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Liu W, Tian G, Chen C, Zhang M, Chen Z, Chen T, Lin Z, Wu W, Wu Y, Wu K, Liu Q. Application of biological agents in the treatment of anti-neutrophil cytoplasmic antibody-associated vasculitis. Front Pharmacol 2024; 15:1378384. [PMID: 38831887 PMCID: PMC11144864 DOI: 10.3389/fphar.2024.1378384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/19/2024] [Indexed: 06/05/2024] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been traditionally treated using glucocorticoids and immunosuppressants. However, these treatment modes are associated with high recurrence AAV rates and adverse reactions. Therefore, treatment strategies for AAV need to be urgently optimized. The efficacy and safety of biological agents in the treatment of vasculitis have been clinically validated. This review comprehensively summarizes the evidence-based support for the clinical use of existing biological agents in AAV. The findings reveal that multiple biological agents not only effectively reduce the adverse reactions associated with glucocorticoids and immunosuppressants but also demonstrate significant therapeutic efficacy. Notably, rituximab, an anti-CD20 antibody, has emerged as a first-line treatment option for AAV. Mepolizumab has shown promising results in relapsed and refractory eosinophilic granulomatosis with polyangiitis. Other biological agents targeting cytokines, complement, and other pathways have also demonstrated clinical benefits in recent studies. The widespread application of biological agents provides new insights into the treatment of AAV and is expected to drive further clinical research. These advancements not only improve patient outcomes but also offer more possibilities and hope in the field of AAV treatment.
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Affiliation(s)
- Weijun Liu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Guanyuan Tian
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Chao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Mingying Zhang
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Zhanmao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Tietao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Zhibin Lin
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Wuzhong Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Yiqaing Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Kefei Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Qinghua Liu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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Guo Y, Zhao H, Ren M, Wang Y, Wang L, Tang L. Efficacy and safety of rituximab in elderly patients with membranous nephropathy. Front Pharmacol 2023; 14:1323334. [PMID: 38186651 PMCID: PMC10771833 DOI: 10.3389/fphar.2023.1323334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Objectives: Advancing age is a risk factor for treatment-related side effects and mortality in membranous nephropathy (MN) patients treated with traditional immunosuppressive regimens. This study aimed to determine the efficacy and safety of rituximab (RTX) in the treatment of elderly patients with MN. Methods: We performed a single center retrospective review of 37 consecutive MN patients aged 70 and older at the time of RTX infusion. We also enrolled 76 young patients (<70 years old) with MN as the control group. We assessed clinical and laboratory indices, remission rates, and adverse events at RTX infusion, 3 months, and last visit. Results: A total of 37 elderly patients with MN were included, with a median follow-up period of 15.50 (10.00, 24.40) months. Of the 37 patients, 75.68% were male, and mean age was 71.89 ± 2.47 years. At last visit, 7 (18.92%) patients achieved complete remission, and 26 (70.27%) patients achieved complete or partial remission. There were no differences in the complete remission rate and complete or partial remission rate at last visit compared to young patients (26.32% vs. 18.92%, p = 0.387; 85.53% vs. 70.27%, p = 0.055). After RTX treatment, three of 6 elderly patients with pneumonia died due to ineffective treatment of the infection in RTX therapy courses. The results of multivariant regression analysis showed that elderly patients have an increased risk of serious infection, compared with patients younger than 70 years (OR = 32.874, 95% CI 1.300-831.490, p = 0.034). For each increase of 1 g/L in serum albumin, the risk of serious infection would decrease by 43.2% (OR = 0.568, 95% CI 0.334-0.969, p = 0.038). Conclusion: This study demonstrates that RTX is effective in the treatment of elderly patients with MN. However, we also observed a high incidence of infectious complications. Our experience was limited by its retrospective design and relatively small sample size, and further randomized controlled studies with large sample size are needed to confirm our preliminary findings.
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Affiliation(s)
- Yanhong Guo
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Huayan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Mingjing Ren
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yulin Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Liuwei Wang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lin Tang
- Department of Nephropathy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Aqeel F, Xu L, Salas A, Wen Y, Eid SM, Geetha D. Outcomes of remission induction therapy for ANCA-associated vasculitis in the elderly. Clin Rheumatol 2023; 42:2427-2435. [PMID: 37225927 PMCID: PMC11128295 DOI: 10.1007/s10067-023-06644-2] [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: 01/25/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Treatment regimens combining glucocorticoids with cyclophosphamide or rituximab or both are used to induce remission in ANCA-associated glomerulonephritis (ANCA-GN). There is a paucity of data on the efficacy and safety of these regimens in elderly patients with ANCA-GN. This study aimed to examine outcomes and adverse events in elderly AAV patients with three induction regimens: cyclophosphamide (CYC), cyclophosphamide and rituximab (CYC + RTX), and rituximab (RTX). METHODS This single-center retrospective cohort study included patients 60 years and older diagnosed with ANCA-GN. Baseline characteristics and outcomes across several clinical parameters were recorded and compared for significance using Kruskal-Wallis test, Chi-squared test, Fisher exact test, univariate, and multivariate logistic regression as appropriate. Cox proportional hazard regression model was used for survival analysis. RESULTS Seventy-five patients were included. The mean (SD) age at diagnosis was 70 (± 6) years. The mean (SD) follow-up duration was 5.17 (± 3.47) years. Remission induction therapy with glucocorticoids plus CYC was used in 25 patients, glucocorticoids plus CYC and RTX in 12 patients, and glucocorticoids plus RTX in 38 patients. RTX-treated patients had a higher baseline estimated glomerular filtration ratio (eGFR) (p = 0.00009). High remission rates were achieved in all groups (100% vs. 100% vs. 94.6% respectively, p = 0.368). The incidence of end-stage renal disease (ESRD) at one year was 8% among all groups (p = 0.999). There was no difference in the number of infections requiring hospitalization (p = 0.822), but a statistical difference in leukopenia was noted (32% vs. 25% vs. 3% respectively, p = 0.005). The use of RTX only was associated with reduced leukopenia (aOR = 0.1, 95% CI = 0.005-0.8) after adjusting for other variables. CONCLUSIONS CYC, CYC + RTX, and RTX are equally effective for remission induction in elderly patients with ANCA-GN. Induction therapy with RTX only was associated with a lower risk of leukopenia compared to CYC-containing regimens. Infections requiring hospitalization were similar among all groups. End-stage kidney disease at one year was comparable among the 3 groups. Key Points • Cyclophosphamide, Rituximab, and Cyclophosphamide+Rituximab are equally effective in remission induction in elderly patients with ANCA glomerulonephritis. • The use of Rituximab only was associated with a lower risk of bone marrow suppression compared to Cyclophosphamide only. • More information is needed on the comparative safety of induction therapy strategies in elderly ANCA glomerulonephritis patients.
