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Drygiannakis I, Valatas V, Filidou E, Tzenaki N, Archontoulaki E, Dovrolis N, Kandilogiannakis L, Kefalogiannis G, Sidiropoulos P, Kolios G, Koutroubakis IE. Low-Grade Activation of the Extrinsic Coagulation Pathway in Patients with Ulcerative Colitis. Dig Dis Sci 2024; 69:3773-3785. [PMID: 39322807 DOI: 10.1007/s10620-024-08640-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 09/06/2024] [Indexed: 09/27/2024]
Abstract
BACKGROUND Ulcerative colitis (UC) increases the risk for venous thromboembolism. Tissue factor (TF) initiates the extrinsic coagulation pathway (ECP). AIMS To investigate the correlation of UC severity with latent ECP activation and TF expression in primary colonic stromal cells (PCSC). METHODS In plasma of 38 UC patients (31 males, disease duration 151 ± 25 months) and 28 healthy controls, exosomes and microparticles (EM) were counted. Moreover, TF protein concentration, activities of EM-bound TF (EM-TFa) and coagulation factor VII (FVIIa) were assessed. In PCSC in culture, TF mRNA (F3) from 12 patients with active UC and 7 controls was evaluated. RESULTS UC patients had 4- and 3.7- times more exosomes and microparticles, respectively, than controls. TF protein in UC was correlated with several disease severity indices, such as partial Mayo score (pMs; r 0.443), albumin (- 0.362), ESR (0.353), PLT (0.575), and endoscopic Ms (eMs 0.468). EM-TFa was also significantly higher in UC and was correlated to SIBDQ (- 0.64), albumin (- 0.624), disease extent and eMs (0.422). Refractory-to-treatment patients had significantly higher TF protein, EM-TFa and FVIIa. Even within responders, the need for steroids or biologics correlated with a 2.2-times higher EM-TFa. PCSC from active UC maintained higher F3 than controls, which was correlated to pMs (0.56), albumin (- 0.543) and eMs. Treatment with cytokines further upregulated F3. P for all comparisons was < 0.05. CONCLUSION Low-grade activation of the ECP associates with clinical, endoscopic UC activity and response to treatment. TF in PCSC mirrors its systemic activity and points to them as a source.
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Affiliation(s)
- Ioannis Drygiannakis
- Gastroenterology Research Laboratory, School of Medicine, University of Crete, 71500, Heraklion, Crete, Greece
- Department of Gastroenterology, University Hospital, P.O. BOX 1352, 71110, Heraklion, Crete, Greece
| | - Vassilis Valatas
- Gastroenterology Research Laboratory, School of Medicine, University of Crete, 71500, Heraklion, Crete, Greece
- Department of Gastroenterology, University Hospital, P.O. BOX 1352, 71110, Heraklion, Crete, Greece
| | - Eirini Filidou
- Laboratory of Pharmacology, Department of Medicine, Democritus University of Thrace, 68100, Alexandroupolis, Greece
| | - Niki Tzenaki
- Gastroenterology Research Laboratory, School of Medicine, University of Crete, 71500, Heraklion, Crete, Greece
| | - Evangelia Archontoulaki
- Gastroenterology Research Laboratory, School of Medicine, University of Crete, 71500, Heraklion, Crete, Greece
| | - Nikolas Dovrolis
- Laboratory of Pharmacology, Department of Medicine, Democritus University of Thrace, 68100, Alexandroupolis, Greece
| | - Leonidas Kandilogiannakis
- Laboratory of Pharmacology, Department of Medicine, Democritus University of Thrace, 68100, Alexandroupolis, Greece
| | | | - Prodromos Sidiropoulos
- Laboratory of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of Crete, 71500, Heraklion, Crete, Greece
| | - George Kolios
- Laboratory of Pharmacology, Department of Medicine, Democritus University of Thrace, 68100, Alexandroupolis, Greece
| | - Ioannis E Koutroubakis
- Gastroenterology Research Laboratory, School of Medicine, University of Crete, 71500, Heraklion, Crete, Greece.
- Department of Gastroenterology, University Hospital, P.O. BOX 1352, 71110, Heraklion, Crete, Greece.
