Renal toxicity associated with disease-modifying antirheumatic drugs used for the treatment of rheumatoid arthritis

[Low-dose methotrexate: Indications and side effects, particularly in cases of diffuse interstitial pneumonia]

INTRODUCTION

Methotrexate (MTX) is a folate antagonist used as an immunosuppressant in a number of conditions, including rheumatoid arthritis (RA). Low-dose MTX (MTX-LD) is associated with a risk of haematological, hepatic, gastrointestinal and pulmonary toxicity, which may up until now have limited its use.

STATE OF THE ART

In RA, data from retrospective cohorts have reported a possible excess risk of methotrexate toxicity in cases of underlying interstitial lung disease (ILD). However, recent prospective and retrospective multicentre studies have found no such increased risk, and have reassuringly concluded that MTX-LD can be prescribed in cases of RA-associated ILD (RA-ILD).

PERSPECTIVES AND CONCLUSIONS

Current recommendations are not to delay the introduction of MTX in patients with RA at risk of developing ILD or in the presence of RA-ILD with mild to moderate respiratory impairment.

Renal manifestations in adult-onset Still's disease: a systematic review

OBJECTIVE

We aimed to review the literature on the clinical presentation, renal pathology, treatment, and outcome of renal manifestations in adult-onset Still's disease (AOSD).

METHODS

We used PRISMA guidelines for our systematic review and included all English-language original articles from inception till September 15, 2023, on AOSD and kidney involvement in any form. Data on patient demographics, diagnostic criteria, clinical presentation, renal pathology, treatment employed including dialysis, outcome, cause of death were collected and analyzed.

RESULTS

The median age at the diagnosis of renal issues was 37, with a higher prevalence among females (58.1%). Among the cases, 28 experienced renal problems after being diagnosed with AOSD, 12 had simultaneous diagnoses of renal issues and AOSD, and in 4 cases, renal problems appeared before AOSD diagnosis. Out of the 44 cases, 36 underwent renal biopsy, revealing various pathology findings including AA amyloidosis (25%), collapsing glomerulopathy (11.4%), thrombotic microangiopathy (TMA) (11.4%), IgA nephropathy (9.1%), minimal change disease (6.8%), and others. Some cases were clinically diagnosed with TMA, proximal tubular dysfunction, or macrophage activation syndrome-related acute kidney injury. Treatment approaches varied, but glucocorticoids were commonly used. Renal involvement was associated with increased mortality and morbidity, with 6 out of 44 patients passing away, 4 progressing to end-stage renal disease (ESRD), and data on 2 cases' outcomes not available.

CONCLUSION

Renal manifestations in AOSD are diverse but rarely studied owing to the rarity of the disease. Studies with larger data would be essential to study further on the pathogenesis and implications.

Lipid Nano-System Based Topical Drug Delivery for Management of Rheumatoid Arthritis: An Overview

The overall purpose of rheumatoid arthritis (RA) treatment is to give symptomatic alleviation; there is no recognized cure for RA. Frequent use of potent drugs like non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs), lead to various adverse effects and patient compliance suffers. On the other hand, there are many drawbacks associated with traditional methods, such as high first pass, high clearance rate, and low bioavailability. Drug administration through the skin can be a promising alternative to cope with these drawbacks, increasing patient compliance and providing site-specific action. The stratum corneum, the uppermost non-viable epidermal layer, is one of the primary limiting barriers to skin penetration. Various nanocarrier technologies come into play as drug vehicles to help overcome these barriers. The nanocarrier systems are biocompatible, stable, and have a lower cytotoxic impact. The review discusses several lipid-based nanocarrier systems for anti-rheumatic medicines for topical administration it also discusses in-vivo animal models for RA and provides information on patents granted.

Encapsulation of Ginger Extract in Nanoemulsions: Preparation, Characterization and in vivo Evaluation in Rheumatoid Arthritis

Ginger is an anti-inflammatory and antioxidant natural substance, however, its effectiveness is limited primarily due to insufficient solubility and low oral bioavailability. This study aimed to formulate ginger extract into nanoemulsion (NE) to enhance therapeutic benefits against rheumatoid arthritis (RA). Hence, ginger extract-loaded NEs were prepared by the spontaneous emulsification method. The NE that passed the thermodynamic stability analyses showed no phase changes or appearance of turbidity. They had an average droplet diameter of 76 ± 45 nm with a zeta potential of - 35 ± 12 mV. Besides, the high antioxidant activities (IC50 = 53.89 µg/mL), about ten times increment of the skin permeability, and no sign of skin irritancy were observed from the ginger-loaded NE. The anti-arthritic evaluations of RA-induced rats treated with ginger-loaded NE showed a significant decline in arthritic symptoms and the highest rate of paw edema inhibition (27.7 %). In addition, the level of involved inflammatory cytokines in the serum of rats was significantly reduced (p < 0.05) compared to the negative control, so that histopathological manifestations also approved the reduction of inflammation indications. Thus, the topical delivery of ginger-loaded NE can be an efficient approach for reducing inflammation and inhibit of RA symptoms.

[Renal manifestations in rheumatoid arthritis and spondylarthritis]

As systemic diseases it is not uncommon for inflammatory rheumatic diseases to exhibit renal involvement. In contrast to connective tissue diseases and vasculitis, in rheumatoid arthritis and spondylarthritis direct inflammatory manifestations in the sense of glomerulonephritis (GN) and autoimmune interstitial nephritis are rare. In these groups of diseases renal biopsies usually show mesangial proliferative GN and IgA nephropathy or less commonly membranous GN. These and secondary amyloid A (AA) amyloidosis are regularly associated with longer lasting disease activity and a poor prognosis; however, clinically more frequent and more relevant are other sequelae of chronic systemic inflammation, namely endothelial function disorder and the premature development of atherosclerosis, resulting in progressive kidney failure. This is accompanied by the undesired effects of antirheumatic treatment and renal complications of comorbidities.