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Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Lillian Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio Salas
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yumeng Wen
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaker M Eid
- Department of Internal Medicine, Division of Hospitalist Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kanaoka K, Ihara S, Nakatani T, Minami S. Rituximab for the Treatment of Anti-glomerular Basement Membrane Disease with Isolated Diffuse Alveolar Hemorrhage. Intern Med 2023; 62:1971-1975. [PMID: 36261370 PMCID: PMC10372275 DOI: 10.2169/internalmedicine.0166-22] [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: 04/17/2022] [Accepted: 09/05/2022] [Indexed: 04/07/2023] Open
Abstract
Anti-glomerular basement membrane (GBM) disease with isolated diffuse alveolar hemorrhage (DAH) is rare. We herein report a 91-year-old man admitted with hypoxia and diagnosed with anti-GBM disease with DAH based on positive bronchoalveolar lavage and serum antibody test results. There was no renal involvement. Although remission was achieved using glucocorticoids and plasmapheresis, the patient experienced DAH relapse one week after the last plasmapheresis. Rituximab 375 mg/m2 was administered 4 times weekly; thereafter, DAH relapse was not observed, and the glucocorticoid dosage was tapered. Rituximab was thus effective in treating anti-GBM disease with isolated DAH in an extremely elderly patient.
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Affiliation(s)
- Kensuke Kanaoka
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
| | - Shoichi Ihara
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
| | - Takeshi Nakatani
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
| | - Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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Thietart S, Karras A, Augusto JF, Philipponnet C, Carron PL, Delbrel X, Mesbah R, Blaison G, Duffau P, El Karoui K, Smets P, London J, Mouthon L, Guillevin L, Terrier B, Puéchal X. Evaluation of Rituximab for Induction and Maintenance Therapy in Patients 75 Years and Older With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. JAMA Netw Open 2022; 5:e2220925. [PMID: 35802372 PMCID: PMC9270693 DOI: 10.1001/jamanetworkopen.2022.20925] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Older patients are underrepresented in studies of rituximab for the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Little is known about outcomes and adverse events associated with the use of rituximab therapy among patients 75 years and older with ANCA-associated vasculitis. OBJECTIVE To examine outcomes and adverse events associated with the use of rituximab therapy in patients 75 years and older with ANCA-associated vasculitis, specifically granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study involved 93 patients 75 years and older with ANCA-associated vasculitis from 36 university and nonuniversity hospitals in France. Data were obtained from the French Vasculitis Study Group database between January 1, 2000, and July 1, 2018, and a call for observation sent to French Vasculitis Study Group members on June 6, 2019. Data analysis was performed from November 15 to December 31, 2021. Inclusion criteria included a diagnosis of GPA or MPA according to European Medicines Agency classification criteria and receipt of treatment with rituximab after age 75 years. Patients were excluded if they were missing relevant clinical or biological data. Data on race and ethnicity were not reported because inclusion of this information was not authorized by the ethics committee. EXPOSURE At least 1 infusion of rituximab as induction or maintenance therapy. MAIN OUTCOMES AND MEASURES Occurrence of remission, relapse, drug discontinuation, death, and serious infections (including types of serious infections). RESULTS Of 238 patients screened, 93 were included (median [IQR] age, 79.4 [76.7-83.1] years; 51 women [54.8%]); 52 patients (55.9%) had a diagnosis of GPA, and 41 (44.1%) had a diagnosis of MPA. Thirty patients (32.3%) received rituximab as induction therapy in combination with high-dose glucocorticoid regimens, 27 (29.0%) received rituximab as maintenance therapy, and 36 (38.7%) received rituximab as both induction and maintenance therapy. The median (IQR) follow-up was 2.3 (1.1-4.0) years. Among 66 patients who received rituximab as induction therapy, 57 (86.4%) achieved remission, and 2 (3.0%) experienced relapses. The incidence of serious infection was significantly higher when rituximab was used as induction therapy vs maintenance therapy (46.6 [95% CI, 24.8-79.7] per 100 patient-years vs 8.4 [95% CI, 3.8-15.9] per 100 patient-years; P = .004). Most infections (12 of 22 [54.5%]) were gram-negative bacterial infections. The incidence of death was 19.7 (95% CI, 7.2-42.9) per 100 patient-years among those who received rituximab as induction therapy and 5.3 (95% CI, 1.9-11.6) per 100 patient-years among those who received rituximab as maintenance therapy. CONCLUSIONS AND RELEVANCE In this cohort study, rituximab therapy was associated with achievement and maintenance of remission in most patients 75 years and older with ANCA-associated vasculitis. The incidence of serious infections and death was high when rituximab was used as induction therapy in combination with high-dose glucocorticoid regimens but not when rituximab was used as maintenance therapy. Efforts might focus on reducing serious infections during the first months of therapy.
