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Mira M, Ohonba N, Vayzband V, Brown R. Severe Granulomatosis With Polyangiitis Treated With Low-Dose Cyclophosphamide, Rituximab, Glucocorticoids, and Plasma Exchange: A Case Report. Cureus 2024; 16:e64765. [PMID: 39156418 PMCID: PMC11329316 DOI: 10.7759/cureus.64765] [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] [Accepted: 07/17/2024] [Indexed: 08/20/2024] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic vasculitis that affects blood vessels and presents with vague constitutional symptoms, but more serious manifestations can develop, including pulmonary complications and glomerulonephritis. Currently, there are no definitive treatment guidelines. We present a case of a 66-year-old male with no previous medical history who was admitted for generalized constitutional symptoms for the past month. Imaging of the patient's brain revealed dural enhancement. Bronchoalveolar lavage was done and revealed diffuse alveolar hemorrhage (DAH). A kidney biopsy revealed granulomatosis with polyangiitis. The patient's hospital course was complicated by acute renal failure and required hemodialysis. Due to the patient's multi-organ involvement, the patient was treated aggressively with cyclophosphamide, rituximab, plasma exchange (PE), and steroids. GPA is a systemic vasculitis that can present with multi-organ involvement. A prompt diagnosis is necessary to initiate treatment and preserve organ function. More research is needed to determine which combination therapies are the best treatment modalities in cases of severe multi-organ system involvement.
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Affiliation(s)
- Michael Mira
- Internal Medicine, Overlook Medical Center, Summit, USA
| | | | - Vlad Vayzband
- Internal Medicine, Overlook Medical Center, Summit, USA
| | - Ryan Brown
- Nephrology, Overlook Medical Center, Summit, USA
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2
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Daca A, Storoniak H, Dębska-Ślizień A, Kusztal MA, Krajewska M, Lisowska KA. Chemokines and Cytokines Profiles in Patients with Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis: A Preliminary Study. Int J Mol Sci 2023; 24:15319. [PMID: 37894997 PMCID: PMC10607460 DOI: 10.3390/ijms242015319] [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: 09/12/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
The damage to small vessels in AAV and inflammatory reactions are accompanied by the release of various chemokines and cytokines. Using a flow cytometry technique, we assessed the levels of specific cytokines, namely IL-1β IL-6, IL-8, IL-10, IL12p70, and TNF, and chemokines, IFN-α, IP-10, and MIG in the serum from 9 healthy volunteers and 20 AAV patients, where 11 of the patients were not treated and evaluated at the time of diagnosis and 9 were already diagnosed and taking CY + GCS. The obtained results were then compared considering the activity of the disease, the type and titre of the ANCA antibodies, the inflammatory status, and the kidneys' condition. Amongst others, the IL-6, IL-8, IL-10, TNF, and MIG levels were much higher in the serum of AAV patients than in healthy controls, whereas the level of IL-1β was higher in healthy volunteers. Additionally, the levels of IL-6, IL-10, IP-10, and MIG negatively correlated with the eGFR level, while the level of IFN-α positively correlated with the titre of PR3-ANCA. As most of the molecules are implicated in trafficking primed neutrophils towards small vessels, looking for links between the levels of these cytokines/chemokines and the clinical symptoms of AAV may facilitate the diagnosis and predict the progression of the disease.
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Affiliation(s)
- Agnieszka Daca
- Department of Pathophysiology, Medical University of Gdańsk, 80-211 Gdansk, Poland;
| | - Hanna Storoniak
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdańsk, 80-211 Gdansk, Poland; (H.S.); (A.D.-Ś.)
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdańsk, 80-211 Gdansk, Poland; (H.S.); (A.D.-Ś.)
| | - Mariusz Andrzej Kusztal
- Department of Nephrology and Translational Medicine, Medical University of Wrocław, 50-137 Wroclaw, Poland; (M.A.K.); (M.K.)
| | - Magdalena Krajewska
- Department of Nephrology and Translational Medicine, Medical University of Wrocław, 50-137 Wroclaw, Poland; (M.A.K.); (M.K.)
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3
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Eloseily E, Henrickson M. Pediatric-onset limited ANCA-associated vasculitis arising during pre-existing chronic recurrent multifocal osteomyelitis. Pediatr Rheumatol Online J 2023; 21:89. [PMID: 37620906 PMCID: PMC10463712 DOI: 10.1186/s12969-023-00876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is an autoimmune disease characterized by chronic vasculitis involving small to medium sized arteries, granulomatous inflammation of the upper and lower respiratory tracts, pauci-immune necrotizing glomerulonephritis, as well as vasculitis of other organs. Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory syndrome characterized by sterile bone inflammation. CASE PRESENTATION We report a case of CRMO that was doing well on non-steroidal anti-inflammatory drugs (NSAID for 6 years and then developed ANCA positive limited GPA presenting with pyoderma gangrenosum, persistent bilateral otalgia with serous otitis, otorrhea, then sensorineural hearing loss. CONCLUSION This is the first report of limited GPA initially presenting as pyoderma gangrenosum in a patient with underlying CRMO. It is unclear how the pathology of an autoimmune and an autoinflammatory condition can overlap.
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Affiliation(s)
- Esraa Eloseily
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet avenue, Cincinnati, OH, 45229, USA.
- Division of Pediatrics, Assiut University School of Medicine, Assiut, Egypt.
| | - Michael Henrickson
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet avenue, Cincinnati, OH, 45229, USA
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4
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Tota M, Donizy P, Byrska M, Krajewska M, Kusztal M. An unsuspected histopathological finding -concomitant IgA nephropathy in a patient with ANCA-associated vasculitis: a case report and literature review. Front Immunol 2023; 14:1227878. [PMID: 37649475 PMCID: PMC10465303 DOI: 10.3389/fimmu.2023.1227878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/21/2023] [Indexed: 09/01/2023] Open
Abstract
Although associations of IgA nephropathy (IgAN) and ANCA-associated vasculitis (AAV) have been described, this coexistence scarcely occurs and requires multidisciplinary management. Herein, we discuss a course of treatment introduced in a patient with two exacerbations. Furthermore, alterations in histopathological images between two kidney biopsies are presented. The applicability of traditional inflammatory markers, e.g., CRP, in monitoring disease severity in AAV and IgAN is limited. Based on our patient and current literature, we suggest ANCA testing in patients with rapidly progressing IgAN for therapeutic and prognostic purposes. As regards the therapy of IgAN associated with AAV, aggressive immunosuppressive regimens with methylprednisolone and cyclophosphamide are recommended. Alternatively, methylprednisolone with rituximab, plasma exchange, mycophenolate mofetil, and intravenous immunoglobulin (IVIG) could also be considered.
