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Yang LYY, Wang YL, Zuo YG. Pemphigoid diseases in patients with end-stage kidney diseases: pathogenesis and treatment. Front Immunol 2024; 15:1427943. [PMID: 39050843 PMCID: PMC11266006 DOI: 10.3389/fimmu.2024.1427943] [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: 05/05/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background Pemphigoid diseases constitute a group of autoimmune blistering disorders characterized by subepithelial blistering. The association between pemphigoid diseases and both end-stage kidney disease (ESKD) and its treatment is notable. However, there is limited evidence about the management of pemphigoid diseases in patients with ESKD. This systematic review compiled case reports and relevant studies, summarized the underlying mechanisms of pemphigoid diseases in patients with ESKD, and summarized the efficacy of various therapies. Methods A systematic search of PubMed and Embase was performed for articles published between 1982 to June 2, 2024. Results Fifty-three case reports and eight relevant studies were included. Triggers for pemphigoids in patients with ESKD included materials used to treat ESKD, immune dysregulation of patients with ESKD, and rejection of renal allograft. Treatment for these patients included removing triggers, as well as administering of corticosteroids, mycophenolate mofetil (MMF), tetracyclines, rituximab, methotrexate, dapsone, azathioprine, cyclosporine, intravenous immunoglobin (IVIG), plasmapheresis, and Janus kinase inhibitors. Conclusion Removing triggers is the most effective strategy. Despite their suboptimal efficacy, corticosteroids remain the most commonly used agents in this patient population. MMF, tetracyclines, and rituximab are less used but with benefits. There are significant adverse effects associated with methotrexate treatment. Other treatment may also be beneficial and require further investigation. These findings may enable clinicians to optimize the therapeutic approach for these patients.
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Affiliation(s)
- Liu-Yi-Yi Yang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Lu Wang
- Department of Dermatology, Xiajin Country People’s Hospital, Dezhou, Shandong, China
| | - Ya-Gang Zuo
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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2
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Hodges WT, Badawi AH, Rosman IS, Musiek AC, Shmuylovich L. Bullous pemphigoid with prominent mucosal involvement in the setting of renal allograft rejection. JAAD Case Rep 2024; 44:53-57. [PMID: 38292570 PMCID: PMC10825267 DOI: 10.1016/j.jdcr.2023.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Affiliation(s)
- Wesley T. Hodges
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - Ahmed H. Badawi
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
- Freeman Health System Dermatology and Skin Cancer Center, Joplin, Missouri
| | - Ilana S. Rosman
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Amy C. Musiek
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - Leonid Shmuylovich
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
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Cui S, Zhang B, Li L. The relationship between bullous pemphigoid and renal disease and related treatments: a review of the current literature. Expert Rev Clin Immunol 2023; 19:1407-1417. [PMID: 37707350 DOI: 10.1080/1744666x.2023.2249238] [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: 04/22/2023] [Accepted: 08/14/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disorder in older adults. There is increasing evidence that BP has connections with renal diseases, such as glomerulopathy and neoplasm; it is also linked to the receipt of renal replacement therapy. AREAS COVERED In this review, we summarize the current evidence that BP is a comorbidity of common renal diseases. Furthermore, our exploration of the characteristics and possible mechanisms underlying these connections provides insights that may facilitate the prevention, diagnosis, and management of BP. EXPERT OPINION There is mounting proof that BP is not just a skin immunological disorder but rather a systemic immune-mediated illness. Quantities of case reports focused on BP as a renal disease comorbidity and the coexistence of them is not accidental. However, the underlying mechanisms are still needed to be investigated. Clinicians should be alert to the comorbidities in order to facilitate effective treatment and improve patient prognosis.
