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Treppo E, Quartuccio L, De Vita S. Recent updates in the diagnosis and management of cryoglobulinemic vasculitis. Expert Rev Clin Immunol 2023; 19:1457-1467. [PMID: 37698547 DOI: 10.1080/1744666x.2023.2249609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/15/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Cryoglobulinemic vasculitis (CV), also known as mixed cryoglobulinemic syndrome (MCS), is a systemic vasculitis that affects small blood vessels. It exhibits a wide range of clinical manifestations, making its treatment a continuing challenge for physicians. AREAS COVERED We conducted a comprehensive review to evaluate the current status of diagnosis, management, and treatment of mixed cryoglobulinemia (MC). The accurate clinical and serological evaluation plays a vital role in diagnosing MC, identifying potential comorbidities, and monitoring its main manifestations and complications. Treatment strategies should be individualized based on the underlying etiopathogenesis, the severity of organ involvement, and the associated underlying disease. At present, the two mainstays of CV treatment are direct antiviral agents (for HCV-related CV) and B-cell-targeted therapy. EXPERT OPINION MC remains one of the few autoimmune diseases where the etiology is known, at least for the majority of patients. Its pathogenetic mechanism offers a unique opportunity to investigate the interplay between infections and the immune system. Moving forward, the primary challenge will continue to lie in the treatment of resistant or refractory cases of CV, particularly those associated with autoimmune diseases, or cases classified as 'essential' CV.
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Affiliation(s)
- Elena Treppo
- Rheumatology Unit, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| | - Luca Quartuccio
- Rheumatology Unit, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
| | - Salvatore De Vita
- Rheumatology Unit, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
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Ishitoku M, Yoshida Y, Matsubara T, Fujii K, Yorishima A, Oka N, Masuda S, Sugimoto T, Mokuda S, Masaki T, Hirata S. Cryoglobulinemic Vasculitis Associated with Monoclonal Gammopathy of Undetermined Significance Developed after Sustained Virologic Response of Hepatitis C: A Case Report. Intern Med 2022. [PMID: 36384905 PMCID: PMC10372272 DOI: 10.2169/internalmedicine.9768-22] [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: 11/16/2022] Open
Abstract
A 72-year-old woman had a history of chronic hepatitis C virus (HCV) infection previously treated with interferon to achieve a sustained virologic response. Thereafter, she developed polyarthritis and purpura of the lower extremities as well as progressive renal dysfunction with hypertension and proteinuria that had occurred in the last three months. Laboratory investigations revealed seropositivity for cryoglobulin but negative findings for HCV RNA. She was ultimately diagnosed with cryoglobulinemic glomerulonephritis complicated by monoclonal gammopathy of undetermined significance (MGUS) based on the pathological findings of the kidney and bone marrow, indicating that MGUS-induced cryoglobulinemic vasculitis may occur even after HCV elimination.
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Affiliation(s)
- Michinori Ishitoku
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Toshiki Matsubara
- Postgraduate Clinical Training Center, Hiroshima University Hospital, Japan
| | - Kenji Fujii
- Department of Nephrology, Hiroshima University Hospital, Japan
| | - Ai Yorishima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Naoya Oka
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Sho Masuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
- Department of Rheumatology, Medical Corporation JR Hiroshima Hospital, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
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Cacoub P, Comarmond C, Vieira M, Régnier P, Saadoun D. HCV-related lymphoproliferative disorders in the direct-acting antiviral era: From mixed cryoglobulinaemia to B-cell lymphoma. J Hepatol 2022; 76:174-185. [PMID: 34600000 DOI: 10.1016/j.jhep.2021.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/31/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023]
Abstract
HCV has been shown to induce many B-cell lymphoproliferative disorders. B lymphocytes specialise in producing immunoglobulins and, during chronic HCV infection, they can cause manifestations ranging from polyclonal hypergammaglobulinaemia without clinical repercussions, through mixed cryoglobulinaemic vasculitis to B-cell non-Hodgkin lymphoma. This spectrum is supported by substantial epidemiological, pathophysiological and therapeutic data. Many, although not all, of the pathogenic pathways leading from one extreme to another have been decrypted. Chronic viral antigen stimulation of B lymphocytes has a central role until the final steps before overt malignancy. This has direct implications for treatment strategies, which always include the use of direct-acting antivirals sometimes alongside immunosuppressants. The role of direct-acting antivirals has been well established in patients with cryoglobulinaemia vasculitis. However, their positive impact on B-cell non-Hodgkin lymphoma needs to be confirmed in larger studies with longer follow-up.