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2
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Prendecki M, Gurung A, Pisacano N, Pusey CD. The role of neutrophils in ANCA-associated vasculitis. Immunol Lett 2024; 270:106933. [PMID: 39362307 DOI: 10.1016/j.imlet.2024.106933] [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: 07/24/2024] [Revised: 09/23/2024] [Accepted: 09/30/2024] [Indexed: 10/05/2024]
Abstract
Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) is a group of rare systemic autoimmune diseases characterised by necrotising inflammation of small blood vessels and usually associated with circulating ANCA. The pathophysiology of AAV is complex, involving many aspects of the innate and adaptive immune system. Neutrophils are central to the pathogenesis of AAV as they are both the target of the autoantibody and effector cells mediating vascular injury. We describe mechanisms for ANCA induced activation of neutrophils, the pathogenic mechanisms by which this leads to endothelial cell injury, and how neutrophil crosstalk modulates other aspects of the immune system in AAV.
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Affiliation(s)
- Maria Prendecki
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdom.
| | - Angila Gurung
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdom
| | - Noelle Pisacano
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdom
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdom
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3
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Poulton JS, Lamba S, Free M, Xi G, McInnis E, Williams G, Kudlacek ST, Thieker D, Kuhlman B, Falk R. High-resolution epitope mapping of commercial antibodies to ANCA antigens by yeast surface display. J Immunol Methods 2024; 528:113654. [PMID: 38432292 PMCID: PMC11023775 DOI: 10.1016/j.jim.2024.113654] [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: 12/21/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
Epitope mapping provides critical insight into antibody-antigen interactions. Epitope mapping of autoantibodies from patients with autoimmune diseases can help elucidate disease immunogenesis and guide the development of antigen-specific therapies. Similarly, epitope mapping of commercial antibodies targeting known autoantigens enables the use of those antibodies to test specific hypotheses. Anti-Neutrophil Cytoplasmic Autoantibody (ANCA) vasculitis results from the formation of autoantibodies to multiple autoantigens, including myeloperoxidase (MPO), proteinase-3 (PR3), plasminogen (PLG), and peroxidasin (PXDN). To perform high-resolution epitope mapping of commercial antibodies to these autoantigens, we developed a novel yeast surface display library based on a series of >5000 overlapping peptides derived from their protein sequences. Using both FACS and magnetic bead isolation of reactive yeast, we screened 19 commercially available antibodies to the ANCA autoantigens. This approach to epitope mapping resulted in highly specific, fine epitope mapping, down to single amino acid resolution in many cases. Our study also identified cross-reactivity between some commercial antibodies to MPO and PXDN, which suggests that patients with apparent autoantibodies to both proteins may be the result of cross-reactivity. Together, our data validate yeast surface display using maximally overlapping peptides as an excellent approach to linear epitope mapping.
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Affiliation(s)
- John S Poulton
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, Chapel Hill, North Carolina, USA.
| | - Sajan Lamba
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Meghan Free
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, Chapel Hill, North Carolina, USA
| | - Gang Xi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, Chapel Hill, North Carolina, USA
| | - Elizabeth McInnis
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gabrielle Williams
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephan T Kudlacek
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Menten AI, San Francisco, California, USA
| | - David Thieker
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian Kuhlman
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald Falk
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, Chapel Hill, North Carolina, USA
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4
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Jonasdottir AD, Manojlovic M, Vojinovic J, Nordin A, Bruchfeld A, Gunnarsson I, Mobarrez F, Antovic A. Augmented thrombin formation is related to circulating levels of extracellular vesicles exposing tissue factor and citrullinated histone-3 in anti-neutrophil cytoplasmic antibody-associated vasculitides. Front Med (Lausanne) 2023; 10:1240325. [PMID: 37915326 PMCID: PMC10616855 DOI: 10.3389/fmed.2023.1240325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023] Open
Abstract
Objectives To study circulating myeloperoxidase (MPO)-positive extracellular vesicles (MPO+EVs) exposing citrullinated histone-3 (H3Cit), tissue factor (TF), and plasminogen (Plg) in association to thrombin generation in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). Methods We have involved well-characterized patients with AAV together with population-based controls. Flow cytometry was used to assess the levels of MPO+EVs in citrated plasma. MPO+EVs were phenotyped by anti-MPO-antibodies together with anti-CD142 (anti-TF), anti-H3Cit, and anti-Plg antibodies. A modified Calibrated Automated Thrombogram (CAT) assay was utilized to measure thrombin generation in plasma initiated by EVs-enriched pellets. The activity of AAV was evaluated with the Birmingham Vasculitis Activity Score (BVAS). Results This study comprised 46 AAV patients, 23 in the active stage of the disease and 23 in remission, as well as 23 age- and sex matched population-based controls. Augmented levels of all investigated MPO+ EVs were found in active AAV patients in comparison to the subgroup of patients in remission and controls. Thrombin generation, measured by endogenous thrombin potential (ETP) and peak of thrombin formation, was higher in plasma when triggered by EVs-enriched pellet from AAV patients. ETP and peak were associated with the levels of MPO+TF+ and MPO+H3Cit+ EVs. Additionally, MPO+TF+ EVs correlated with the disease activity evaluated with BVAS. Conclusion Augmented thrombin generation is found in AAV patients regardless of disease activity and is associated with higher exposure of TF and H3Cit on MPO+EVs. This may contribute to the increased risk of thrombosis seen in AAV patients.