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Affiliation(s)
- Maciej Tota
- Faculty of Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Piotr Donizy
- Department of Clinical and Experimental Pathology, Wroclaw Medical University, Wrocław, Poland
| | - Martyna Byrska
- Faculty of Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
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5
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Kudo T, Nakazawa D, Watanabe-Kusunoki K, Kanda M, Shiratori-Aso S, Abe N, Nishio S, Koga JI, Iwasaki S, Tsuji T, Fukasawa Y, Yamasaki M, Watanabe M, Masuda S, Tomaru U, Murakami M, Aratani Y, Ishizu A, Atsumi T. Regulation of NETosis and Inflammation by Cyclophilin D in Myeloperoxidase-Positive Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2023; 75:71-83. [PMID: 35905194 DOI: 10.1002/art.42314] [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: 11/02/2021] [Revised: 05/19/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is pathologically characterized by focal fibrinoid necrosis, in which ANCA-mediated neutrophil extracellular trap (NET) formation and subsequent endothelial cell necrosis occur. Cyclophilin D (CypD) plays an important role in mediation of cell necrosis and inflammation via the opening of mitochondrial permeability transition pores. This study was undertaken to examine the role of CypD in AAV pathogenesis. METHODS We assessed the role and mechanism of CypD in ANCA-stimulated neutrophils in vitro by immunostaining and electron microscopy observation. We performed a comprehensive RNA-sequencing analysis on ANCA-treated murine neutrophils. To investigate the role of CypD in vivo, we assessed disease features in CypD-knockout mice and wild-type mice using 2 different murine AAV models: anti-myeloperoxidase IgG transfer-induced AAV and spontaneous AAV. RESULTS In vitro experiments showed that pharmacologic and genetic inhibition of CypD suppressed ANCA-induced NET formation via the suppression of reactive oxygen species and cytochrome c release from the mitochondria. RNA-sequencing analyses in ANCA-treated murine neutrophils revealed the involvement of inflammatory responses, with CypD deficiency reducing ANCA-induced alterations in gene expression. Furthermore, analyses of upstream regulators revealed the relevance of intracellular calcium (CypD activator) and cyclosporin (CypD inhibitor) in ANCA stimulation, indicating that the CypD-dependent opening of mitochondrial permeability transition pores is associated with ANCA-induced neutrophil activation and NETosis. In both AAV mouse models, the genetic deletion of CypD ameliorated crescentic glomerulonephritis via the inhibition of CypD-dependent neutrophil and endothelial necrosis. CONCLUSION CypD targeting is a novel and specific therapeutic strategy for AAV via the resolution of necrotizing vasculitis.
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Affiliation(s)
- Takashi Kudo
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daigo Nakazawa
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kanako Watanabe-Kusunoki
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masatoshi Kanda
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University, Sapporo, Japan
| | - Satoka Shiratori-Aso
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nobuya Abe
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, and Division of Molecular Psychoimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Saori Nishio
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Jun-Ichiro Koga
- Department of Cardiovascular Medicine, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
| | - Sari Iwasaki
- Department of Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Takahiro Tsuji
- Department of Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Yuichiro Fukasawa
- Department of Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Miwako Yamasaki
- Department of Anatomy, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masahiko Watanabe
- Department of Anatomy, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Sakiko Masuda
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Utano Tomaru
- Department of Pathology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaaki Murakami
- Division of Molecular Psychoimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yasuaki Aratani
- Graduate School of Nanobioscience, Yokohama City University, Yokohama, Japan
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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6
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Ta H, Awada H, Kang P, Gilbert N, Haller N, Mostow E, Lane J, Singh I. Antineutrophil Cytoplasmic Autoantibody (ANCA)-Associated Vasculitis With Mucosal Involvement Following COVID-19 Pneumonia. Cureus 2022; 14:e31441. [DOI: 10.7759/cureus.31441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/14/2022] Open
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7
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Zhou Y, Bréchard S. Neutrophil Extracellular Vesicles: A Delicate Balance between Pro-Inflammatory Responses and Anti-Inflammatory Therapies. Cells 2022; 11:cells11203318. [PMID: 36291183 PMCID: PMC9600967 DOI: 10.3390/cells11203318] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/16/2022] Open
Abstract
Extracellular vesicles (EVs) are released in the extracellular environment during cell activation or apoptosis. Working as signal transducers, EVs are important mediators of intercellular communication through the convoying of proteins, nucleic acids, lipids, and metabolites. Neutrophil extracellular vesicles (nEVs) contain molecules acting as key modulators of inflammation and immune responses. Due to their potential as therapeutic tools, studies about nEVs have been increasing in recent years. However, our knowledge about nEVs is still in its infancy. In this review, we summarize the current understanding of the role of nEVs in the framework of neutrophil inflammation functions and disease development. The therapeutic potential of nEVs as clinical treatment strategies is deeply discussed. Moreover, the promising research landscape of nEVs in the near future is also examined.