The Anti-Rheumatic Drug, Leflunomide, Induces Nephrotoxicity in Mice via Upregulation of TGFβ-Mediated p53/Smad2/3 Signaling

Recent studies indicated renal toxicity and interstitial nephritis in patients receiving leflunomide (LEFN), but the exact mechanism is still unknown. The transforming growth factor β (TGFβ)/p53/Smad2/3 pathway crucially mediates renal fibrosis. We aimed to assess the nephrotoxic effect of LEFN in mice and the possible role of TGFβ-stimulated p53/SMAD2/3 signaling. The study design involved distributing sixty male albino mice into four groups: (i) vehicle-treated mice, (ii) LEFN (2.5 mg/kg), (iii) LEFN (5 mg/kg), and (iv) LEFN (10 mg/kg). The drug was given orally every 48 h and continued for 8 weeks. Blood samples were then taken from mice for the determination of kidney function parameters. Right kidneys were used for histopathologic staining and immunohistochemistry, whereas left kidneys were frozen and used for Western blot analysis of the target proteins, p-p53 and Smad2/3. Results indicated that chronic administration of LEFN in mice resulted in a four- and nine-fold increase in serum urea and creatinine levels, respectively. Kidney specimens stained with hematoxylin and eosin or periodic acid-Schiff showed significant histopathological manifestations, such as cellular irregularity, interstitial congestion, and moderate lymphocytic inflammatory infiltrate in mice treated with LEFN. Western blotting indicated upregulation of the p-p53/Smad2/3 proteins. LEFN, especially in the highest dose (10 mg/kg), produced prominent nephrotoxicity in mice. This toxicity is mediated through stimulating fibrotic changes through TGFβ-stimulated p53/Smad2/3 signaling and induction of glomerular and tubular apoptosis. An improved understanding of LEFN-induced nephrotoxicity would have great implications in the prediction, prevention, and management of leflunomide-treated rheumatic patients, and may warrant further clinical studies for following up these toxidromes.

Autoimmune disease and sickle cell anaemia: 'Intersecting pathways and differential diagnosis'

Sickle cell disease (SCD) is an inherited disorder, which occurs due to a single gene mutation. It has multisystemic manifestations, affecting millions of people worldwide. The effect of SCD on joints and musculature can overlap with clinical features of autoimmune disease (AD). It is therefore difficult for clinical haematologists and physicians treating SCD patients to discriminate between these two conditions clinically. A delay in diagnosis leads to untreated symptoms and treatment differs considerably. An accurate knowledge of clinical findings and laboratory results of AD and SCD can help physicians avoid this. In the review that follows, we examine the existing literature on SCD and AD, and describe the features that may distinguish SCD and autoimmune disease such as systemic lupus erythematosus and rheumatoid arthritis. We aim to guide clinical haematologists and physicians towards a more rapid diagnosis of AD in sickle cell anaemia patients, by correct interpretation of the clinical assessment and commonly available diagnostics.

Psoriatic Arthritis: The Influence of Co-morbidities on Drug Choice

Psoriatic arthritis (PsA) is associated with a higher burden of co-morbidities such as obesity, cardiovascular disease, non-alcoholic fatty liver disease, inflammatory eye disease, inflammatory bowel disease, skin cancer and depression compared to the general population. In the last 20 years, the therapeutic options for PsA have increased exponentially with the availability of tumor necrosis factor-alpha (TNF) inhibitors, interleukin (IL)-17 inhibitors, IL-12/23 inhibitors and Janus kinases/signal transducer and activator of transcription proteins (JAK/STAT) inhibitors. The articular and extra-articular manifestations of PsA usually dictate the treatment choice but important consideration must be given to the corresponding co-morbidities while deciding the drug therapy due to associated safety profile, effect on disease activity, etc. This review provides a comprehensive review of common co-morbidities in PsA and how they can influence treatment choices.

Effect of Leflunomide on Pegloticase Response Rate in Patients with Uncontrolled Gout: A Retrospective Study

Background

Pegloticase, a PEGylated uricase for uncontrolled gout, rapidly lowers serum urate (SU). Not all patients complete a full-therapy course because anti-pegloticase antibodies can develop, causing efficacy loss and infusion reactions. The literature and clinical trial data indicate that methotrexate co-administration markedly improves pegloticase response rates from the established monotherapy response rate of 42%. Unfortunately, methotrexate use is restricted by kidney disease, which is often present in uncontrolled gout patients. Leflunomide is less restricted in patients with renal dysfunction. This study examined the treatment response rate of pegloticase co-administered with leflunomide.

Methods

Patients co-treated with pegloticase (8 mg biweekly infusion) and oral leflunomide (20 mg/day) were included. Patient/treatment characteristics and safety parameters (adverse events [AEs], laboratory parameters) were examined. Pre-infusion prophylaxis was administered (day of infusion: IV solumedrol, night before and morning of infusion: oral fexofenadine or diphenhydramine). Patients were considered treatment responders if ≥ 12 pegloticase infusions were administered and pre-infusion SU < 6 mg/dl at infusion-12.

Results

Ten patients (five male, 72.7 ± 12.5 years) were included. The most common comorbidities were chronic kidney disease (90%), hypertension (70%), diabetes mellitus (60%), obesity (60%), and congestive heart failure (50%). Baseline SU was 7.1 ± 2.4 mg/dl and nine patients (90%) had subcutaneous tophi noted. Seven patients (70%) met responder criteria, receiving 26.6 ± 14.0 infusions (range 13–55) with a pre-infusion-12 SU of 0.9 ± 1.5 mg/dl. The three non-responders received < 12 infusions because of unrelated AEs or loss of follow-up. Three patients (30%) experienced AEs. One had unrelated cardiac disease worsening and three gout flares, one had a pre-infusion solumedrol reaction (wooziness/loss of consciousness), and one had two mild, transient increases in liver enzymes.

