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Dashjamts G, Ganzorig AE, Tsedendorj Y, Dondov G, Nergui O, Badamjav T, Huang CF, Liang PC, Lonjid T, Batsaikhan B, Dai CY. Post-Treatment Occurrence of Serum Cryoglobulinemia in Chronic Hepatitis C Patients. Diagnostics (Basel) 2024; 14:1188. [PMID: 38893714 PMCID: PMC11171999 DOI: 10.3390/diagnostics14111188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Persistent cryoglobulinemia after the completion of antiviral treatment is an important consideration of clinical management in chronic hepatitis C patients. We aimed to investigate the occurrence of serum cryoglobulinemia in chronic hepatitis C patients without cryoglobulinemia at the initiation of antiviral treatment. METHODS In total, 776 patients without cryoglobulinemia were assessed for serum cryoglobulinemia after the completion of anti-HCV treatment. Serum cryoglobulinemia precipitation was assessed upon both the initiation and the completion of the treatment and analyzed for the clinical laboratory factors associated with chronic hepatitis C. RESULTS One hundred eighteen (118) patients were checked for serum cryo-precipitation after the completion of the treatment, and eight patients (4.6%) were positive for serum cryoglobulinemia. The patients who tested positive for cryoglobulinemia included a higher proportion of liver cirrhosis patients (4/50%, p = 0.033) and other organ cancer patients (5/62.5%, p = 0.006) than patients who showed no signs of cryoglobulinemia after treatment. In a multivariate analysis, liver cirrhosis (odds ratio [OR]-17.86, 95% confidence interval [95% CI]-1.79-177.35, p = 0.014) and other organ cancer (OR-25.17 95% CI-2.59-244.23, p = 0.005) were independently and significantly associated with positive cryoglobulinemia 3 months after antiviral treatment. CONCLUSIONS Three months after the antiviral DAA therapy had concluded, eight patients tested positive for cryoglobulinemia, representing a 6.7% prevalence. Liver cirrhosis and other organ cancer were independently and significantly associated with positive cryoglobulinemia after antiviral treatment. Further investigation into the causes of positive cryoglobulinemia after DAA antiviral therapy is warranted.
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Affiliation(s)
- Gantogtokh Dashjamts
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Amin-Erdene Ganzorig
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Yumchinsuren Tsedendorj
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Ganchimeg Dondov
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Otgongerel Nergui
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Tegshjargal Badamjav
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
- Department of Biological Sciences, School of Life Sciences, Inner Mongolia University, Hohhot 010031, China
| | - Chung-Feng Huang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Po-Cheng Liang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Tulgaa Lonjid
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Batbold Batsaikhan
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
- Department of Health Research, Graduate School, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia
| | - Chia-Yen Dai
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Ph.D. Program in Environmental and Occupational Medicine, Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- College of Professional Studies, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
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Chang ML, Cheng JS, Chen WT, Hsu CW, Chen KH, Chen YC, Chien RN. Long-term renal function alterations in hepatitis C patients with SVRs: Impacts of therapies and mixed cryoglobulinemia. J Infect Public Health 2024; 17:486-494. [PMID: 38280352 DOI: 10.1016/j.jiph.2024.01.010] [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: 10/22/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND / AIMS Effects of anti-hepatitis C virus (HCV) therapeutic regimens and mixed cryoglobulinemia on long-term renal function of HCV-infected patients with viral clearance have not been determined. METHODS/MATERIALS A prospective 10-year cohort study of 1212 HCV-infected patients (interferon-based therapy, n = 615; direct-acting antiviral (DAA) therapy, n = 434) was