Bullous pemphigoid in patients receiving peritoneal dialysis: a case series and a literature survey

Pemphigoid diseases in patients with end-stage kidney diseases: pathogenesis and treatment

Background

Pemphigoid diseases constitute a group of autoimmune blistering disorders characterized by subepithelial blistering. The association between pemphigoid diseases and both end-stage kidney disease (ESKD) and its treatment is notable. However, there is limited evidence about the management of pemphigoid diseases in patients with ESKD. This systematic review compiled case reports and relevant studies, summarized the underlying mechanisms of pemphigoid diseases in patients with ESKD, and summarized the efficacy of various therapies.

Methods

A systematic search of PubMed and Embase was performed for articles published between 1982 to June 2, 2024.

Results

Fifty-three case reports and eight relevant studies were included. Triggers for pemphigoids in patients with ESKD included materials used to treat ESKD, immune dysregulation of patients with ESKD, and rejection of renal allograft. Treatment for these patients included removing triggers, as well as administering of corticosteroids, mycophenolate mofetil (MMF), tetracyclines, rituximab, methotrexate, dapsone, azathioprine, cyclosporine, intravenous immunoglobin (IVIG), plasmapheresis, and Janus kinase inhibitors.

Conclusion

Removing triggers is the most effective strategy. Despite their suboptimal efficacy, corticosteroids remain the most commonly used agents in this patient population. MMF, tetracyclines, and rituximab are less used but with benefits. There are significant adverse effects associated with methotrexate treatment. Other treatment may also be beneficial and require further investigation. These findings may enable clinicians to optimize the therapeutic approach for these patients.

Assoziation zwischen chronischer Nierenerkrankung und dem Risiko für bullöses Pemphigoid: eine nationale bevölkerungsbasierte Kohortenstudie

Hintergrund

Studien haben gezeigt, dass das bullöse Pemphigoid (BP) auch bei Patienten mit chronischer Nierenerkrankung (CKD, chronic kidney disease) auftritt. Unklar ist, wie hoch das BP‐Risiko bei CKD‐Patienten ist.

Zielsetzung

Es sollte untersucht werden, ob eine CKD das BP‐Risiko erhöht.

Methodik

Die Studienteilnehmer wurden für den Zeitraum von 2007 bis 2018 aus der nationalen Datenbank der taiwanesischen Krankenversicherung rekrutiert. Insgesamt wurden 637 664 neu diagnostizierte Patienten mit CKD sowie 637 664 nach Alter, Geschlecht und Komorbidität übereinstimmende Kontrollpersonen ohne CKD in die Untersuchung aufgenommen. Zur Bewertung des BP‐Risikos kam ein Modell für konkurrierende Risiken zum Einsatz.

Ergebnisse

Nach Adjustierung für Alter, Geschlecht und Komorbidität im multivariaten Modell zeigte sich die CKD als signifikanter Risikofaktor für BP (adjustierte Hazard Ratio [aHR]: 1,29; 95%‐Konfidenzintervall [KI]: 1,17–1,42; p < 0,001). CKD‐Patienten wurden in die Gruppen dialysepflichtig und nicht‐dialysepflichtig unterteilt und mit den Patienten ohne CKD verglichen. Es zeigte sich, dass dialysepflichtige CKD‐Patienten das höchste BP‐Risiko aufwiesen (aHR 1,75; 95%‐KI 1,51–2,03), gefolgt von nicht‐dialysepflichtigen CKD‐Patienten (aHR 1,20; 95%‐KI 1,08–1,32).

Limitationen

Detaillierte Laborbefunde zur Einschätzung des CKD‐Schweregrads fehlten.

Schlussfolgerungen

Im Vergleich zu Personen ohne CKD hatten Patienten mit CKD ein 1,3‐fach erhöhtes BP‐Risiko. Bei Patienten mit dialysepflichtiger CKD war das Risiko 1,8‐fach erhöht.

Risk of bullous pemphigoid and pemphigus in patients on chronic dialysis: A nationwide population-based cohort study

Bullous pemphigoid has a high incidence among dialysis patients. However, whether or not chronic dialysis is an independent risk factor of bullous pemphigoid remains unclear. We aimed to investigate the effect of chronic dialysis on the development of bullous pemphigoid and pemphigus. We performed a retrospective cohort study using records from Taiwan's National Health Insurance Research Database between 2008 and 2019. We identified a dialysis cohort that included patients on chronic hemodialysis and peritoneal dialysis, and the hazard ratios (HRs) for bullous pemphigoid and pemphigus were compared with those of a sex-, age-, and index-matched cohort, then the results were adjusted for various confounding factors. Among 93 538 patients on chronic dialysis and 93 538 patients in the control group, 287 and 139 developed incident bullous pemphigoid, and 45 and 35 developed incident pemphigus after a median follow-up of 3.7 and 5.6 years, respectively. The incidence rates of bullous pemphigoid in the dialysis patients and the control group were 74.2 and 25.2 per 100 000 person-years, respectively (difference between groups, P < 0.0001). The incidence rates of pemphigus in the dialysis patients and the control group were 11.6 and 6.3 per 100 000 person-years, respectively (difference between groups, P < 0.01). Cox proportional hazard adjustment showed the HR for bullous pemphigoid in dialysis patients was 2.12 (95% confidence interval [CI] 1.64-2.74, P < 0.0001) compared with the control group. Dialysis patients aged <75 years had an even higher risk of bullous pemphigoid development (5- to 8-fold) than the control group. The adjusted HR for pemphigus was not elevated in dialysis patients (adjusted HR 1.52, 95% CI 0.87-2.67, P = 0.14). Chronic dialysis is an independent risk factor for developing bullous pemphigoid, but not a risk factor for pemphigus. Physicians should be aware of the predisposition of chronic dialysis patients to bullous pemphigoid.