Conclusions

This study supports leflunomide as co-therapy to pegloticase in uncontrolled gout patients. Heterogeneity and high comorbidity burden in uncontrolled gout patients makes having a variety of immunomodulators options important.

Kidneys in SARS-CoV-2 Era; a challenge of multiple faces

INTRODUCTION

With the evolution of SARS-CoV-2 pandemic, it was believed to be a direct respiratory virus. But, its deleterious effects were observed on different body systems, including kidneys.

AIM OF WORK

In this review, we tried as much as we can to summarize what has been discussed in the literature about the relation between SARS-CoV-2 infection and kidneys since December, 2019.

METHODS

Each part of the review was assigned to one or two authors to search for relevant articles in three databases (Pubmed, Scopus and Google scholar) and collected data were summarized and revised by two independent researchers.

CONCLUSION

The complexity of COVID-19 pandemic and kidney could be attributed to the direct effect of SARS-CoV-2 infection on the kidneys, different clinical presentation, difficulties confronting dialysis patients, restrictions of the organ transplant programs, poor outcomes and bad prognosis in patients with known history of kidney diseases who got infected with SARS-CoV-2. This article is protected by copyright. All rights reserved.

Evaluating a Living Donor With Rheumatoid Arthritis for a Recipient With End-Stage Renal Disease From Antineutrophil Cytoplasmic Antibodies Associated Vasculitis

A 60-year-old Caucasian female with sero-positive rheumatoid arthritis (RA) was evaluated as a potential kidney donor for her brother-in-law with end-stage kidney disease (ESKD) secondary to c-antineutrophil cytoplasmic antibody (c-ANCA) associated vasculitis (AAV) and membranous nephropathy (MN). With little to no data supporting or contradicting this unique scenario, in addition to the varying viewpoints expressed by the different specialists, our multidisciplinary transplant committee encountered a difficult decision of whether to approve a candidate with RA for a living kidney donation or not. As a result, we carried out a careful literature review addressing aspects of recipients' outcomes following kidney transplants from a living donor with RA, especially when the recipient has AAV, living donor's short- and long-term outcomes post kidney donation, renal disease in AAV and RA, and maintenance of disease remission.

Prevalence of and factors associated to chronic kidney disease and hypertension in a cohort of children with juvenile idiopathic arthritis

We evaluated chronic kidney disease (CKD) (proteinuria or estimated glomerular filtration rate < 60 mL/min/1.73 m²) or hypertension prevalence in 110 children with juvenile idiopathic arthritis (JIA). CKD and hypertension were clustered under the umbrella term of "renal injury". Median age at the last visit was 14 years. Nine out of 110 (8.1%) patients showed renal injury (8 hypertension, 1 proteinuria). Patients with renal injury presented higher age at last visit, longer duration of active JIA, shorter intervals free from JIA relapses, longer duration of non-steroidal anti-inflammatory drugs (NSAIDs) treatment but with similar cumulative NSAIDs dose and higher rate of methotrexate (MTX) prescription, longer time of MTX administration, and higher cumulative MTX dose compared to patients without renal injury. At the last visit, patients with and without renal injury presented similar prevalence of active disease. The cumulative proportion of patients free from renal injury at 240 months since JIA onset was 40.72% for all population; while the cumulative proportion was 23.7% for patients undergoing NSAIDs+MTX treatment and 100% for those undergoing NSAIDs (p = 0.039) treatment.Conclusion:About 8% of the children with JIA develop hypertension or CKD. The main risk factor was longer exposure to both NSAIDs and MTX due to a more severe form of the disease. What is Known •Anecdotal reports showed that rarely juvenile idiopathic arthritis (JIA) could present renal involvement due to prolonged and uncontrolled inflammation (renal amyloidosis) or to long exposure to anti-rheumatic drugs. •No cohort studies investigated renal health in children with JIA. What is new •About 8% of the children with JIA developed hypertension or chronic kidney disease. •The main risk factor was long exposure to non-steroidal anti-inflammatory drugs and methotrexate for patients suffering from a more severe form of the disease. •In JIA patients, periodic evaluation of renal function, blood pressure and proteinuria should be warranted.

Renal disorders in rheumatologic diseases: the spectrum is changing (part 2. Arthridides)

This review is devoted to rheumatologic diseases mainly characterized by different types of arthritis. They may involve also different organs, including the kidney, but renal disease is more frequently caused by the nephrotoxicity of drugs to relieve pain or to interfere with the pathophysiology of the underlying disease. Rheumatoid arthritis is the prototype of arthropathies. This autoimmune disease mainly attacks joints, tendons and ligaments but can also involve internal organs including the kidney. Psoriatic arthritis is a complex disease in which psoriasis, a chronic inflammatory disease, is associated with the development of peripheral arthritis or spondylitis. The disease or its treatment may lead to kidney complications. Gout is a form of inflammatory arthritis which is characterized by an increase in the serum uric acid deposits in and around the joints of the extremities, the so called tophi. The disease is often associated with a metabolic syndrome with diabetes, obesity, hypertension, and cardiovascular disease. Kidney injury is frequent. It may be caused by kidney stones, urinary tract obstruction, tubulointerstitial and vascular lesions leading to CKD and renal failure.

Adverse Effects of Low-Dose Methotrexate: A Randomized Trial

BACKGROUND

Low-dose methotrexate (LD-MTX) is the most commonly used drug for systemic rheumatic diseases worldwide and is the recommended first-line agent for rheumatoid arthritis. Despite extensive clinical use for more than 30 years, few data on adverse event (AE) rates derive from randomized, placebo-controlled trials, where both causality and magnitude of risk can be inferred.

OBJECTIVE

To investigate AE rates, risk, and risk differences comparing LD-MTX versus placebo.

