsing disease. There was wide variability regarding disease characteristics, endpoints, concomitant immunosuppressives and RTX schedule. Most studies reported > 80% complete or partial remission rates with the lowest response (37.5%) for granulomatous lesions. The relapse rate was 30%. Infections and infusion reactions were the main adverse events. Our experience with RTX in refractory AAV is in line with the literature in terms of efficacy and safety. The systematic review underlines many uncertainties on its optimal use.
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48
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Palamara K, Nagarur A, Fintelmann FJ, Kohler MJ, Cortazar FB. Case 32-2017. A 64-Year-Old Man with Dyspnea, Wheezing, Headache, Cough, and Night Sweats. N Engl J Med 2017; 377:1569-1578. [PMID: 29045211 DOI: 10.1056/nejmcpc1703513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kerri Palamara
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Amulya Nagarur
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Florian J Fintelmann
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Minna J Kohler
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Frank B Cortazar
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
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49
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Shi L. Anti-neutrophil cytoplasmic antibody-associated vasculitis: prevalence, treatment, and outcomes. Rheumatol Int 2017; 37:1779-1788. [DOI: 10.1007/s00296-017-3818-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
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50
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Pérez-De-Lis M, Retamozo S, Flores-Chávez A, Kostov B, Perez-Alvarez R, Brito-Zerón P, Ramos-Casals M. Autoimmune diseases induced by biological agents. A review of 12,731 cases (BIOGEAS Registry). Expert Opin Drug Saf 2017; 16:1255-1271. [DOI: 10.1080/14740338.2017.1372421] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Marta Pérez-De-Lis
- Servicio de Anestesiologia y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Alejandra Flores-Chávez
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Unidad de Investigación Biomédica 02, Unidad de Investigación en Epidemiología Clínica, Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Hospital de Especialidades, Guadalajara, Mexico
- Programa de Doctorado en Ciencias Médicas, Centro Universitario de Investigaciones Biomédicas (CUIB), Universidad de Colima, Colima, Mexico
| | | | | | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
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