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8
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Ge S, Zhu X, Xu Q, Wang J, An C, Hu Y, Yang F, Wang X, Yang Y, Chen S, Jin R, Li H, Peng X, Liu Y, Xu J, Zhu M, Shuai Z. Neutrophils in ANCA-associated vasculitis: Mechanisms and implications for management. Front Pharmacol 2022; 13:957660. [PMID: 36210838 PMCID: PMC9545605 DOI: 10.3389/fphar.2022.957660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of systemic autoimmune diseases, which is typified by inflammatory necrosis predominantly affecting the small vessels and often accompanied by positive ANCA. Clinically, AAV primarily includes microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA). It has been found that in AAV pathogenesis, both innate and adaptive immunity are related to neutrophil function mutually. Many proteins, such as myeloperoxidase (MPO) and proteinase 3 (PR3), in neutrophil cytoplasm lead to the production of proteins such as MPO-ANCA and PR3-ANCA by activating adaptive immunity. In addition, through the process of neutrophil extracellular trap (NET) formation, activation of an alternative complement pathway and the respiratory burst can stimulate the neutrophils close to vascular endothelial cells and will participate the vessel inflammation. This review aims to reveal the potential mechanisms regulating the association between the neutrophils and various types of AAVs and to emphasize the results of recent findings on these interactions. Moreover, multiple underlying signaling pathways involved in the regulation of neutrophils during AAV processes have also been discussed. The ultimate goal of this review is to identify novel biomarkers and therapeutic targets for AAV management in the future.
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Affiliation(s)
- Shangqing Ge
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xingyu Zhu
- National Institute of Clinical Drug Trials, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Qinyao Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Junyan Wang
- Department of Clinical Medical, The Second Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Cheng An
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ying Hu
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
| | - Fan Yang
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Xinyi Wang
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Yipin Yang
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Shuwen Chen
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Ruimin Jin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Haiyan Li
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xinchen Peng
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yue Liu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Junnan Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Minhui Zhu
- National Institute of Clinical Drug Trials, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Zongwen Shuai,
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9
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Del Rio APT, Frade-Guanaes JO, Ospina-Prieto S, Duarte BKL, Bertolo MB, Ozelo MC, Sachetto Z. Impaired repair properties of endothelial colony-forming cells in patients with granulomatosis with polyangiitis. J Cell Mol Med 2022; 26:5044-5053. [PMID: 36052734 PMCID: PMC9549508 DOI: 10.1111/jcmm.17531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/04/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022] Open
Abstract
In patients with ANCA‐associated vasculitis, interactions between neutrophils and endothelial cells cause endothelial damage and imbalance. Endothelial colony‐forming cells (ECFCs) represent a cellular population of the endothelial lineage with proliferative capacity and vasoreparative properties. This study aimed to evaluate the angiogenic capacity of ECFCs of patients with granulomatosis with polyangiitis (GPA). The ECFCs of 13 patients with PR3‐positive GPA and 14 healthy controls were isolated and characterized using fluorescence‐activated cell sorting, capillary tube formation measurement, scratching assays and migration assays with and without plasma stimulation. Furthermore, three patients with active disease underwent post‐treatment recollection of ECFCs for longitudinal evaluation. The ECFCs from the patients and controls showed similar capillary structure formation. However, the ECFCs from the patients with inactive GPA exhibited early losses of angiogenic capacity. Impairments in the migration capacities of the ECFCs were also observed in patients with GPA and controls (12th h, p = 0.05). Incubation of ECFCs from patients with GPA in remission with plasma from healthy controls significantly decreased migration capacity (p = 0.0001). Longitudinal analysis revealed that treatment significantly lowered ECFC migration rates. This study revealed that ECFCs from the patients with PR3‐positive GPA in remission demonstrated early losses of tube formation and reduced migration capacity compared to those of the healthy controls, suggesting impairment of endothelial function.
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Affiliation(s)
- Ana Paula Toledo Del Rio
- Rheumatology Discipline, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Jéssica O Frade-Guanaes
- Hemocentro UNICAMP, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Stephanie Ospina-Prieto
- Hemocentro UNICAMP, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Bruno K L Duarte
- Hemocentro UNICAMP, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Manoel Barros Bertolo
- Rheumatology Discipline, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Margareth C Ozelo
- Hemocentro UNICAMP, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Zoraida Sachetto
- Rheumatology Discipline, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
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10
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Churilla BM, Aqeel F, Azar A, Antiochos B, Seo P, Hellmann DB, Geetha D. Do the benefits of subcutaneous immunoglobulin therapy for secondary hypogammaglobulinemia in ANCA vasculitis extend beyond infection prevention? Kidney Int 2022; 102:444-445. [PMID: 35870815 DOI: 10.1016/j.kint.2022.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 04/23/2022] [Accepted: 04/29/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Bryce M Churilla
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Antoine Azar
- Department of Internal Medicine, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brendan Antiochos
- Department of Internal Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philip Seo
- Department of Internal Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David B Hellmann
- Department of Internal Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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11
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Massicotte-Azarniouch D, Herrera CA, Jennette JC, Falk RJ, Free ME. Mechanisms of vascular damage in ANCA vasculitis. Semin Immunopathol 2022; 44:325-345. [PMID: 35254509 PMCID: PMC9064952 DOI: 10.1007/s00281-022-00920-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
The discovery of anti-neutrophil cytoplasmic antibodies (ANCA) and their antigenic targets, myeloperoxidase (MPO) and proteinase 3 (PR3), has led to further understanding as to the pathophysiologic processes that underlie vascular and tissue damage in ANCA vasculitis. ANCA trigger neutrophil activation leading to vascular damage in ANCA vasculitis. However, decades of study have determined that neutrophil activation alone is not sufficient to cause disease. Inflammatory stimuli are drivers of ANCA autoantigen expression and ANCA production. Certain infections or bacterial peptides may be crucial players in the initial steps of ANCA immunopathogenesis. Genetic and epigenetic alterations of gene encoding for MPO and PR3 provide additional disturbances to the immune homeostasis which provide a substrate for pathogenic ANCA formation from an adaptive immune system predisposed to autoreactivity. Promoted by inflammatory cytokines, ANCA binding leads to neutrophil activation, a process characterized by conformational changes, production and release of cytotoxic substances, and alternative complement pathway activation, thus creating an intense inflammatory milieu. This cascade of events perpetuates a vicious cycle of further inflammatory cell recruitment and activation, culminating in tissue necrosis. Our understanding of the pathogenic process in ANCA vasculitis paves the way for the development of therapies targeting crucial steps in this process. The greater appreciation of the role for complement, monocytes, and the adaptive immune system has already led to novel complement blockers and is poised to lead to further innovations which will allow for tailored antigen- or cell-specific immunotherapy targeting the autoimmune process without exposure to undue risks or toxicities.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Carolina A Herrera
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Meghan E Free
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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12
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Lakhdar S, Nassar M, Shatabdi S, Buttar C, Abrudescu A, Trandafirescu T. A Cavitary Lesion in a Patient with Antineutrophilic Cytoplasmic Antibody (ANCA) Associated Vasculitis: A Case Report and Review of the Literature. J Intensive Care Med 2022; 38:114-120. [PMID: 35437034 DOI: 10.1177/08850666221095498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis who were on immunosuppressive therapy with corticosteroids may be susceptible to cavitary lesions.1 Only a few cases have been reported in the literature to date. Immunosuppression was shown to improve prognosis in patients with vasculitis. However, adverse therapy events and the risk of opportunistic infections become a major cause of morbidity and mortality in this specific patient population. We present a case of a 75-year-old female who was diagnosed and treated in our hospital for ANCA-associated vasculitis and returned within a few weeks of medical therapy and was found to have developed cavitation concerning for worsening vasculitis or an opportunistic fungal infection or combination of both. Given the risk of severe complications from opportunistic fungal infections, close monitoring and prophylactic antifungal therapy should be considered. Further studies are needed to evaluate the benefit of prophylaxis in this patient population.
