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Tao SS, Tang J, Yang XK, Fang X, Luo QQ, Xu YQ, Ge M, Ye F, Wang P, Pan HF. Two Decades of Publications in Journals Dedicated to Autoimmunity: A Bibliometric Analysis of the Autoimmunity Field from 2004 to 2023. Clin Exp Med 2024; 24:117. [PMID: 38833019 DOI: 10.1007/s10238-024-01369-1] [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: 04/01/2024] [Accepted: 05/04/2024] [Indexed: 06/06/2024]
Abstract
To carry out an in-depth analysis of the scientific research on autoimmunity, we performed the first bibliometric analysis focusing on publications in journals dedicated to autoimmunity (JDTA) indexed by science citation index during the period 2004-2023. Using bibliometric analysis, we quantitatively and qualitatively analyzed the country, institution, author, reference and keywords information of publications in JDTA, so as to understand the quantity, publication pattern and publication characteristics of these publications. The co-occurrence networks, clustering map and timeline map were created by CiteSpace and VOSviewer software to visualize the results. The CiteSpace was also used to analyze the strongest citation burst of keywords, which could describe the frequency, intensity and time period of high-frequency keywords, and indicate the research hotspots in the field. A total of 5 710 publications were analyzed, and their annual distribution number was basically stable from 2004 to 2023, fluctuating around 300. The United States and Italy led the way in terms of the number of publications, followed by France and China. For international cooperation, the developed countries represented by the United States cooperate more closely, but the cooperation was localized, reflecting that there was no unified model of autoimmunity among countries. UDICE-French Research Universities had the greatest number of publications. Subsequently, the number of publications decreased slowly with the ranking, and the gradient was not large. Eric Gershwin and Yehuda Shoenfeld stood out among the authors. They had an excellent academic reputation and great influence in the field of autoimmunity. The results of keyword analysis showed that JDTA publications mainly studied a variety of autoimmune diseases, especially SLE and RA. At the same time, JDTA publications also paid special attention to the research of cell function, autoantibody expression, animal experiments, disease activity, pathogenesis and treatment. This study is the first to analyze the publications in JDTA from multiple indicators by bibliometrics, thus providing new insights into the research hotspots and development trends in the field of autoimmunity.
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Affiliation(s)
- Sha-Sha Tao
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China
- Preventive Medicine Experimental Teaching Center, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Jian Tang
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Xiao-Ke Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, Anhui, China
| | - Xi Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Qing-Qing Luo
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Yi-Qing Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Man Ge
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Fan Ye
- Department of Environmental Health, School of Public Health, Shanxi Medical University, TaiYuan, 030001, Shanxi, People's Republic of China
| | - Peng Wang
- Teaching Center for Preventive Medicine,School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China.
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Medical University, Hefei, 230032, Anhui, China.
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Paredes-Ruiz D, Martin-Iglesias D, Ruiz-Irastorza G. Balancing risks and benefits in the use of hydroxychloroquine and glucocorticoids in systemic lupus erythematosus. Expert Rev Clin Immunol 2024; 20:359-373. [PMID: 38112074 DOI: 10.1080/1744666x.2023.2294938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/08/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Hydroxychloroquine (HCQ) and glucocorticoids (GCs) constitute the oldest and more used drugs in the treatment of systemic lupus erythematosus (SLE). Despite this long experience, both are still subject to a number of uncertainties, mainly regarding the dose. AREAS COVERED We review the main mechanisms of action, the clinical and toxic effects of HCQ and GCs and analyze the recommendations for the use of both in guidelines published since 2018. We offer a set of recommendations based on the pharmacology, mechanisms of action and clinical evidence. EXPERT OPINION HCQ is the backbone therapy for SLE, and a judicious use must be accomplished, using doses that allow a good control of lupus without compromising the safety of treatments very much prolonged over the time. Stable doses of 200 mg/day seem to accomplish both conditions. GCs should be used more judiciously, with methyl-prednisolone pulses as the main therapy for inducing rapid remission and doses ≤5-2.5 mg/day be never exceeded in long-term maintenance treatments.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
| | - Daniel Martin-Iglesias
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
- Department of Medicine, University of the Basque Country, The Basque Country, Spain
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Sobhy N, Ezzat Y, Gamal SM, Ghoniem SA, Nasr SS, Badran S, Soliman A, Fouad NA. Cumulative pulse methylprednisolone and its relation to disease activity, damage and mortality in systemic lupus erythematosus patients: A post hoc analysis of COMOSLE-EGYPT study. Clin Rheumatol 2024; 43:985-992. [PMID: 38198114 PMCID: PMC10876750 DOI: 10.1007/s10067-023-06858-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE To investigate the relation between cumulative intravenous methylprednisolone dose and disease activity, damage, and mortality among a group of Egyptian SLE patients. PATIENTS AND METHODS This is a post hoc analysis of a retrospective multicenter COMOSLE study. Cumulative pulse methylprednisolone dose was abstracted from COMOSLE database. Patients with cumulative pulse dose of ≤ 3.0 g (median dose) were compared to those with cumulative dose of > 3.0 g regarding demographic data, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and The Systemic Lupus International Collaborating Clinics/ACR Damage Index (SLICC) score as well as treatment received. Additionally, at 1.5, 3, 6, and 9 g of cumulative methylprednisolone, patients were compared regarding SLICC score and risk of mortality. RESULTS Patients who received > 3 g of methylprednisolone were statistically significantly younger at disease onset, had longer disease duration, higher SLEDAI score at last visit, and higher SLICC score (p = 003, p = 0.002, p = 0.004 and p = < 0.001, respectively). Additionally, with every gram increase in the cumulative methylprednisolone, there was a significant increase in SLICC score by 0.169 (B = 0.169, CI = 0.122-0.216, p-value = < 0.001) and an increased risk of mortality by 13.5% (hazard ratio (HR) = 1.135, CI = 1.091-1.180, p-value = 0.001). The best cutoff value of methylprednisolone dose at which damage may occur, ranged between 2.75 (with sensitivity of 81.4% and specificity of 33.9%) and 3.25 g (with sensitivity of 48.3% and specificity of 71.5%). CONCLUSION With every gram increase in the cumulative methylprednisolone, there may be increase in damage and mortality, especially in doses exceeding the range of 2.75-3.25 g. Key Points • Treatment of systemic lupus erythematosus should be with the least possible dose of steroids to decrease the risk of damage and mortality. • With every gram increase in the cumulative intravenous methylprednisolone there may be increase in damage and mortality.