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Affiliation(s)
- Sara Thietart
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Department of Geriatrics, Sorbonne Université, Assistance Publique–Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université de Paris Cité, Paris, France
| | - Jean-François Augusto
- Department of Nephrology, Dialysis, and Transplantation, Centre Hospitalier Universitaire, Angers, France
| | - Carole Philipponnet
- Department of Nephrology, Centre Hospitalier Universitaire, Clermont-Ferrand, France
| | - Pierre-Louis Carron
- Department of Nephrology, Dialysis, and Transplantation, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France
| | - Xavier Delbrel
- Department of Internal Medicine, Centre Hospitalier de Pau, Pau, France
| | - Rafik Mesbah
- Department of Nephrology, Centre Hospitalier, Boulogne-sur-Mer, France
| | - Gilles Blaison
- Department of Internal Medicine, Louis Pasteur Colmar Hospital, Colmar, France
| | - Pierre Duffau
- Department of Internal Medicine, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Khalil El Karoui
- Department of Nephrology and Renal Transplantation, Hôpital Henri-Mondor, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Perrine Smets
- Department of Internal Medicine, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | - Jonathan London
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Department of Internal Medicine, Groupe Hospitalier Diaconesses Croix Saint Simon, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Assistance Publique–Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Assistance Publique–Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Assistance Publique–Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Assistance Publique–Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
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Thietart S, Beinse G, Smets P, Karras A, Philipponnet C, Augusto JF, El Karoui K, Mesbah R, Titeca-Beauport D, Hamidou M, Carron PL, Maurier F, Sacre K, Cohen P, Liozon E, Blanchard-Delaunay C, Kostianovsky A, Pagnoux C, Mouthon L, Guillevin L, Terrier B, Puéchal X. Patients of 75 years and over with ANCA-associated vasculitis have a lower relapse risk than younger patients: A multicentre cohort study. J Intern Med 2022; 291:350-363. [PMID: 34755398 DOI: 10.1111/joim.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) in older patients. We aim to study relapse risk of granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) in patients diagnosed after 75 years and compare it with those of patients aged 65-75 years. METHODS Data from AAV patients aged ≥65 years were extracted from the French Vasculitis Study Group (FVSG) database and from a call for observation to FVSG members. Cox and Fine-Gray models were used to assess relapse risk, taking death into account either as a censoring or a competing event, respectively. RESULTS The analysis included 219 patients aged ≥75 years (median 79) and 80 patients aged 65-75 years (median 70), of those 155 had GPA (52%), 136 MPA (45%), with 95 (32%) anti-proteinase 3 positivity and 179 (61%) anti-myeloperoxidase. Patients aged ≥75 years had a lower relapse risk in multivariate analysis (cause-specific hazards ratio [CSHR] 0.54, 95% CI [0.33-0.89], p = 0.016, Cox model; subdistribution hazard ratio [SHR] 0.46, 95% CI [0.29-0.74], p = 0.001, Fine-Gray model) after taking into account vasculitis type. Patients aged ≥75 years had a lower probability of being treated for remission maintenance with a combination of glucocorticoids and immunosuppressants (vs. glucocorticoids alone, HR 0.28, 95% CI [0.11-0.68], p = 0.005) after adjusting to Five Factor Score, although relapse-free survival was significantly longer when receiving such combination (CSHR 0.40, 95% [CI 0.24-0.67], p < 0.001). CONCLUSIONS AAV patients ≥75 years have a lower relapse risk than patients aged 65-75 years despite a lower probability of having received maintenance therapy with a combination of glucocorticoids and immunosuppressants, but they still benefit from such treatment regimen.
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Affiliation(s)
- Sara Thietart
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Guillaume Beinse
- Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université INSERM, Team Personalized Medicine, Pharmacogenomics and Therapeutic Optimization (MEPPOT), Paris, France
| | - Perrine Smets
- Department of Internal Medicine, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Carole Philipponnet
- Department of Nephrology, Centre Hospitalier Universitaire, Clermont-Ferrand, France
| | - Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, Centre Hospitalier Universitaire, Angers, France
| | - Khalil El Karoui
- Department of Nephrology and Renal transplantation, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Rafik Mesbah
- Department of Nephrology, Centre Hospitalier, Boulogne-sur-Mer, France
| | | | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | - Pierre-Louis Carron
- Department of Nephrology-Dialysis-Transplantation, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France
| | - François Maurier
- Department of Internal Medicine and Immunology, Groupe Hospitalier UNEOS, Metz-Vantoux, France
| | - Karim Sacre
- Department of Internal Medicine, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, INSERM U1149, Paris, France
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Eric Liozon
- Department of Internal Medicine and Clinical Immunology, Dupuytren University Hospital, Limoges, France
| | | | - Alex Kostianovsky
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
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- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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8
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[ANCA-associated vasculitis in an older male patient]. Z Gerontol Geriatr 2021; 54:451-453. [PMID: 34115174 DOI: 10.1007/s00391-021-01913-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
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9
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Guchelaar NAD, Waling MM, Adhin AA, van Daele PLA, Schreurs MWJ, Rombach SM. The value of anti-neutrophil cytoplasmic antibodies (ANCA) testing for the diagnosis of ANCA-associated vasculitis, a systematic review and meta-analysis. Autoimmun Rev 2020; 20:102716. [PMID: 33197574 DOI: 10.1016/j.autrev.2020.102716] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 12/24/2022]
Abstract
The testing of anti-neutrophil cytoplasmic antibodies (ANCA) takes an important place in the diagnostic workup to ANCA-associated vasculitis (AAV). Nowadays, it is recommended to screen for the presence of PR3 and MPO specific antibodies first using immunoassay, without the need for ANCA measurement by indirect immunofluorescence (IIF). A literature search was performed to assess the diagnostic test value of ANCA IIF and PR3- and MPO-antibody immunoassay to diagnose AAV. This meta-analysis shows that the c-ANCA testing by IIF has a pooled sensitivity of 75.2% and a pooled specificity of 98.4%. For PR3-antibody immunoassay, the pooled sensitivity depended on the immunoassay method used, and ranged from 79.8% to 86.6%, whereas the pooled specificity ranged from 96.8% to 98.3%. For both p-ANCA IIF and MPO-antibody immunoassay (all methods) sensitivity varied considerably showing pooled values of respectively 46.3% and 58.1%, whereas respective pooled specificity was 91.4% and 95.6%. These findings support the 2017 international consensus that primary anti-PR3 and anti-MPO screening by immunoassay, based on superior immunoassay sensitivity without the need for IIF ANCA testing, improves the diagnostic workup of AAV.
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Affiliation(s)
- Niels A D Guchelaar
- Department of Internal Medicine, Allergy and Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Manon M Waling
- Department of Internal Medicine, Allergy and Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Anviti A Adhin
- Department of Internal Medicine, Allergy and Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paul L A van Daele
- Department of Internal Medicine, Allergy and Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Saskia M Rombach
- Department of Internal Medicine, Allergy and Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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10
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Efficacy of repeat-dose rituximab maintenance therapy for minimal change disease in adults. Clin Exp Nephrol 2020; 24:1132-1139. [PMID: 32761467 DOI: 10.1007/s10157-020-01943-3] [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: 04/10/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rituximab (RTX) has been reported to effectively treat minimal change disease (MCD) in adults. However, the efficacy of RTX as maintenance therapy, especially in older patients, remains unclear. This study aimed to evaluate the efficacy of repeat-dose RTX maintenance therapy regardless of age. METHODS We retrospectively reviewed the clinical courses of 13 biopsy-proven adult MCD patients receiving RTX and evaluated the relapse rate, concomitant steroid and immunosuppressant use, relationship between B-cell depletion time and relapse, and adverse events. RESULTS Mean patient age at start of RTX therapy was 51.5 ± 20.1 years. Each RTX induction consisted of a single 375 mg/m2 dose. One patient received two RTX doses with a 1-year interval. The remaining 12 patients received RTX at 6-month intervals up to four times after RTX introduction. The median observation period was 28 (16-60) months after RTX induction, median relapse frequency was significantly decreased from 0.83 (0.18-1.92) to 0 (0-0.71) times/year (P < 0.001), and median prednisolone dose was reduced from 25 (5-40) mg to 2.5 (0-10) mg (P < 0.001). CD19-positive B cells remained depleted during RTX administration in 6-month intervals. No serious adverse events were observed after RTX administration. CONCLUSIONS Repeat-dose RTX as maintenance therapy efficiently prevented recurrence and was well tolerated in adult MCD patients including older. This regimen has the potential to maintain prolonged remission. Future studies in larger cohorts are needed to identify the optimal dose and frequency and evaluate the long-term effectiveness and safety of this regimen.