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Affiliation(s)
- Patrice Cacoub
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France; Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; Institut National de la Santé et de la Recherche Médicale, INSERM, UMR_S 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; Sorbonne Université, UPMC Univ Paris 06, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France.
| | - Cloé Comarmond
- AP-HP, Lariboisière Hospital, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - Matheus Vieira
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France; Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; Institut National de la Santé et de la Recherche Médicale, INSERM, UMR_S 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; Sorbonne Université, UPMC Univ Paris 06, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France
| | - Paul Régnier
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France; Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; Institut National de la Santé et de la Recherche Médicale, INSERM, UMR_S 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; Sorbonne Université, UPMC Univ Paris 06, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France
| | - David Saadoun
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France; Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; Institut National de la Santé et de la Recherche Médicale, INSERM, UMR_S 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; Sorbonne Université, UPMC Univ Paris 06, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France
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Wang CR, Tsai HW. Human hepatitis viruses-associated cutaneous and systemic vasculitis. World J Gastroenterol 2021; 27:19-36. [PMID: 33505148 PMCID: PMC7789062 DOI: 10.3748/wjg.v27.i1.19] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/19/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Human hepatitis viruses (HHVs) include hepatitis A virus, hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis delta virus, and hepatitis E virus and can cause liver inflammation in their common human host. Usually, HHV is rapidly cleared by the immune system, following acute HHV invasion. The morbidities associated with hepatitis A virus and hepatitis E virus infection occur shortly after their intrusion, in the acute stage. Nevertheless, the viral infectious process can persist for a long period of time, especially in HBV and HCV infection, leading to chronic hepatitis and further progressing to hepatic cirrhosis and liver cancer. HHV infection brings about complications in other organs, and both acute and chronic hepatitis have been associated with clinical presentations outside the liver. Vascular involvement with cutaneous and systemic vasculitis is a well-known extrahepatic presentation; moreover, there is growing evidence for a possible causal relationship between viral pathogens and vasculitis. Except for hepatitis delta virus, other HHVs have participated in the etiopathogenesis of cutaneous and systemic vasculitis via different mechanisms, including direct viral invasion of vascular endothelial cells, immune complex-mediated vessel wall damage, and autoimmune responses with stimulation of autoreactive B-cells and impaired regulatory T-cells. Cryoglobulinemic vasculitis and polyarteritis nodosa are recognized for their association with chronic HHV infection. Although therapeutic guidelines for HHV-associated vasculitis have not yet been established, antiviral therapy should be initiated in HBV and HCV-related systemic vasculitis in addition to the use of corticosteroids. Plasma exchange and/or combined cyclophosphamide and corticosteroid therapy can be considered in patients with severe life-threatening vasculitis manifestations.
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Affiliation(s)
- Chrong-Reen Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
| | - Hung-Wen Tsai
- Department of Pathology, National Cheng Kung University Hospital, Tainan 70403, Taiwan
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Comarmond C, Cacoub P, Saadoun D. Treatment of chronic hepatitis C-associated cryoglobulinemia vasculitis at the era of direct-acting antivirals. Therap Adv Gastroenterol 2020; 13:1756284820942617. [PMID: 32782479 PMCID: PMC7383649 DOI: 10.1177/1756284820942617] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/12/2020] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection is responsible for both hepatic and extrahepatic manifestations. Before the era of direct-acting antivirals (DAA), cryoglobulinemia was related to HCV infection in 70-90% of cases. Observed in 30% to 40% of patients with hepatitis C, mixed cryoglobulinemia is mainly asymptomatic. Conversely, symptomatic cryoglobulinemia vasculitis (CV) can occur in 5-10% of patients with HCV-associated cryoglobulinemia. CV is a small-vessel systemic vasculitis, and organ damage results from circulation and precipitation of cryoglobulins and complement activation. A wide range of clinical symptoms can be observed during CV, and manifestations are potentially life-threatening. The most frequent manifestations occurring in CV are cutaneous, with recurrent purpura, articular with joint pains, neurologic with peripheric neuropathy, and renal with membranoproliferative glomerulonephritis. DAA have drastically changed chronic HCV therapy. DAA induce sustained virological response (SVR) rates greater than 95%, and also improve extrahepatic manifestations such as CV. We review recent studies investigating the clinical and immune effects of DAA therapy on HCV-CV.