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Affiliation(s)
- Nesreen Sobhy
- Rheumatology Department, Cairo University, Cairo, Egypt.
| | - Yasser Ezzat
- Rheumatology Department, Fayoum University, Fayoum, Egypt
| | | | | | - Sarah S Nasr
- Department of Cancer Epidemiology and Biostatistics, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Ahmed Soliman
- Department of Dermatology and Venereology, National Research Center Egypt, Cairo, Egypt
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Paredes-Ruiz D, Ruiz-Irastorza G, Amoura Z. Systemic lupus erythematosus and glucocorticoids: A never-ending story? Best Pract Res Clin Rheumatol 2023; 37:101873. [PMID: 37957076 DOI: 10.1016/j.berh.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 11/15/2023]
Abstract
Glucocorticoids (GCs) continue to be essential agents for the management of systemic lupus erythematosus, since there are no other drugs able to active remission of active disease so rapidly. However, their potential for causing irreversible damage greatly limit their use. Fortunately, some strategies may help take advantage of their huge anti-inflammatory power while limiting GC-induced side effects. This article reviews the pharmacological basis of GC action and their translation into the clinical ground. We also offer the practical approach for the use of GC in induction and maintenance therapy as well as the strategies for GC withdrawal of the respective practice of the authors. The three main basic principles are a) using methyl-prednisolone pulses to induce remission not only in severe disease; b) limiting initial doses of prednisone to ≤30 mg/d, with rapid tapering to ≤5 mg/d, which should be the dose for maintenance therapy; and c) individualizing the decision and the strategy to withdraw GCs. Long-term therapy with HCQ and the early introduction of immunosuppressive treatment would help achieve these objectives.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bizkaia, Spain.
| | - Zahir Amoura
- Sorbonne Université, Faculté de Médecine, Groupement Hospitalier Pitié Salpêtrière, Centre National de Référence du Lupus Systémique, du Syndrome des Antiphospholipides et autres maladies auto-immunes, Service de Médecine Interne 2, Institut E3M, CIMI-Paris, Paris, France
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Katarzyna PB, Wiktor S, Ewa D, Piotr L. Current treatment of systemic lupus erythematosus: a clinician's perspective. Rheumatol Int 2023:10.1007/s00296-023-05306-5. [PMID: 37171669 DOI: 10.1007/s00296-023-05306-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Its variable course makes it difficult to standardize patient treatment. This article aims at a literature review on available drugs for treating SLE and on drugs that have shown therapeutic effects in this disease. The PubMed/MEDLINE electronic search engine was used to identify relevant studies. This review presents the current therapeutic options, new biological therapies, and combination therapies of biologics with standard immunosuppressive and immunomodulating drugs. We have also underlined the importance to implement the treat-to-target strategy aimed at reducing or discontinuing therapy with glucocorticosteroids (GCs). The awareness of the benefits and risks of using GCs helps in refining their dosage and thereby obtaining a better safety profile. The advent of biological targeted therapies, and more recently, low-molecular-weight compounds such as kinase inhibitors, initiated numerous clinical trials in SLE patients and led to the approval of two biological drugs, belimumab, and anifrolumab, for SLE treatment. Progress in the treatment of SLE was reflected in the 2019 and 2021 recommendations of the European Alliance of Associations for Rheumatology (EULAR). However, a mass of recent clinical research data requires continuous consolidation to optimize patient outcomes.
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Affiliation(s)
- Pawlak-Buś Katarzyna
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland.
| | - Schmidt Wiktor
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
- Doctoral School, Poznań University of Medical Sciences, Poznań, Poland
| | - Dudziec Ewa
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Leszczyński Piotr
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
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Wang L, Yang Z, Yu H, Lin W, Wu R, Yang H, Yang K. Predicting diagnostic gene expression profiles associated with immune infiltration in patients with lupus nephritis. Front Immunol 2022; 13:839197. [PMID: 36532018 PMCID: PMC9755505 DOI: 10.3389/fimmu.2022.839197] [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: 12/19/2021] [Accepted: 11/09/2022] [Indexed: 12/03/2022] Open
Abstract
Objective To identify potential diagnostic markers of lupus nephritis (LN) based on bioinformatics and machine learning and to explore the significance of immune cell infiltration in this pathology. Methods Seven LN gene expression datasets were downloaded from the GEO database, and the larger sample size was used as the training group to obtain differential genes (DEGs) between LN and healthy controls, and to perform gene function, disease ontology (DO), and gene set enrichment analyses (GSEA). Two machine learning algorithms, least absolute shrinkage and selection operator (LASSO) and support vector machine-recursive feature elimination (SVM-RFE), were applied to identify candidate biomarkers. The diagnostic value of LN diagnostic gene biomarkers was further evaluated in the area under the ROC curve observed in the validation dataset. CIBERSORT was used to analyze 22 immune cell fractions from LN patients and to analyze their correlation with diagnostic markers. Results Thirty and twenty-one DEGs were screened in kidney tissue and peripheral blood, respectively. Both of which covered macrophages and interferons. The disease enrichment analysis of DEGs in kidney tissues showed that they were mainly involved in immune and renal diseases, and in peripheral blood it was mainly enriched in cardiovascular system, bone marrow, and oral cavity. The machine learning algorithm combined with external dataset validation revealed that C1QA(AUC = 0.741), C1QB(AUC = 0.758), MX1(AUC = 0.865), RORC(AUC = 0.911), CD177(AUC = 0.855), DEFA4(AUC= 0.843)and HERC5(AUC = 0.880) had high diagnostic value and could be used as diagnostic biomarkers of LN. Compared to controls, pathways such as cell adhesion molecule cam, and systemic lupus erythematosus were activated in kidney tissues; cell cycle, cytoplasmic DNA sensing pathways, NOD-like receptor signaling pathways, proteasome, and RIG-1-like receptors were activated in peripheral blood. Immune cell infiltration analysis showed that diagnostic markers in kidney tissue were associated with T cells CD8 and Dendritic cells resting, and in blood were associated with T cells CD4 memory resting, suggesting that CD4 T cells, CD8 T cells and dendritic cells are closely related to the development and progression of LN. Conclusion C1QA, C1QB, MX1, RORC, CD177, DEFA4 and HERC5 could be used as new candidate molecular markers for LN. It may provide new insights into the diagnosis and molecular treatment of LN in the future.