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11
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Neumann I. Immunosuppressive and glucocorticoid therapy for the treatment of ANCA-asssociated vasculitis. Rheumatology (Oxford) 2020; 59:iii60-iii67. [DOI: 10.1093/rheumatology/keaa035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
ANCA-associated vasculitis (AAV) is a systemic, potentially organ and life threatening chronic autoimmune disease. With current management strategies, such as high-dose glucocorticoids in combination with cyclophosphamide or rituximab, outcomes have progressively improved with overall remission rates of 70–90%. However, relapse rates after discontinuation of therapy are consistently high, and treatment-related toxicity, mainly driven by glucocorticoids, still determines morbidity and quality of life. Prevention of relapses while minimizing adverse events is a major goal of long-term treatment, but the optimal duration of maintenance therapy and the role and utility of glucocorticoids in this context remains controversial. This review of induction and maintenance treatment of AAV aims to offer practical advice on immunosuppressive therapies and patient care, addressing individual risk factors and their therapeutic implications. It will discuss benefits and harms of the use of glucocorticoids, particularly focusing on recent advances in steroid sparing concepts.
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Affiliation(s)
- Irmgard Neumann
- Vasculitis.at, Vienna, Austria
- IZZ, Immunologiezentrum Zurich, Zurich, Switzerland
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12
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Alhassan E, Johnson J, Nakity R, Shah HZ. Rituximab Use and Hypogammaglobulinemia. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e920681. [PMID: 32269210 PMCID: PMC7171369 DOI: 10.12659/ajcr.920681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Female, 59-year-old Final Diagnosis: Granulomatosis with polyangiitis Symptoms: Dyspnea Medication: Rituximab Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Eaman Alhassan
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Justina Johnson
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Rasha Nakity
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Hajra Zehra Shah
- Division of Rheumatology, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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13
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Thery-Casari C, Euvrard R, Mainbourg S, Durupt S, Reynaud Q, Durieu I, Belot A, Lobbes H, Cabrera N, Lega JC. Severe infections in patients with anti-neutrophil cytoplasmic antibody-associated vasculitides receiving rituximab: A meta-analysis. Autoimmun Rev 2020; 19:102505. [PMID: 32173512 DOI: 10.1016/j.autrev.2020.102505] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 12/31/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The efficacy of rituximab (RTX) for remission induction and maintenance in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) is now established, but the safety, particularly concerning severe infection risk, is not well known. OBJECTIVE The purpose of this meta-analysis is to assess the prevalence and incidence of severe infections and the factors explaining heterogeneity in AAV patients treated with RTX. METHODS PubMed and Embase were searched up to December 2017. Prevalence and incidence was pooled using a random-effects model in case of significant heterogeneity (I2 > 50%). Severe infection was defined as severe when it led to hospitalization, intravenous antibiotics therapy, and/or death. The heterogeneity was explored by subgroup analyses and meta-regression. RESULTS The included studies encompassed 1434 patients with a median age of 51.9 years. The overall prevalence and incidence of severe infections was 15.4% (95% CI [8.9; 23.3], I2 = 90%, 33 studies) and 6.5 per 100 person-years (PY) (95% CI [2.9; 11.4], I2 = 76%, 18 studies), respectively. The most common infections were bacterial (9.4%, 95% CI [5.1; 14.8]). The prevalence of opportunistic infection was 1.5% (95% CI [0.5; 3.1], I2 = 58%) including pneumocytis jirovecii infections (0.2%, 95% CI [0.0; 0.6], I2 = 0), irrespective of prophylaxis administration. Mortality related to infection was estimated at 0.7% (95% CI [0.2; 1.2], I2 = 27%). The RTX cumulative dose was positively associated with prevalence of infections (13 studies, prevalence increase of 4% per 100 mg, p < .0001). The incidence of infection was negatively associated with duration of follow-up (8 studies, incidence decrease of 9% per year, p = .03). CONCLUSION Prevalence and incidence of severe infections, mainly bacterial ones, were high in AAV patients treated with RTX. This meta-analysis highlights the need for prospective studies to stratify infectious risk and validate cumulative RTX dose and duration of follow-up as modifying factors.
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Affiliation(s)
- Clémence Thery-Casari
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Romain Euvrard
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Sabine Mainbourg
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - Stéphane Durupt
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Quitterie Reynaud
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Univ Lyon, Health Services and Performance Research EA7425, Claude Bernard University Lyon, F-69003, France
| | - Isabelle Durieu
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Univ Lyon, Health Services and Performance Research EA7425, Claude Bernard University Lyon, F-69003, France
| | - Alexandre Belot
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; INSERM U1111, National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases (RAISE) and Department of Paediatric Rheumatology, Lyon University Hospital, University of Lyon, France
| | - Hervé Lobbes
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Internal Medicine Department, University Hospital Clermont-Ferrand, 1 place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - Natalia Cabrera
- Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - Jean-Christophe Lega
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France.
