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Walulik A, Łysak K, Błaszkiewicz M, Górecki I, Gomułka K. The Role of Neutrophils in ANCA-Associated Vasculitis: The Pathogenic Role and Diagnostic Utility of Autoantibodies. Int J Mol Sci 2023; 24:17217. [PMID: 38139045 PMCID: PMC10743134 DOI: 10.3390/ijms242417217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Recent years have brought progress in understanding the role of the neutrophil, dispelling the dogma of homogeneous cells mainly involved in the prime defence against pathogens, shedding light on their pathogenic role in inflammatory diseases and on the importance of antineutrophil-cytoplasmic antibodies' pathogenic role in ANCA-associated vasculitides vasculitis (AAV). Myeloperoxidase (MPO) and proteinase 3 (PR3) expressed in neutrophil granulocytes are the most common targets for ANCAs and contribute to the formation of MPO-ANCAs and PR3-ANCAs which, released to the bloodstream, become an excellent diagnostic tool for AAV. In this study, we focus on increasing the clinical and experimental evidence that supports the pathogenic role of ANCAs in AAV. Additionally, we discuss the diagnostic utility of ANCAs for disease activity and prognosis in AAV. Understanding the central role of ANCAs in AAV is crucial for advancing our knowledge of these complex disorders and developing targeted therapeutic strategies in the era of personalized medicine.
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Affiliation(s)
- Agata Walulik
- Student Scientific Group of Adult Allergology and Internal Medicine, Wroclaw Medical University, 50-369 Wrocław, Poland; (A.W.); (I.G.)
| | - Kinga Łysak
- Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland;
| | - Michał Błaszkiewicz
- Student Scientific Group of Adult Allergology and Internal Medicine, Wroclaw Medical University, 50-369 Wrocław, Poland; (A.W.); (I.G.)
| | - Ignacy Górecki
- Student Scientific Group of Adult Allergology and Internal Medicine, Wroclaw Medical University, 50-369 Wrocław, Poland; (A.W.); (I.G.)
| | - Krzysztof Gomułka
- Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, 50-369 Wrocław, Poland
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2
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Berti A, Cornec D, Dua AB. Treatment Approaches to Granulomatosis with Polyangiitis and Microscopic Polyangiitis. Rheum Dis Clin North Am 2023; 49:545-561. [PMID: 37331732 DOI: 10.1016/j.rdc.2023.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
We have made significant headway in our ability to induce and maintain remission in patients with granulomatosis with polyangiitis and microscopic polyangiitis. With increased understanding of the pathogenesis of antineutrophilic cytoplasmic antibody-associated vasculitides (AAV), therapeutic targets have been identified and studied in clinical trials. From initial induction strategies including glucocorticoids and cyclophosphamide, we have discovered effective induction regimens with rituximab and complement inhibition that can significantly decrease the glucocorticoid cumulative doses in patients with AAV. There are many trials underway evaluating management strategies for refractory patients and exploring new and old therapies that may help to continuously improve outcomes for patients with AAV.
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Affiliation(s)
- Alvise Berti
- Center for Medical Sciences (CISMed), Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, and Division of Rheumatology, Santa Chiara Hospital, APSS Trento, Italy
| | - Divi Cornec
- Rheumatology Department, INSERM UMR1227 LBAI, Lymphocytes B, Autoimmunité et Immunothérapies, University of Brest, National Reference Center for Rare Systemic Autoimmune Diseases CERAINO, CHRU Brest, Brest, France.
| | - Anisha B Dua
- Division of Rheumatology, Northwestern University Feinberg School of Medicine, 675 North Saint Clair Street, Suite 14-100, Chicago, IL 60611, USA
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3
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Flisiak R, Flisiak-Jackiewicz M, Rzymski P, Zarębska-Michaluk D. Tocilizumab for the treatment of COVID-19. Expert Rev Anti Infect Ther 2023; 21:791-797. [PMID: 37326214 DOI: 10.1080/14787210.2023.2226867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/14/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Since the beginning of the COVID-19 pandemic, the repurposing of medicines has been pursued to find interventions effective in preventing fatal outcome of the disease. One of these drugs was tocilizumab, an interleukin-6 inhibiting monoclonal antibody, previously used to treat several immune-related disorders. AREAS COVERED In this article, we present the results of the initial observational studies and subsequent randomized clinical trials on the efficacy and safety of tocilizumab in the treatment of COVID-19. Despite conflicting results, possibly due to the heterogeneity of the studied populations, large studies have ultimately proven that preventing IL-6 from attaching to its receptors can effectively reverse the fatal course of the disease. We also discuss the meta-analyses, which mostly supported the validity of tocilizumab therapy. We show how tocilizumab found its place in the most important recommendations on COVID-19 treatment and obtained authorization from the major regulatory authorities. EXPERT OPINION The criteria for optimizing tocilizumab therapy in COVID-19 still need to be established. They are also important considering the existing risks of future zoonotic spillovers and epidemics that may trigger hyperinflammation that could be efficiently blocked. The experience gained with tocilizumab shall be perceived as preparedness for future challenges.
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Affiliation(s)
- Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, Poland
| | - Marta Flisiak-Jackiewicz
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznań, Poland
- Integrated Science Association (ISA), Universal Scientific Education and Research Network (USERN), Poznań, Poland
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Correia JA, Crespo J, Alves G, Salvador F, Matos-Costa J, Alves JD, Fortuna J, Almeida I, Campar A, Brandão M, Faria R, Marado D, Oliveira S, Santos L, Silva F, Vasconcelos C, Fernandes M, Marinho A. Biologic therapy in large and small vessels vasculitis, and Behçet's disease: Evidence- and practice-based guidance. Autoimmun Rev 2023:103362. [PMID: 37230310 DOI: 10.1016/j.autrev.2023.103362] [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: 05/02/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Vasculitis are a very heterogenous group of systemic autoimmune diseases, affecting large vessels (LVV), small vessels or presenting as a multisystemic variable vessel vasculitis. We aimed to define evidence and practice-based recommendations for the use of biologics in large and small vessels vasculitis, and Behçet's disease (BD). METHODS Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice on autoimmune diseases management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2022. Preliminary recommendations were drafted by working groups for each disease and voted in two rounds, in June and September 2021. Recommendations with at least 75% agreement were approved. RESULTS A total of 32 final recommendations (10 for LVV treatment, 7 for small vessels vasculitis and 15 for BD) were approved by the experts and several biologic drugs were considered with different supporting evidence. Among LVV treatment options, tocilizumab presents the higher level of supporting evidence. Rituximab is recommended for treatment of severe/refractory cryoglobulinemic vasculitis. Infliximab and adalimumab are most recommended in treatment of severe/refractory BD manifestations. Other biologic drugs can be considered is specific presentations. CONCLUSION These evidence and practice-based recommendations are a contribute to treatment decision and may, ultimately, improve the outcome of patients living with these conditions.