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Affiliation(s)
- Lin Wang
- Nephrology Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhihua Yang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hangxing Yu
- Nephrology Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Wei Lin
- Nephrology Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ruoxi Wu
- Nephrology Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hongtao Yang
- Nephrology Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Kang Yang
- Nephrology Department, The First Affiliated Hospital of Henan University of Chinese Medicine, Henan, China
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Jourde-Chiche N, Costedoat-Chalumeau N, Baumstarck K, Loundou A, Bouillet L, Burtey S, Caudwell V, Chiche L, Couzi L, Daniel L, Deligny C, Dussol B, Faguer S, Gobert P, Gondran G, Huart A, Hummel A, Kalbacher E, Karras A, Lambert M, Le Guern V, Lebourg L, Loubière S, Maillard-Lefebvre H, Maurier F, Pha M, Queyrel V, Remy P, Sarrot-Reynauld F, Verhelst D, Hachulla E, Amoura Z, Daugas E. Weaning of maintenance immunosuppressive therapy in lupus nephritis (WIN-Lupus): results of a multicentre randomised controlled trial. Ann Rheum Dis 2022; 81:1420-1427. [PMID: 35725295 PMCID: PMC9484365 DOI: 10.1136/annrheumdis-2022-222435] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 11/05/2022]
Abstract
Objectives Lupus nephritis (LN) is a frequent complication of systemic lupus erythematosus (SLE). Severe (proliferative) forms of LN are treated with induction immunosuppressive therapy (IST), followed by maintenance IST, to target remission and avoid relapses. The optimal duration of maintenance IST is unknown. The WIN-Lupus trial tested whether IST discontinuation after 2‒3 years was non-inferior to IST continuation for two more years in proliferative LN. Methods WIN-Lupus was an investigator-initiated multicentre randomised controlled trial. Patients receiving maintenance IST with azathioprine or mycophenolate mofetil for 2–3 years, and hydroxychloroquine, were randomised (1:1) into two groups: (1) IST continuation and (2) IST discontinuation. The primary endpoint was the relapse rate of proliferative LN at 24 months. Main secondary endpoints were the rate of severe SLE flares, survival without renal relapse or severe flare, adverse events. Results Between 2011 and 2016, 96 patients (out of 200 planned) were randomised in WIN-Lupus: IST continuation group (n=48), IST discontinuation group (n=48). Relapse of proliferative LN occurred in 5/40 (12.5%) patients with IST continuation and in 12/44 (27.3%) patients with IST discontinuation (difference 14.8% (95% CI −1.9 to 31.5)). Non-inferiority was not demonstrated for relapse rate; time to relapse did not differ between the groups. Severe SLE flares (renal or extrarenal) were less frequent in patients with IST continuation (5/40 vs 14/44 patients; p=0.035). Adverse events did not differ between the groups. Conclusions Non-inferiority of maintenance IST discontinuation after 2‒3 years was not demonstrated for renal relapse. IST discontinuation was associated with a higher risk of severe SLE flares. Trial registration number NCT01284725.
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Affiliation(s)
- Noemie Jourde-Chiche
- Nephrology, AP-HM, Marseille, France .,C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France
| | - Nathalie Costedoat-Chalumeau
- entre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, Universite de Paris, Paris, France.,Centre de référence maladies rares, Hôpital Cochin, AP-HP, Paris, France
| | - Karine Baumstarck
- Laboratoire de Santé Publique, CERESS, Aix-Marseille Universite, Marseille, France
| | - Anderson Loundou
- Laboratoire de Santé Publique, CERESS, Aix-Marseille Universite, Marseille, France
| | - Laurence Bouillet
- Internal Medicine, Centre Hospitalier Universitaire Grenoble, Michallon Hospital, Grenoble, France
| | - Stéphane Burtey
- C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France.,Nephrology, AP-HM, Marseille, France
| | | | | | - Lionel Couzi
- Nephrology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Laurent Daniel
- C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France.,Laboratoire d'Anatomie Pathologique, AP-HM, Marseille, France
| | | | - Bertrand Dussol
- Nephrology, AP-HM, Marseille, France.,Centre d'Investigation Clinique, AP-HM, Marseille, France
| | - Stanislas Faguer
- Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | | | | | - Antoine Huart
- Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | - Aurélie Hummel
- Nephrology, Necker-Enfants Malades Hospitals, Paris, France
| | | | - Adexandre Karras
- Nephrology, Hopital Europeen Georges Pompidou, Paris, France.,Universite Paris Descartes, Paris, France
| | | | | | | | - Sandrine Loubière
- Support Unit for Clinical Research and Health Economics, AP-HM, Marseille, France
| | | | | | - Micheline Pha
- Médecine Interne 2, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | | | | | | | | | - Eric Hachulla
- Internal Medicine, Lille University School of Medicine, Lille, France
| | - Zahir Amoura
- Centre de reference maladies auto-immunes et systemiques, Internal Medicine, AP-HP, Paris, France
| | - Eric Daugas
- Nephrology, AP-HP, Paris, France.,INSERM U1149, Universite de Paris, Paris, France
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Jieduquyuzishen Prescription Attenuates Renal Fibrosis in MRL/lpr Mice via Inhibiting EMT and TGF- β1/Smad2/3 Pathway. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4987323. [PMID: 35591863 PMCID: PMC9113882 DOI: 10.1155/2022/4987323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/03/2021] [Accepted: 03/29/2022] [Indexed: 12/31/2022]
Abstract
Jieduquyuziyin prescription (JP) has been used to treat lupus nephritis (LN) and its effectiveness in the treatment of LN has been clinically proven, but the underlying mechanisms have yet to be completely understood. This aim of this study was to clarify the efficacy of JP on the epithelial-mesenchymal transition (EMT) of renal tubular epithelial cells and the molecular mechanisms of JP in MRL/lpr mice. In vivo, we observed the therapeutic actions of JP in MRL/lpr mice as well as its antifibrosis effect and potential mechanism. In vitro, we evaluated the role of JP in EMT and its possible mechanism through the EMT of human renal proximal tubular epithelial cells (HK-2) induced by transforming growth factor-beta 1 (TGF-β1) and M2c macrophages. HK-2 cells were treated with JP-treated serum, and MRL/lpr mice were treated by JP for 8 weeks. The results showed that JP alleviated disease activity, improved renal function, decreased proteinuria, and improved renal injury and fibrosis in MRL/lpr mice. Furthermore, JP suppressed the activation of the TGF-β1/Smad2/3 signaling pathway, upregulated the E-cadherin levels, and downregulated the Vimentin and mesenchymal α-smooth muscle actin (α-SMA) levels in the kidney of MRL/lpr mice. JP was further found to prevent the TGF-β1 and M2c macrophages-induced EMT of HK-2 cells. Collectively, JP could alleviate the disease activity of MRL/lpr mice, improve renal function, and attenuate renal fibrosis, and its underlying mechanisms may be related to the inhibition of EMT and TGF-β1/Smad2/3 signaling pathway.