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14
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Berti A, Specks U. Remission maintenance in ANCA-associated vasculitis: does one size fit all? Expert Rev Clin Immunol 2019; 15:1273-1286. [PMID: 31762340 DOI: 10.1080/1744666x.2020.1693260] [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: 10/25/2022]
Abstract
Introduction: The majority of the patients with anti-neutrophil cytoplasmic autoantibody (ANCA) associated vasculitis (AAV) achieve remission with effective induction therapy. Therefore, prevention of relapses and avoiding long-term damage and treatment-related toxicity are major challenges.Areas covered: This review provides an update on maintenance therapy in AAV, emphasizing the available treatment options for granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Among the spectrum of all patients with AAV, those at higher risk of relapse have recently been identified. Clinical trials have yielded robust results about various options for maintenance of remission including common disease-modifying anti-rheumatic drugs (DMARDs, i.e. azathioprine, methotrexate, and mycophenolate mofetil) and rituximab (RTX). However, outcomes of these studies are not easy to compare.Expert opinion: Regardless of the treatment used, patients presenting with an anti-proteinase-3 ANCA, relapsing GPA have a substantially higher risk of relapse compared to patients with newly diagnosed MPA or positive anti-myeloperoxidase ANCA. While the efficacy of common DMARDs for remission maintenance is heterogeneous, the role of RTX seems particularly promising for the high-risk patients, although the most appropriate dose and timing of retreatment with RTX remain under controversial. Low-dose glucocorticoid use for remission maintenance versus complete discontinuation also remains under investigation.
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Affiliation(s)
- Alvise Berti
- Rheumatology Department, Santa Chiara Hospital and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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15
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Adverse Cutaneous Reactions of Common Biologic Medications for Rheumatic Diseases. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00129-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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16
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Hamroun A, Frimat M, Beuscart JB, Buob D, Lionet A, Lebas C, Daroux M, Provôt F, Hazzan M, Boulanger É, Glowacki F. [Kidney disease care for the elderly]. Nephrol Ther 2019; 15:533-552. [PMID: 31711751 DOI: 10.1016/j.nephro.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.
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Affiliation(s)
- Aghilès Hamroun
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marie Frimat
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | | | - David Buob
- Service d'anatomopathologie, Centre de biologie-pathologie, CHRU de Lille, 59037 Lille, France
| | - Arnaud Lionet
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Céline Lebas
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Maïté Daroux
- Service de néphrologie, hôpital Duchenne, allée Jacques Monod, 62200 Boulogne-sur-Mer, France
| | - François Provôt
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marc Hazzan
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Éric Boulanger
- Service de gériatrie, CHRU de Lille, 59037 Lille, France
| | - François Glowacki
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France.
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17
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Schroeder C, Schenk H, Khalifa A, Braesen JH, von Vietinghoff S. [Acute on chronic renal failure in a 62-year-old man with ANCA-associated vasculitis]. Internist (Berl) 2019; 60:1106-1110. [PMID: 31435719 DOI: 10.1007/s00108-019-0657-9] [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: 11/24/2022]
Abstract
We describe a patient with ANCA (antineutrophil cytoplasmic antibodies) associated vasculitis and acute-on-chronic renal failure. He had initially presented with severe pulmonary hemorrhage and anuric renal failure and improved rapidly with immunosuppressive therapy. Repeat renal biopsy revealed candida interstitial nephritis. Candida was also detected in bronchoalveolar lavage. Kidney function improved with long-term antifungal therapy. This report adds induction therapy for ANCA vasculitis to the conditions where invasive candidal infections including nephritis need to be considered.
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Affiliation(s)
- C Schroeder
- Klinik für Nieren- und Hochdruckerkrankungen, OE 6840, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - H Schenk
- Klinik für Nieren- und Hochdruckerkrankungen, OE 6840, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - A Khalifa
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - J H Braesen
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - S von Vietinghoff
- Klinik für Nieren- und Hochdruckerkrankungen, OE 6840, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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18
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Grossin D, Broner J, Arnaud E, Goulabchand R, Gris JC. [Acquired autoimmune haemophilia: Where is the place of rituximab in the treatment strategy? Reflection from a monocentric series of 8 patients and literature review]. Rev Med Interne 2019; 40:574-580. [PMID: 30904179 DOI: 10.1016/j.revmed.2019.02.008] [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] [Received: 11/12/2018] [Revised: 02/14/2019] [Accepted: 02/24/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Autoimmune acquired haemophilia is a rare autoimmune disease. The purpose of immunosuppressive therapy is to stop the production of autoantibodies that inhibit clotting factors VIII or IX. A corticosteroids-cyclophosphamide combination is recommanded as first-line therapy. From our experience at the University Hospital of Nîmes, we discuss the place of rituximab in the therapeutic arsenal. METHODS We report a monocentric observational retrospective study. Our data are discussed in light of literature data, in particular cohorts EACH2 and SACHA. RESULTS Eight patients (7 with FVIII anibodies) were consecutively included from 2005. The average age was 68.5 years with a male predominance (62.5%). Bleeding manifestations were usually spontaneous and superficial. A pathology, mostly autoimmune or neoplastic, was associated in 5/8 patients. A "by-pass" haemostatic treatment was prescribed for 3/8 patients. Rituximab was prescribed for 5/8 patients, three times as first-line therapy, and always associated with corticosteroids. Three patients received a cyclophosphamid/cortisone combination, two were treated exclusively with oral corticosteroids. Remission was obtained in all patients, without subsequent relapse. The average time to obtain remission under rituximab (after the first injection) was 32.5 days (10-143). The results observed in our series of patients are consistent with the data from the literature. CONCLUSIONS Rituximab appears to be an effective and well-tolerated treatment for autoimmune acquired haemophilia. However, its place remains to be specified.
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Affiliation(s)
- D Grossin
- Service de médecine interne, CHU Nîmes, 30029 Nîmes, France.
| | - J Broner
- Service de médecine interne, CHU Nîmes, 30029 Nîmes, France
| | - E Arnaud
- Service de médecine interne, CHU Nîmes, 30029 Nîmes, France
| | - R Goulabchand
- Département de médecine interne maladies multi-organiques, CHU Saint-Éloi, Montpellier, France
| | - J C Gris
- Service d'hématologie, CHU Nîmes, 30029 Nîmes, France
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19
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Okada M, Suemori K, Takagi D, Teraoka M, Yamada H, Ishizaki J, Matsumoto T, Hasegawa H, Hato N. The treatment outcomes of rituximab for intractable otitis media with ANCA-associated vasculitis. Auris Nasus Larynx 2019; 46:38-42. [DOI: 10.1016/j.anl.2018.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/08/2018] [Accepted: 05/24/2018] [Indexed: 02/06/2023]
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20
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Shavit E, Alavi A, Sibbald RG. Vasculitis-What Do We Have to Know? A Review of Literature. INT J LOW EXTR WOUND 2018; 17:218-226. [PMID: 30501545 DOI: 10.1177/1534734618804982] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cutaneous and other vasculitides are specific inflammations of the blood vessel wall that can take place in any organ system of the body including the skin. Vasculitis has been traditionally divided according to the size of the vessel involved (small, medium, and large). Vasculitis is more of a reaction pattern rather than a specific disease entity. Therefore, the clinical presentation of vasculitis (most commonly palpable purpura on the lower extremities) dictates a thorough history, review of systems, and a meticulous physical examination. The diagnosis of vasculitis relies also on the histopathological and immunofluorescence studies. Wound care specialist may face with vasculitis-associated ulcers along with a spectrum of other cutaneous presentations associated with vasculitis. The focus of this article is to update the types, etiology, pathogenesis, and management options for cutaneous vasculitis.