DESIGN

Prespecified secondary analyses of a double-blind, placebo-controlled, randomized trial. (ClinicalTrials.gov: NCT01594333).

SETTING

North America.

PARTICIPANTS

Adults with known cardiovascular disease and diabetes or metabolic syndrome.

INTERVENTION

Random allocation to LD-MTX (≤20 mg/wk) or placebo. All participants received folic acid, 1 mg/d, 6 days per week.

MEASUREMENTS

Risks for specific AEs of interest, as well as for all AEs, were compared across treatment groups after blinded adjudication.

RESULTS

After an active run-in period, 6158 patients were enrolled and 4786 randomly assigned to a group; median follow-up was 23 months and median dosage 15 mg/wk. Among the randomly assigned participants, 81.2% were male, median age was 65.7 years, and median body mass index was 31.5 kg/m2. Of 2391 participants assigned to LD-MTX, 2080 (87.0%) had an AE of interest, compared with 1951 of 2395 (81.5%) assigned to placebo (hazard ratio [HR], 1.17 [95% CI, 1.10 to 1.25]). The relative hazards of gastrointestinal (HR, 1.91 [CI, 1.75 to 2.10]), pulmonary (HR, 1.52 [CI, 1.16 to 1.98]), infectious (HR, 1.15 [CI, 1.01 to 1.30]), and hematologic (HR, 1.15 [CI, 1.07 to 1.23]) AEs were elevated for LD-MTX versus placebo. With the exception of increased risk for skin cancer (HR, 2.05 [CI, 1.28 to 3.28]), the treatment groups did not differ in risk for other cancer or mucocutaneous, neuropsychiatric, or musculoskeletal AEs. Renal AEs were reduced in the LD-MTX group (HR, 0.85 [CI, 0.78 to 0.93]).

LIMITATION

The trial was done in patients without rheumatic disease who tolerated LD-MTX during an active run-in period.

CONCLUSION

Use of LD-MTX was associated with small to moderate elevations in risks for skin cancer and gastrointestinal, infectious, pulmonary, and hematologic AEs, whereas renal AEs were decreased.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Should a patient with rheumatoid arthritis be a kidney donor?

We cared for a woman with sero-positive rheumatoid arthritis (RA), in clinical remission on oral methotrexate (MTX) and hydroxychloroquine, who wished to donate a kidney to a brother with end-stage renal disease (ESRD). We could find scant literature about this unusual clinical circumstance, and therefore review pertinent aspects of renal disease in RA, perioperative medical management, maintenance of disease remission, outcomes for RA patients who have donated kidneys, and relevant ethical issues. Renal complications in RA are not uncommon, with as many as 50% of patients at risk of reduced eGFR. This reflects anti-rheumatic and analgetic medication use (non-steroidal anti-inflammatory drugs, acetaminophen, DMARDs [cyclosporine and, historically, D-penicillamine and gold compounds], and others), glomerulitis, interstitial nephritis, complicating Sjogren's syndrome, vasculitis, or amyloidosis, and/or emergence of an "overlap" syndrome or other rheumatic disorder. The literature suggests that MTX need not be interrupted for surgery. The risk of perioperative infection to our patient would be low and remission should be sustained. We are aware of one study of six patients with RA who donated kidneys; they experienced no complications, ESRD, or deaths after a median follow-up of 8.2 years. Our ethical responsibilities are to balance patient autonomy of decision-making while assuring clinical beneficence and minimizing potential maleficence. Our perspective was that it would not be unreasonable to support this patient donating a kidney if, when fully informed, that remained her wish.

Hydroxychloroquine Use and Risk of CKD in Patients with Rheumatoid Arthritis

BACKGROUND AND OBJECTIVES

Hydroxychloroquine is widely used in patients with rheumatoid arthritis. However, large-scale studies examining the long-term effects of hydroxychloroquine on the development of kidney disease in patients with rheumatoid arthritis are lacking. We aimed to assess the long-term association of hydroxychloroquine use with the risk of developing CKD in this population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted an observational cohort study for patients with newly diagnosed rheumatoid arthritis who were enrolled prospectively in Taiwan's National Health Insurance Research Database between January 1, 2000 and December 31, 2013. We used multivariable Cox proportional hazard regression to analyze the association of hydroxychloroquine use with incident CKD.

RESULTS

A total of 2619 patients, including 1212 hydroxychloroquine users and 1407 hydroxychloroquine nonusers, were analyzed. Incident CKD was reported in 48 of 1212 hydroxychloroquine users and 121 of 1407 hydroxychloroquine nonusers. The incidence rate of CKD was lower in hydroxychloroquine users than in hydroxychloroquine nonusers (10.3 versus 13.8 per 1000 person-years). After multivariable adjustment, hydroxychloroquine users still had a lower risk of incident CKD (adjusted hazard ratio, 0.64; 95% confidence interval, 0.45 to 0.90; P=0.01) than hydroxychloroquine nonusers. The lower risk of subsequent CKD development was dose dependent and consistent across subgroup analyses.

CONCLUSIONS

Hydroxychloroquine use in patients with newly diagnosed rheumatoid arthritis is associated with a significantly lower risk of incident CKD compared with in nonusers.