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Affiliation(s)
- Shengnan Cui
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Bingjie Zhang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Li Li
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
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4
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Barata R, Moreira Fonseca N, Assis Pereira T, Góis M, Sousa H, Carvalho D, Ribeiro F, Fernandes C, Pena A, Nolasco F. [A rare presentation of kidney allograft intolerance syndrome: Bullous pemphigoid]. Nephrol Ther 2021; 17:547-551. [PMID: 34629318 DOI: 10.1016/j.nephro.2021.07.001] [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: 02/12/2021] [Revised: 06/20/2021] [Accepted: 07/02/2021] [Indexed: 11/26/2022]
Abstract
Bullous pemphigoid is an autoimmune bullous cutaneous disease. We report the case of a 60 year-old male patient whose kidney allograft failed and was on hemodialysis for the previous 16 months. After tapering immunosuppressive medication, he presented simultaneous bullous eruption and kidney allograft intolerance syndrome. Investigation showed a positive BP180 anti-basement membrane zone antibody and skin biopsy was consistent with bullous pemphigoid. The patient was treated with corticotherapy and bullous pemphigoid resolved. The development of new onset diabetes and concerns over long term immunosuppression, halted the decision to continue corticotherapy and the patient underwent graft nephrectomy, with resolution of the kidney allograft intolerance syndrome without recurrence of the bullous disease. The occurrence of bullous pemphigoid in patients with failed renal allograft is rare, with only eleven cases reported in literature. This case illustrates how graft nephrectomy can provide a definitive cure to bullous pemphigoid in this setting.
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Affiliation(s)
- Rui Barata
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal.
| | - Nuno Moreira Fonseca
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Tiago Assis Pereira
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Mário Góis
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal; Laboratoire de morphologie rénale, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Helena Sousa
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal; Laboratoire de morphologie rénale, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Dulce Carvalho
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Francisco Ribeiro
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Cândida Fernandes
- Service de dermatologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Ana Pena
- Service de chirurgie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
| | - Fernando Nolasco
- Service de néphrologie, Centro Hospitalar Universitário de Lisboa Central, R. Beneficência 8, 1050-099 Lisboa, Portugal
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Pulpillo Ruiz Á. Dermatologic Manifestations in Kidney Transplant Recipients. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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6
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Dermatologic Manifestations in kidney transplant recipients. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:854. [PMID: 30396510 DOI: 10.1016/j.ad.2018.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/17/2018] [Indexed: 11/23/2022] Open
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7
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Rosique López F, Martínez Losa A, Sánchez-Pedreño Guillén P, Ishii N, Hashimoto T, Martínez García P. Bullous pemphigoid and chronic kidney graft rejection. J Eur Acad Dermatol Venereol 2017; 31:e508-e510. [PMID: 28605575 DOI: 10.1111/jdv.14396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- F Rosique López
- Department of Nephrology, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - A Martínez Losa
- Department of Nephrology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | - N Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - T Hashimoto
- Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - P Martínez García
- Department of Immunology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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Osipowicz K, Kalinska-Bienias A, Kowalewski C, Wozniak K. Development of bullous pemphigoid during the haemodialysis of a young man: case report and literature survey. Int Wound J 2016; 14:288-292. [PMID: 27748034 DOI: 10.1111/iwj.12670] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/22/2016] [Indexed: 12/17/2022] Open
Abstract
Haemodialysis is the most frequent form of renal replacement therapy (RRT) in patients with end-stage renal disorder (ESRD). Patients with ESRD frequently develop skin problems, mainly xerosis, pruritus and hyperpigmentation, as well as bullous diseases, mainly porphyria or pseudoporphyria and, in some cases, bullous pemphigoid (BP). BP is the most common autoimmune sub-epidermal blistering disease, and it predominantly affects elderly people. Clinically, BP is characterised by generalised pruritic, bullous eruptions and urticaria-like lesions. Usually, BP is an idiopathic disorder; however, in some cases, underlying internal disorders are present, like diabetes or neurological disorders. Herein, we present a 33-year-old man with ESRD, maintained on haemodialysis, who developed BP. There are only six cases with BP provoked by the placement of a fistula for haemodialysis. BP in the current patient was confirmed by direct immunofluorescence (DIF) and indirect immunofluorescence using BIOCHIP. The patient responded promptly to tertracycline and 0·05% clobetasol propionate lesionally. However, the relationship between BP and the fistula for haemodialisys still remains unknown. It is highly likely that the skin injury associated with fistula placement was responsible for the alteration of the basement membrane zone (BMZ) and the stimulation of the immune system, leading to BP development. To explain the real role of fistula placement as a provocative factor in BP, other such cases are required for assessment.