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Affiliation(s)
- Asta Dogg Jonasdottir
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Department of Medicine, Landspitali – The National University Hospital, Reykjavik, Iceland
| | - Milena Manojlovic
- Department of Pediatrics, Medical Faculty, University of Niš, Niš, Serbia
| | - Jelena Vojinovic
- Department of Pediatrics, Medical Faculty, University of Niš, Niš, Serbia
| | - Annica Nordin
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden
| | - Annette Bruchfeld
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Iva Gunnarsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden
- Rheumatology, Karolinska University Hospital Stockholm, Stockholm, Sweden
| | | | - Aleksandra Antovic
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden
- Rheumatology, Karolinska University Hospital Stockholm, Stockholm, Sweden
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5
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Scurt FG, Bose K, Hammoud B, Brandt S, Bernhardt A, Gross C, Mertens PR, Chatzikyrkou C. Old known and possible new biomarkers of ANCA-associated vasculitis. J Autoimmun 2022; 133:102953. [PMID: 36410262 DOI: 10.1016/j.jaut.2022.102953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/06/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises a group of multisystem disorders involving severe, systemic, small-vessel vasculitis with short- and long term serious and life-threating complications. Despite the simplification of treatment, fundamental aspects concerning assessment of its efficacy and its adaptation to encountered complications or to the relapsing/remitting/subclinical disease course remain still unknown. The pathogenesis of AAV is complex and unique, and despite the progress achieved in the last years, much has not to be learnt. Foremost, there is still no accurate marker enabling us to monitoring disease and guide therapy. Therefore, the disease management relays often on clinical judgment and follows a" trial and error approach". In the recent years, an increasing number of new molecules s have been explored and used for this purpose including genomics, B- and T-cell subpopulations, complement system factors, cytokines, metabolomics, biospectroscopy and components of our microbiome. The aim of this review is to discuss both the role of known historical and clinically established biomarkers of AAV, as well as to highlight potential new ones, which could be used for timely diagnosis and monitoring of this devastating disease, with the goal to improve the effectiveness and ameliorate the complications of its demanding therapy.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany.
| | - K Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - S Brandt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - A Bernhardt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - C Gross
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Peter R Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
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6
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Hounkpe BW, Moraes CRP, Lanaro C, Santos MNN, Costa FF, De Paula EV. Evaluation of the mechanisms of heme-induced tissue factor activation: Contribution of innate immune pathways. Exp Biol Med (Maywood) 2022; 247:1542-1547. [PMID: 35775605 PMCID: PMC9554166 DOI: 10.1177/15353702221106475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hemolytic diseases such as Sickle Cell Disease (SCD) are characterized by a natural propensity for both arterial and venous thrombosis. The ability of heme to induce tissue factor (TF) activation has been shown both in animal models of SCD, and in human endothelial cells and monocytes. Moreover, it was recently demonstrated that heme can induce coagulation activation in the whole blood of healthy volunteers in a TF-dependent fashion. Herein, we aim to further explore the cellular mechanisms by which heme induces TF-coagulation activation, using human mononuclear cells, which have been shown to be relevant to in vivo hemostasis. TF mRNA expression was evaluated by qPCR and TF procoagulant activity was evaluated using a 2-stage assay based on the generation of activated factor X (FXa). Heme was capable of inducing both TF expression and activation in a TLR4-dependent pathway. This activity was further amplified after TNF-α-priming. Our results provide additional details on the mechanisms by which heme is involved in the pathogenesis of hypercoagulability in hemolytic diseases.