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Affiliation(s)
- Cloé Comarmond
- Sorbonne Université, Département de Médecine Interne et Immunologie Clinique, Paris, France, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Centre National de Référence Maladies Auto-Immunes Systémiques Rares, Centre National de Référence Maladies Auto-Inflammatoires et Amylose Inflammatoire INSERM, UMR_S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière
| | - Patrice Cacoub
- Sorbonne Université, Département de Médecine Interne et Immunologie Clinique, Paris, France, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Centre National de Référence Maladies Auto-Immunes Systémiques Rares, Centre National de Référence Maladies Auto-Inflammatoires et Amylose Inflammatoire INSERM, UMR_S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière
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Urrea-Pineda LY, Gómez-Jiménez S, Jaramillo-Arroyave D, Muñoz-Vahos CH, Vanegas-García AL, Vasquéz G, Restrepo-Escobar M, González-Naranjo LA. Cryoglobulinemic vasculitis and psoriatic arthritis: Case report of an unusual association. REUMATOLOGIA CLINICA 2020; 16:242-244. [PMID: 29789229 DOI: 10.1016/j.reuma.2018.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/07/2018] [Indexed: 06/08/2023]
Abstract
We report the case of a 47-year-old man with a 9-year history of psoriatic arthritis (PsA) in whom we detected renal involvement, hypocomplementemia, peripheral neuropathy, acral necrotic lesions and positive cryoglobulins. The results of the diagnosis led us to conclude that the clinical picture corresponded to cryoglobulinemic vasculitis concomitant with PsA. In addition, we present a review of the literature on the presence of these two diseases in a single patient.
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Affiliation(s)
| | | | - Daniel Jaramillo-Arroyave
- Servicio de Reumatología, IPS Universitaria, Clínica León XIII, Medellín, Colombia; Sección de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia; Grupo de Epidemiología y Bioestadística, Facultad de Medicina, Universidad CES, Medellín, Colombia.
| | - Carlos Horacio Muñoz-Vahos
- Servicio de Reumatología, IPS Universitaria, Clínica León XIII, Medellín, Colombia; Sección de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia; Servicio de Reumatología, Hospital San Vicente Fundación, Medellín, Colombia
| | - Adriana Lucía Vanegas-García
- Sección de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia; Servicio de Reumatología, Hospital San Vicente Fundación, Medellín, Colombia
| | - Gloria Vasquéz
- Sección de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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Hellmich B, Löffler C. [What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]. Z Rheumatol 2019; 78:955-966. [PMID: 31485728 PMCID: PMC7101899 DOI: 10.1007/s00393-019-00687-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.