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Affiliation(s)
- João Araújo Correia
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira, Centro Hospitalar Alto Ave, Rua dos Cutileiros 4810-055, Guimarães, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, 5000-508 Vila Real, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Avenida Bernardo Santareno, 2005-177 Santarém,Portugal
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, IC19 - 2720-276, Amadora, Portugal; 4Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School; R. Câmara Pestana 6, 1150-082 Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, IC19 - 2720-276, Amadora, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, 3000-370 Coimbra, Portugal; CIMAGO, Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, 3000-370 Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Milene Fernandes
- RWE & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, R. Tierno Galvan, 1250-096 Lisboa, Portugal
| | - António Marinho
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal.
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Tang PF, Xu LC, Hong WT, Shi HY. Successful treatment of granulomatosis with polyangiitis using tocilizumab combined with glucocorticoids: A case report. World J Clin Cases 2023; 11:1144-1151. [PMID: 36874435 PMCID: PMC9979291 DOI: 10.12998/wjcc.v11.i5.1144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/03/2022] [Accepted: 01/28/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Tocilizumab is a humanized monoclonal antibody against the interleukin-6 (IL-6) receptor that is commonly used to treat large vessel vasculitis and antineutrophil cytoplasmic antibody-related small vessel vasculitis. However, tocilizumab in combination with glucocorticoids for successfully treating granulomatosis with polyangiitis (GPA) has rarely been reported.
CASE SUMMARY Here, we report a 40-year-old male patient who suffered GPA for 4 years. He was treated with multiple rounds of drugs, including cyclophosphamide, Tripterygium wilfordii, mycophenolate mofetil, and belimumab, with no improvement. In addition, he exhibited persistently high IL-6 levels. After tocilizumab treatment, his symptoms improved, and his inflammatory marker levels returned to normal.
CONCLUSION Tocilizumab may be effective for treating GPA.
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Affiliation(s)
- Peng-Fang Tang
- Department of Rheumatology, Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Long-Chuan Xu
- Department of Pathology, Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Wen-Ting Hong
- Department of Rheumatology, Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Hong-Ying Shi
- Department of Immunology, Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
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Molnár A, Studinger P, Ledó N. Diagnostic and Therapeutic Approach in ANCA-Associated Glomerulonephritis: A Review on Management Strategies. Front Med (Lausanne) 2022; 9:884188. [PMID: 35721093 PMCID: PMC9205443 DOI: 10.3389/fmed.2022.884188] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is a destructive small vessel vasculitis affecting multiple organs. Renal involvement often leads to end-stage renal disease and increases mortality. Prompt diagnosis and initiation of adequate immunosuppressive therapy are critical for the best patient and kidney outcomes. However, considerable heterogeneity in symptoms and severity across the patients frequently hinder the diagnosis and management. The objective of this review is to emphasize the heterogeneity of the ANCA-associated vasculitis, facilitate the recognition and give guidance to the therapeutical possibilities. We present epidemiologic and risk factors, pathogenesis, and provide comprehensive clinical features of the disease. This article also focuses on the currently available therapeutic options and emerging cellular and molecular targets for the management of systemic and especially renal disease. We conducted extensive literature research published on PubMed and Google Scholar. We systematically reviewed, analyzed, and assembled databases, covering a broad spectrum of aspects of the disease. We compared and summarized the recommendations of two recent guidelines on ANCA-associated vasculitis. The incidence of ANCA-associated vasculitis, hence glomerulonephritis shows a steady increase. Familiarity with the presenting symptoms and laboratory abnormalities are necessary for rapid diagnosis. Early initiation of treatment is the key aspect for favorable patient and renal outcomes. A better understanding of the pathogenesis constantly leads to more targeted and therefore more efficient and less toxic treatment.
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Affiliation(s)
| | | | - Nóra Ledó
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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7
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d’Alessandro M, Conticini E, Bergantini L, Cameli P, Cantarini L, Frediani B, Bargagli E. Neutrophil Extracellular Traps in ANCA-Associated Vasculitis and Interstitial Lung Disease: A Scoping Review. Life (Basel) 2022; 12:life12020317. [PMID: 35207604 PMCID: PMC8877891 DOI: 10.3390/life12020317] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Deregulated neutrophil extracellular traps (NETs) formation is implicated in various diseases, including ANCA-associated vasculitis and pulmonary fibrosis (PF). Lung involvement is frequent in AAV, and interstitial lung diseases (ILDs) are strongly related to MPO-ANCA positivity and mainly reported in microscopic polyangiitis. The association between AAV and ILD is a strong indicator of poor prognosis and limited survival. Neutrophils, ANCA and NET interplay in PF development in AAV. This study aimed to review the literature concerning the implications of NET in lung fibrogenesis specifically focused on AAV associated with ILD, and the potential of NET as a theranostic marker. Methods: Through scoping review methodology, we used a descriptive thematic analysis to understand the pathogenic role of NETs in patients with AAV and pulmonary fibrosis and their further role as a theranostic marker of this disease. Results: The implications of NET in the pathogenesis of AAV and ILD, as well as an association between these two diseases, have been identified, but the underlying pathophysiological mechanisms are still unknown. The pharmacological or genetic inhibition of NET release reduces disease severity in multiple inflammatory disease models, indicating that NETs are potential therapeutic targets. In this regard, despite the lack of clinical data, we may hypothesise that an optimal management of AAV-ILD patients would require not only B-cells targeted therapy, but also NETs inhibition. Conclusion: Preliminary findings seem to display a lack of efficacy of traditional immunosuppressants, such as Rituximab, in this subset of patients, while to date no patients suffering from a definite ILD have been enrolled in clinical trials. Further insights would be provided by their employment, as a combination treatment, in common clinical practice. Although we can imagine that the inhibition of NETs in patients with AAV-ILD could reduce severity and mortality, we still lack the scientific basis that could improve our understanding of the disease from a molecular point of view.