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Affiliation(s)
| | | | - Carolina Lanaro
- Hematology and Hemotherapy Center, University of Campinas, CEP 13083-970 Campinas, Brazil
| | | | - Fernando Ferreira Costa
- School of Medical Sciences, University of Campinas, CEP 13083-894 Campinas, Brazil,Hematology and Hemotherapy Center, University of Campinas, CEP 13083-970 Campinas, Brazil
| | - Erich Vinicius De Paula
- School of Medical Sciences, University of Campinas, CEP 13083-894 Campinas, Brazil,Hematology and Hemotherapy Center, University of Campinas, CEP 13083-970 Campinas, Brazil,Erich Vinicius De Paula.
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7
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King C, Patel R, Mendoza C, Walker JK, Wu EY, Moss P, Morgan MD, O'Dell Bunch D, Harper L, Chanouzas D. Cytomegalovirus infection is a risk factor for venous thromboembolism in ANCA-associated vasculitis. Arthritis Res Ther 2022; 24:192. [PMID: 35948984 PMCID: PMC9364516 DOI: 10.1186/s13075-022-02879-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) and confers significant morbidity and mortality. Both acute and past cytomegalovirus (CMV) infection have been identified as risk factors for VTE in immunocompetent and immunosuppressed individuals. Here, we examine whether past exposure to CMV is a risk factor for VTE amongst patients with AAV. METHODS We retrospectively analysed outcomes of patients with a new diagnosis of AAV from a UK cohort. All confirmed cases of VTE where CMV IgG serology was available were recorded. Retrospective collection of the same data for patients at a North American centre was used as a validation cohort. RESULTS VTE was common with 12% of patients from the study cohort (total 259 patients) developing an event during the median follow-up period of 8.5 years of which 60% occurred within the first 12 months following diagnosis. Sixteen percent of CMV seropositive patients developed a VTE compared with 5% of patients who were seronegative (p = 0.007) and CMV seropositivity remained an independent predictor of VTE in multivariable analysis (HR 2.96 [1.094-8.011] p = 0.033). CMV seropositivity at diagnosis was confirmed as a significant risk factor for VTE in the American validation cohort (p = 0.032). CONCLUSIONS VTE is common in patients with AAV, especially within the first year of diagnosis. Past infection with CMV is an independent risk factor associated with VTE in AAV.
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Affiliation(s)
- C King
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Cancer Sciences Building, Edgbaston, Birmingham, B15 2TT, UK.
| | - R Patel
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - C Mendoza
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - J K Walker
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - E Y Wu
- University of North Carolina Pediatric Allergy, Immunology, and Rheumatology, Chapel Hill, USA
| | - P Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Cancer Sciences Building, Edgbaston, Birmingham, B15 2TT, UK
| | - M D Morgan
- Hull York Medical School, University of Hull, Hull, UK
| | - D O'Dell Bunch
- University of North Carolina Department of Medicine, Kidney Centre, Chapel Hill, NC, USA
| | - L Harper
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - D Chanouzas
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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8
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Pfister H. Neutrophil Extracellular Traps and Neutrophil-Derived Extracellular Vesicles: Common Players in Neutrophil Effector Functions. Diagnostics (Basel) 2022; 12:diagnostics12071715. [PMID: 35885618 PMCID: PMC9323717 DOI: 10.3390/diagnostics12071715] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 02/06/2023] Open
Abstract
Neutrophil granulocytes are a central component of the innate immune system. In recent years, they have gained considerable attention due to newly discovered biological effector functions and their involvement in various pathological conditions. They have been shown to trigger mechanisms that can either promote or inhibit the development of autoimmunity, thrombosis, and cancer. One mechanism for their modulatory effect is the release of extracellular vesicles (EVs), that trigger appropriate signaling pathways in immune cells and other target cells. In addition, activated neutrophils can release bactericidal DNA fibers decorated with proteins from neutrophil granules (neutrophil extracellular traps, NETs). While NETs are very effective in limiting pathogens, they can also cause severe damage if released in excess or cleared inefficiently. Since NETs and EVs share a variety of neutrophil molecules and initially act in the same microenvironment, differential biochemical and functional analysis is particularly challenging. This review focuses on the biochemical and functional parallels and the extent to which the overlapping spectrum of effector molecules has an impact on biological and pathological effects.
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Affiliation(s)
- Heiko Pfister
- Munich Biomarker Research Center, Institute of Laboratory Medicine, German Heart Center Munich, Technical University Munich, D-80636 Munich, Germany
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9
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Nevares A, Yaseen K, Tamaki H, Bena J, Messner W, Villa-Forte A. Recurrence rate of venous thromboembolic events in granulomatosis with polyangiitis. Rheumatol Adv Pract 2022; 6:rkac058. [PMID: 35855108 PMCID: PMC9291358 DOI: 10.1093/rap/rkac058] [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: 02/08/2022] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objective
The incidence of first-time venous thromboembolic events (VTEs) is high in granulomatosis with polyangiitis (GPA). The incidence of recurrent VTEs is unknown. We aimed to describe the recurrence rate of second VTEs in patients with GPA.