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Affiliation(s)
- Sofia Lakhdar
- 5925Icahn School of Medicine at Mount Sinai / 24843NYC Health + Hospitals Queens, Jamaica, NY, USA
| | - Mahmoud Nassar
- 5925Icahn School of Medicine at Mount Sinai / 24843NYC Health + Hospitals Queens, Jamaica, NY, USA
| | - Shabnam Shatabdi
- 5925Icahn School of Medicine at Mount Sinai / 24843NYC Health + Hospitals Queens, Jamaica, NY, USA
| | - Chandan Buttar
- 5925Icahn School of Medicine at Mount Sinai / 24843NYC Health + Hospitals Queens, Jamaica, NY, USA
| | - Adriana Abrudescu
- 5925Icahn School of Medicine at Mount Sinai / 24843NYC Health + Hospitals Queens, Jamaica, NY, USA
| | - Theo Trandafirescu
- 5925Icahn School of Medicine at Mount Sinai / 24843NYC Health + Hospitals Queens, Jamaica, NY, USA
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13
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Koritala T, Mene-Afejuku TO, Schaefer M, Dondapati L, Pleshkova Y, Yasmin F, Mushtaq HA, Khedr A, Adhikari R, Al Mutair A, Alhumaid S, Rabaan AA, Al-Tawfiq JA, Jain NK, Khan SA, Kashyap R, Surani S. Granulomatous Polyangiitis With Renal Involvement: A Case Report and Review of Literature. Cureus 2021; 13:e19814. [PMID: 34963834 PMCID: PMC8695666 DOI: 10.7759/cureus.19814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consolidation, and bronchoscopy findings of friable tissue that was not amenable for biopsy. Methylprednisolone and rituximab (RTX) were administered, which resulted in marked clinical improvement. Therefore, a keen eye for details is necessary to diagnose GPA early, which can improve disease outcomes dramatically.
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Affiliation(s)
| | | | | | - Lavanya Dondapati
- Internal Medicine, Dr. N.T.R University of Health Sciences, Vijayawada, IND
| | | | - Farah Yasmin
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Anwar Khedr
- Critical Care Medicine, Mayo Clinic, Mankato, USA.,Medicine, Tanta University Faculty of Medicine, Tanta, EGY
| | - Ramesh Adhikari
- Hospital Medicine, Franciscan Health, Lafayette, USA.,Geriatrics, Brown University, Providence, USA
| | - Abbas Al Mutair
- Emergency Medicine, Almoosa Specialist Hospital, Al-Ahsa, SAU
| | - Saad Alhumaid
- Pharmaceutical Care, Al-Ahsa Health Cluster, Al-Ahsa, SAU
| | - Ali A Rabaan
- Molecular Microbiology, Johns Hopkins Aramco Healthcare, Dhahran, SAU
| | | | | | | | - Rahul Kashyap
- Anesthesiology and Critical Care, Mayo Clinic, Rochester, USA
| | - Salim Surani
- Anesthesiology, Mayo Clinic, Rochester, USA.,Medicine, Texas A&M University, College Station, USA.,Medicine, University of North Texas Dallas, Dallas, USA.,Internal Medicine, Pulmonary Associates of Corpus Christi, Corpus Christi, USA.,Clinical Medicine, University of Houston, Houston, USA
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14
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Yamakawa H, Sato S, Nakamura T, Nishizawa T, Kawabe R, Oba T, Horikoshi M, Akasaka K, Amano M, Kuwano K, Sasaki H, Matsushima H. Prognostic value of radiological findings indeterminate for UIP pattern and anterior upper lobe honeycomb-like lesion in chronic fibrosing interstitial lung disease associated with MPO-ANCA. BMC Pulm Med 2021; 21:346. [PMID: 34732182 PMCID: PMC8565010 DOI: 10.1186/s12890-021-01718-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) is often positive in patients with interstitial lung disease (ILD), which is also often present in patients with microscopic polyangiitis (MPA). A possible association between MPO-ANCA, MPA, and idiopathic ILD remains unclear. The objective of this study was to determine whether high-resolution computed tomography (HRCT) classification based on recent idiopathic pulmonary fibrosis guideline and specific CT findings can obtain new knowledge of prognostic factors in all MPO-ANCA-positive patients with ILD including both idiopathic ILD and MPA-ILD. Methods We analyzed 101 consecutive MPO-ANCA-positive patients with respiratory disease. We assessed the diagnostic accuracy of CT findings, HRCT pattern, and specific radiological signs. Prognostic predictors were determined using Cox regression models. Results Subjects with chronic ILD included 22 patients with MPA-ILD and 39 patients with ILD but without MPA. A quarter of the patients were radiological indeterminate for usual interstitial pneumonia (UIP) pattern, which resulted in a better prognosis than that for UIP pattern. “Increased attenuation around honeycomb and traction bronchiectasis” and “anterior upper lobe honeycomb-like lesion” were found to be highly frequent radiological findings (39% and 30%, respectively). In addition, the latter finding was a significant negative prognostic factor. Conclusions Radiological indeterminate for UIP was a useful HRCT classification in MPO-ANCA-positive patients with ILD. In addition, anterior upper lobe honeycomb-like lesion was found to be specific radiological finding that was a significant prognostic factor. The present results might aid in the assessment of appropriate strategies of diagnosis in these patients.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan. .,Department of Respiratory Medicine, Tokyo Jikei University Hospital, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiko Nakamura