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Porta SV, Ugarte-Gil MF, García-de la Torre I, Bonfá E, Gómez-Puerta JA, Arnaud L, Cardiel MH, Alarcón GS, Pons-Estel BA, Pons-Estel G. Controversies in Systemic Lupus Erythematosus: Are We Treating Our Patients Adequately? J Clin Rheumatol 2022; 28:e651-e658. [PMID: 34897194 DOI: 10.1097/rhu.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is characterized by great clinical heterogeneity. The objectives of its management are to make a timely diagnosis and to initiate treatment as promptly as possible so organ damage can be avoided while at the same time exposure to potentially toxic drugs is minimized so that its overall course and outcome improve. In reviewing the current literature, it became quite clear that there are specific topics in which controversies do exist. These include how to treat patients with incomplete lupus erythematosus, the real possibility of abandoning altogether the use of oral glucocorticoids, and the pros and cons of the use of cyclophosphamide and mycophenolate mofetil for the induction treatment of lupus nephritis. Herein we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the PANLAR Virtual Congress (Pan American League of Associations for Rheumatology) and that was organized by the PANLAR Lupus study group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on September 19, 2020.
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Affiliation(s)
- Sabrina Valeria Porta
- From the Rheumatology Department, J. M. Ramos Mejía Hospital, Buenos Aires, Argentina
| | - Manuel F Ugarte-Gil
- Universidad Científica del Sur, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Ignacio García-de la Torre
- Department of Immunology and Rheumatology, Hospital General de Occidente de la Secretaría de Salud, Universidad de Guadalajara, Guadalajara, México
| | - Eloísa Bonfá
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, National Reference Center for Rare Auto-immune and Systemic Diseases (CRMR RESO); Strasbourg, France
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia, SC, Morelia, Mich, México
| | - Graciela S Alarcón
- Division of Rheumatology and Clinical Immunology, The University of Alabama at Birmingham, Birmingham, AL; Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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Bankole AA, Nwaonu JN. The Shifting Landscape of Lupus Nephritis Management: A Review. Cureus 2022; 14:e20950. [PMID: 35154930 PMCID: PMC8815326 DOI: 10.7759/cureus.20950] [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] [Accepted: 01/05/2022] [Indexed: 11/09/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is commonly the first autoimmune disease that comes to mind for most people when rheumatology is mentioned. It remains an enigma that many of us, including patients and healthcare providers, do not fully understand. Although an ancient disease, it still remains difficult to both diagnose and treat. Historically, there has always been a paucity of therapeutic interventions for SLE as a whole. One of the most distressing manifestations for the patient and diagnostic and therapeutically challenging aspects of SLE is lupus nephritis (LN). There has historically been some difficultly in the development of LN drugs that provide significant therapeutic benefits while having an acceptable side-effect profile. This difficulty led to decades in which no drugs were approved for LN. With a better understanding of the pathogenesis of SLE and LN and improvement in trial design, great therapeutic strides have recently been made. The immunosuppressive landscape of LN has changed recently with the approval of two newer agents as well as a number of promising trials in LN. With the increased number of therapeutic agents (both immunosuppressive and non-immunosuppressive), the clinical question is how and when to use these medications, and, more importantly, which agents to use first. With the increased number of agents, the answers to these questions are becoming more difficult to answer. The purpose of the paper is to review updates in LN diagnosis and management.
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Alamilla-Sanchez ME, Alcala-Salgado MA, Alonso-Bello CD, Fonseca-Gonzalez GT. Mechanism of Action and Efficacy of Immunosupressors in Lupus Nephritis. Int J Nephrol Renovasc Dis 2021; 14:441-458. [PMID: 34924767 PMCID: PMC8675090 DOI: 10.2147/ijnrd.s335371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Approximately 70% of the patients with systemic lupus erythematosus will have clinical evidence of kidney damage during their evolution. Patients with impaired renal function at onset and those with recurrent flares have a poor prognosis. Understanding the mechanism of action of immunosuppressants is essential for proper prescription. Steroids inhibit the DNA sequence that promotes the release of inflammatory cytokines. Phosphoramide mustard, metabolite of cyclophosphamide, cross-link with the DNA, causing the aggregation of an alkyl group, causing cell death. Mycophenolate inhibits inosine monophosphate dehydrogenase, prevents de novo synthesis of guanine, inducing cell arrest in S phase. Azathioprine blocks the synthesis of purines and induces apoptosis. Calcineurin inhibitors prevent the dephosphorylation of NFAT and reduce the production of interleukin 2. Antimalarials alter the enzymatic release of lysosomes by increasing intravesicular pH. The mechanism of action of rituximab is related to complement-dependent cytotoxicity and the elimination of anti-CD20-labeled B cells. Progress in the knowledge and management of low doses of steroids may change the current paradigm and reduce the frequency of related adverse events. Mycophenolate seems to be a better choice than cyclophosphamide for induction, it is also preferred over azathioprine as a maintenance immunosuppressive agent, although azathioprine is preferred in women with a desire for conception, those pregnant, or with low resources. For treatment-resistant cases, tacrolimus, rituximab or belimumab may be effective. Ongoing clinical trials with new drugs offer promising results.
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Affiliation(s)
| | | | - Cesar D Alonso-Bello
- Department of Immunology, Centro Medico Nacional "20 de Noviembre", Mexico City, Mexico
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12
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Tamirou F, Houssiau FA. Management of Lupus Nephritis. J Clin Med 2021; 10:jcm10040670. [PMID: 33572385 PMCID: PMC7916202 DOI: 10.3390/jcm10040670] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/24/2022] Open
Abstract
Lupus nephritis (LN) is a frequent and severe manifestation of systemic lupus erythematosus. The main goal of the management of LN is to avoid chronic kidney disease (CKD). Current treatment strategies remain unsatisfactory in terms of complete renal response, prevention of relapses, CKD, and progression to end-stage kidney disease. To improve the prognosis of LN, recent data suggest that we should (i) modify our treat-to-target approach by including, in addition to a clinical target, a pathological target and (ii) switch from conventional sequential therapy to combination therapy. Here, we also review the results of recent controlled randomized trials.