Effect of anti-tumor necrosis factor alpha treatment of rheumatoid arthritis and chronic kidney disease

Although chronic kidney disease (CKD) may constitute a chronic inflammatory state indicated by elevated inflammatory mediators such as tumor necrosis factor alpha (TNF-α), the impact of anti-TNF-α therapy on progression of CKD in patients with rheumatoid arthritis (RA) is unclear. Seventy patients with RA and CKD were retrospectively analyzed. Outcomes were evaluated using the difference in the annual change of estimated glomerular filtration rate (eGFR) between patients treated with anti-TNF-α or without. Anti-TNF-α therapy significantly decreased disease activity score (DAS) 28 from 5.32 ± 0.78 to 3.59 ± 0.85 (p < 0.001). There was a tendency toward stabilization of eGFR after a mean of 2.9 ± 1.1 years from 50.3 ± 8.4 ml/min/1.73 m(2) to 54.5 ± 16.0 ml/min/1.73 m(2) in patients received anti-TNF-α therapy along with decreased DAS28 (p = 0.084). Conversely, eGFR decreased significantly in patients not receiving anti-TNF-α therapy after a mean of 2.8 ± 1.7 years from 52.6 ± 7.5 ml/min/1.73 m(2) to 46.5 ± 11.5 ml/min/1.73 m(2) (p = 0.041) without significant DAS28 change (p = 0.078). The annual change of eGFR was significantly different between patients treated with anti-TNF-α drugs and without (2.0 ± 7.0 ml/min/1.73 m(2)/year vs. -1.9 ± 4.0 ml/min/1.73 m(2)/year; difference in mean vs. -3.9 ± 7.3 ml/min/1.73 m(2)/year; p = 0.006). Use of anti-TNF-α drugs was significantly associated with positive annual change of eGFR in multivariate logistic regression analysis (p = 0.019). Among patients with RA and CKD, treatment with anti-TNF-α drugs was associated with less renal function decline. Anti-TNF-α drugs may be beneficial for managing RA combined with CKD.

Evaluation of renal function in patients with psoriasis using immunobiologicals

The aim of this study was to evaluate renal function in patients with psoriasis using immunobiologicals. A prospective study was conducted with 15 patients with confirmed diagnosis of psoriasis who were starting to use immunobiologicals. The mean age was 41 ± 11 years, with 60% females. The mean time of disease was 11 ± 6.6 years. Significant changes in creatinine and creatinine clearance were not observed in the course of the study. There was an increase in transaminases and a decrease in magnesium levels.

Metallic gold beads in hyaluronic acid: a novel form of gold-based immunosuppression? Investigations of the immunosuppressive effects of metallic gold on cultured J774 macrophages and on neuronal gene expression in experimental autoimmune encephalomyelitis

Multiple sclerosis (MS) is a neurodegenerative disease caused by recurring attacks of neuroinflammation leading to neuronal death. Immune-suppressing gold salts are used for treating connective tissue diseases; however, side effects occur from systemic spread of gold ions. This is limited by exploiting macrophage-induced liberation of gold ions (dissolucytosis) from gold surfaces. Injecting gold beads in hyaluronic acid (HA) as a vehicle into the cavities of the brain can delay clinical signs of disease progression in the MS model, experimental autoimmune encephalitis (EAE). This study investigates the anti-inflammatory properties of metallic gold/HA on the gene expression of tumor necrosis factor (Tnf-α), Interleukin (Il)-1β, Il-6, Il-10, Colony-stimulating factor (Csf)-v2, Metallothionein (Mt)-1/2, Bcl-2 associated X protein (Bax) and B cell lymphoma (Bcl)-2 in cultured J774 macrophages and in rodents with early stages of EAE. Cells grew for 5 days on gold/HA or HA, then receiving 1,000 ng/mL lipopolysaccharide (LPS) as inflammatory challenge. In the EAE experiment, 12 Lewis rats received gold injections and control groups included 11 untreated and 12 HA-treated EAE rats and five healthy animals. The experiment terminated day 9 when the first ten animals showed signs of EAE, only one of which were gold-treated (1p = 0.0367). Gene expression in the macrophages showed a statistically significant decrease in Il-6, Il-1β and Il-10-response to LPS; interestingly HA induced a statistically significant increase of Il-10. In the EAE model gene expression of inflammatory cytokines increased markedly. Compared to EAE controls levels of Tnf-α, Il-1β, Il-10, Il-6, IL-2, Ifn-γ, Il-17, transforming growth factor (Tgf)-β, superoxide dismutase (Sod)-2, Mt-2 and fibroblast growth factor (Fgf)-2 were lower in the gold-treated group. HA-treated animals expressed similar or intermediate levels. Omnibus testing for reduced inflammatory response following gold-treatment was not significant, but tendencies towards a decrease in the Sod-2, Fgf-2, Il-1β response and a higher Bdnf and IL-23 gene expression were seen. In conclusion, our findings support that bio-liberation of gold from metallic gold surfaces have anti-inflammatory properties similar to classic gold compounds, warranting further studies into the pharmacological potential of this novel gold-treatment and the possible synergistic effects of hyaluronic acid.

Renal involvement in autoimmune connective tissue diseases

Connective tissue diseases (CTDs) are a heterogeneous group of disorders that share certain clinical presentations and a disturbed immunoregulation, leading to autoantibody production. Subclinical or overt renal manifestations are frequently observed and complicate the clinical course of CTDs. Alterations of kidney function in Sjögren syndrome, systemic scleroderma (SSc), auto-immune myopathies (dermatomyositis and polymyositis), systemic lupus erythematosus (SLE), antiphospholipid syndrome nephropathy (APSN) as well as rheumatoid arthritis (RA) are frequently present and physicians should be aware of that.In SLE, renal prognosis significantly improved based on specific classification and treatment strategies adjusted to kidney biopsy findings. Patients with scleroderma renal crisis (SRC), which is usually characterized by severe hypertension, progressive decline of renal function and thrombotic microangiopathy, show a significant benefit of early angiotensin-converting-enzyme (ACE) inhibitor use in particular and strict blood pressure control in general. Treatment of the underlying autoimmune disorder or discontinuation of specific therapeutic agents improves kidney function in most patients with Sjögren syndrome, auto-immune myopathies, APSN and RA.In this review we focus on impairment of renal function in relation to underlying disease or adverse drug effects and implications on treatment decisions.