conducted. RESULTS At baseline, age, body mass index (BMI), hemoglobin (Hb) and uric acid (UA) levels, and fibrosis-4 score were associated with estimated glomerular filtration rates (eGFRs) in HCV-infected patients. At 24 weeks posttherapy, age, BMI, and Hb and UA levels were associated with eGFRs in patients with a sustained virological response (SVR) (n = 930). Compared with those at baseline, the eGFRs were lower in SVR patients at 24 weeks posttherapy, regardless of the therapeutic regimen. The eGFRs reverted to baseline levels in interferon-treated SVR patients up to 10 years posttherapy but remained decreased in DAA-treated SVR patients up to 4 years posttherapy. Longitudinally, repeated measures analyses with generalized estimating equations showed that the interactions between DAA-based therapy and mixed cryoglobulinemia (OR: 3.291) and Hb levels (1.778) were positively, while DAA-based therapy (0.442), age (0.956), UA levels (0.698), homeostasis model assessment-insulin resistance index (0.961) and complement 4 levels (0.9395) were negatively associated with the eGFR. Among DAA-treated SVR patients, the baseline eGFR (OR: 1.014; 95%CI OR: 1.004-1.023) and high-sensitivity C-reactive protein (HR: 1.082; 95%CI HR: 1.018-1.15) were associated with eGFR reduction at 24 weeks and 4 years posttherapy, respectively. CONCLUSIONS Hepatic fibrosis was an HCV-related factor for renal function. Longitudinally, DAA therapy was negatively, while the interaction between DAA therapy and mixed cryoglobulinemia was positively associated with renal function in SVR patients; deteriorated renal function was recovered in interferon-treated SVR patients. Particularly in DAA-treated SVR patients, baseline renal function and systemic inflammation were associated with short- and long-term reductions in renal function, respectively.
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Affiliation(s)
- Ming-Ling Chang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Jur-Shan Cheng
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-Ting Chen
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chao-Wei Hsu
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Hsing Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Raimondo P, Intini G, Lauletta G, Teora V, Lenoci SD, Rubino G, Villani MA, Armenise A, Stripoli A, Colantuono G, Di Bari N, Fiore G, Paternoster G, Grasso S. Cryoglobulinemia: the "cold" problem in cardiac surgery, a single-center experience and a literature review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:6. [PMID: 38273411 PMCID: PMC10811818 DOI: 10.1186/s44158-024-00141-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Abstract
Cardiac surgery with cardiopulmonary bypass (CBP) is essential for different cardiac procedures in order to perform surgery with a clear sight field.To safely perform surgery with CPB and preserve brain, kidney, and patient tissue from ischemic damage, cold cardioplegia, and mild to deep hypothermia are induced during the operation.Cryoglobulinemia is a hematological/infective-related disease (in certain cases idiopathic) in which temperature-dependent antibodies tend to aggregate and form emboli in the vascular system causing tissue damage if exposed to low temperature.The patient with cryoglobulinemia (known and unknown) can be at risk of a major ischemic event during CPB and induced hypothermia.This article's aim is to evaluate the present scientific literature in order to understand how, in years, the therapeutic or preventive approach, is evolving, and to analyze and make improvements to the management of a cryoglobulinemic patient who must undergo elective or emergency cardiac surgery.In the last part of our article, we expose our single-center experience during a 32-month-long period of survey.In all cases, our medical team (anesthesiologists, perfusionists, and cardiac surgeons) opted for a normothermic cardiopulmonary bypass to lower the risk of cryoglobulin-associated complications.In our experience, along with therapeutic intervention to lower the cryoglobulin titer, normothermic management of cardiopulmonary bypass is as safe as hypothermic management.Notwithstanding our results, further studies with a larger population are needed to confirm this perioperative management in a cardiac surgery setting.