Methods
Retrospective chart review was performed in patients with GPA and at least one VTE at a single centre from 2002 to 2016. Inclusion criteria were 1990 ACR criteria or 2012 Revised International Chapel Hill nomenclature for GPA, at least two follow-up visits, at least one VTE during the study period, and VTE occurrence after or within 3 months before GPA diagnosis. Second VTE event-free survival rates were estimated.
Results
Out of 147 patients initially screened for GPA and with at least one VTE, 84 met inclusion criteria. Median age at first VTE was 57 years. Incidence rate for second VTE was 8.4 events per 100 patient-years (95% CI: 5.7, 12.3). Eighty-three point three per cent of first VTEs and 57.7% of second VTEs occurred when disease was active (P < 0.001). Renal involvement and constitutional symptoms at the time of first VTE were associated with VTE recurrence.
Conclusion
GPA has a high rate of VTE recurrence compared with the reported data in the general population with unprovoked VTE. Our results suggest that VTE in GPA is a recurrent co-morbidity, not always during active vasculitis, and more so in those with renal involvement and constitutional symptoms at the time of first VTE.
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Affiliation(s)
- Alana Nevares
- Correspondence to: Alana Nevares, Division of Rheumatology and Clinical Immunology, Robert Larner, MD, College of Medicine, at the University of Vermont Medical Center, Main Campus, 111 Colchester Avenue, Burlington, VT 05401, USA. E-mail:
| | - Kinanah Yaseen
- Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland, OH, USA
| | | | - James Bena
- Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
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10
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Aberrant stromal tissue factor localisation and mycolactone-driven vascular dysfunction, exacerbated by IL-1β, are linked to fibrin formation in Buruli ulcer lesions. PLoS Pathog 2022; 18:e1010280. [PMID: 35100311 PMCID: PMC8846541 DOI: 10.1371/journal.ppat.1010280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 02/15/2022] [Accepted: 01/13/2022] [Indexed: 12/23/2022] Open
Abstract
Buruli ulcer (BU) is a neglected tropical disease caused by subcutaneous infection with Mycobacterium ulcerans and its exotoxin mycolactone. BU displays coagulative necrosis and widespread fibrin deposition in affected skin tissues. Despite this, the role of the vasculature in BU pathogenesis remains almost completely unexplored. We hypothesise that fibrin-driven ischemia can be an ‘indirect’ route to mycolactone-dependent tissue necrosis by a mechanism involving vascular dysfunction. Here, we tracked >900 vessels within contiguous tissue sections from eight BU patient biopsies. Our aim was to evaluate their vascular and coagulation biomarker phenotype and explore potential links to fibrin deposition. We also integrated this with our understanding of mycolactone’s mechanism of action at Sec61 and its impact on proteins involved in maintaining normal vascular function. Our findings showed that endothelial cell dysfunction is common in skin tissue adjacent to necrotic regions. There was little evidence of primary haemostasis, perhaps due to mycolactone-dependent depletion of endothelial von Willebrand factor. Instead, fibrin staining appeared to be linked to the extrinsic pathway activator, tissue factor (TF). There was significantly greater than expected fibrin staining around vessels that had TF staining within the stroma, and this correlated with the distance it extended from the vessel basement membrane. TF-induced fibrin deposition in these locations would require plasma proteins outside of vessels, therefore we investigated whether mycolactone could increase vascular permeability in vitro. This was indeed the case, and leakage was further exacerbated by IL-1β. Mycolactone caused the loss of endothelial adherens and tight junctions by the depletion of VE-cadherin, TIE-1, TIE-2 and JAM-C; all Sec61-dependent proteins. Taken together, our findings suggest that both vascular and lymphatic vessels in BU lesions become “leaky” during infection, due to the unique action of mycolactone, allowing TF-containing structures and plasma proteins into skin tissue, ultimately leading to local coagulopathy and tissue ischemia. To date, the debilitating skin disease Buruli ulcer remains a public health concern and financial burden in low or middle-income countries, especially in tropical regions. Late diagnosis is frequent in remote areas, perhaps due to the painlessness of the disease. Hence patients often present with large, destructive opened ulcers leading to delayed wound closure or even lifelong disability. The infectious agent produces a toxin called mycolactone that drives the disease. We previously found evidence that the vascular system is disrupted by mycolactone in these lesions, and now we have further explored potential explanations for these findings by looking at the expression of vascular markers in BU. In a detailed analysis of patient skin punch biopsies, we identified distinct expression patterns of certain proteins and found that tissue factor, which initiates the so-called extrinsic pathway of blood clotting, is particularly important. Mycolactone is able to disrupt the barrier function of the endothelium, further aggravating the diseased phenotype, which may explain how clotting factors access the tissue. Altogether, such localised hypercoagulation in Buruli ulcer skin lesions may contribute to the development of the lesion.