Metallic gold slows disease progression, reduces cell death and induces astrogliosis while simultaneously increasing stem cell responses in an EAE rat model of multiple sclerosis

Multiple sclerosis (MS) is the most common neurodegenerative disease in the Western world affecting younger, otherwise healthy individuals. Today no curative treatment exists. Patients suffer from recurring attacks caused by demyelination and underlying neuroinflammation, ultimately leading to loss of neurons. Recent research shows that bio-liberation of gold ions from metallic gold implants can ameliorate inflammation, reduce apoptosis and promote proliferation of neuronal stem cells (NSCs) in a mouse model of focal brain injury. Based on these findings, the present study investigates whether metallic gold implants affect the clinical signs of disease progression and the pathological findings in experimental autoimmune encephalomyelitis (EAE), a rodent model of MS. Gold particles 20-45 μm suspended in hyaluronic acid were bilaterally injected into the lateral ventricles (LV) of young Lewis rats prior to EAE induction. Comparing gold-treated animals to untreated and vehicle-treated ones, a statistically significant slowing of disease progression in terms of reduced weight loss was seen. Despite massive inflammatory infiltration, terminal deoxynucleotidyl transferase dUTP nick end labeling staining revealed reduced apoptotic cell death in disease foci in the brain stem of gold-treated animals, alongside an up-regulation of glial fibrillary acidic protein-positive reactive astrocytes near the LV and in the brain stem. Cell counting of frizzled-9 and nestin-stained cells showed statistically significant up-regulation of NSCs migrating from the subventricular zone. Additionally, the neuroprotective proteins Metallothionein-1 and -2 were up-regulated in the corpus callosum. In conclusion, this study is the first to show that the presence of small gold implants affect disease progression in a rat model of MS, increasing the neurogenic response and reducing the loss of cells in disease foci. Gold implants might thus improve clinical outcome for MS patients and further research into the long-term effects of such localized gold treatment is warranted.

Inflammatory response to therapeutic gold bead implantation in canine hip joint osteoarthritis

Inflammatory changes associated with periarticular pure gold bead implants were studied in dogs involved in a clinical trial investigating motor dysfunction and chronic pain owing to hip joint dysplasia and osteoarthritis. Gold beads were percutaneously implanted via a needle into different locations surrounding the greater trochanter of the femur. Nine dogs with implants were necropsied. In all examined animals, characteristic histologic lesions were observed in the tissue surrounding the gold implants--namely, a fibrous capsule composed of concentric fibroblasts intermixed with a variable number of inflammatory cells and a paucicellular innermost layer of collagen with a few fibrocyte-like cells in empty lacunae. Lymphocytes dominated the inflammatory infiltrate, with rarely observed macrophages present in close proximity to the implant site. No giant cells were observed. Immunohistochemistry showed mixed populations of lymphocytes, both CD3 positive (T cells) and CD79a positive (B cells), which in some cases formed lymphoid follicles. Diffuse inflammatory changes were present to a minor extent in the perimysium and surrounding fascia. The inflammation observed in dogs is similar to that observed with gold implants in humans. It is possible that the clinically beneficial effect of gold beads for chronic osteoarthritis depends on sustained localized inflammation with localized release of soluble mediators. The encapsulation of the implant by a paucicellular and poorly vascularized fibrous capsule may help prevent an exaggerated inflammatory reaction by sequestering the gold bead from the surrounding tissue.

Etanercept treatment in rheumatoid arthritis patients with chronic kidney failure on predialysis

Rheumatoid arthritis (RA) patients with chronic kidney failure are intolerant to most disease-modifying antirheumatic drugs (DMARDs) and NSAIDs due to their potential toxicities. Although the tumor necrosis factor (TNF) inhibitors have emerged as a highly effective treatment for RA, their safety and efficacy in RA patients with chronic kidney failure have not been well reported. We retrospectively evaluated the safety and efficacy of etanercept treatment in RA patients with chronic kidney failure. We describe three RA patients with chronic kidney failure who had been treated with DMARDs, steroids and NSAIDs, but were discontinued from these classical agents due to several side effects and nephrotoxicity. The patients were treated with 25 mg of etanercept once or twice a week. We evaluated disease activity and used decreasing renal function and increasing number of infections to monitor safety. All three patients improved after starting etanercept treatment and their steroid requirements were decreased. Linear relationships between Modification of Diet in Renal Disease study equation (MDRD) glomerular filtration rate (GFR) and time were observed. Thus, in all patients, the changes in GFR did not represent superimposed acute drug toxicity, but rather chronic progressive renal failure. These cases show that etanercept may be a safe and effective treatment option for RA patients with chronic kidney failure.

Gold salts, D-penicillamine and allopurinol

Gold salts have been used in the treatment of patients with rheumatoid arthritis since 1927 [1]. After a controlled study, the Empire Rheumatism Council [2], confirmed the effectiveness of gold salts for the treatment of rheumatoid arthritis. Even today, chrysotherapy has remained one of the major therapeutic modalities in the second line treatment of progressive rheumatoid arthritis. Gold salts are also used in the treatment of pemphigus vulgaris [3] and bronchial asthma [4]. Before the introduction of an orally administered gold compound, auranofin (triethylphosphine gold tetra-acetyl glycopyranoside), to clinical use [5-7], parenterally administered gold salts, such as sodium aurothiomalate and gold thioglucose comprised chrysotherapy. The frequency and severity of the side effects for patients treated with parenteral gold versus those given oral gold preparations are significantly different [8-10]. With introduction of newer parental DMARDs, toxicity has been reduced using combination therapy [10a, 10b].

Immunomodulators: interleukins, interferons, and IV immunoglobulin

The outstanding progress in immunology and the development of new technologies have resulted in the introduction of new immunotherapies, the so-called “immunomodulators”, for autoimmune diseases, inflammatory disorders, allograft rejection, and cancer. These immunomodulators comprise recombinant cytokines and specific blocking or depleting antibodies. Many of these therapies achieve their effect by stimulating the release of cytokines. The term cytokines includes interleukins (IL-), chemokines, growth factors, interferons (IFN), colony stimulating factors (CSF), and tumor necrosis factors (TNF). These molecules are involved in inflammation, cell proliferation and apoptosis, tissue injury and repair.