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Affiliation(s)
- Pasquale Raimondo
- Anesthesia and Intensive Care II, AOUC Policlinico Di Bari, Bari, Italy.
| | - Gianmarco Intini
- Division of Anesthesia and Intensive Care, University of Bari, Bari, Italy
| | - Gianfranco Lauletta
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Valentina Teora
- Division of Cardiac Surgery, AOUC Policlinico Di Bari, Bari, Italy
| | | | - Giovanni Rubino
- Anesthesia and Intensive Care II, AOUC Policlinico Di Bari, Bari, Italy
| | | | - Agnese Armenise
- Anesthesia and Intensive Care II, AOUC Policlinico Di Bari, Bari, Italy
| | - Antonia Stripoli
- Anesthesia and Intensive Care II, AOUC Policlinico Di Bari, Bari, Italy
| | | | - Nicola Di Bari
- Division of Cardiac Surgery, AOUC Policlinico Di Bari, Bari, Italy
| | - Giuseppe Fiore
- Anesthesia and Intensive Care II, AOUC Policlinico Di Bari, Bari, Italy
| | - Gianluca Paternoster
- Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital Potenza, Potenza, Italy
| | - Salvatore Grasso
- Anesthesia and Intensive Care II, AOUC Policlinico Di Bari, Bari, Italy
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The wide spectrum of cryoglobulinemic vasculitis and an overview of therapeutic advancements. Clin Exp Med 2022; 23:255-272. [PMID: 35348938 PMCID: PMC8960698 DOI: 10.1007/s10238-022-00808-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/14/2022] [Indexed: 11/11/2022]
Abstract
Immunoglobulins that reversibly precipitate at temperatures below 37 °C are called cryoglobulins (CGs). Cryoglobulinemia often manifests as cryoglobulinemic vasculitis (CV), whose symptoms range in severity from purpuric eruptions to life-threatening features. The majority of CV patients are infected with hepatitis C virus (HCV), whereas lymphoproliferative disorders or connective tissue diseases (CTD) are commonly diagnosed among patients with CV of non-infectious origin. In the absence of detectable associated disease, cryoglobulinemia is classified as “essential” (EMC). All HCV-positive CV patients should be given direct-acting antiviral agents (DAAs) that are consistently able to induce a sustained virologic response (SVR). Glucocorticoids (GCs) can mitigate CV-associated vasculitis, but they have no role as maintenance therapy. Cyclophosphamide restrains the hyperactive phase(s) of the disease and the post-apheresis rebound of newly synthesized CGs. Its use has been largely replaced by rituximab (RTX) in patients unresponsive to DAAs, patients progressing to B-cell non-Hodgkin lymphoma (B-NHL) and patients in whom CV persists or reappears after clearance of HCV. Therapeutic apheresis is an emergency treatment for CV patients with hyperviscosity syndrome. HCV-positive CV patients are at an increased risk of developing NHL, but the achievement of SVR can effectively prevent HCV-related NHL or induce the remission of an already established lymphoma, even without chemotherapy. The treatment of patients with IgM or IgG monoclonal cryoglobulins and an underlying immunoproliferative disorder is based on the regimens adopted for patients with the same B-cell malignancies but without circulating CGs. For patients with CTD, GCs plus alkylating agents or RTX are similarly effective as first-line therapy and in the relapse/refractory setting. In patients with EMC, treatment should consist of GCs plus RTX, with the dose of GCs tapered as soon as possible to reduce the risk of infectious complications.
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Secular trends in cryoglobulinemia mortality in the USA in the era of direct-acting antivirals. Arthritis Res Ther 2022; 24:41. [PMID: 35151354 PMCID: PMC8840313 DOI: 10.1186/s13075-022-02720-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hepatitis C virus (HCV) is the main etiology of cryoglobulinemia with mortality around 25%. Little is known on the changes in cryoglobulinemia mortality after the introduction of direct-acting antivirals (DAA) for treatment of HCV in 2014 in the USA. Methods We used the multiple-cause mortality files compiled by the National Center for Health Statistics to calculate cryoglobulinemia mortality from 1999 to 2018. The proportionate mortality ratio (PMR) of cryoglobulinemia cases with HCV and those with autoimmune diseases was computed to assess the impact of introduction of DAA. Results We identified 1299 people aged ≥ 20 years who died with cryoglobulinemia between 1999 and 2018. The cryoglobulinemia mortality (deaths per million) declined from 1999 (0.4) to 2010 (0.22) and mildly increased to 2014 (0.26), and then decreased abruptly from 2014 to 2018 (0.19) with annual percent change of − 14.3%. The proportion of cryoglobulinemia patients with HCV was 39% (118/302) in 2009–2013 and 26% (81/310) in 2014–2018, with a PMR of 0.67 (95% CI 0.50–0.89). By contrast, the proportion of cryoglobulinemia patients with systemic autoimmune diseases was 2.6% (8/302) in 2009–2013 and 4.2% (13/310) in 2014–2018, with a PMR of 1.58 (95% CI 0.66–3.82). Conclusion The changes in cryoglobulinemia mortality during the past two decades are mainly related to the aging and dying of the “baby boomer” cohort who had a high HCV prevalence and to the introduction of a DAA in 2014.