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Affiliation(s)
- Eran Shavit
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Alavi
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - R Gary Sibbald
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
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21
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Aging in Primary Systemic Vasculitis: Implications for Diagnosis, Clinical Manifestations, and Management. Drugs Aging 2018; 36:53-63. [DOI: 10.1007/s40266-018-0617-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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22
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Oda K, Ishikawa E, Ito T, Mizoguchi S, Hirabayashi Y, Suzuki Y, Haruki A, Fujimoto M, Murata T, Katayama K, Onishi T, Ito M. Improvement of Alveolar Hemorrhaging in an Elderly and Renally Impaired Patient with Relapsing Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis by Single Infusion of Rituximab. Intern Med 2018; 57:3267-3270. [PMID: 29984747 PMCID: PMC6287994 DOI: 10.2169/internalmedicine.0936-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rituximab (RTX) has become a therapeutic option for inducing remission of anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV). However, the optimum dosage of RTX to induce remission of AAV and reduce adverse events, such as infection, remains unclear. We herein report an elderly and renally impaired patient with alveolar hemorrhaging due to refractory AAV who was successfully treated with single infusion of RTX. Single infusion of RTX may be a therapeutic option in refractory AAV patients who are vulnerable to infections.
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Affiliation(s)
- Keiko Oda
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Eiji Ishikawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Takayasu Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Shoko Mizoguchi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Yosuke Hirabayashi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Yasuo Suzuki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Ayumi Haruki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Mika Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Tomohiro Murata
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Kan Katayama
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | | | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
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23
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ANCA-associated vasculitis (AAV) in the elderly: clinical presentation, treatment and outcomes. Eur Geriatr Med 2018; 9:725-728. [PMID: 34654225 DOI: 10.1007/s41999-018-0093-8] [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] [Received: 01/26/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To explore treatment and outcomes in older patients with AAV. METHODS Retrospective review (1 year) of patients > 75 years with positive MPO/PR3 antibodies. RESULTS Thirty-nine evaluable patients had new positive MPO/PR3 antibodies. Nine patients had AAV and two possible AAV (2M, 9F mean age 82 years). Nine patients had renal impairment and three died during their presenting admission, all having required dialysis ± plasma exchange. Non-survivors had higher average creatinine (442 vs 265 µmol/L) and more co-morbidities (2 or more co-morbidities vs 0 or 1). All patients deemed fit received treatment, one discontinued (infection). Survival in AAV was 46% at 1 year and 18% at 2 years. 1/3 of positive MPO/PR3 results were not acknowledged in case records by clinicians. CONCLUSIONS Renal involvement is common in elderly patients with AAV. High creatinine, co-morbidity and need for dialysis are associated with a poorer prognosis. Mortality is high but survivors tolerate treatments well.
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Lin M, Anesi SD, Ma L, Ahmed A, Small K, Foster CS. Characteristics and Visual Outcome of Refractory Retinal Vasculitis Associated With Antineutrophil Cytoplasm Antibody-Associated Vasculitides. Am J Ophthalmol 2018; 187:21-33. [PMID: 29258731 DOI: 10.1016/j.ajo.2017.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To describe the clinical characteristics, therapies, visual outcomes, and prognoses of patients with retinal vasculitis associated with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). DESIGN Retrospective case series. METHODS Patients diagnosed with retinal vasculitis associated with AAV and at least 6 months of follow-up were included. Demographic data, systemic and ocular features, best-corrected visual acuity at the initial visit and latest visit, fluorescein angiography (FA) and indocyanine green angiography (ICGA) findings, therapy regimen, and outcome were collected from the Massachusetts Eye Research and Surgery Institution (MERSI) database from 2006 to 2017. RESULTS Fourteen patients (22 eyes) were identified. Twelve had granulomatosis with polyangiitis (GPA) and 1 each had microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). FA showed that AAV affected small-to-medium-size retinal vessels. Seven cases (50%) had both vein/venule and artery/arteriole involvement. Four cases co-presented with choroidal vasculitis. All of them failed various immunomodulatory therapies prior to referral to MERSI. Six patients received rituximab plus prednisone as their final therapy and 5 of them achieved remission. Four patients who failed cyclophosphamide previously were induced into remission by rituximab. Patients were followed for 33.4 ± 25.5 (range 6-84) months. Nine of 14 patients (64.3%) achieved remission at their latest visit. Seventeen of 22 eyes (77.3%) met the criteria for a good (≥20/40) visual outcome. CONCLUSION The majority of patients enjoyed a good visual outcome and achieved remission after aggressive treatment. Rituximab should be considered as an initial treatment for patients with refractory retinal vasculitis associated with AAV.
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Rituximab for anti-neutrophil cytoplasmic antibodies-associated vasculitis: experience of a single center and systematic review of non-randomized studies. Rheumatol Int 2018; 38:607-622. [PMID: 29322343 DOI: 10.1007/s00296-018-3928-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/02/2018] [Indexed: 10/27/2022]
Abstract
Rituximab (RTX) is becoming a standard treatment for patients with anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) but heterogeneity exists regarding its use. We present our uncontrolled experience with RTX in patients with refractory AAV and also the results of a systematic review of non-randomized studies on RTX in AAV patients. We retrospectively reviewed the records of AAV patients treated with RTX following an inadequate response to immunosuppressives between 2011 and 2015. The systematic review covered all English articles listed in PubMed until June 2017. There were 25 AAV patients (21 GPA, four unclassified) treated with RTX (median 2, IQR 1-3 courses; median follow-up 24, IQR 17-50 months). The kidney and the lung were the most commonly affected organs, observed in 14 and 16 patients, respectively. Complete remission rate was 72% at month 6 and 88% at month 12. Two patients had died and three serious adverse events occurred. The systematic review included 56 studies on 1422 patients with the majority being on refractory or relapsing disease. There was wide variability regarding disease characteristics, endpoints, concomitant immunosuppressives and RTX schedule. Most studies reported > 80% complete or partial remission rates with the lowest response (37.5%) for granulomatous lesions. The relapse rate was 30%. Infections and infusion reactions were the main adverse events. Our experience with RTX in refractory AAV is in line with the literature in terms of efficacy and safety. The systematic review underlines many uncertainties on its optimal use.