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11
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Misra DP, Thomas KN, Gasparyan AY, Zimba O. Mechanisms of thrombosis in ANCA-associated vasculitis. Clin Rheumatol 2021; 40:4807-4815. [PMID: 34109491 PMCID: PMC8189705 DOI: 10.1007/s10067-021-05790-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/07/2021] [Accepted: 05/22/2021] [Indexed: 12/19/2022]
Abstract
Patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have a two- to threefold greater risk of developing venous as well as arterial thrombotic events. Although such thrombotic events are more commonly seen during phases of active AAV, they are also recognized to occur during AAV in remission. Endothelial injury is a key pathogenic event in AAV. Endothelial injury can be caused by neutrophil activation and release of thrombogenic tissue factor into the circulation. Neutrophil activation further results in the formation of neutrophil extracellular traps (NETs). NETs contribute to thrombosis by expressing tissue factor. NETs have also been detected in cutaneous thrombi from patients with AAV induced by hydralazine. Activated neutrophils in AAV patients release thrombogenic microparticles loaded with tissue factor which further enhances clotting of blood. Antiphospholipid antibodies (APLs) have been detected in up to a third of AAV and might also be induced by drugs such as cocaine adulterated with levamisole and propylthiouracil, which are known to trigger AAV. Such APLs further drive the thrombosis in AAV. Once thrombogenesis occurs, the homeostatic mechanisms resulting in clot dissolution are further impaired in AAV due to anti-plasminogen antibodies. The ongoing pandemic of coronavirus disease 2019 (COVID-19) is associated with endothelial injury and NETosis, mechanisms which are in common with AAV. Reports of new-onset AAV following COVID-19 have been described in the literature, and there could be shared mechanisms driving these processes that require further evaluation.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
| | - Koshy Nithin Thomas
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Armen Yuri Gasparyan
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands, UK
| | - Olena Zimba
- Department of Internal Medicine #2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
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12
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Yang N, Zhao Y, Wu X, Zhang N, Song H, Wei W, Liu ML. Recent advances in Extracellular Vesicles and their involvements in vasculitis. Free Radic Biol Med 2021; 171:203-218. [PMID: 33951487 PMCID: PMC9107955 DOI: 10.1016/j.freeradbiomed.2021.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 01/08/2023]
Abstract
Systemic vasculitis is a heterogeneous group of multisystem autoimmune disorders characterized by inflammation of blood vessels. Although many progresses in diagnosis and immunotherapies have been achieved over the past decades, there are still many unanswered questions about vasculitis from pathological understanding to more advanced therapies. Extracellular vesicles (EVs) are double-layer phospholipid membrane vesicles harboring various cargoes. EVs can be classified into exosomes, microvesicles (MVs), and apoptotic bodies depending on their size and origin of cellular compartment. EVs can be released by almost all cell types and may be involved in physical and pathological processes including inflammation and autoimmune responses. In systemic vasculitis, EVs may have pathogenic involvement in inflammation, autoimmune responses, thrombosis, endothelium injury, angiogenesis and intimal hyperplasia. EV-associated redox reaction may also be involved in vasculitis pathogenesis by inducing inflammation, endothelial injury and thrombosis. Additionally, EVs may serve as specific biomarkers for diagnosis or monitoring of disease activity and therapeutic efficacy, i.e. AAV-associated renal involvement. In this review, we have discussed the recent advances of EVs, especially their roles in pathogenesis and clinical involvements in vasculitis.
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Affiliation(s)
- Nan Yang
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, PR China
| | - Yin Zhao
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, PR China
| | - Xiuhua Wu
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, PR China
| | - Na Zhang
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, PR China
| | - Haoming Song
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, PR China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, PR China.
| | - Ming-Lin Liu
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Corporal Michael J. Crescenz VA Medical Center (Philadelphia), Philadelphia, PA, 19104, USA.