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Affiliation(s)
- B Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
| | - C Löffler
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland
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Chen YP, Cheng H, Rui HL, Dong HR. Cryoglobulinemic vasculitis and glomerulonephritis: concerns in clinical practice. Chin Med J (Engl) 2019; 132:1723-1732. [PMID: 31283654 PMCID: PMC6759094 DOI: 10.1097/cm9.0000000000000325] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Cryoglobulinemia often causes systemic vasculitis, thereby damaging to skin and internal organs including kidneys, even life-threatening. This review aimed to introduce the advances in understanding, detection, and treatment of this disease in recent years, with a particular concern to clinical practice. DATA SOURCES All the data in this review were from the English or Chinese literature in the PubMed and China National Knowledge Infrastructure databases as of March 2019. STUDY SELECTION This review selected important original articles, meaningful reviews, and some reports on cryoglobulinemia published in recent years and in history, as well as the guidelines for treatment of underlying diseases which lead to cryoglobulinemia. RESULTS Diagnosis of cryoglobulinemia relies on serum cryoglobulin test, in which to ensure that the blood sample temperature is not less than 37°C in the entire pre-analysis phase is the key to avoid false negative results. Cryoglobulinemic vasculitis (Cryo Vas), including cryoglobulinemic glomerulonephritis (Cryo GN), usually occurs in types II and III mixed cryoglobulinemia, and can also be seen in type I cryoglobulinemia caused by monoclonal IgG3 or IgG1. Skin purpura, positive serum rheumatoid factor, and decreased serum levels of C4 and C3 are important clues for prompting types II and III Cryo Vas. Renal biopsy is an important means for diagnosis of Cryo GN, while membranous proliferative GN is the most common pathological type of Cryo GN. In recent years, great advances have been made in the treatment of Cryo Vas and its underlying diseases, and this review has briefly introduced these advances. CONCLUSIONS Laboratory examinations of serum cryoglobulins urgently need standardization. The recent advances in the diagnosis and treatment of Cryo Vas and GN need to be popularized among the clinicians in related disciplines.
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Affiliation(s)
- Yi-Pu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Cao Q, Qi H, Yao L, Liu Q. Monoclonal gammopathy of renal significance: clinical manifestation, pathogenic characteristic and treatment. Panminerva Med 2019; 62:38-53. [PMID: 30848114 DOI: 10.23736/s0031-0808.19.03609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a dangerous plasmatic/B-cell clone hyperplasia through MIg deposition or dysfunction of complement pathway, with increasing risk of progress to end stage renal disease (ESRD) and the underlying hematologic malignancy. The combination of renal biopsy, complete laboratory examination and bone marrow biopsy is an indispensable diagnostic tool for MGRS to identify accurately and unequivocally the pathogenic monoclonal MIg and provide guidance to treatment. Treatment of MGRS is composed of conventional therapy, chemotherapy, and stem cell transplantation to target the underlying clone and eliminate the noxious MIg on the basis of clinical data of some retrospective studies and a small amount of prospective trial. In addition, it is worthwhile point out assessment of therapeutic effect is significantly relevant for renal and overall prognosis. Thus, by comprehensively analyzing the clinical manifestations and pathogenic characteristic of MGRS, early recognition and prompt treatment can improve the prognosis and prevent post-translation recurrence with multidisciplinary cooperation.
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Affiliation(s)
- Qin Cao
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Huimeng Qi
- Department of General Practice, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Qiang Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China -
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Toriu N, Sawa N, Oguro M, Mizuno H, Oshima Y, Hasegawa E, Sumida K, Suwabe T, Kawada M, Ueno T, Hayami N, Sekine A, Hiramatsu R, Yamanouchi M, Hoshino J, Takaichi K, Ohashi K, Fujii T, Yanagita M, Ubara Y. Renal-limited Cryoglobulinemic Vasculitis: Two Case Reports. Intern Med 2018; 57:1879-1886. [PMID: 29962417 PMCID: PMC6064702 DOI: 10.2169/internalmedicine.0131-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022] Open
Abstract
Cryoglobulinemic vasculitis (CV) presents with systemic manifestations, including renal disease, arthritis, peripheral neuropathy, and muscle weakness. We encountered two patients who developed severe nephrotic range proteinuria; however, extrarenal manifestations were not noted during the clinical course. A renal biopsy revealed typical membranoproliferative glomerulonephritis (MPGN) with huge thrombus-like endothelial deposits and predominant IgM positivity, but electron microscopy did not reveal any definite microtubules. Immunosuppressive therapy and plasmapheresis were only partially effective, and the improvement was not durable. Biological therapy with rituximab (RTX) had no effect. Renal-limited CV should be recognized as a subset of essential CV.