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Hruskova Z, Tesar V. Management of Elderly Patients with Rapidly Progressive Glomerulonephritis. Blood Purif 2018; 45:213-217. [DOI: 10.1159/000485368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
<b><i>Background:</i></b> Rapidly progressive glomerulonephritis (RPGN) is characterized by a rapid deterioration of renal function and by extracapillary proliferation in >50% of glomeruli. The most common type of RPGN is “pauci-immune” glomerulonephritis caused by anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV). <b><i>Summary:</i></b> The incidence of AAV increases with age<b><i></i></b> and pauci-immune glomerulonephritis is the most common diagnosis found in renal biopsies in the elderly population. Age was identified as an independent negative risk factor for both death and end-stage renal disease in AAV, and the mortality of older patients was uniformly higher than in younger patients in all retrospective studies. Early diagnosis may be difficult particularly in elderly patients with renal-limited disease but is important for the good outcome of the patients. Immunosuppressive treatment options include cyclophosphamide or rituximab combined with corticosteroids with or without plasma exchange in case of severe disease. Data from randomized trials are completely missing for patient aged >75 years. Based on retrospective studies, elderly patients seem to respond to immunosuppressive drugs just as younger patients are able to, but they are at a higher risk of adverse events.<b><i> Key Messages:</i></b> RPGN is relatively common in the elderly patients. Immunosuppressive treatment in older patients with AAV or RPGN may be useful but needs to be strictly individualized with all the risks taken into consideration. Further studies are needed to examine the role of novel therapeutic options in the elderly population with RPGN.
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Wang H, Zhang C, Tong Z, Bu X. Elevated serum levels of immunoglobulin A correlate with the possibility of readmission in patients with microscopic polyangiitis. J Thorac Dis 2017; 9:1201-1208. [PMID: 28616269 DOI: 10.21037/jtd.2017.03.166] [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: 11/06/2022]
Abstract
BACKGROUND The evidence for the short-term prognosis of patients with microscopic polyangiitis (MPA) is weak, and the objective of this study was to analyze the clinical features of the disease and evaluate the risk factors for readmission in patients with MPA. METHODS Fifty-seven patients with MPA were recruited into this study. The clinical data of these MPA patients were collected. Clinical manifestations, laboratory results, and imaging results were analyzed. Patients who were readmitted to our hospital within 6 months after their first diagnosis and treatment of MPA were defined as the readmission group; the remaining patients were defined as the control group. RESULTS Respiratory symptoms, including cough, dyspnea (87.72%), and hemoptysis (3.51%), seemed to be the initial symptoms in many patients with MPA. Systemic symptoms included fever (71.93%), hearing loss (12.28%), vision loss (3.51%), and joint involvement (5.27%). The D-dimer levels of 43 patients (75.44%) were >500 ng/dL, and only three of these patients had venous thrombosis. Age and immunoglobulin A (IgA) were the risk factors for readmission in patients with MPA, with odds ratios (ORs) of 1.162 [95% confidence interval (CI): 1.025-1.317, P=0.019] and 1.010 (95% CI: 1.001-1.018, P=0.028). The days of hospitalization and the a2-globulin level were protective factors with ORs of 0.849 (95% CI: 0.725-0.993 P=0.041) and 0.789 (95% CI: 0.64-0.971, P=0.025), respectively. IgA levels were positively correlated with the number of hospitalizations, with a correlation coefficient of 0.428 (P=0.002). Receiver operating characteristic curve analysis showed that the possibility of readmission increases when the serum levels of IgA were >217.5 mg/dL. CONCLUSION The level of serum IgA is a risk factor for the readmission of patients with MPA, and correlated with the number of hospitalizations in these patients.
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Affiliation(s)
- Huijuan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
| | - Chao Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
| | - Xiaoning Bu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
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Martinez AR, Faber I, Nucci A, Appenzeller S, França MC. Autoimmune neuropathies associated to rheumatic diseases. Autoimmun Rev 2017; 16:335-342. [DOI: 10.1016/j.autrev.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
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Catroux M, Lauda-Maillen M, Pathe M, De Boisgrollier de Ruolz AC, Cazenave-Roblot F, Roblot P, Souchaud-Debouverie O. [Infectious events during the course of autoimmune diseases treated with rituximab: A retrospective study of 93 cases]. Rev Med Interne 2016; 38:160-166. [PMID: 27836224 DOI: 10.1016/j.revmed.2016.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Describe the occurring infections in patients treated with rituximab for an autoimmune disease. METHODS Retrospective and monocentric study of 93 adult patients treated with rituximab for autoimmune indications over a nine years period. RESULTS Thirty-eight patients suffered from a total of 95 infections. Out of them, 18 patients (19 %) had had at least an infectious episode triggering a hospital admission and/or intravenous treatment. The infections occurred mainly during the first year of the treatment (65 %) and if the courses are repeated (P=0.04). They were mainly pulmonary infections. Severe infections, recorded in 79 % of the cases, were mostly of bacterial origin (43 %) and viral (23 %). Two cases of pneumocystis pneumonia and one case of invasive pulmonary aspergillosis were also recorded. The notion of vaccination was present in less than half of the cases, and 39 % of the patients were already receiving a prophylactic treatment against pneumocystis pneumonia. Patients over the age of 65 years (40 %) had developed less infections (P<0.05). Eight of the initial 93 patients died, half of them because of infectious complications. CONCLUSION Infectious complications are frequent, become early and are potentially severe. Imputability to rituximab is not certain. However, this could lead to better codify rituximab prescriptions and take adapted and associated measures in order to facilitate infection prevention and, if an infection does occur, to treat it at the earliest stage possible. The age doesn't seem to be a risk factor.