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Masanobu Horikoshi
- Department of Rheumatology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroki Sasaki
- Department of Radiology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
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15
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Mosakowska M, Kania DB, Szamotulska K, Rymarz A, Niemczyk S. Assessment of the correlation of commonly used laboratory tests with clinical activity, renal involvement and treatment of systemic small-vessel vasculitis with the presence of ANCA antibodies. BMC Nephrol 2021; 22:290. [PMID: 34445984 PMCID: PMC8390216 DOI: 10.1186/s12882-021-02495-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 08/09/2021] [Indexed: 11/24/2022] Open
Abstract
Background The aim of the study was to assess the correlation of commonly used laboratory tests with clinical activity, degree of kidney involvement and treatment of systemic small-vessel vasculitis with the presence of ANCA antibodies. Methods The study included 28 patients with active AAV (BVAS ≥ 3). The following tests were performed: MPO-ANCA, PR3-ANCA, peripheral blood count, ESR, CRP, procalcitonin, creatinine, GFR, urea, albumin, fibrinogen, d-dimer, components of the C3 and C4 complement systems, urinalysis with sediment evaluation and diurnal proteinuria. The assessments were conducted twice: at study entry (A0) and after 6 months (A6) (BVAS = 0). Results At the time of inclusion in the study, the mean creatinine concentration was 3.39 mg/dl (GFR 33.17 ml/min/1.73 m²), after achieving remission in 11 patients (39.3 %) GFR remained below 30 ml/min/1.73 m², 4 patients (14.3 %) continued renal replacement therapy, and 3 patients (10.7 %) with advanced renal failure died. Microscopic hematuria occurred in 80.9 % of the studied population, withdrew in most patients, strongly correlated with renal involvement p < 0.001 and was not related to disease severity p = 0.147. CRP, ESR, fibrinogen, d-dimer, albumin and hemoglobin in the peripheral blood showed a strong correlation with the clinical activity of AAV and well identified severe patients. High procalcitonin concentrations correlated with a severe form of the disease, pulmonary involvement with respiratory failure and alveolar hemorrhage (mean 3.41 ng/ml, median 0.91 ng/ml, SD 7.62, p = 0.000), and were associated with the occurrence of infectious complications and the need to administer antibiotic therapy. ANCA antibodies were useful in the evaluation of patients with AAV, the amount of antibodies did not correlate with the severity of vasculitis (p = 0.685) and the results in many patients did not match the expected assumptions. Conclusions CRP, ESR, fibrinogen, d-dimers, albumin and hemoglobin in the peripheral blood correlate well with the activity of vasculitis and identify severe patients. The resolution of microscopic hematuria suggests remission of the disease in the renal area. Procalcitonin may be slightly increased in patients with active AAV without infection, high concentrations are strongly associated with infectious complications. ANCA antibodies should always be interpreted in the context of the observed clinical symptoms.
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Affiliation(s)
- Magdalena Mosakowska
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141, Warsaw, Poland.
| | - Dorota Brodowska Kania
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141, Warsaw, Poland
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, Institute of Mother and Child, 17a, Kasprzaka Street, 01-211, Warsaw, Poland
| | - Aleksandra Rymarz
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141, Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141, Warsaw, Poland
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16
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Oki R, Hirakawa Y, Oda Y, Nakamura M, Honda K, Abe H, Domoto Y, Miyashita N, Nagase T, Nangaku M. Renal-limited ANCA-associated vasculitis during erlotinib treatment for lung carcinoma. CEN Case Rep 2021; 11:67-72. [PMID: 34309804 DOI: 10.1007/s13730-021-00632-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022] Open
Abstract
Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) had clinical success in the treatment of non-small cell lung carcinoma (NSCLC). An effect of this drug on kidney has not been clarified and the occurrence of glomerulonephritis related to EGFR-TKI has rarely been reported. We present the case of a 71-year-old man with NSCLC who developed proteinuria and microscopic hematuria with the rise in a titer of MPO-ANCA, when 2 years and 3 months passed since the initiation of erlotinib, one of oral EGFR-TKI. Two serial biopsies support that ANCA-associated vasculitis may have been modified by the persistent use of erlotinib. We initiated intravenous pulse therapy with methylprednisolone followed by oral prednisone. The proteinuria has decreased and serum CRP was normalized. However, the serum creatinine level and hematuria did not change during the treatment period. While EGFR inhibition is implicated in protective control for glomerulonephritis, it may exacerbate vasculitis. Close monitoring of the kidney function and urinary findings is required during the use of EGFR inhibitors, such as erlotinib, because it may cause renal adverse events.