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Affiliation(s)
- Katarzyna Osipowicz
- Department of Dermatology and Immunodermatology, Medical University of Warsaw, Warsaw, Poland
| | | | - Cezary Kowalewski
- Department of Dermatology and Immunodermatology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Wozniak
- Department of Dermatology and Immunodermatology, Medical University of Warsaw, Warsaw, Poland
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Hoorn EJ, Taams NE, Hurskainen T, Salih M, Weening JJ, Jonkman MF, Pas HH, Schreurs MWJ. Bullous Pemphigoid With a Dual Pattern of Glomerular Immune Complex Disease. Am J Kidney Dis 2015; 67:302-6. [PMID: 26616334 DOI: 10.1053/j.ajkd.2015.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/01/2015] [Indexed: 12/12/2022]
Abstract
A 75-year-old man presented with a blistering skin disease and nephrotic syndrome. Bullous pemphigoid was diagnosed by linear immunoglobulin G (IgG) and C3 staining along the basement membrane zone of a skin biopsy specimen and by the presence of circulating IgG recognizing the 180-kDa bullous pemphigoid antigen (BP180; type XVII collagen). A kidney biopsy specimen showed endocapillary inflammation without crescents. Direct immunofluorescence showed strong IgG and C3 staining in a combined granular and linear pattern along the glomerular basement membrane. Electron microscopy showed subepithelial deposits. In serum, no antibodies against the Goodpasture antigen (type IV collagen) or phospholipase A2 receptor were detected. Indirect immunofluorescence studies using the patient's serum showed a strikingly linear but not granular IgG pattern along the epithelial basement membranes of monkey esophagus and kidney. Although type XVII collagen was recently identified in the glomerulus, the patient's serum did not produce a 180-kDa band on immunoblot of kidney tissue and still stained glomeruli of BP180 knockout mice by indirect immunofluorescence. The patient was treated with prednisone and azathioprine, which resulted in complete remission of skin and kidney manifestations. Although bullous pemphigoid has been reported previously in association with anti-glomerular basement membrane disease or membranous nephropathy, this case demonstrates both elements in 1 patient. This concurrence and the linear pattern on indirect immunofluorescence support the possibility of cross-reactive or parallel autoantibodies to basement membranes with a secondary membranous component.
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Affiliation(s)
- Ewout J Hoorn
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Noor E Taams
- Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tiina Hurskainen
- Department of Dermatology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mahdi Salih
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jan J Weening
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marcel F Jonkman
- Department of Dermatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Hendri H Pas
- Department of Dermatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Marco W J Schreurs
- Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
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Atzori L, Conti B, Zucca M, Pau M. Bullous pemphigoid induced by m-TOR inhibitors in renal transplant recipients. J Eur Acad Dermatol Venereol 2014; 29:1626-30. [PMID: 25174440 DOI: 10.1111/jdv.12662] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/25/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an acquired autoimmune disease, with typical histology and immune pathological findings, which might be associated with drug therapy. The list of responsible drugs increases every year, but a current literature revision do not include the mammalian target of rapamycin (mTOR) inhibitors. By converse, bullous pemghigoid cases have been described in renal transplant recipients and associated with the allogenic graft itself, causing a cross reaction against the skin, or unbalancing the immune response, through a chronic cell-mediated suppression, non-specifically favouring the autoantibody production. OBJECT AND RESULTS Two cases of BP occurred, respectively, 10 days to 2 months after the addition to their current regimen of everolimus in a 35-year-old woman and sirolimus in a 65-year-old man. The graft functionality was within normal range. General corticosteroids therapy resistance, immediate improvement after drug discontinuation (dechallenge) and relapse after re-exposure (rechallenge) were striking criteria supporting a causative role of the drugs, grouped in the mTOR inhibitors class. CONCLUSIONS The diagnosis of drug-induced events is crucial for early management, and particularly bullous eruptions affect patients' health and quality of life. Additional research is necessary to confirm the m-TOR inhibitors association, which exploit the possible mechanisms and eventually point out preventive measures.
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Affiliation(s)
- L Atzori
- Dermatology Clinic, Department of Medical Science "M.Aresu", University of Cagliari, Italy
| | - B Conti
- Department of Dermatology, AOU of Cagliari, Cagliari, Italy
| | - M Zucca
- Department of Dermatology, AOU of Cagliari, Cagliari, Italy
| | - M Pau
- Department of Dermatology, AOU of Cagliari, Cagliari, Italy
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Peruzzo J, Dias Pinheiro Dantas L, Zampese M. Bullous pemphigoid associated with chronic renal allograft rejection. J Am Acad Dermatol 2013; 68:e192-3. [PMID: 23680218 DOI: 10.1016/j.jaad.2012.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 11/22/2012] [Accepted: 11/29/2012] [Indexed: 11/26/2022]
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