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Affiliation(s)
- Miriana d’Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
- Correspondence:
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
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Bayas A, Christ M, Berlis A, Naumann M, Ertl M, Joachimski F, Müller M, Welzel J, Ann Gerdes L, Seelos K, Maurer C. Incidence, clinical spectrum, and immunotherapy of non-ischemic cerebral enhancing lesions after endovascular therapy. Ther Adv Neurol Disord 2022; 15:17562864211072372. [PMID: 35126670 PMCID: PMC8808010 DOI: 10.1177/17562864211072372] [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: 10/14/2021] [Accepted: 12/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Symptomatic and asymptomatic delayed non-ischemic cerebral enhancing (NICE) lesions in magnetic resonance imaging (MRI) have been reported as a rare complication after endovascular therapy (EVT) in recent years with incidence rates between 0.05% and 0.9% in most studies. Information on long-term clinical course and immunotherapies is scarce or has not been reported in detail in the literature. Objective: Aims of our study were to assess the incidence of NICE lesions in patients after cerebral EVT over a period of more than 12 years, describe clinical and EVT characteristics, and immunotherapies applied. Methods: A retrospective chart review of all patients treated by endovascular therapy for symptomatic or asymptomatic aneurysms at the University Hospital of Augsburg from May 1, 2008 to December 31, 2020 was performed. Patients were identified retrospectively and followed-up prospectively where appropriate. In addition, one case treated at another institution was included. Results: Five out of 746 patients, 0.67%, developed NICE lesions after EVT, all with non-ruptured aneurysms and all symptomatic upon detection of NICE lesions by MRI. In total, the disease course of 6 female patients is reported. Symptoms occurred after a mean time of 15 days (±13.42, SD) after EVT with headache (6/6 patients), focal neurological signs (6/6 patients), epileptic seizures (2/6 patients) and cognitive deficits (3/6 patients). All 6 patients received glucocorticosteroids (GCS), 1/6 azathioprine (AZA), 4/6 mycophenolate mofetil (MMF), 1/6 methotrexate (MTX), 1/6 rituximab (RTX), 2/6 cyclophosphamide (CYC) and 3/6 tocilizumab (TCZ). A treatment response could be observed for GCS, TCZ and MMF (in two of four cases), RTX and AZA did not result in disease stabilization. Conclusions: Delayed NICE lesions are a rare complication after EVT, requiring immunotherapies in all patients reported here. Physicians should be aware of this disorder in case of new symptoms or contrast enhancing lesions after EVT.
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Affiliation(s)
- Antonios Bayas
- Department of Neurology, University Hospital of Augsburg, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Monika Christ
- Department of Neurology, University Hospital of Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department of Neuroradiology, University Hospital of Augsburg, Augsburg, Germany
| | - Markus Naumann
- Department of Neurology, University Hospital of Augsburg, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology, University Hospital of Augsburg, Augsburg, Germany
| | - Felix Joachimski
- Department of Neuroradiology, University Hospital of Augsburg, Augsburg, Germany
| | - Mona Müller
- Department of Neurology, University Hospital of Augsburg, Augsburg, Germany
| | - Julia Welzel
- Department of Dermatology, University Hospital of Augsburg, Augsburg, Germany
| | - Lisa Ann Gerdes
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, LMU Munich, Munich, Germany
| | - Klaus Seelos
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Christoph Maurer
- Department of Neuroradiology, University Hospital of Augsburg, Augsburg, Germany
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9
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Adeeb F, Malik H, Sitram R, Mahmood W, Bhutta S. Steroid-free management and recent advances in antineutrophil cytoplasmic antibody-associated vasculitis. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_87_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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10
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Martín Navarro JA, Cintra Cabrera M, Proccacini F, Muñoz Rodríguez J, Roldán Cortés D, Lucena Valverde R, Ortega Díaz M, Puerta Carretero M, Gil Herrera J, Jaldo Rodríguez MT, Albalate Ramón M, Corchete Prats E, Medina Zahonero L, de Sequera Ortiz P, Alcázar Arroyo R. More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia. Nefrologia 2022; 42:94-98. [PMID: 36153904 PMCID: PMC8851205 DOI: 10.1016/j.nefroe.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 06/16/2023] Open
Abstract
We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.
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Affiliation(s)
| | | | - Fabio Proccacini
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Jorge Muñoz Rodríguez
- Servicio de Anatomía Patológica, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - David Roldán Cortés
- Servicio de Anatomía Patológica, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Mayra Ortega Díaz
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
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11
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Renal Tissue miRNA Expression Profiles in ANCA-Associated Vasculitis—A Comparative Analysis. Int J Mol Sci 2021; 23:ijms23010105. [PMID: 35008531 PMCID: PMC8745125 DOI: 10.3390/ijms23010105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 11/17/2022] Open
Abstract
Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises autoimmune disease entities that cause target organ damage due to relapsing-remitting small vessel necrotizing vasculitis, and which affects various vascular beds. The pathogenesis of AAV is incompletely understood, which translates to considerable disease- and treatment-related morbidity and mortality. Recent advances have implicated microRNAs (miRNAs) in AAV; however, their accurate characterization in renal tissue is lacking. The goal of this study was to identify the intrarenal miRNA expression profile in AAV relative to healthy, non-inflammatory and inflammatory controls to identify candidate-specific miRNAs. Formalin-fixed, paraffin-embedded renal biopsy tissue samples from 85 patients were obtained. Comprehensive miRNA expression profiles were performed using panels with 752 miRNAs and revealed 17 miRNA that differentiated AAV from both controls. Identified miRNAs were annotated to characterize their involvement in pathways and to define their targets. A considerable subset of differentially expressed miRNAs was related to macrophage and lymphocyte polarization and cytokines previously deemed important in AAV pathogenesis, lending credence to the obtained results. Interestingly, several members of the miR-30 family were detected. However, a validation study of these differentially expressed miRNAs in an independent, larger sample cohort is needed to establish their potential diagnostic utility.