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Gohari A, Matsell DG, Mammen C, Goldman RD. Henoch-Schönlein purpura in children: Use of corticosteroids for prevention and treatment of renal disease. CANADIAN FAMILY PHYSICIAN 2020; 66:895-897. [PMID: 33334956 DOI: 10.46747/cfp.6612895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
QUESTION A few patients have previously presented to my clinic with palpable purpura, joint inflammation, and severe abdominal pain characteristic of Henoch-Schönlein purpura (HSP). Considering that renal injury is the primary long-term complication of HSP, are corticosteroids effective in preventing or treating renal disease in children with HSP? ANSWER Henoch-Schönlein purpura is self-limiting in 94% of children, but permanent renal injury is reported in one-fifth of children with nephritic or nephrotic features. Corticosteroids have been considered as candidates for preventing and treating renal involvement in HSP. There is a moderate level of evidence to suggest corticosteroids are not effective in preventing renal involvement in HSP. However, based on low-level evidence and similarities with primary immunoglobulin A nephropathy, experts recommend corticosteroids in treating renal involvement in HSP to prevent long-term kidney injury. Dose and duration of therapy should be carefully considered in consultation with a pediatric nephrologist.
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Gasparotto M, Gatto M, Binda V, Doria A, Moroni G. Lupus nephritis: clinical presentations and outcomes in the 21st century. Rheumatology (Oxford) 2020; 59:v39-v51. [PMID: 33280015 PMCID: PMC7751166 DOI: 10.1093/rheumatology/keaa381] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/28/2020] [Indexed: 01/17/2023] Open
Abstract
Lupus nephritis (LN) is a frequent and severe manifestation of SLE. Along the decades, the epidemiology of LN and its clinical presentation have been changing. However, even though retrospective cohort studies report a decreased mortality rate and an improvement in the disease prognosis, the percentage of patients progressing into end stage renal disease (ESRD) keeps steady despite the improvements in therapeutic strategies. Current in-use medications have been available for decades now, yet over the years, regimens for optimizing their efficacy and minimizing toxicity have been developed. Therapeutic research is now moving towards the direction of precision medicine and several new drugs, targeting selectively different pathogenetic pathways, are currently under evaluation with promising results. In this review, we address the main changes and persistent unmet needs in LN management throughout the past decades, with a focus on prognosis and upcoming treatments.
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Affiliation(s)
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Valentina Binda
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Khan F, Granville N, Malkani R, Chathampally Y. Health-Related Quality of Life Improvements in Systemic Lupus Erythematosus Derived from a Digital Therapeutic Plus Tele-Health Coaching Intervention: Randomized Controlled Pilot Trial. J Med Internet Res 2020; 22:e23868. [PMID: 33079070 PMCID: PMC7609202 DOI: 10.2196/23868] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE), a systemic autoimmune disease with no known cure, remains poorly understood and patients suffer from many gaps in care. Recent work has suggested that dietary and other lifestyle factors play an important role in triggering and propagating SLE in some susceptible individuals. However, the magnitude of influence of these triggers, how to identify pertinent triggers in individual patients, and whether removing these triggers confers clinical benefit is unknown. OBJECTIVE To demonstrate that a digital therapeutic intervention, utilizing a mobile app that allows self-tracking of dietary, environmental, and lifestyle triggers, paired with telehealth coaching, added to usual care, improves quality of life in patients with SLE compared with usual care alone. METHODS In this randomized controlled pilot study, adults with SLE were assigned to a 16-week digital therapeutic intervention plus usual care or usual care alone. Primary outcome measures were changes from baseline to 16 weeks on 3 validated health-related quality of life (HRQoL) tools: Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Brief Pain Inventory-Short Form (BPI-SF), and Lupus Quality of Life (LupusQoL). RESULTS A total of 50 patients were randomized (23 control, 27 intervention). In per-protocol analysis, the intervention group achieved significantly greater improvement than the control group in 9 of 11 domains: FACIT-F (34% absolute improvement for the intervention group vs -1% for the control group, P<.001), BPI-SF-Pain Interference (25% vs 0%, P=.02), LupusQoL-Planning (17% vs 0%, P=.004), LupusQoL-Pain (13% vs 0%, P=.004), LupusQoL-Emotional Health (21% vs 4%, P=.02), and LupusQoL-Fatigue (38% vs 13%, P<.001) were significant when controlling for multiple comparisons; BPI-SF-Pain Severity (13% vs -6%, P=.049), LupusQoL-Physical Health (17% vs 3%, P=.049), and LupusQoL-Burden to Others (33% vs 4%, P=.04) were significant at an unadjusted 5% significance level. CONCLUSIONS A digital therapeutic intervention that pairs self-tracking with telehealth coaching to identify and remove dietary, environmental, and lifestyle symptom triggers resulted in statistically significant, clinically meaningful improvements in HRQoL when added to usual care in patients with SLE. TRIAL REGISTRATION ClinicalTrials.gov NCT03426384; https://clinicaltrials.gov/ct2/show/NCT03426384.