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Affiliation(s)
- Rikako Oki
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yosuke Hirakawa
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yasuhiro Oda
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Motonobu Nakamura
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kenjiro Honda
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Abe
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yukako Domoto
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoya Miyashita
- Department of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate School of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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17
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McClure ME, Zhu Y, Smith RM, Gopaluni S, Tieu J, Pope T, Kristensen KE, Jayne DRW, Barrett J, Jones RB. Long-term maintenance rituximab for ANCA-associated vasculitis: relapse and infection prediction models. Rheumatology (Oxford) 2021; 60:1491-1501. [PMID: 33141217 PMCID: PMC7937025 DOI: 10.1093/rheumatology/keaa541] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/14/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Following a maintenance course of rituximab (RTX) for ANCA-associated vasculitis (AAV), relapses occur on cessation of therapy, and further dosing is considered. This study aimed to develop relapse and infection risk prediction models to help guide decision making regarding extended RTX maintenance therapy. METHODS Patients with a diagnosis of AAV who received 4-8 grams of RTX as maintenance treatment between 2002 and 2018 were included. Both induction and maintenance doses were included; most patients received standard departmental protocol consisting of 2× 1000 mg 2 weeks apart, followed by 1000 mg every 6 months for 2 years. Patients who continued on repeat RTX dosing long-term were excluded. Separate risk prediction models were derived for the outcomes of relapse and infection. RESULTS A total of 147 patients were included in this study with a median follow-up of 63 months [interquartile range (IQR): 34-93]. Relapse: At time of last RTX, the model comprised seven predictors, with a corresponding C-index of 0.54. Discrimination between individuals using this model was not possible; however, discrimination could be achieved by grouping patients into low- and high-risk groups. When the model was applied 12 months post last RTX, the ability to discriminate relapse risk between individuals improved (C-index 0.65), and once again, clear discrimination was observed between patients from low- and high-risk groups. Infection: At time of last RTX, five predictors were retained in the model. The C-index was 0.64 allowing discrimination between low and high risk of infection groups. At 12 months post RTX, the C-index for the model was 0.63. Again, clear separation of patients from two risk groups was observed. CONCLUSION While our models had insufficient power to discriminate risk between individual patients they were able to assign patients into risk groups for both relapse and infection. The ability to identify risk groups may help in decisions regarding the potential benefit of ongoing RTX treatment. However, we caution the use of these prediction models until prospective multi-centre validation studies have been performed.
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Affiliation(s)
- Mark E McClure
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Yajing Zhu
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rona M Smith
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Seerapani Gopaluni
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Joanna Tieu
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Tasneem Pope
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Karl Emil Kristensen
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jessica Barrett
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
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18
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Cox CW, Bartholmai BJ, Baqir M, Geske JR, Specks U. Pulmonary Low Attenuation Areas on CT in ANCA-associated Vasculitis: A quantitative and semi-quantitative analysis correlated with pulmonary function testing for obstructive airway disease. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2021; 37:e2020016. [PMID: 33597803 PMCID: PMC7883516 DOI: 10.36141/svdld.v37i4.9584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 12/02/2020] [Indexed: 11/12/2022]
Abstract
Objective: A subset of ANCA-associated vasculitis (AAV) patients are known to manifest obstructive airway disease. Using low attenuation areas (LAA) in the lung on HRCT as an imaging marker for obstructive airway disease, we analyze HRCT studies in AAV patients compared to a matched non-AAV group using visual semi-quantitative and automated quantitative analysis for presence and severity of LAA. Furthermore, HRCT and pulmonary function testing are compared to assess agreement between tests for airway obstruction. Materials and Methods: 100 randomly selected AAV patients with HRCT were compared to 100 best-fit matched control subjects. HRCT cases were visually assessed for LAA, along with additional pulmonary patterns. Automated quantitative software analyzed images for texture features and volume of attenuation values of −950 HU or less (e-950). Evidence of obstructive airway disease established by pulmonary function testing, when available, was compared to HRCT analysis for LAA. Additional clinical information, diagnostic testing and mortality data were also compared. Results: Both study groups were comprised of 57 females and 43 males with 35 smokers averaging 10.7 pk/yrs, with average age for the AAV and control groups being 59.4 yrs and 61.9 yrs, respectively. Visually, 46 AAV patients demonstrated LAA on HRCT compared to 25 control patients (p=0.0017) with the difference in LAA presence entirely within the non-smoking subgroup (25 to 3, respectively, p=<0.0001). Quantitatively, greater than 5% e-950 demonstrated similar significant differences between AAV (36/100) and controls (19/100) (p=0.0065), predominantly in non-smokers (p=0.006). Obstruction on PFTs was significantly increased in AAV (p=0.002) with moderate agreement of obstructive disease with visual LAA on CT (Kappa 0.509). Of the obstructive disease metrics, visual LAA on CT correlated best with mortality (p=0.0085). Conclusion: Visual LAA and automated quantitative analysis for e-950 on HRCT demonstrate statistically significant increases in AAV patients compared to age, gender and smoking matched controls, with differences primarily seen in the non-smoking subset. AAV revealed statistically significant greater obstructive pulmonary disease on PFTs (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020016)
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19
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Montero M, Mom T, Smets P, Gilain L. Very painful acute frontal sinusitis revealing granulomatosis with polyangiitis. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:509-511. [PMID: 31395462 DOI: 10.1016/j.anorl.2019.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitis of small and medium-sized vessels comprising inflammation of the vessel wall and perivascular and extravascular granulomas, frequently presenting in the form of chronic sinusitis. OBSERVATION We report the case of a 27-year-old man who presented with very painful acute frontal sinusitis that was managed medically and surgically. The symptoms rapidly recurred despite treatment and CT scan demonstrated diffuse thickening of the sinus mucosa. Anti-proteinase 3 ANCA were positive. Biopsy of a pulmonary nodule confirmed the diagnosis of GPA. The patient was treated with corticosteroids in combination with rituximab, resulting in improvement of the clinical, laboratory and CT signs. DISCUSSION In the presence of persistent, acute, localized sinusitis despite appropriate treatment, associated systemic signs and/or the presence of other signs suggestive of GPA, the ENT surgeon must request a targeted work-up. In the absence of treatment, GPA can be fatal within a few months. However, with currently available treatment, remission is obtained in 80% of cases with a 75% 10-year survival rate.