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Hecker C, Welponer T, Herold M, Trinka E, Broussalis E, Killer-Oberpfalzer M. Update on treatment strategies for vasculitis affecting the central nervous system. Drug Discov Today 2021; 27:1142-1155. [PMID: 34838730 DOI: 10.1016/j.drudis.2021.11.020] [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: 06/10/2021] [Revised: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022]
Abstract
Vasculitis affecting the nervous system is a rare disease that can not only present with nonspecific initial symptoms, but also run a severe course without accurate treatment. Although improvements have been achieved, diagnosis of vasculitis remains challenging, because many classification criteria are unspecific or inconclusive with regard to central nervous system (CNS) manifestations. Currently, beside an isolated primary CNS vasculitis, several systemic types of vasculitis are known to affect the nervous system. In this review, we provide an overview of the pathophysiology, current therapeutic guidelines, and highlight novel treatment strategies for CNS vasculitis.
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Affiliation(s)
- Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria.
| | - Tobias Welponer
- Department of Dermatology and Allergology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Manfred Herold
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology, and Rheumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
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13
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An update on the pathogenic role of IL-6 in rheumatic diseases. Cytokine 2021; 146:155645. [PMID: 34303949 DOI: 10.1016/j.cyto.2021.155645] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
Interleukin (IL)-6 is a pleiotropic cytokine that is involved in the pathogenesis of various rheumatic diseases. Direct inhibition of the IL-6 pathway by an anti-IL-6 receptor or inhibiting the ligand itself has proved to be efficacious in the treatment of these diseases. Juvenile idiopathic arthritis, adult-onset Still's disease, large vessel vasculitis including giant cell arteritis and Takayasu disease, systemic sclerosis, and polymyalgia rheumatica respond well to IL-6 inhibition as expected. However, no clinically meaningful effect has been observed with regard to IL-6 blockade in ankylosing spondylitis, psoriatic arthritis, and systemic lupus erythematosus. This review discusses the current state of IL-6 targeting approaches in various rheumatic diseases other than rheumatoid arthritis.
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Vegting Y, Vogt L, Anders HJ, de Winther MPJ, Bemelman FJ, Hilhorst ML. Monocytes and macrophages in ANCA-associated vasculitis. Autoimmun Rev 2021; 20:102911. [PMID: 34298153 DOI: 10.1016/j.autrev.2021.102911] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/05/2021] [Indexed: 12/15/2022]
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) are characterized by inflammation of small-to-medium-sized blood vessels and the presence of autoantibodies against cytoplasmic proteases sited in neutrophils and monocytes. Increasing evidence indicates a substantial role of monocytes and macrophages in the pathogenesis of AAV. Activated monocytes and macrophages contribute to necroinflammation in peripheral vasculitic lesions as well as to central and peripheral mechanisms of autoimmunity. The intermediate monocyte subset (CD14++CD16+) is increased and monocytes show elevated expression of CD14, Toll-like receptor 2/4, MHCII and integrins, likely reflecting activation and increased monocyte extravasation. Monocytes differentiate locally predominantly into alternatively activated (M2) macrophages, which are known for cell-clearance and phagocytosis, but may ultimately lead to fibrosis. Phagocytotic function of macrophages can be impaired by surface expression of cytoplasmic proteases on apoptotic neutrophils and causes release of inflammatory cytokines and immunogenic contents, presumably resulting in a vicious circle of increased neutrophil, T and B cell activation and consequent ANCA production. Considering their crucial role in initiating necroinflammation as well as fibrogenesis, monocytes and macrophages may represent a logic first-line target for new treatment options in AAV.
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Affiliation(s)
- Yosta Vegting
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hans-Joachim Anders
- Department of Internal Medicine IV, Division of Nephrology, University Hospital of the Ludwig Maximilians University Munich, Munich, Germany
| | - Menno P J de Winther
- Department of Medical Biochemistry, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Frederike J Bemelman
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc L Hilhorst
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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15
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Chung SW. Vasculitis: From Target Molecules to Novel Therapeutic Approaches. Biomedicines 2021; 9:757. [PMID: 34209028 PMCID: PMC8301353 DOI: 10.3390/biomedicines9070757] [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: 05/27/2021] [Revised: 06/17/2021] [Accepted: 06/25/2021] [Indexed: 12/18/2022] Open
Abstract
Systemic vasculitis is a group of diverse diseases characterized by immune-mediated inflammation of blood vessels. Current treatments for vasculitis, such as glucocorticoids and alkylating agents, are associated with significant side effects. In addition, the management of both small and large vessel vasculitis is challenging due to a lack of robust markers of disease activity. Recent research has advanced our understanding of the pathogenesis of both small and large vessel vasculitis, and this has led to the development of novel biologic therapies capable of targeting key cytokine and cellular effectors of the inflammatory cascade. It is anticipated that these novel treatments will lead to more effective and less toxic treatment regimens for patients with systemic vasculitis.