Association between chronic kidney disease and risk of bullous pemphigoid: a nationwide population-based cohort study

BACKGROUND

Studies have shown that bullous pemphigoid (BP) occurs in patients with chronic kidney disease (CKD). However, the risk of developing BP in patients with CKD remains inconclusive.

OBJECTIVE

To investigate whether CKD increases the risk of BP.

METHODS

Participants were recruited from the National Health Insurance Database of Taiwan between 2007 and 2018. Overall, 637,664 newly diagnosed patients with CKD and 637,664 age-, sex-, and comorbidity-matched non-CKD participants were selected. A competing risk model was used to evaluate the risk of development of BP.

RESULTS

After adjusting for age, sex, and comorbid diseases in the multivariate model, CKD was a significant risk factor for BP (adjusted hazard ratio [aHR]: 1.29; 95% confidence interval [CI]: 1.17-1.42; p < 0.001). CKD patients were classified into the dialytic or non-dialytic groups and compared to non-CKD participants, and this revealed that patients with dialysis-dependent CKD had the highest risk of BP (aHR 1.75; 95% CI 1.51-2.03), followed by patients with non-dialysis-dependent CKD (aHR 1.20; 95% CI 1.08-1.32).

LIMITATIONS

We lacked detailed laboratory data on the severity of CKD.

CONCLUSIONS

Compared with individuals without CKD, those with CKD had a 1.3-fold increased risk of BP. Patients with dialysis-dependent CKD had an even higher BP risk (1.8-fold).

Bullous Pemphigoid in X-linked Alport Syndrome

Skin lesions in X-linked Alport syndrome (XLAS) are rarely observed. Bullous pemphigoid (BP) is caused by autoantibodies against BP180, also called α1 (XVII) chain, in the basement membrane zone (BMZ). A 48-year-old man with XLAS developed tense blisters. A skin biopsy showed a cleft between the basal cell layer and dermis, with the infiltration of neutrophils and eosinophils. α1 (XVII) staining was positive on the epidermal side of α2/5 (IV) staining. Oral prednisolone improved his symptoms gradually. Abundant tense blisters on the palms and soles might suggest an important role of the α5 (IV) chain in the integrity of BMZ.

The relationship between bullous pemphigoid and renal disease and related treatments: a review of the current literature

INTRODUCTION

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disorder in older adults. There is increasing evidence that BP has connections with renal diseases, such as glomerulopathy and neoplasm; it is also linked to the receipt of renal replacement therapy.

AREAS COVERED

In this review, we summarize the current evidence that BP is a comorbidity of common renal diseases. Furthermore, our exploration of the characteristics and possible mechanisms underlying these connections provides insights that may facilitate the prevention, diagnosis, and management of BP.

EXPERT OPINION

There is mounting proof that BP is not just a skin immunological disorder but rather a systemic immune-mediated illness. Quantities of case reports focused on BP as a renal disease comorbidity and the coexistence of them is not accidental. However, the underlying mechanisms are still needed to be investigated. Clinicians should be alert to the comorbidities in order to facilitate effective treatment and improve patient prognosis.

Levofloxacin-Associated Bullous Pemphigoid in a Hemodialysis Patient After Kidney Transplant Failure

BACKGROUND Patients with end-stage renal disease (ESRD) who require dialysis can develop a variety of skin conditions, such as pruritus, xerosis, skin infections, and autoimmune reactions. Bullous pemphigoid (BP) is an autoimmune bullous disorder with an increasing incidence. It can be caused by over 90 medications, but levofloxacin-induced BP in hemodialysis patients has not yet been reported. This report is of a 27-year-old woman with ESRD on hemodialysis who developed BP after levofloxacin treatment. CASE REPORT A 27-year-old woman with hemodialysis after kidney transplantation failure was started with levofloxacin for suspected urinary tract infection 1.5 months prior to admission. Her urinary tract infection symptoms were improved after 3 weeks of levofloxacin treatment, but a serious rash developed, presenting with progressive bullous throughout the body and facial involvement. A thorough workup showed a remarkably elevated hemidesmosomal antigen, BP180 (116 RU/mL), and cutaneous indirect immunofluorescence on human salt-split skin substrate was positive for serum basement membrane zone IgG with an epidermal pattern. Skin biopsy direct immunofluorescence staining showed continuous linear C3 deposition along the basement membrane zone. Prednisone 60 mg daily was started with a taper schedule. She no longer had new skin rash during a follow-up of over 3 months. CONCLUSIONS To the best of our knowledge, this is the first case of levofloxacin-induced BP in a patient undergoing hemodialysis. This report highlights the importance of recognizing skin reactions associated with ESRD in dialysis patients, the correct diagnosis by biopsy and histopathology, and the correct and timely management.