These new therapeutic tools can be associated with side effects among which nephrotoxicity. The most common immunomodulators associated with nephrotoxicity are described in Table 1. The nephrotoxic side effects of immunomodulators can be roughly divided into (ischemic) tubular necrosis, thrombotic microangiopathy, serum sickness, and autoimmune disorders.

Rheumatoid arthritis: acute presentations and urgent complications

Rheumatoid arthritis is a common chronic disorder. Its many complications, comorbidities and adverse effects of treatment often involve general physicians. Particular risks are septic arthritis, systemic infections, upper gastrointestinal ulcers and systemic vasculitis. Delayed diagnosis will result in poor outcomes.

Management of co-morbidities and general medical conditions in patients with rheumatoid arthritis

Rheumatologists, in addition to providing subspecialty care, are frequently called to treat general medical conditions in their patients with rheumatoid arthritis (RA). Co-morbid medical problems are common in the RA population and may require a different approach from standard practice recommendations. In this paper, we review the evaluation and treatment of cardiovascular disease, chronic kidney disease, gastrointestinal disease, depression, and metabolic bone disease in patients with RA. Appreciation of the unique interaction between arthritis and common medical co-morbidities may have a significant impact on management and outcomes of RA.

Tacrolimus and nonsteroidal anti-inflammatory drugs: an association to be avoided

BACKGROUND

Tacrolimus (FK) and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause acute nephrotoxicity. The expanding use of tacrolimus and the intense consumption of NSAIDS increase the chances of their simultaneous use.

METHODS

Rats receiving a nonselective COX inhibitor (diclofenac, D) and FK or a selective COX-2 inhibitor (rofecoxib, RO) and FK were treated with FK (2 mg/kg/day), D (10 mg/kg/day), RO (3 mg/kg/day), FK+D, FK+RO and vehicle for 7 days on low-salt diet.

RESULTS

Both associations significantly impaired glomerular filtration rate (GFR; 0.63 +/- 0.06 ml/min/100 g in FK+D, 0.83 +/- 0.06 ml/min/100 g in FK+RO) which did not occur with single drug therapy (0.98 +/- 0.03 ml/min/100 g in D, 1.06 +/- 0.04 ml/min/100 g in RO, 0.99 +/- 0.05 ml/min/ 100 g in FK) or vehicle (1.10 +/- 0.05 ml/min/100 g). GFR decrease was significantly higher with FK+D. GFR impairment occurred without RBF or RVR major changes. Mild tubular vacuolization and dilatation and acute degenerative changes were observed in tubular cells. FK+D animals showed a marked weight loss, not observed in the other groups. FK+NSAIDs association decreased FK blood levels (1.73 +/- 0.3 ng/ml in FK+D, 1.8 +/- 0.3 ng/ml in FK+RO, 3.2 +/- 0.4 ng/ml in FK, p < 0.05).

CONCLUSIONS

The association of FK and nonselective or COX-2 selective NSAIDs in salt-depleted animals caused a significant GFR impairment and decreased FK blood levels.

Renale Manifestationen rheumatischer Erkrankungen

Inflammatory rheumatic diseases are frequently complicated by subclinical or overt renal manifestations. This is well known for the connective tissue diseases and vasculitides in which renal disease can be of significant prognostic value and therapeutic implication. However, rheumatoid arthritis and the spondyloarthritides can also be associated with direct renal manifestation or with secondary renal AA-amyloidosis. The clinician should be aware of the different glomerular (i. e. nephritic or nephritic syndrome, rapidly progressive renal disease) and tubulo-interstitial syndromes. In any case of renal dysfunction in a rheumatic patient, the differential diagnosis should include renal disease independent from the rheumatic condition, infection, and drug-induced renal toxicity.

Management Issues with Elderly-Onset Rheumatoid Arthritis

Elderly-onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) starting at >60 years of age. EORA is characterised by a lower female/male ratio compared with RA in younger patients and it more frequently has an acute onset accompanied by constitutional symptoms. Two incompletely overlapping subsets of RA have been recognised: one exhibits the classical RA clinical picture while the other has a polymyalgia rheumatica-like appearance, characterised by shoulder involvement, absence of rheumatoid factor and, usually, by a nonerosive course. Identification of anti-cyclic citrullinated peptide antibodies is useful for distinguishing the latter subset from true polymyalgia rheumatica. Elderly-onset spondyloarthritis, crystal-related arthritis, remitting seronegative symmetrical synovitis with pitting oedema syndrome and hepatitis C virus-related arthritis must also be considered in the differential diagnosis. EORA treatment requires prudence because of the increase in age-related risks pertaining principally to the renal, cardiovascular and gastrointestinal systems. No groups of molecules usually employed for RA therapy in younger subjects (analgesics, NSAIDs, corticosteroids, disease-modifying antirheumatic drugs, anticytokine drugs) can be excluded a priori from the treatment of EORA patients. Nevertheless, the risk/benefit ratio relating to their use must be accurately evaluated for every single patient. Recently marketed compounds such as leflunomide and tumour necrosis factor-alpha antagonists have also increased the therapeutic opportunities for aged RA patients.