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Affiliation(s)
- Faiz Khan
- EVP, CityMD, Dix Hills, NY, United States
| | | | - Raja Malkani
- Independent Researcher, Austin, TX, United States
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Ramanujam M, Steffgen J, Visvanathan S, Mohan C, Fine JS, Putterman C. Phoenix from the flames: Rediscovering the role of the CD40-CD40L pathway in systemic lupus erythematosus and lupus nephritis. Autoimmun Rev 2020; 19:102668. [PMID: 32942031 DOI: 10.1016/j.autrev.2020.102668] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/15/2020] [Indexed: 12/11/2022]
Abstract
Lupus nephritis (LN) is a significant complication of systemic lupus erythematosus (SLE), increasing its morbidity and mortality. Although the current standard of care helps suppress disease activity, it is associated with toxicity and ultimately does not cure SLE. At present, there are no therapies specifically indicated for the treatment of LN and there is an unmet need in this disease where treatment remains a challenge. The CD40-CD40L pathway is central to SLE pathogenesis and the generation of autoantibodies and their deposition in the kidneys, resulting in renal injury in patients with LN. CD40 is expressed on immune cells (including B cells, monocytes and dendritic cells) and also non-haematopoietic cells. Interactions between CD40L on T cells and CD40 on B cells in the renal interstitium are critical for the local expansion of naive B cells and autoantibody-producing B cells in LN. CD40L-mediated activation of myeloid cells and resident kidney cells, including endothelial cells, proximal tubular epithelial cells, podocytes and mesangial cells, further amplifies the inflammatory milieu in the interstitium and the glomeruli. Several studies have highlighted the upregulated expression of CD40 in LN kidney biopsies, and preclinical data have demonstrated the importance of the CD40-CD40L pathway in murine SLE and LN. Blocking this pathway is expected to ameliorate inflammation driven by infiltrating immune cells and resident kidney cells. Initial experimental therapeutic interventions targeting the CD40-CD40L pathway, based on CD40L antibodies, were associated with an increased incidence of thrombosis. However, this safety issue has not been observed with second-generation CD40/CD40L antibodies that have been engineered to prevent platelet activation. With these advancements, together with recent preclinical and clinical findings, it is anticipated that selective blockade of the CD40-CD40L pathway may address the unmet treatment needs in SLE, LN and other autoimmune diseases.
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Affiliation(s)
- Meera Ramanujam
- Immunology & Respiratory Diseases Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA; Institute of Infection, Immunity and Inflammation, University of Glasgow, UK.
| | - Jürgen Steffgen
- TA Inflammation Medicine, Boehringer Ingelheim, International GmbH, Biberach, Germany; Department of Nephrology and Rheumatology, Georg-August University of Göttingen, Göttingen, Germany
| | - Sudha Visvanathan
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Jay S Fine
- Immunology & Respiratory Diseases Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Chaim Putterman
- Albert Einstein College of Medicine, Bronx, NY, USA; Azrieli School of Medicine, Bar-Ilan Universtiy, Zefat, Israel; Research Institute, Galilee Medical Center, Nahariya, Israel.
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Porta S, Danza A, Arias Saavedra M, Carlomagno A, Goizueta MC, Vivero F, Ruiz-Irastorza G. Glucocorticoids in Systemic Lupus Erythematosus. Ten Questions and Some Issues. J Clin Med 2020; 9:jcm9092709. [PMID: 32839376 PMCID: PMC7563630 DOI: 10.3390/jcm9092709] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 12/16/2022] Open
Abstract
Since the discovery of glucocorticoids (GCs), their important anti-inflammatory effect, rapid mechanism of action, low cost, and accessibility have made them one of the mainstays of treatment for Systemic lupus erythematosus (SLE). Although their use has allowed controlling the disease and reducing acute mortality in severe conditions, the implementation of a scheme based on high doses for long periods has inevitably been accompanied by an increase in adverse effects and infections, including long-term damage. The objective of this review is to answer some important questions that may arise from its use in daily clinical practice, and to propose a paradigm based on the use of methylprednisolone pulses followed by medium-low doses and a rapid decrease of prednisone.
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Affiliation(s)
- Sabrina Porta
- Rheumatology Department, Hospital JM Ramos Mejía, Buenos Aires 1221, Argentina; (S.P.); (M.A.S.)
| | - Alvaro Danza
- Department of Internal Medicine, Faculty of Medicine, Universidad de la República, Montevideo 11000, Uruguay; (A.D.); (A.C.)
| | - Maira Arias Saavedra
- Rheumatology Department, Hospital JM Ramos Mejía, Buenos Aires 1221, Argentina; (S.P.); (M.A.S.)
| | - Adriana Carlomagno
- Department of Internal Medicine, Faculty of Medicine, Universidad de la República, Montevideo 11000, Uruguay; (A.D.); (A.C.)
| | | | - Florencia Vivero
- Autoimmune Disease Unit, Hospital Privado de Comunidad, Mar del Plata B7600, Argentina;
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, BioCruces Bizkaia Health Research Institute, Cruces Univeristy Hospital, 48903 Bizkaia, Spain
- University of the Basque Country, 48940 Leioa, Spain
- Correspondence:
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Ruiz-Irastorza G, Ugarte A, Ruiz-Arruza I, Khamashta M. Seventy years after Hench’s Nobel prize: revisiting the use of glucocorticoids in systemic lupus erythematosus. Lupus 2020; 29:1155-1167. [DOI: 10.1177/0961203320930099] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 1950, Hench, Kendall and Reichstein were awarded with the Nobel Prize in Physiology and Medicine for the isolation and first therapeutic use of glucocorticoids. Since then, they have become one of the main agents in the treatment of systemic lupus erythematosus (SLE). The use of high-dose oral glucocorticoids (usually 1 mg/kg/day of prednisone equivalent) have become the rule for treating moderate to severe lupus activity. In addition, tapering schemes have not been well defined, all this leading to prolonged exposures to potentially damaging amounts of glucocorticoids. Several studies have shown that glucocorticoids are a major cause of toxicity in SLE in a dose-dependent manner, with prolonged doses greater than 7.5 mg/day being associated with damage accrual. Thus, there is an urgent need for different therapeutic schedules that can achieve a rapid and durable control of lupus activity while reducing the many unwanted effects of glucocorticoids. Recent data show that pulses of methyl-prednisolone are an effective first-line therapy to treat lupus flares (not only severe ones) without major short or long-term toxicity and allowing a reduction in oral prednisone doses. Universal use of hydroxychloroquine – always recommended, infrequently accomplished – and early therapy with immunosuppressive drugs also help control SLE and reduce prednisone load. Results from observational studies confirm the more rapid achievement of remission and the reduction of long-term damage using these combination schedules with reduced prednisone doses. Seventy years after their first therapeutic use, we are learning to use glucocorticoids in a more efficient and safe manner.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Hospital Universitario Cruces, BioCruces Bizkaia Health Research Institute, University of the Basque Country, Spain
| | - Amaia Ugarte
- Hospital Universitario Cruces, BioCruces Bizkaia Health Research Institute, University of the Basque Country, Spain
| | - Ioana Ruiz-Arruza
- Hospital Universitario Cruces, BioCruces Bizkaia Health Research Institute, University of the Basque Country, Spain
| | - Munther Khamashta
- Department of Women and Children’s Health, St Thomas Hospital, London
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Kim S, Reen Ooi AY, Stephens T, Jiang H. Cost-effectiveness of tacrolimus for the treatment of moderate-to-severe lupus nephritis in China. J Comp Eff Res 2019; 8:1125-1141. [PMID: 31580156 DOI: 10.2217/cer-2018-0111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Aim: Therapy for lupus nephritis (LN) requires treatment with immunosuppressive regimens, often including intravenous cyclophosphamide (IVCY), mycophenolate mofetil (MMF) or azathioprine. Additionally, tacrolimus (original form or generic) is recommended to treat LN patients in Asia, including China. However, the cost-effectiveness of tacrolimus therapy has not previously been assessed. We aimed to estimate the cost-effectiveness of tacrolimus in the treatment of moderate-to-severe LN versus standard therapies in China. Materials & methods: This cost-effectiveness model combined a decision-tree/Markov-model structure to map transitions between health states during induction and maintenance treatment phases. Induction with tacrolimus, IVCY or MMF, was followed by tacrolimus, MMF or azathioprine maintenance. Results: According to the model, during induction, complete remission rates were higher with tacrolimus versus IVCY (relative risk 1.40 vs IVCY [deterministic sensitivity analysis minimum 0.92, maximum 2.13]) and time to response was shorter. Relapse rates were lower with tacrolimus versus azathioprine or MMF during maintenance. Tacrolimus induction and maintenance was the most cost-effective regimen, incurring the lowest total costs (CN¥180,448) with the highest quality-adjusted life-years. Conclusion: The model demonstrated that tacrolimus use in both induction and maintenance therapy may be an efficacious and cost-effective treatment for LN in China.