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13
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Mazzariol M, Camussi G, Brizzi MF. Extracellular Vesicles Tune the Immune System in Renal Disease: A Focus on Systemic Lupus Erythematosus, Antiphospholipid Syndrome, Thrombotic Microangiopathy and ANCA-Vasculitis. Int J Mol Sci 2021; 22:ijms22084194. [PMID: 33919576 PMCID: PMC8073859 DOI: 10.3390/ijms22084194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 01/02/2023] Open
Abstract
Extracellular vesicles (EV) are microparticles released in biological fluids by different cell types, both in physiological and pathological conditions. Owing to their ability to carry and transfer biomolecules, EV are mediators of cell-to-cell communication and are involved in the pathogenesis of several diseases. The ability of EV to modulate the immune system, the coagulation cascade, the angiogenetic process, and to drive endothelial dysfunction plays a crucial role in the pathophysiology of both autoimmune and renal diseases. Recent studies have demonstrated the involvement of EV in the control of renal homeostasis by acting as intercellular signaling molecules, mediators of inflammation and tissue regeneration. Moreover, circulating EV and urinary EV secreted by renal cells have been investigated as potential early biomarkers of renal injury. In the present review, we discuss the recent findings on the involvement of EV in autoimmunity and in renal intercellular communication. We focused on EV-mediated interaction between the immune system and the kidney in autoimmune diseases displaying common renal damage, such as antiphospholipid syndrome, systemic lupus erythematosus, thrombotic microangiopathy, and vasculitis. Although further studies are needed to extend our knowledge on EV in renal pathology, a deeper investigation of the impact of EV in kidney autoimmune diseases may also provide insight into renal biological processes. Furthermore, EV may represent promising biomarkers of renal diseases with potential future applications as diagnostic and therapeutic tools.
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14
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Moiseev S, Kronbichler A, Makarov E, Bulanov N, Crnogorac M, Direskeneli H, Galesic K, Gazel U, Geetha D, Guillevin L, Hrušková Z, Little MA, Ahmed A, McAdoo SP, Mohammad AJ, Moran S, Novikov P, Pusey CD, Rahmattulla C, Satrapová V, Silva J, Terrier B, Tesař V, Westman K, Jayne DRW. Association of venous thromboembolic events with skin, pulmonary and kidney involvement in ANCA-associated vasculitis: a multinational study. Rheumatology (Oxford) 2021; 60:4654-4661. [PMID: 33523099 DOI: 10.1093/rheumatology/keab071] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/24/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To investigate the occurrence of venous thromboembolic events (VTE) in a large cohort of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) across the European Union, Turkey, Russia, UK, and North America. METHODS Patients with a definite diagnosis of AAV who were followed for at least 3 months and had sufficient documentation were included. Data on VTE, including either deep vein thrombosis or pulmonary embolism, were collected retrospectively from tertiary vasculitis centers. Univariate and multivariate regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Over a median follow up of 63 (29; 101) months, VTE occurred in 278 (9.7%) of 2869 AAV patients with a similar frequency across different countries (from 6.3% to 13.7%), and AAV subtype (granulomatosis with polyangiitis: 9.8%; 95% CI 8.3-11.6, microscopic polyangiitis: 9.6%; 95% CI 7.9-11.4, and eosinophilic granulomatosis with polyangiitis: 9.8%; 95% CI 7.0-13.3). Most VTE (65.6%) were reported in the first-year post diagnosis. Multiple factor logistic regression analysis adjusted for sex and age showed that skin (OR 1.71, 95% CI 1.01-2.92), pulmonary (OR 1.78, 95% CI 1.04-3.14) and kidney involvement (eGFR 15-60 mL/min/1.73 m2, OR 2.86, 95% CI 1.27-6.47; eGFR < 15 mL/min/1.73 m2, OR 6.71, 95% CI 2.94-15.33) were independent variables associated with a higher occurrence of VTE. CONCLUSION Two thirds of VTE occurred during the initial phase of active disease. We confirmed previous findings from smaller studies that a decrease in kidney function, skin involvement and pulmonary disease are independently associated with VTE.