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Abstract
PURPOSE OF REVIEW This article describes the neurologic sequelae of various nutritional micronutrient deficiencies, celiac disease, inflammatory bowel disease, and liver disease. Where relevant, appropriate treatments for these conditions are also discussed. The developing field of the microbiome and nervous system interaction is also outlined. RECENT FINDINGS Pathology in the gastrointestinal system can affect the nervous system when it causes micronutrient deficiency, when immune responses created by the gastrointestinal system affect the nervous system, when toxins caused by gastrointestinal organ failure harm the nervous system, and when treatments aimed at a gastrointestinal medical condition cause damage to the nervous system as a side effect. SUMMARY This article addresses familiar concepts and new developments in the treatment and understanding of diseases that affect the gut and nervous system simultaneously.
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De Re V, Tornesello ML, De Zorzi M, Caggiari L, Pezzuto F, Leone P, Racanelli V, Lauletta G, Zanussi S, Repetto O, Gragnani L, Rossi FM, Dolcetti R, Zignego AL, Buonaguro FM, Steffan A. PDCD1 and IFNL4 genetic variants and risk of developing hepatitis C virus-related diseases. Liver Int 2021; 41:133-149. [PMID: 32937024 PMCID: PMC7839592 DOI: 10.1111/liv.14667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 08/11/2020] [Accepted: 09/03/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Genetic variants of IFNL4 and PDCD1 genes have been shown to influence the spontaneous clearance of hepatitis C virus (HCV) infection. We investigated the IFNL4 rs12979860 and the PDCD1 polymorphisms in 734 HCV-positive patients, including 461 cases with liver disease of varying severity and 273 patients with lymphoproliferative disorders to determine the association of these genes with patient's outcome. METHODS Expression levels of PDCD1 mRNA encoded by haplotypes were investigated by quantitative PCR in hepatocellular carcinoma (HCC) tissue and peripheral blood mononuclear cells. Flow cytometry was used to detect PD-1 and its ligand PD-L1. RESULTS The frequency of IFNL4 rs12979860 C/T or T/T genotypes was significantly higher in patients with HCV-related diseases than blood donors (P < .0001). Patients expressing the IFNλ4 variant with one amino acid change that reduces IFNλ4 secretion was found increased in frequency in HCV-related diseases compared to HCC PDCD1 mRNA levels in HCC tissue were significantly higher in cases carrying the PD-1.3 A or the PD-1.7 G allele (P = .0025 and P = .0167). Linkage disequilibrium (LD) between PD-1.3 and IFNL4 was found in patients with mixed cryoglobulinaemia (MC) only (LD = 0 in HCC; LD = 72 in MC). PBMCs of MC patients expressed low levels of PD-L1 in CD19+IgM+B cells and of PD-1 in CD4+T cells suggesting the involvement of regulatory B cell-T cell interaction to the pathogenesis of MC. CONCLUSION Collectively, our data indicate an important contribution of IFNλ4 expression to the development of HCV-related HCC and an epistatic contribution of IFNL4 and PDCD1 in MC. LAY SUMMARY Studies of IFNL4 and PDCD1 genes are helpful to better understand the role of host genetic factors and immune antigens influencing the outcome of HCV-related diseases. Our data support an association between the expression of IFNλ4, which prevents the expression of IFNλ3, with all the different HCV-related diseases studied, and besides, evidence that a higher IFNλ4 expression is associated with hepatocellular at a younger age. The expression pattern of low PD-L1 on B cells and high PD-1 on CD4+T-cells in patients with HCV-positive cryoglobulinaemia suggests a critical role of the PD-1/PD-L1 signaling in modulating B cell-T cell interaction in this lymphoproliferative disease.