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Affiliation(s)
- Sang-Wan Chung
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea
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Müller-Deile J, Jaremenko C, Haller H, Schiffer M, Haubitz M, Christiansen S, Falk C, Schiffer L. Chemokine/Cytokine Levels Correlate with Organ Involvement in PR3-ANCA-Associated Vasculitis. J Clin Med 2021; 10:jcm10122715. [PMID: 34205404 PMCID: PMC8234887 DOI: 10.3390/jcm10122715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
Background: ANCA-associated vasculitis (AAV) is a rare small vessel disease characterized by multi-organ involvement. Biomarkers that can measure specific organ involvement are missing. Here, we ask whether certain circulating cytokines and chemokines correlate with renal involvement and if distinct cytokine/chemokine patterns can differentiate between renal, ear/nose/throat, joints, and lung involvement of AAV. Methods: Thirty-two sets of Birmingham vasculitis activity score (BVAS), PR3-ANCA titers, laboratory marker, and different cytokines were obtained from 17 different patients with AAV. BVAS, PR3-ANCA titers, laboratory marker, and cytokine concentrations were correlated to different organ involvements in active AAV. Results: Among patients with active PR3-AAV (BVAS > 0) and kidney involvement we found significant higher concentrations of chemokine ligand (CCL)-1, interleukin (IL)-6, IL21, IL23, IL-28A, IL33, monocyte chemoattractant protein 2 (MCP2), stem cell factor (SCF), thymic stromal lymphopoietin (TSLP), and thrombopoietin (TPO) compared to patients without PR3-ANCA-associated glomerulonephritis. Patients with ear, nose, and throat involvement expressed higher concentrations of MCP2 and of the (C-X-C motif) ligand-12 (CXCL-12) compared to patients with active AAV and no involvement of these organs. Conclusion: We identified distinct cytokine patterns for renal manifestation and for ear, nose and throat involvement of PR3-AAV. Distinct plasma cytokines might be used as non-invasive biomarkers of organ involvement in AAV.
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Affiliation(s)
- Janina Müller-Deile
- Department of Nephrology and Hypertension, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany;
- Correspondence:
| | - Christian Jaremenko
- Institute for Nanotechnology and Correlative Microscopy eV, INAM, 91301 Forchheim, Germany; (C.J.); (S.C.)
- Institute of Optics, Information and Photonics, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Hermann Haller
- Department of Nephrology, Hannover Medical School, 30625 Hannover, Germany;
| | - Mario Schiffer
- Department of Nephrology and Hypertension, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany;
| | - Marion Haubitz
- Department of Nephrology and Hypertension, Center for Internal Medicine and Medical Clinic III, Klinikum Fulda, 36043 Fulda, Germany;
| | - Silke Christiansen
- Institute for Nanotechnology and Correlative Microscopy eV, INAM, 91301 Forchheim, Germany; (C.J.); (S.C.)
| | - Christine Falk
- Institute of Transplant Immunology, Hannover Medical School, 30625 Hannover, Germany;
| | - Lena Schiffer
- Department of Pediatric Nephrology, Hannover Medical School, 30625 Hannover, Germany;
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Brede KM, Schmid J, Steinmetz OM, Panzer U, Klinge S, Mittrücker HW. Neutralization of IL-6 inhibits formation of autoreactive TH17 cells but does not prevent loss of renal function in experimental autoimmune glomerulonephritis. Immunol Lett 2021; 236:51-60. [PMID: 34015360 DOI: 10.1016/j.imlet.2021.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/31/2021] [Accepted: 05/11/2021] [Indexed: 12/17/2022]
Abstract
In anti-glomerular basement membrane glomerulonephritis (anti-GBM GN), antibodies and T cells directed against the Goodpasture antigen, the non-collagenous domain of the α3-chain of type IV collagen (α3(IV)NC1), provoke renal inflammation resulting in rapidly progressing crescentic GN. Interleukin 6 (IL-6) is a pleiotropic cytokine with both pro- and anti-inflammatory activities, and IL-6 blockade is successfully used for treatment of diseases associated with acute and chronic inflammation. However, the role of IL-6 in anti-GBM GN is unclear. Here, we use the mouse model of experimental autoimmune glomerulonephritis (EAG) to study the role of IL-6 in anti-GBM GN. DBA/1J mice were immunized with α3(IV)NC1 and developed fatal crescentic GN. Treatment of mice with neutralizing anti-IL-6 antibodies impaired the generation of α3(VI)NC1-specific TH1 and TH17 cells. However, despite lasting reduction of the TH17 cell response, antibody treatment did not prevent crescentic GN. Antibody treatment was also ineffective in a therapeutic setting with pre-existing autoantibodies and T cells. In conclusion, our results indicate that although the blockade of IL-6 impairs the development of autoimmunity against α3(VI)NC1, this treatment does not ameliorate crescentic GN both in a preemptive and a therapeutic approach.
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Affiliation(s)
- Karen-Maria Brede
- Department for Immunology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Joanna Schmid
- Department for Immunology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Oliver M Steinmetz
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Panzer
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefanie Klinge
- Department for Immunology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Hans-Willi Mittrücker
- Department for Immunology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Prendecki M, McAdoo SP. New Therapeutic Targets in Antineutrophil Cytoplasm Antibody–Associated Vasculitis. Arthritis Rheumatol 2021; 73:361-370. [DOI: 10.1002/art.41407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
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19
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Martín Navarro JA, Cintra Cabrera M, Lucca Proccacini F, Muñoz Rodríguez J, Roldán Cortés D, Lucena Valverde R, Ortega Díaz M, Puerta Carretero M, Gil Herrera J, Jaldo Rodríguez MT, Albalate Ramón M, Corchete Prats E, Medina Zahonero L, de Sequera Ortiz P, Alcázar Arroyo R. More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia. Nefrologia 2021; 42:S0211-6995(21)00012-6. [PMID: 33781578 PMCID: PMC7843118 DOI: 10.1016/j.nefro.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022] Open
Abstract
We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.