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Affiliation(s)
- Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.,Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Egor Makarov
- Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Nikolay Bulanov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Haner Direskeneli
- Department of Internal Medicine, Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Kresimir Galesic
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Ummugulsum Gazel
- Department of Internal Medicine, Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Loic Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Zdenka Hrušková
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Prague, Czech Republic, in
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland.,Irish Centre for Vascular Biology, Tallaght University Hospital, Dublin, Ireland
| | | | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Aladdin J Mohammad
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden, Vasculitis and Lupus Clinic, Addenbrooke's Hospital Cambridge University Hospitals, Cambridge, UK
| | - Sarah Moran
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Chinar Rahmattulla
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Veronika Satrapová
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Prague, Czech Republic, in
| | - Joana Silva
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Prague, Czech Republic, in
| | - Kerstin Westman
- Department of Clinical Sciences Lund, Nephrology, Lund University, Lund, Sweden
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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15
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Claudel SE, Tucker BM, Kleven DT, Pirkle JL, Murea M. Narrative Review of Hypercoagulability in Small-Vessel Vasculitis. Kidney Int Rep 2020; 5:586-599. [PMID: 32405580 PMCID: PMC7210611 DOI: 10.1016/j.ekir.2019.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/31/2019] [Indexed: 01/08/2023] Open
Abstract
Pauci-immune necrotizing and crescentic glomerulonephritis (GN) is the most common etiology of rapidly progressive GN. Clinical presentation in those afflicted is usually related to rapid loss of kidney function. We report the case of a 70-year-old woman who came to medical attention for signs and symptoms related to lower-extremity deep vein thrombosis (DVT). At presentation, the patient had biochemical abnormalities consistent with active GN, which quickly progressed to rapid loss in kidney function requiring renal replacement therapy. Kidney biopsy revealed small-vessel vasculitis with glomerular crescents. Serologic studies were negative for antineutrophil cytoplasmic antibody antibodies and other causes of acute GN. Plasmapheresis, immunosuppressive, and anticoagulant therapies were prescribed. Absence of other apparent end-organ involvement with vasculitis pointed toward renal-limited small-vessel vasculitis, yet presence of unprovoked DVT argues for systemic vascular inflammation. This case illustrates that venous thrombosis can be the presenting manifestation in patients with vasculitis and silent, severe end-organ involvement. The epidemiology and pathophysiology of venous thromboembolism in small-vessel vasculitis are discussed in this report.
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Affiliation(s)
| | - Bryan M. Tucker
- Department of Internal Medicine, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel T. Kleven
- Department of Pathology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - James L. Pirkle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
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16
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Isaacs B, Gapud EJ, Antiochos B, Seo P, Geetha D. Venous Thrombotic Events in ANCA-Associated Vasculitis: Incidence and Risk Factors. KIDNEY360 2020; 1:258-262. [PMID: 35372925 PMCID: PMC8809268 DOI: 10.34067/kid.0000572019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/02/2020] [Indexed: 06/14/2023]
Abstract
Background The incidence of venous thromboembolism (VTE) is increased in ANCA-associated vasculitis (AAV). We assessed the frequency of VTE observed among patients with AAV evaluated at our center and identified risk factors. Methods Patients from the Johns Hopkins Vasculitis Center cohort who were evaluated between 1998 and 2018 and had a diagnosis of granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) were eligible for analysis. Baseline demographics and clinical and serologic data were extracted. Univariate and multivariate analyses were performed to identify factors associated with VTE in AAV. Results A total of 162 patients with AAV were identified, 105 (65%) with GPA; 22 (14%) of these patients had a recorded VTE with a median time to VTE of 1 month. The mean (SD) age in the VTE versus non-VTE groups was 54±20 versus 55±17 years (P=0.99), 64% versus 60% female (P=0.93), 82% versus 49% PR3-ANCA positive (P=0.01), with a total mean BMI of 33.3±5.7 versus 28.3±6.1 kg/m2, (P<0.001) respectively. The median Birmingham Vasculitis Activity Score (BVAS version 3) was 19 versus 14 (P=0.02). Univariate analyses identified PR3-ANCA, rapidly progressive GN (RPGN), and hypoalbuminemia. In multivariate analysis, the significant associations with VTE included PR3-ANCA (OR, 4.77; P=0.02), hypoalbuminemia (OR, 4.84; P=0.004), and BMI (OR, 1.18; P<0.001). Conclusions VTE is a surprisingly common complication of AAV. PR3-ANCA and hypoalbuminemia are risk factors for developing VTEs. Further studies are needed to confirm these findings. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_04_30_KID0000572019.mp3.
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Affiliation(s)
- Bradley Isaacs
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Eric J. Gapud
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Brendan Antiochos
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Philip Seo
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
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Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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