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Affiliation(s)
- M Montero
- Service d'ORL et chirurgie cervico-faciale, CHU de Clermont-Ferrand, 58, rue Montalembert, Clermont-Ferrand, France.
| | - T Mom
- Service d'ORL et chirurgie cervico-faciale, CHU de Clermont-Ferrand, 58, rue Montalembert, Clermont-Ferrand, France
| | - P Smets
- Service de médecine interne, CHU de Clermont-Ferrand, 58, rue Montalembert, Clermont-Ferrand, France
| | - L Gilain
- Service d'ORL et chirurgie cervico-faciale, CHU de Clermont-Ferrand, 58, rue Montalembert, Clermont-Ferrand, France
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20
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Grygiel-Górniak B, Limphaibool N, Perkowska K, Puszczewicz M. Clinical manifestations of granulomatosis with polyangiitis: key considerations and major features. Postgrad Med 2018; 130:581-596. [PMID: 30071173 DOI: 10.1080/00325481.2018.1503920] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) presents a wide spectrum of manifestations from the common respiratory symptoms to infrequent neurological and cardiac complications. The challenge in diagnosis and management makes the rapidly progressive disorder one of the most challenging dilemmas in clinical medicine. METHOD An extensive electronic literature search was done using multiple databases (e.g. PubMed) from January 2007 to August 2017 to gather information on the etiopathogenesis, clinical presentation, and current treatment management plan of GPA. The language used was English. Search items included 'Granulomatosis with Polyangiitis symptoms,' 'Wegener's Granulomatosis,' and 'Treatment of Granulomatosis with Polyangiitis' for the databases. Inclusion criteria consisted of published articles in the English language which reported on the clinical manifestations of GPA, as well as on the treatment of the disease. Exclusion criteria included articles that: (1) did not specifically report on GPA vasculitis but also focused on discussion of other vasculitis such as MPA or Churg-Strauss; (2) reported on treatment/symptoms of GPA prior to 2007. RESULT This review provides an overview of work undertaken in key areas of GPA research, including its complex multifactorial etiology, clinical manifestations, treatment strategies, and treatment-related adverse effects. CONCLUSION Major advances in the understanding and treatment of GPA over recent decades have contributed to the notable decline in morbidity and mortality of patients. The ultimate goal is an improved prognosis through outcome measures which assesses the disease control with minimal adverse effects of intensive immunosuppressive regimens, an integral part of the clinical approach to improve the quality of life of GPA patients.
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Affiliation(s)
- Bogna Grygiel-Górniak
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Nattakarn Limphaibool
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Katarzyna Perkowska
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Mariusz Puszczewicz
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
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21
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Sun XJ, Wang C, Zhang LX, Yu F, Chen M, Zhao MH. Sphingosine-1-phosphate and its receptors in anti-neutrophil cytoplasmic antibody-associated vasculitis. Nephrol Dial Transplant 2018; 32:1313-1322. [PMID: 28206609 DOI: 10.1093/ndt/gfw427] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 11/02/2016] [Indexed: 11/13/2022] Open
Abstract
Background C5a plays a crucial role in anti-neutrophil cytoplasmic antibody (ANCA)-mediated neutrophil recruitment and activation. Our previous studies found that the interaction between sphingosine-1-phosphate (S1P) and C5a plays an important role in the ANCA-mediated activation of neutrophils. In the current study, the expression levels of S1P in plasma and its receptors (S1PR1-5) in kidneys were analysed in patients with ANCA-associated vasculitis (AAV). Methods Plasma samples from 32 AAV patients in active stage and 20 AAV patients in remission were collected. The plasma levels of S1P were determined by an enzyme-linked immunosorbent assay (ELISA). The expression of S1PR1-5 in the renal specimens from 24 AAV patients was detected by immunohistochemistry. The associations of the plasma levels of S1P and renal expression of S1PRs with clinical and pathological parameters were analysed. Results The level of plasma S1P was significantly higher in AAV patients in active stage than it was in both patients in remission and in normal controls. Correlation analysis showed that the plasma levels of S1P correlated with the initial serum creatinine levels (r = 0.502, P = 0.003) and inversely correlated with the estimated glomerular filtration rate (eGFR; r = -0.358, P = 0.044) in AAV patients. Double-labelling immunofluorescence assay suggested that S1PR1-5 were expressed on endothelial cells in the glomeruli and that S1PR1, 4 and 5 were expressed on neutrophils. Conclusions In AAV patients, the circulating S1P levels were elevated and the renal expression of S1PR2-5 was upregulated. The levels of circulating S1P and the renal expression of S1PR were associated with the renal involvement and disease activity of AAV.
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Affiliation(s)
- Xiao-Jing Sun
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Peking-Tsinghua Center for Life Sciences, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Chen Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Peking-Tsinghua Center for Life Sciences, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Lu-Xia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Peking-Tsinghua Center for Life Sciences, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Peking-Tsinghua Center for Life Sciences, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Peking-Tsinghua Center for Life Sciences, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Peking-Tsinghua Center for Life Sciences, No.8, Xishiku Street, Xicheng District, Beijing, China
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22
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Muray Cases S, Alcázar Fajardo C, Cabezuelo Romero JB. Severe pulmonary emphysema in a young patient with vasculitis associated with proteinase-3 anti-neutrophil cytoplasmic antibodies (PR3-ANCA). Arch Bronconeumol 2018; 54:S0300-2896(17)30438-6. [PMID: 29357994 DOI: 10.1016/j.arbres.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/15/2017] [Accepted: 12/03/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Salomé Muray Cases
- Servicio de Nefrología, Hospital General Universitario Reina Sofía, Murcia, España.
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23
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Rees DO, Gunavardhan A, Glover DA. Granulomatosis with polyangiitis: an unusual cause of acute liver injury. BMJ Case Rep 2018; 2018:bcr-2017-222464. [PMID: 29298788 DOI: 10.1136/bcr-2017-222464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) causing liver injury is rare. Where liver biopsies have been taken findings are not always typical and diagnosis can be challenging. Here, we present a case of a 58-year-old male who on admission to hospital was found to have acute liver injury. Diagnosis of liver involvement in GPA is supported by liver histology and the resolution of hepatitis after commencement of immunosuppressive treatment.