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Affiliation(s)
| | | | | | - Jorge Muñoz Rodríguez
- Servicio de Anatomía Patológica, Hospital Universitario Infanta Leonor, Madrid, España
| | - David Roldán Cortés
- Servicio de Anatomía Patológica, Hospital Universitario Infanta Leonor, Madrid, España
| | | | - Mayra Ortega Díaz
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
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20
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Sakai R, Ito M, Yoshimoto K, Chikuma S, Kurasawa T, Kondo T, Suzuki K, Takeuchi T, Amano K, Yoshimura A. Tocilizumab monotherapy uncovered the role of the CCL22/17-CCR4 + Treg axis during remission of crescentic glomerulonephritis. Clin Transl Immunology 2020; 9:e1203. [PMID: 33163184 PMCID: PMC7596393 DOI: 10.1002/cti2.1203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/08/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022] Open
Abstract
Objectives Tocilizumab (TCZ) is a humanised anti‐interleukin (IL)‐6 receptor (IL‐6R) monoclonal antibody that is a promising agent to treat various autoimmune diseases. However, the mechanism of TCZ efficacy is unclear. This study aims to elucidate the relationship between Tregs and IL‐6R blockade in autoimmunity‐mediated renal disease based on a TCZ‐treated cohort of patients with anti‐neutrophil cytoplasmic antibody (ANCA)‐associated vasculitis (AAV) and in an experimental model of crescentic glomerulonephritis (cGN). Methods We examined multiple serum levels of cytokines and chemokines and peripheral blood mononuclear cells in patients with AAV who received TCZ monotherapy and achieved drug‐free remission. Moreover, we investigated the mechanistic role of IL‐6R blockade in accelerated cGN model to analyse the local sites of inflammation. Results Serum chemokines CCL22 and CCL17, in addition to the CCR4+Foxp3+ Treg population, increased in patients who demonstrated drug‐free remission after the cessation of TCZ. In the cGN model, IL‐6R blockade ameliorated the disease, elevated CCL22/17 in CD206+CD11b+CD11c+ kidney M2‐like type macrophages, and increased the migration of Tregs into the kidney and regional lymph nodes. The local administration of CCL22 in the kidney facilitated Treg accumulation and reduced glomerular crescent formation. Conclusions This study revealed a new mechanism whereby effector Tregs migrate into the inflammatory kidney via the CCL22/17–CCR4 axis that is facilitated by M2‐like type macrophages that are induced by IL‐6R blockade.
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Affiliation(s)
- Ryota Sakai
- Department of Microbiology and Immunology Keio University School of Medicine Tokyo Japan.,Department of Rheumatology and Clinical Immunology Saitama Medical Center Saitama Medical University Kawagoe Japan
| | - Minako Ito
- Department of Microbiology and Immunology Keio University School of Medicine Tokyo Japan
| | - Keiko Yoshimoto
- Division of Rheumatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Shunsuke Chikuma
- Department of Microbiology and Immunology Keio University School of Medicine Tokyo Japan
| | - Takahiko Kurasawa
- Department of Rheumatology and Clinical Immunology Saitama Medical Center Saitama Medical University Kawagoe Japan
| | - Tsuneo Kondo
- Department of Rheumatology and Clinical Immunology Saitama Medical Center Saitama Medical University Kawagoe Japan
| | - Katsuya Suzuki
- Division of Rheumatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology Saitama Medical Center Saitama Medical University Kawagoe Japan
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology Keio University School of Medicine Tokyo Japan
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21
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Immunopathogenesis of ANCA-Associated Vasculitis. Int J Mol Sci 2020; 21:ijms21197319. [PMID: 33023023 PMCID: PMC7584042 DOI: 10.3390/ijms21197319] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune disorder which affects small- and, to a lesser degree, medium-sized vessels. ANCA-associated vasculitis encompasses three disease phenotypes: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). This classification is largely based on clinical presentations and has several limitations. Recent research provided evidence that genetic background, risk of relapse, prognosis, and co-morbidities are more closely related to the ANCA serotype, proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, compared to the disease phenotypes GPA or MPA. This finding has been extended to the investigation of biomarkers predicting disease activity, which again more closely relate to the ANCA serotype. Discoveries related to the immunopathogenesis translated into clinical practice as targeted therapies are on the rise. This review will summarize the current understanding of the immunopathogenesis of ANCA-associated vasculitis and the interplay between ANCA serotype and proposed disease biomarkers and illustrate how the extending knowledge of the immunopathogenesis will likely translate into development of a personalized medicine approach in the management of ANCA-associated vasculitis.
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Gapud EJ, Kronbichler A, Gauckler P, Geetha D. Immunotherapy for ANCA-associated vasculitis during the COVID-19 pandemic. Eur J Rheumatol 2020; 7:S121-S128. [PMID: 32716836 DOI: 10.5152/eurjrheum.2020.2067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/06/2020] [Indexed: 12/19/2022] Open
Abstract
Since the first description of infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in China in December 2019, it has evolved into a pandemic and emerged as an unprecedented worldwide crisis overwhelming healthcare systems globally. Analysis of the available literature to date suggests that, in addition to older age, patients with underlying co-morbidities including hypertension, diabetes, heart disease are at higher risk for severe disease with increased mortality. Practitioners around the world also have become increasingly concerned that immunosuppressed patients including those with autoimmune diseases may be at increased risk for developing Coronavirus Disease 2019 (COVID-19) with serious complications. Very little is known about how anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis modifies the susceptibility, clinical presentation and disease course of COVID-19. In this review, we discuss the mechanism of action and challenges of the current therapeutic armamentarium of ANCA-associated vasculitis and outline approaches to management of ANCA-associated vasculitis during the COVID-19 pandemic.
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Affiliation(s)
- Eric J Gapud
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Andreas Kronbichler
- Department of Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Philipp Gauckler
- Department of Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine
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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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24
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Garner S, Khalidi N. Updates in the treatment of granulomatosis with polyangiitis and microscopic polyangiitis: At a crossroad. Presse Med 2020; 49:104038. [PMID: 32634467 DOI: 10.1016/j.lpm.2020.104038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
There have been great advances in the management of ANCA associated vasculitis over the past decades. We have gone from an era where the disease was almost universally fatal to trying to prevent long-term side effects of treatment regimens. With the ability to use pulse cyclophosphamide or rituximab as alternates to oral cyclophosphamide for induction of remission, side effects of therapy have been greatly reduced. New approaches have drastically changed our approach to maintenance and we now favor much longer durations of maintenance therapy, as they are more successful in preventing relapse. Steroids have long been the bane of treatment as they are associated with a significant risk of infection and metabolic consequences. We are now in a steroid-sparing and looking ahead to a steroid-free era with new data being published showing lower doses of steroids being equally effective and several ongoing seminal trials looking at agents that could completely replace steroids very early on.