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Affiliation(s)
- Naoya Toriu
- Nephrology Center, Toranomon Hospital, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital, Japan
- Okinaka Memorial Institute for Medical Research, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Pathology, Yokohama City Hospital, Japan
| | | | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Japan
- Okinaka Memorial Institute for Medical Research, Japan
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Spatola L, Generali E, Angelini C, Badalamenti S, Selmi C. HCV-negative mixed cryoglobulinemia and kidney involvement: in-depth review on physiopathological and histological bases. Clin Exp Med 2018; 18:465-471. [PMID: 29956004 DOI: 10.1007/s10238-018-0514-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/21/2018] [Indexed: 11/28/2022]
Abstract
Type II mixed cryoglobulinemia without evidence of HCV infection but rather with renal involvement has been occasionally described. The pathogenesis of cryoglobulinemic kidney disease is most likely related to immune complex deposition including cryoglobulins, and cryoaggregation after cold exposure could play a pivotal role in clinical expression of cryoglobulinemia. In these cases, acute kidney injury and proteinuria remain the most frequent clinical expression of a cryoglobulinemic glomerulonephritis. Type II cryoglobulinemia with the laboratory finding of both monoclonal and polyclonal cryoglobulins is the most prevalent bio-humoral pattern among HCV-negative phenotypes with renal involvement, while type III cryoglobulinemia with polyclonal Ig is rare. Histological data in renal biopsies support the hypothesis that regardless of the HCV status cryoglobulinemia vasculitis share the same frequent pathological finding of membranoproliferative glomerulonephritides, but other histological patterns have also been observed in a minority of cases. In HCV-negative mixed cryoglobulinaemia, the paraneoplastic origin of the immune dysfunction should be ruled out and sporadic cases have been reported, while there is no cumulative evidence on the prevalence of these tumour-associated manifestations. Moving from the classification criteria and the etiopathogenesis of mixed cryoglobulinaemia, we provide a comprehensive review of the literature on the appearance of the disease with kidney injury in association with malignancies or autoimmune disorders without HCV coexistence.
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Affiliation(s)
- Leonardo Spatola
- Unit of Nephrology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Elena Generali
- Unit of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Claudio Angelini
- Unit of Nephrology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Salvatore Badalamenti
- Unit of Nephrology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carlo Selmi
- Unit of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,BIOMETRA Department, University of Milan, Milan, Italy
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Montero N, Favà A, Rodriguez E, Barrios C, Cruzado JM, Pascual J, Soler MJ. Treatment for hepatitis C virus-associated mixed cryoglobulinaemia. Cochrane Database Syst Rev 2018; 5:CD011403. [PMID: 29734473 PMCID: PMC6494545 DOI: 10.1002/14651858.cd011403.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV)-associated mixed cryoglobulinaemia is the manifestation of an inflammation of small and medium-sized vessels produced by a pathogenic IgM with rheumatoid factor activity generated by an expansion of B-cells. The immune complexes formed precipitate mainly in the skin, joints, kidneys or peripheral nerve fibres. Current therapeutic approaches are aimed at elimination of HCV infection, removal of cryoglobulins and also of the B-cell clonal expansions. The optimal treatment for it has not been established. OBJECTIVES This review aims to look at the benefits and harms of the currently available treatment options to treat the HCV-associated mixed cryoglobulinaemia with active manifestations of vasculitis (cutaneous or glomerulonephritis). SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 30 November 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at interventions directed at treatment of HCV-associated cryoglobulinaemic vasculitis (immunosuppressive medications and plasma exchange therapy) have been included. DATA COLLECTION AND ANALYSIS Two authors independently assessed the retrieved titles and abstracts. Authors of included studies were contacted to obtain missing information. Statistical analyses were performed using random effects models and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). The planned primary outcomes were kidney disease, skin vasculitis, musculoskeletal symptoms, peripheral joint arthralgia, peripheral neuropathies, liver involvement, interstitial lung involvement, widespread vasculitis and death. Other planned outcomes were: therapy duration, laboratory findings, adverse effects, antiviral therapy failure, B-cell