Evaluation and management of psoriatic arthritis: the role of biologic therapy

Clinicians often view psoriatic arthritis (PsA) as a rather minor arthritic disorder because many are unaware of the substantial damage, disability, and reduced quality of life that patients with this disease can suffer. Compared with better-studied arthritic conditions, such as rheumatoid arthritis (RA) with well-known consequences of disease progression, PsA does not elicit the same urgency to treat early and aggressively. This is largely owing to the lack of predictive epidemiologic data regarding disease progression in PsA. However, numerous studies indicate that PsA and RA are comparable in terms of overall severity of joint involvement and disability over equivalent disease duration. Many of the drugs traditionally used for PsA therapy are also used to treat RA, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, methotrexate (MTX), sulfasalazine, cyclosporine, etretinate, auranofin, intramuscular gold, and azathioprine. All of these drugs have significant risk of toxicity over long-term use, and all provide variable efficacy. This makes it difficult for clinicians to make sound risk-benefit assessments regarding treatment or nontreatment of PsA, because the risks of disease progression cannot be weighed against the risks of therapy. The newer biologic antirheumatic drugs appear to combine greater efficacy of treatment with significantly less toxicity by targeting specific mediators involved in the pathogenesis of PsA.

18. Immune-mediated renal disease

Immune-mediated renal diseases can be classified by the clinical syndromes they produce, by the attendant renal pathology, or by the dominant immune effector mechanism of renal injury. The major clinical syndromes produced by immune-mediated renal injury include the nephrotic syndrome, the nephritic syndrome, rapidly progressive glomerulonephritis, and acute renal failure. The notion of clinical syndromes facilitates diagnosis and treatment, but does not accurately define disease pathogenesis. In this summary, we discuss pathologically defined immune-mediated renal diseases under the clinical syndrome with which they are most frequently associated. There is overlap between the clinical syndromes, but the syndromes provide a useful framework. Relevant information regarding the proposed pathogenesis of disease entities is included under specific disease entities.

Mechanisms of NSAID-induced hepatotoxicity: focus on nimesulide

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with idiosyncratic hepatotoxicity in susceptible patients. The molecular mechanisms underlying this toxicity have not yet been fully elucidated. However, experimental evidence suggests that they include increased concentration of the drugs in the hepatobiliary compartment, formation of reactive metabolites that covalently modify proteins and produce oxidative stress, and mitochondrial injury. Genetic and/or acquired patient factors can either augment the pathways leading to hepatic toxicity or impede the protective and detoxifying pathways. An example is nimesulide, a selective cyclo-oxygenase-2 inhibitor widely used for the treatment of inflammatory and pain conditions, which has been recently associated with rare but serious and unpredictable adverse reactions in the liver (increases in serum aminotransferase activities, hepatocellular necrosis, and/or intrahepatic cholestasis). Similar to other drugs causing idiosyncratic hepatotoxicity, both the molecule and the patient contribute to the hazard. Here, the weakly acidic sulfonanilide drug undergoes bioreductive metabolism of the nitroarene group to reactive intermediates that have been implicated in oxidative stress, covalent binding, and mitochondrial injury. It is only in a small number of susceptible patients, however, that genetic or nongenetic factors will cause this potential toxicity to become clinically manifest. In view of the very large recipient population, the incidence of nimesulide-induced liver injury has been low (approximately 0.1 per 100,000 patients treated). Although this estimation is based on spontaneous reporting data versus sales units and needs correction due to the classical bias of this system, the type and incidence of these rare but severe hepatic adverse reactions are comparable to that of other NSAIDs.

Psychological interventions for rheumatoid arthritis: a meta-analysis of randomized controlled trials

OBJECTIVE

To carry out a systematic review of the literature examining the efficacy of psychological interventions (e.g., relaxation, biofeedback, cognitive-behavioral therapy) in the treatment of rheumatoid arthritis (RA).

METHODS

Studies that met the following criteria were included: random assignment, wait-list or usual care control condition; publication in peer-reviewed journals; treatment that included some psychological component beyond simply providing education information; and separate data provided for patients with RA if subjects with conditions other than RA were included. Two investigators independently extracted data on study design, sample size and characteristics, type of intervention, type of control, direction and nature of the outcome(s).

RESULTS

Twenty-five trials met the inclusion criteria. Methodologic quality was assessed, and effect sizes were calculated for 6 outcomes. Significant pooled effect sizes were found postintervention for pain (0.22), functional disability (0.27), psychological status (0.15), coping (0.46), and self efficacy (0.35). At followup (averaging 8.5 months), significant pooled effect sizes were observed for tender joints (0.33), psychological status (0.30), and coping (0.52). No clear or consistent patterns emerged when effect sizes for different types of treatment and control conditions were compared, or when higher quality trials were compared to lower quality ones. Findings do, however, suggest that these psychological interventions may be more effective for patients who have had the illness for shorter duration.

CONCLUSIONS

Despite some methodologic flaws in the literature, psychological interventions may be important adjunctive therapies in the medical management of RA.

Advances in anti-inflammatory therapy

Our goal was to evaluate the state of nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of rheumatoid arthritis (RA), before the introduction of the coxibs. The prerequisite for inclusion was the presence of RA (ACR criteria) plus therapy with an NSAID with or without a disease modifying antirheumatic drug (DMARD). A total of 368 consecutive RA patients (81% women) from the outpatient clinic at the Vienna General Hospital were included. Rheumatoid factor was positive in 62%, the patients' mean age was 60 +/- 14 years. The period of observation was 1972-1998. Seventy-seven per cent of the patients had DMARD and NSAID therapy. NSAID therapy was dominated by diclofenac, accounting for 60% of all therapies. Eighteen other substances were applied more rarely. All NSAIDs together were given for 768 patient years (with a mean duration of therapy of 17 years +/- 21 months). Seventy-two per cent of the patients received GI-protective therapy mainly with histamine antagonists and sucralfate while on nonsteroidal therapy. NSAID toxicity mostly affected the GI tract. There was a similar incidence of GI-related adverse events between patients with and patients without GI protection, mainly dyspepsia and nausea. NSAIDs have the potential to cause adverse events in the GI tract. Therapy with histamine antagonists or sucralfate did not reduce the patients' rate of gastrointestinal adverse events.