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Abstract
Vasculitis is characterized by inflammation of the vascular wall. It reaches vessels of different sizes and locations, conditioning multisystem and complex manifestations that require a holistic approach. Antineutrophil cytoplasmic antibody-associated vasculitis has an annual incidence rate of 20 per million inhabitants. It is the result of the interaction of infectious, genetic and environmental factors and manifest itself with varied and unspecific symptoms, often reaching the general state, respiratory and renal systems. The combination of clinical, laboratory, imaging and fundamentally histological changes allows the diagnosis and classification of the extent / severity of the disease necessary for the decision of the therapeutics to be taken. Glucocorticoids are generally used; with methotrexate being considered when localized disease and cyclophosphamide, rituximab or azathioprine when generalized disease. A systematized approach can increase survival rates from 12% to 70% over a 5-year span.
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Affiliation(s)
- Fernando Salvador
- Autoimmune Diseases Unit, Internal Medicine Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, 5000-508 Vila Real, Portugal; NEDAI/SPMI Autoimmune Diseases Group/Portuguese Society of Internal Medicine, Portugal.
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Hagenstein J, Melderis S, Nosko A, Warkotsch MT, Richter JV, Ramcke T, Herrnstadt GR, Scheller J, Yan I, Mittrücker HW, Kluger MA, Steinmetz OM. A Novel Role for IL-6 Receptor Classic Signaling: Induction of ROR γt +Foxp3 + Tregs with Enhanced Suppressive Capacity. J Am Soc Nephrol 2019; 30:1439-1453. [PMID: 31311828 DOI: 10.1681/asn.2019020118] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/02/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND New therapies blocking the IL-6 receptor (IL-6R) have recently become available and are successfully being used to treat inflammatory diseases like arthritis. Whether IL-6 blockers may help patients with kidney inflammation currently remains unknown. METHODS To learn more about the complex role of CD4+ T cell-intrinsic IL-6R signaling, we induced nephrotoxic nephritis, a mouse model for crescentic GN, in mice lacking T cell-specific IL-6Ra. We used adoptive transfer experiments and studies in reporter mice to analyze immune responses and Treg subpopulations. RESULTS Lack of IL-6Ra signaling in mouse CD4+ T cells impaired the generation of proinflammatory Th17 cells, but surprisingly did not ameliorate the course of GN. In contrast, renal damage was significantly reduced by restricting IL-6Ra deficiency to T effector cells and excluding Tregs. Detailed studies of Tregs revealed unaltered IL-10 production despite IL-6Ra deficiency. However, in vivo and in vitro, IL-6Ra classic signaling induced RORγt+Foxp3+ double-positive Tregs (biTregs), which carry the trafficking receptor CCR6 and have potent immunoregulatory properties. Indeed, lack of IL-6Ra significantly reduced Treg in vitro suppressive capacity. Finally, adoptive transfer of T cells containing IL-6Ra-/- Tregs resulted in severe aggravation of GN in mice. CONCLUSIONS Our data refine the old paradigm, that IL-6 enhances Th17 responses and suppresses Tregs. We here provide evidence that T cell-intrinsic IL-6Ra classic signaling indeed induces the generation of Th17 cells but at the same time highly immunosuppressive RORγt+ biTregs. These results advocate caution and indicate that IL-6-directed therapies for GN need to be cell-type specific.
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Affiliation(s)
| | | | | | | | | | | | | | - Jürgen Scheller
- Medical Faculty, Institute of Biochemistry and Molecular Biology II, Heinrich-Heine University, Dusseldorf, Germany
| | - Isabell Yan
- Institute for Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and
| | - Hans-Willi Mittrücker
- Institute for Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and
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Tedesco M, Gallieni M, Pellegata F, Cozzolino M, Alberici F. Update on ANCA-associated vasculitis: from biomarkers to therapy. J Nephrol 2019; 32:871-882. [DOI: 10.1007/s40620-019-00628-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022]
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Harigai M, Tsutsumino M, Takada H, Nagasaka K. Molecular targeted therapies for microscopic polyangiitis and granulomatosis with polyangiitis. Korean J Intern Med 2019; 34:492-503. [PMID: 30613065 PMCID: PMC6506735 DOI: 10.3904/kjim.2018.366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 11/17/2018] [Indexed: 11/27/2022] Open
Abstract
Clinical trials and observational studies have established cyclophosphamide (CY) or rituximab plus glucocorticoid (GC) as standard remission induction therapies in patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). However, because these regimens are associated with serious adverse drug reactions, the development of drugs with novel mechanisms of actions are needed. Progress in basic and clinical research has identified novel candidate targeting molecules, including B-cell activating factor (BAF), C5a receptor, and interleukin-6. The combination of rituximab and BAF blockade in patients with MPA and GPA is under investigation in an effort to strike a better benefit-risk balance. Phase II clinical trials of avacopan (CCX168), an orally administered C5a receptor antagonist, have suggested a reduction in the dosage of concomitant GC or the replacement of GC in patients with MPA and GPA. The results from a currently ongoing phase III trial are awaited. Anecdotal case reports and an open-label pilot study have indicated the effectiveness of tocilizumab in patients with MPA and GPA. A randomized clinical trial comparing tocilizumab and intravenous CY in combination with GC is currently in progress. Molecular targeted therapy is expected to transform the treatment strategy for MPA and GPA to allow GC-free or at least less GC-dependent forms of therapy.