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Affiliation(s)
- Soyoung Kim
- Astellas Pharma Singapore Pte. Ltd, Singapore
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20
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IL233, an IL-2-IL-33 hybrid cytokine induces prolonged remission of mouse lupus nephritis by targeting Treg cells as a single therapeutic agent. J Autoimmun 2019; 102:133-141. [PMID: 31103267 DOI: 10.1016/j.jaut.2019.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/01/2019] [Accepted: 05/04/2019] [Indexed: 12/29/2022]
Abstract
Lupus glomerulonephritis (GN) is an autoimmune disease characterized by immune complex-deposition, complement activation and glomerular inflammation. In lupus-prone NZM2328 mice, the occurrence of lupus GN was accompanied by a decrease in Treg cells and an increase in proinflammatory cytokine-producing T cells. Because IL-33 in addition to IL-2 has been shown to be important for Treg cell proliferation and ST2 (IL-33 receptor) positive Treg cells are more potent in suppressor activity, a hybrid cytokine with active domains of IL-2 and IL-33 was generated to target the ST2+ Treg cells as a therapeutic agent to treat lupus GN. Three mouse models were used: spontaneous and Ad-IFNα- accelerated lupus GN in NZM2328 and the lymphoproliferative autoimmune GN in MRL/lpr mice. Daily injections of IL233 for 5 days prevented Ad-IFNα-induced lupus GN and induced remission of spontaneous lupus GN. The remission was permanent in that no relapses were detected. The remission was accompanied by persistent elevation of Treg cells in the renal lymph nodes. IL233 is more potent than IL-2 and IL-33 either singly or in combination in the treatment of lupus GN. The results of this study support the thesis that IL233 should be considered as a novel agent for treating lupus GN.
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Dall’Era M, Solomons N, Federico R, Truman M. Comparison of standard of care treatment with a low steroid and mycophenolate mofetil regimen for lupus nephritis in the ALMS and AURA studies. Lupus 2019; 28:591-596. [DOI: 10.1177/0961203319842924] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Lupus nephritis is the most common organ-threatening manifestation of systemic lupus erythematosus. The current standard of care for patients is treatment with a combination of steroids plus either mycophenolate mofetil (MMF) or cyclophosphamide. However, these medications are associated with considerable toxicity and suboptimal efficacy. This retrospective propensity analysis of data from 63 matched patients enrolled in two of the largest active lupus nephritis controlled trials, ALMS and AURA, suggests that the high dose regimen of MMF and steroids as described in the 2012 American College of Rheumatology lupus nephritis guidelines may not be necessary in all lupus nephritis patients. A lower dose regimen may result in better long-term safety, including a reduction in lymphoproliferative disorders, skin cancers and steroid related side effects, without compromising efficacy. An ongoing randomized controlled double-blind phase 3 study, AURORA (NCT03021499), is investigating renal response in 358 patients randomized to receive a low dose regimen containing voclosporin, MMF and steroid therapy as used in the AURA trial. It is anticipated that the AURORA study and its blinded two-year extension will provide important long-term outcome data.
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Affiliation(s)
- M Dall’Era
- University of California, San Francisco, USA
| | - N Solomons
- Aurinia Pharmaceuticals, Inc., Victoria, Canada
| | - R Federico
- Aurinia Pharmaceuticals, Inc., Victoria, Canada
| | - M Truman
- Aurinia Pharmaceuticals, Inc., Victoria, Canada
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22
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Schaier M, Gottschalk C, Uhlmann L, Speer C, Kälble F, Eckstein V, Müller-Tidow C, Meuer S, Mahnke K, Lorenz HM, Zeier M, Steinborn A. Immunosuppressive therapy influences the accelerated age-dependent T-helper cell differentiation in systemic lupus erythematosus remission patients. Arthritis Res Ther 2018; 20:278. [PMID: 30563559 PMCID: PMC6299578 DOI: 10.1186/s13075-018-1778-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/26/2018] [Indexed: 12/16/2022] Open
Abstract
Background CD4+ T cells are of great importance in the pathogenesis of systemic lupus erythematosus (SLE), as an imbalance between CD4+ regulatory T cells (Tregs) and CD4+ responder T cells (Tresps) causes flares of active disease in SLE patients. In this study, we aimed to find the role of aberrant Treg/Tresp cell differentiation for maintaining Treg/Tresp cell balance and Treg functionality. Methods To determine differences in the differentiation of Tregs/Tresps we calculated the percentages of CD45RA+CD31+ recent thymic emigrant (RTE) Tregs/Tresps and CD45RA+CD31− mature naive (MN) Tregs/Tresps, as well as CD45RA−CD31+ and CD45RA−CD31− memory Tregs/Tresps (CD31+ and CD31− memory Tregs/Tresps) within the total Treg/Tresp pool of 78 SLE remission patients compared with 94 healthy controls of different ages. The proliferation capacity of each Treg/Tresp subset was determined by staining the cells with anti-Ki67 monoclonal antibodies. Differences in the autologous or allogeneic Treg function between SLE remission patients and healthy controls were determined using suppression assays. Results With age, we found an increased differentiation of RTE Tregs via CD31+ memory Tregs and of RTE Tresps via MN Tresps into CD31− memory Tregs/Tresp in healthy volunteers. This opposite differentiation of RTE Tregs and Tresps was associated with an age-dependent increase in the suppressive activity of both naive and memory Tregs. SLE patients showed similar age-dependent Treg cell differentiation. However, in these patients RTE Tresps differentiated increasingly via CD31+ memory Tresps, whereby CD31− memory Tresps arose that were much more difficult to inhibit for Tregs than those that emerged through differentiation via MN Tresps. Consequently, the increase in the suppressive activity of Tregs with age could not be maintained in SLE patients. Testing the Tregs of healthy volunteers and SLE patients with autologous and nonautologous Tresps revealed that the significantly decreased Treg function in SLE patients was not exclusively attributed to an age-dependent diminished sensitivity of the Tresps for Treg suppression. The immunosuppressive therapy reduced the accelerated age-dependent Tresp cell proliferation to normal levels, but simultaneously inhibited Treg cell proliferation below normal levels. Conclusions Our data reveal that the currently used immunosuppressive therapy has a favorable effect on the differentiation and proliferation of Tresps but has a rather unfavorable effect on the proliferation of Tregs. Newer substances with more specific effects on the immune system would be desirable. Electronic supplementary material The online version of this article (10.1186/s13075-018-1778-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Schaier