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Affiliation(s)
- M Catroux
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France.
| | - M Lauda-Maillen
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | - M Pathe
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | | | - F Cazenave-Roblot
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | - P Roblot
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
| | - O Souchaud-Debouverie
- Service de médecine interne et maladies infectieuses, université de Poitiers, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers, France
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Houben E, Bax WA, van Dam B, Slieker WA, Verhave G, Frerichs FC, van Eijk IC, Boersma WG, de Kuyper GT, Penne EL. Diagnosing ANCA-associated vasculitis in ANCA positive patients: A retrospective analysis on the role of clinical symptoms and the ANCA titre. Medicine (Baltimore) 2016; 95:e5096. [PMID: 27749588 PMCID: PMC5059091 DOI: 10.1097/md.0000000000005096] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 01/01/2023] Open
Abstract
Currently no validated diagnostic system for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is available. Therefore, diagnosing AAV is often challenging. We aimed to identify factors that lead to a clinical diagnosis AAV in ANCA positive patients in a teaching hospital in The Netherlands.In this study, all patients that tested positive for ANCA proteinase 3 (PR3) and/or myeloperoxidase (MPO) between 2005 and 2015 were analysed. Patients with a clinical diagnosis of AAV were compared with patients without a clinical diagnosis of AAV. Clinical symptoms and laboratory variables at presentation, including the ANCA titre, were collected for both patients with and without AAV. Clinical and laboratory variables related with AAV were investigated, using multivariable logistic regression.Two hundred thirty seven consecutive patients with a positive ANCA were included, of whom 119 were clinically diagnosed with AAV. Of the 118 ANCA positive patients without AAV, 87 patients had an alternative diagnosis, including inflammatory bowel disease (n = 24), other rheumatic diseases (n = 23), infection (n = 11), malignancy (n = 4), and other diagnoses (n = 25). In a multivariable regression model, a high ANCA titre (odds ratio [OR] 14.16, 95% confidence interval [CI] 6.93-28.94) and a high number of affected organ systems (OR 7.67, 95% CI 3.69-15.94) were associated with AAV.MPO and PR3 ANCA can be positive in a variety of diseases that mimic AAV. A higher ANCA titre and multiple affected organ systems may help to discriminate between AAV and other systemic illnesses in anti-PR3 and anti-MPO positive patients. A diagnostic scoring system incorporating these factors should be considered.
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Abe Y, Tamura N, Yang KS, Matsuoka J, Kon T, Yamaji K, Hashimoto H, Tsuda H, Takasaki Y. Predictive factors for mortality in elderly Japanese patients with severe microscopic polyangiitis: A retrospective single-center study. Mod Rheumatol 2016; 27:315-319. [DOI: 10.1080/14397595.2016.1205778] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan,
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan,
| | - Kwang-Seok Yang
- Geriatric General Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan,
| | - Joe Matsuoka
- Clinical Research Support Center, Juntendo University School of Medicine, Tokyo, Japan, and
| | - Takayuki Kon
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan,
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan,
| | | | - Hiroshi Tsuda
- Geriatric General Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan,
| | - Yoshinari Takasaki
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan,
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Iwasaki S, Suzuki A, Fujisawa T, Sato T, Shirai S, Kamigaki M, Otsuka N, Tomaru U, Ishizu A. Fatal cardiac small-vessel involvement in ANCA-associated vasculitis: an autopsy case report. Cardiovasc Pathol 2015; 24:408-10. [PMID: 26275759 DOI: 10.1016/j.carpath.2015.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/11/2015] [Accepted: 07/17/2015] [Indexed: 11/26/2022] Open
Abstract
An 80-year-old Japanese man, who had fever and generalized fatigue not improved by antibiotics, was admitted to our hospital. Laboratory data indicative of renal dysfunction and antineutrophil cytoplasmic antibody (ANCA) in the serum led to the consideration of ANCA-associated vasculitis as a differential diagnosis. However, before the diagnostic confirmation, he was found dead on the bed. Autopsy revealed necrotizing crescentic glomerulonephritis in the kidneys. In addition, necrotizing granulomatous vasculitis with infiltration of multinucleated giant cells and neutrophils but not eosinophils was present in multiple organs. The direct cause of death was presumed as cardiac arrest by lethal arrhythmia because vasculitic lesions were distributed widely in the cardiac walls, acute congestion was observed in the systemic organs, and other causes of death were ruled out. This report presents the unusual manifestation of cardiac small-vessel involvement in ANCA-associated vasculitis related to sudden death.
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Affiliation(s)
- Sari Iwasaki
- Department of Pathology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Akira Suzuki
- Department of Pathology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Takashi Fujisawa
- Department of Pathology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Taiju Sato
- Department of Cardiology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Shinya Shirai
- Department of Cardiology, KKR Sapporo Medical Center, Sapporo, Japan
| | | | - Noriyuki Otsuka
- Department of Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Utano Tomaru
- Department of Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akihiro Ishizu
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan.
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Shah S, Geetha D. Place in therapy of rituximab in the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. Immunotargets Ther 2015; 4:173-83. [PMID: 27471722 PMCID: PMC4918256 DOI: 10.2147/itt.s55516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Granulomatosis with polyangiitis and microscopic polyangiitis are small vessel vasculitides characterized by circulating antineutrophil circulating antibodies. Standard treatment for active severe disease has consisted of cyclophosphamide with glucocorticoids with or without plasmapheresis, which achieves approximately 75% sustained remission, but carries significant adverse effects such as malignancy, infertility, leukopenia, and infections. The role of B cells in the pathogenesis of anti-neutrophil circulating antibodies-associated vasculitis has been established, and as such, rituximab, a monoclonal anti-CD20 antibody, has been studied in treatment of active granulomatosis with polyangiitis and microscopic polyangiitis (induction) and in maintaining remission. Rituximab has been shown to be effective in inducing remission in several retrospective studies in patients with refractory disease or cyclophosphamide intolerance. The RAVE and RITUXVAS trials demonstrated rituximab is a noninferior alternative to standard cyclophosphamide-based therapy; however, its role in elderly patients and patients with severe renal disease warrants further investigation. Rituximab has been compared with azathioprine for maintaining remission in the MAINRITSAN trial and may be more efficacious in maintaining remission in patients treated with cyclophosphamide induction. Rituximab is not without risks and carries a similar adverse event risk rate as cyclophosphamide in randomized control trials. However, its use can be considered over cyclophosphamide in patients who have relapsing or refractory disease or in young patients seeking to preserve fertility.
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Affiliation(s)
- Shivani Shah
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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