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Affiliation(s)
- Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology, Tokyo Women’s Medical University, Tokyo, Japan
- Correspondence to Masayoshi Harigai, M.D. Division of Epidemiology and Pharmacoepidemiology, Department of Rheumatology, School of Medicine, Tokyo Women’s Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo 162-0054, Japan Tel: +81-3-5269-1725 Fax: +81-3-5269-9154 E-mail:
| | - Michi Tsutsumino
- Department of Rheumatology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hideto Takada
- Department of Rheumatology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital, Tokyo, Japan
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The Two-Faced Cytokine IL-6 in Host Defense and Diseases. Int J Mol Sci 2018; 19:ijms19113528. [PMID: 30423923 PMCID: PMC6274717 DOI: 10.3390/ijms19113528] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/07/2023] Open
Abstract
Interleukein-6 (IL-6), is produced locally from infectious or injured lesions and is delivered to the whole body via the blood stream, promptly activating the host defense system to perform diverse functions. However, excessive or sustained production of IL-6 is involved in various diseases. In diseases, the IL-6 inhibitory strategy begins with the development of the anti-IL-6 receptor antibody, tocilizumab (TCZ). This antibody has shown remarkable effects on Castleman disease, rheumatoid arthritis and juvenile idiopathic arthritis. In 2017, TCZ was proven to work effectively against giant cell arteritis, Takayasu arteritis and cytokine releasing syndrome, initiating a new era for the treatment of these diseases. In this study, the defensive functions of IL-6 and various pathological conditions are compared. Further, the diseases of which TCZ has been approved for treatment are summarized, the updated results of increasing off-label use of TCZ for various diseases are reviewed and the conditions for which IL-6 inhibition might have a beneficial role are discussed. Given the involvement of IL-6 in many pathologies, the diseases that can be improved by IL-6 inhibition will expand. However, the important role of IL-6 in host defense should always be kept in mind in clinical practice.
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30
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Kondo T, Amano K. Era of steroid sparing in the management of immune-mediated inflammatory diseases. Immunol Med 2018; 41:6-11. [PMID: 30938261 DOI: 10.1080/09114300.2018.1451593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Glucocorticoids (GCs) have played a pivotal role in the treatment of immune-mediated inflammatory diseases (IMIDs) for a long time. However, GCs also incur a significant risk of undesirable adverse events such as Cushingoid changes, osteoporosis, glaucoma and metabolic abnormalities such as diabetes and hypercholesterolemia, which may lead to life-threatening cerebrovascular and cardiovascular events. High-dose GCs may also cause mental disorders and osteonecrosis. Recently, new therapeutic strategies have been developed to reduce the dose or even eliminate the need for GCs; multi-target drug therapies for systemic lupus erythematosus (SLE), biological agents such as tocilizumab and rituximab for systemic vasculitis, and anakinra and tocilizumab for adult-onset still's disease. Therefore, the era of GC-sparing or GC-free treatment for IMIDs is on the horizon.
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Affiliation(s)
- Tsuneo Kondo
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
| | - Koichi Amano
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Saitama , Japan
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Jariwala MP, Laxer RM. Primary Vasculitis in Childhood: GPA and MPA in Childhood. Front Pediatr 2018; 6:226. [PMID: 30167431 PMCID: PMC6107029 DOI: 10.3389/fped.2018.00226] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/25/2018] [Indexed: 12/17/2022] Open
Abstract
Childhood onset anti-neutrophilic cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a rare group of primary systemic vasculitides affecting medium and small blood vessels. AAV includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), and renal limited ANCA vasculitis. These disorders are associated with severe clinical manifestations, frequent relapses and a high cumulative morbidity, and often present with multisystem involvement. Renal involvement is common in the pediatric age group, characterized by pauci-immune necrotizing and crescentic glomerulonephritis which frequently progresses to chronic kidney disease in adulthood. ANCAs against proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO) (MPO-ANCA) remain the hallmark of AAV and are integral to the disease pathogenesis. Newer understanding of neutrophil extracellular traps and complement activation have provided better insights into disease pathogenesis. A pediatric vasculitis working group has developed and validated childhood vasculitis classification criteria and disease activity and damage scores. No specific pediatric treatment recommendations exist due to rare nature of the illness in pediatric population. Smaller case series have been published on the efficacy of adult treatment regimens in pediatric patients. The prognosis often remains guarded with frequent relapses and a high cumulative morbidity. The aim of this article is to provide a comprehensive review on pediatric AAV with a focus on recent observations regarding epidemiology, disease pathogenesis, treatment, and prognosis.
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Affiliation(s)
- Mehul P Jariwala
- Saskatoon Health Region, Saskatoon, SK, Canada.,Department of Pediatrics, Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | - Ronald M Laxer
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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32
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Sag E, Batu ED, Ozen S. Childhood systemic vasculitis. Best Pract Res Clin Rheumatol 2017; 31:558-575. [PMID: 29773273 DOI: 10.1016/j.berh.2017.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/16/2017] [Accepted: 11/20/2017] [Indexed: 01/19/2023]
Abstract
Vasculitides are characterized by inflammation of the vessel wall. Most of the vasculitides tend to occur in vessels of a specific size and certain target organs. In this review, we discuss each specific childhood vasculitis according to the latest Chapel Hill Consensus Conference 2012 nomenclature system and the Ankara 2008 classification criteria. We have also reviewed the clinical and laboratory characteristics and the recent treatment recommendations for the vasculitides we encounter in children.
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Affiliation(s)
- Erdal Sag
- Hacettepe University, Ihsan Dogramaci Children's Hospital, Department of Pediatric Rheumatology, Turkey
| | - Ezgi Deniz Batu
- Hacettepe University, Ihsan Dogramaci Children's Hospital, Department of Pediatric Rheumatology, Turkey
| | - Seza Ozen
- Hacettepe University, Ihsan Dogramaci Children's Hospital, Department of Pediatric Rheumatology, Turkey.
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Morishita KA, Tiller G, Cabral DA. Therapeutic Management of Pediatric Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0077-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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