lymphoma, endocrine disorders and costs of treatment. MAIN RESULTS Ten studies were included in the review (394 participants). None of them evaluated direct-acting antivirals. Seven studies were single-centre studies and three were multicentre. The duration of the studies varied from six to 36 months. The risk of bias was generally unclear or low. Three different interventions were examined: use of rituximab (3 studies, 118 participants); interferon (IFN) (IFN compared to other strategies (5 studies, 223 participants); six IFN months versus one year (1 study, 36 participants), and immunoadsorption apheresis versus only immunosuppressive therapy (1 study, 17 participants).The use of rituximab may slightly improve skin vasculitis (2 studies, 78 participants: RR 0.57, 95% CI 0.28 to 1.16; moderate certainty evidence) and made little of no difference to kidney disease (moderate certainty evidence). In terms of laboratory data, the effect of rituximab was uncertain for cryocrit (MD -2.01%, 95% CI -10.29% to 6.27%, low certainty evidence) and HCV replication. Rituximab may slightly increase infusion reactions compared to immunosuppressive medication (3 studies, 118 participants: RR 4.33, 95%CI 0.76 to 24.75, moderate certainty evidence) however discontinuations of the treatment due to adverse reactions were similar (3 studies, 118 participants: RR 0.97, 95% CI 0.22 to 4.36, moderate certainty evidence).Effects of lFN on clinical symptoms were evaluated only in narrative results. When laboratory parameters were assessed, IFN made little or no difference in levels of alanine transaminase (ALT) at six months (2 studies, 39 participants: MD -5.89 UI/L, 95%CI -55.77 to 43.99); rheumatoid factor activity at six months (1 study, 13 participants: MD 97.00 UI/mL, 95%CI -187.37 to 381.37), or C4 levels at 18 months (2 studies, 49 participants: MD -0.04 mg/dL, 95%CI -2.74 to 2.67). On the other hand, at 18 months IFN may probably decrease ALT (2 studies, 39 participants: MD -28.28 UI/L, 95%CI -48.03 to -8.54) and Ig M (-595.75 mg/dL, 95%CI -877.2 to -314.3), but all with low certainty evidence. One study reported infusion reactions may be higher in IFN group compared to immunosuppressive therapy (RR 27.82, 95%CI 1.72 to 449.18), and IFN may lead to higher discontinuations of the treatment due to adverse reactions (4 studies, 148 participants: RR 2.32, 95%CI 0.91 to 5.90) with low certainty evidence. Interferon therapy probably improved skin vasculitis (3 studies, 95 participants: RR 0.60, 95% CI 0.36 to 1.00) and proteinuria (2 studies, 49 participants: MD -1.98 g/24 h, 95% CI -2.89 to -1.07), without changing serum creatinine at 18 months (2 studies, 49 participants: MD -30.32 μmol/L, 95%CI -80.59 to 19.95).Six months versus one year treatment with IFN resulted in differences terms of the maintenance of the response, 89% of patients in the six months group presented a relapse and only 11% maintained a long-term response at one year, while in the one year group only 78% relapsed and long-term response was observed in 22%. The one-year therapy was linked to a higher number of side-effects (severe enough to cause the discontinuation of treatment in two cases) than the six-month schedule.One study reported immunoadsorption apheresis had uncertain effects on skin vasculitis (RR 0.44, 95% CI 0.05 to 4.02), peripheral neuropathies (RR 2.70, 95%CI 0.13 to 58.24), and peripheral joint arthralgia (RR 2.70, 95%CI 0.13 to 58.24), cryocrit (MD 0.01%, 95%CI -1.86 to 1.88) at six months, and no infusion reactions were reported. However when clinical scores were evaluated, they reported changes were more favourable in immunoadsorption apheresis with higher remission of severe clinical complications (80% versus 33%, P = 0.05) compared to immunosuppressive treatment alone.In terms of death, it was not possible to present a pooled intervention effect estimate because most of the studies reported no deaths, or did not report death as an outcome. AUTHORS' CONCLUSIONS To treat HCV-associated mixed cryoglobulinaemia, it may be beneficial to eliminate HCV infection by using antiviral treatment and to stop the immune response by using rituximab. For skin vasculitis and for some laboratory findings, it may be appropriate to combine antiviral treatment with deletion of B-cell clonal expansions by using of rituximab. The applicability of evidence reviewed here is limited by the absence of any studies with direct-acting antivirals, which are urgently needed to guide therapy.
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Affiliation(s)
- Nuria Montero
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Alexandre Favà
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Eva Rodriguez
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Clara Barrios
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Josep M Cruzado
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Maria Jose Soler
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
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