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Affiliation(s)
- David Owen Rees
- Nephrology and Transplant Department, Cardiff and Vale University Health Board, Cardiff, UK
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24
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Wuhrer M, Stavenhagen K, Koeleman CAM, Selman MHJ, Harper L, Jacobs BC, Savage COS, Jefferis R, Deelder AM, Morgan M. Skewed Fc Glycosylation Profiles of Anti-proteinase 3 Immunoglobulin G1 Autoantibodies from Granulomatosis with Polyangiitis Patients Show Low Levels of Bisection, Galactosylation, and Sialylation. J Proteome Res 2015; 14:1657-65. [DOI: 10.1021/pr500780a] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Manfred Wuhrer
- Center
for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
- Division
of BioAnalytical Chemistry, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department
of Molecular Cell Biology and Immunology, VU University Medical Center, 1081 BT Amsterdam, The Netherlands
| | - Kathrin Stavenhagen
- Center
for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
- Division
of BioAnalytical Chemistry, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Carolien A. M. Koeleman
- Center
for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Maurice H. J. Selman
- Center
for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Lorraine Harper
- School
of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, U.K
| | - Bart C. Jacobs
- Department
of Immunology and Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3015 CE Rotterdam, The Netherlands
| | - Caroline O. S. Savage
- School
of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, U.K
| | - Roy Jefferis
- School
of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, U.K
| | - André M. Deelder
- Center
for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Matthew Morgan
- School
of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, U.K
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25
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Salama AD, Rees AJ. Autoantibodies in anti-neutrophil cytoplasm antibody-associated vasculitis. Nephrol Dial Transplant 2014; 29:1105-7. [PMID: 24459139 DOI: 10.1093/ndt/gft526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alan D Salama
- UCL Centre for Nephrology, Royal Free Hospital, London, UKClinical Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Andrew J Rees
- UCL Centre for Nephrology, Royal Free Hospital, London, UKClinical Department of Pathology, Medical University of Vienna, Vienna, Austria
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26
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Isa H, Lightman S, Pusey CD, Taylor SRJ. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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27
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Gregorini M, Maccario R, Avanzini MA, Corradetti V, Moretta A, Libetta C, Esposito P, Bosio F, Dal Canton A, Rampino T. Antineutrophil cytoplasmic antibody-associated renal vasculitis treated with autologous mesenchymal stromal cells: evaluation of the contribution of immune-mediated mechanisms. Mayo Clin Proc 2013; 88:1174-9. [PMID: 24079687 DOI: 10.1016/j.mayocp.2013.06.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/28/2013] [Accepted: 06/07/2013] [Indexed: 02/07/2023]
Abstract
We report the first case of renal antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis treated with autologous mesenchymal stromal cells (MSCs). A 73-year-old man was admitted to the hospital for malaise, weight loss, and oliguria. His serum creatinine level was 2.7 mg/dL but it rapidly increased to 7.8 mg/dL; urinalysis showed proteinuria and hematuria, and the ANCA to myeloperoxidase with a perinuclear pattern (pANCA) titer was high (132 IU/mL). Renal biopsy showed necrotizing crescentic glomerulonephritis. Standard immunosuppressive therapy (cyclophosphamide and corticosteroids) was ineffective. Rituximab therapy was started, but it was discontinued after the third dose to minimize the risk of systemic spread of a severe oral Candida infection and to prevent superinfections that were facilitated by leukopenia. The patient received autologous MSCs, 1.5 × 10(6) cells/kg body weight, intravenously. After 7 days, his serum creatinine level decreased to 2.2 mg/dL, pANCA titer decreased to 75 IU/mL, and urinalysis findings normalized. Eight months later, he received a second MSC infusion because his serum creatinine level increased. In 1 week, his creatinine level decreased to 1.9 mg/dL and his pANCA titer decreased to 14 IU/mL. Immunosuppressive therapy was subsequently withdrawn. At the last follow-up visit, 12 months after the second MSC infusion, the patient remained in clinical remission without any therapy. Infusion of MSCs induced expansion of the T-lymphocyte subset expressing a regulatory T-cell phenotype (CD4(+)CD25(+)Foxp3(+)) and a notable reduction in interferon-γ, interleukin 6, and tumor necrosis factor serum levels.
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Affiliation(s)
- Marilena Gregorini
- Unità Complessa di Nefrologia Dialisi e Trapianto, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Policlinico San Matteo e Università di Pavia, Pavia, Italy
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28
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Abstract
The pulmonary vasculitides are a rare group of heterogeneous disorders unified by the histopathologic finding of inflammation and destruction of the blood vessel wall. Diagnosis of these disorders is exceptionally challenging, given their highly variable clinical presentation, their relative rarity, and the overlap of the signs and symptoms of vasculitis with much more common entities. However, advances in the management of vasculitis allow for accurate diagnosis, risk stratification in the individual patient, and the implementation of evidence-based, effective pharmacologic therapies. This concise clinical review addresses the diagnosis and management of the patient with pulmonary vasculitis and provides an up-to-date review of the state of the field.
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Affiliation(s)
- Stephen K Frankel
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA.
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29
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Couser WG. Basic and translational concepts of immune-mediated glomerular diseases. J Am Soc Nephrol 2012; 23:381-99. [PMID: 22282593 DOI: 10.1681/asn.2011030304] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Genetically modified immune responses to infections and self-antigens initiate most forms of GN by generating pathogen- and danger-associated molecular patterns that stimulate Toll-like receptors and complement. These innate immune responses activate circulating monocytes and resident glomerular cells to release inflammatory mediators and initiate adaptive, antigen-specific immune responses that collectively damage glomerular structures. CD4 T cells are needed for B cell-driven antibody production that leads to immune complex formation in glomeruli, complement activation, and injury induced by both circulating inflammatory and resident glomerular effector cells. Th17 cells can also induce glomerular injury directly. In this review, information derived from studies in vitro, well characterized experimental models, and humans summarize and update likely pathogenic mechanisms involved in human diseases presenting as nephritis (postinfectious GN, IgA nephropathy, antiglomerular basement membrane and antineutrophil cytoplasmic antibody-mediated crescentic GN, lupus nephritis, type I membranoproliferative GN), and nephrotic syndrome (minimal change/FSGS, membranous nephropathy, and C3 glomerulopathies). Advances in understanding the immunopathogenesis of each of these entities offer many opportunities for future therapeutic interventions.
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Affiliation(s)
- William G Couser
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
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30
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Current world literature. Curr Opin Ophthalmol 2011; 22:523-9. [PMID: 22005482 DOI: 10.1097/icu.0b013e32834cb7d7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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