- Department of Medicine I (Nephrology), University of Heidelberg, Heidelberg, Germany
| | - Claudius Gottschalk
- Department of Obstetrics and Gynaecology, University of Heidelberg, Research Cooperation Unit Gynaecology/Nephrology, INF 162, 69120, Heidelberg, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Claudius Speer
- Department of Medicine I (Nephrology), University of Heidelberg, Heidelberg, Germany
| | - Florian Kälble
- Department of Medicine I (Nephrology), University of Heidelberg, Heidelberg, Germany
| | - Volker Eckstein
- Department of Medicine V (Haematology, Rheumatology), University of Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Medicine V (Haematology, Rheumatology), University of Heidelberg, Heidelberg, Germany
| | - Stefan Meuer
- Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | - Karsten Mahnke
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Medicine V (Haematology, Rheumatology), University of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Medicine I (Nephrology), University of Heidelberg, Heidelberg, Germany
| | - Andrea Steinborn
- Department of Obstetrics and Gynaecology, University of Heidelberg, Research Cooperation Unit Gynaecology/Nephrology, INF 162, 69120, Heidelberg, Germany.
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Gatto M, Zen M, Iaccarino L, Doria A. New therapeutic strategies in systemic lupus erythematosus management. Nat Rev Rheumatol 2018; 15:30-48. [DOI: 10.1038/s41584-018-0133-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Liu P, Tan HZ, Li H, Choo JCJ, Lim CC. Infection mitigation a necessity in lupus patients. Clin Rheumatol 2018; 38:261-262. [PMID: 30349984 DOI: 10.1007/s10067-018-4346-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 10/14/2018] [Accepted: 10/17/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Peiyun Liu
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore.
| | - Hui Zhuan Tan
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Huihua Li
- Health Services Research Unit, Singapore General Hospital, 226 Outram Road, Blk A, Level 4, Singapore, 169039, Singapore
| | - Jason Chon Jun Choo
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Cynthia Ciwei Lim
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
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Enriquez Merayo E, Sciascia S, Roccatello D, Cuadrado MJ. Can we treat systemic lupus erythematosus and other autoimmune diseases without oral steroids? Expert Rev Clin Immunol 2018; 14:877-879. [DOI: 10.1080/1744666x.2018.1527219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- SCU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- SCU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Maria J. Cuadrado
- Rheumatology Department, Clinica Universidad de Navarra, Madrid, Spain
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Pham GS, Mathis KW. Lipopolysaccharide Challenge Reveals Hypothalamic-Pituitary-Adrenal Axis Dysfunction in Murine Systemic Lupus Erythematosus. Brain Sci 2018; 8:E184. [PMID: 30287776 PMCID: PMC6211064 DOI: 10.3390/brainsci8100184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 01/04/2023] Open
Abstract
Crosstalk between the brain and innate immune system may be dysregulated in systemic lupus erythematosus (SLE), a chronic autoimmune disease that presents with dysautonomia and aberrant inflammation. The hypothalamic-pituitary-adrenal (HPA) axis is an endogenous neuro-endocrine-immune pathway that can regulate inflammation following activation of vagal afferents. We hypothesized that chronic inflammatory processes in SLE are in part due to HPA axis dysfunction, at the level of either the afferent vagal-paraventricular nuclei (PVN) interface, the anterior pituitary, and/or at the adrenal glands. To study this, we challenged female control and SLE mice with lipopolysaccharide (LPS) and measured c-Fos expression as an index of neuronal activation, plasma adrenocorticotrophic hormone (ACTH) as an index of anterior pituitary function, and plasma corticosterone as an index of adrenal function. We found that c-Fos expression in the PVN, and plasma ACTH and corticosterone were comparable between unchallenged SLE and control mice. PVN c-Fos was increased similarly in control and SLE mice three hours after LPS challenge; however, there were no changes in plasma ACTH amongst any experimental groups post inflammatory challenge. Plasma corticosterone was markedly increased in LPS-challenged SLE mice compared to their vehicle-treated counterparts, but not in controls. Paradoxically, following LPS challenge, brain and spleen TNF-α were elevated in LPS-challenged SLE mice despite heightened plasma corticosterone. This suggests that, despite normal c-Fos expression in the PVN and activation of the HPA axis following LPS challenge, this cumulative response may not adequately defend SLE mice against inflammatory stimuli, leading to abnormally heightened innate immune responses and peripheral inflammation.
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Affiliation(s)
- Grace S Pham
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107, USA.
| | - Keisa W Mathis
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107, USA.
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Glucocorticoids and antimalarials in systemic lupus erythematosus: an update and future directions. Curr Opin Rheumatol 2018; 30:482-489. [DOI: 10.1097/bor.0000000000000527] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Doria A, Gatto M, Iaccarino L, Sarzi-Puttini P. Controversies in Rheumatology and Autoimmunity: Approaching the truth by the discussion. Clin Exp Rheumatol 2018; 17:1-3. [DOI: 10.1016/j.autrev.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
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