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Affiliation(s)
- Valli De Re
- Immunopathology and Cancer Biomarkers/Bioproteomic facilityDepartment of Translational ResearchCentro di Riferimento Oncologico (CRO) IRCCSCancer InstituteAvianoItaly
| | - Maria Lina Tornesello
- Molecular biologyviral oncology Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale"NapoliItaly
| | - Mariangela De Zorzi
- Immunopathology and Cancer Biomarkers/Bioproteomic facilityDepartment of Translational ResearchCentro di Riferimento Oncologico (CRO) IRCCSCancer InstituteAvianoItaly
| | - Laura Caggiari
- Immunopathology and Cancer Biomarkers/Bioproteomic facilityDepartment of Translational ResearchCentro di Riferimento Oncologico (CRO) IRCCSCancer InstituteAvianoItaly
| | - Francesca Pezzuto
- Molecular biologyviral oncology Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale"NapoliItaly
| | - Patrizia Leone
- Biomedical Sciences and Human OncologyUniversity of Bari Medical SchoolBariItaly
| | - Vito Racanelli
- Biomedical Sciences and Human OncologyUniversity of Bari Medical SchoolBariItaly
| | - Gianfranco Lauletta
- Biomedical Sciences and Human OncologyUniversity of Bari Medical SchoolBariItaly
| | - Stefania Zanussi
- Immunopathology and Cancer Biomarkers/Bioproteomic facilityDepartment of Translational ResearchCentro di Riferimento Oncologico (CRO) IRCCSCancer InstituteAvianoItaly
| | - Ombretta Repetto
- Immunopathology and Cancer Biomarkers/Bioproteomic facilityDepartment of Translational ResearchCentro di Riferimento Oncologico (CRO) IRCCSCancer InstituteAvianoItaly
| | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE)Internal Medicine and Liver UnitDepartment of Experimental and Clinical MedicineCareggi University Hospital, Florence, ItalyFlorenceItaly
| | - Francesca Maria Rossi
- Clinical and Experimental Onco‐Hematology UnitCentro di Riferimento Oncologico (CRO) IRCCSAviano (PN)Italy
| | - Riccardo Dolcetti
- The University of Queensland Diamantina InstituteTranslational Research InstituteBrisbaneAustralia
| | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE)Internal Medicine and Liver UnitDepartment of Experimental and Clinical MedicineCareggi University Hospital, Florence, ItalyFlorenceItaly
| | - Franco M. Buonaguro
- Molecular biologyviral oncology Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale"NapoliItaly
| | - Agostino Steffan
- Immunopathology and Cancer Biomarkers/Bioproteomic facilityDepartment of Translational ResearchCentro di Riferimento Oncologico (CRO) IRCCSCancer InstituteAvianoItaly
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Lee KC, Cheng YT, Lin CY, Kuo CJ, Chien RN, Yeh CT, Chang ML. Impact of mixed cryoglobulinemia on patients with spontaneous hepatitis C virus clearance: A 13-year prospective cohort study. Eur J Clin Invest 2020; 50:e13189. [PMID: 31782138 DOI: 10.1111/eci.13189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 10/09/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prevalence and associations of mixed cryoglobulinemia (MC) in patients with spontaneous clearance of hepatitis C virus (HCV) remain elusive. MATERIALS AND METHODS A 13-year prospective cohort study of patients with spontaneous HCV clearance was conducted in a tertiary care centre. Baseline characteristics, incident cardiovascular and neurologic events and cancers were analysed. RESULTS Of 104 consecutive patients (mean age: 54.08 years old; females: 71 [68%]), 37 (34.6%) had MC and 6 (5.8%) had cirrhosis. MC (+) patients were more female (86% vs 58%, P = .002), had higher rate of cirrhosis (14% vs 1.5%, P = .012), higher levels of Immunoglobulin G (IgG; P = .001), IgM (P = .002) and fibrosis-4 (FIB-4) (P = .004), but lower levels of complement C4 (P = .034) than the MC (-) patients. Female gender (95% confidence interval [CI] of odds ratio: 1.402-26.715), levels of IgG (1.000-1.004), IgM (1.009-1.037) and FIB-4 (1.217-3.966) were independently associated with MC. Baseline rheumatoid factor (RF) levels were independently associated with incident cancer (95% CI hazard ratio [HR]: 1.001-1.030 [HR: 1.015], P = .039). With a cut-off value of 11.3 IU/mL, RF levels significantly predicted incident cancer (area under curve: 0.865, P = .002). No different cumulative incidences of cardiovascular and neurologic events, cancers or mortalities were identified between MC (+) and MC (-) patient. CONCLUSIONS Approximately 1/3 of patients with spontaneous HCV clearance yielded MC, which harboured similar characteristics of MC in patients with chronic hepatitis C. Despite the negligible role of MC in the prognosis of patients with spontaneous HCV clearance, the connection between RF and incident cancer demands further investigation.
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Affiliation(s)
- Kuan-Chieh Lee
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ya-Ting Cheng
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Yu Lin
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Jung Kuo
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chau-Ting Yeh
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Ling Chang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Abstract
PURPOSE OF THE REVIEW Cryoglobulins are immunoglobulins with the ability to precipitate at temperatures <37 °C. They are related to hematological disorders, infections [especially hepatitis C virus (HCV)], and autoimmune diseases. In this article, the state of the art on Cryoglobulinemic Vasculitis (CV), in a helpful and schematic way, with a special focus on HCV related Mixed Cryoglobulinemia treatment are reviewed. RECENT FINDINGS Direct - acting antivirals (DAA) against HCV have emerged as an important key in HCV treatment to related Cryoglobulinemic Vasculitis, and should be kept in mind as the initial treatment in non-severe manifestations. On the other hand, a recent consensus panel has published their recommendations for treatment in severe and life threatening manifestations of Mixed Cryoglobulinemias. HCV-Cryoglobulinemic vasculitis is the most frequent form of CV. There are new treatment options in HCV-CV with DAA, with an important number of patients achieving complete response and sustained virologic response (SVR). In cases of severe forms of CV, treatment with Rituximab and PLEX are options. The lack of data on maintenance therapy could impulse future studies in this setting.
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Affiliation(s)
- Alejandro Fuentes
- Departamento de Inmunología clínica y Reumatología, Pontificia Universidad Católica de Chile, Diagonal Paraguay, #362, Santiago, Chile
| | - Claudia Mardones
- Departamento de Inmunología clínica y Reumatología, Pontificia Universidad Católica de Chile, Diagonal Paraguay, #362, Santiago, Chile
| | - Paula I Burgos
- Departamento de Inmunología clínica y Reumatología, Pontificia Universidad Católica de Chile, Diagonal Paraguay, #362, Santiago, Chile.
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Colussi G, Donnini D, Brizzi RF, Maier S, Valenti L, Catena C, Cavarape A, Sechi LA, Soardo G. Sustained virologic response to direct-acting antiviral agents predicts better outcomes in hepatitis C virus-infected patients: A retrospective study. World J Gastroenterol 2019; 25:6094-6106. [PMID: 31686765 PMCID: PMC6824275 DOI: 10.3748/wjg.v25.i40.6094] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/09/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Direct-acting antiviral agents (DAAs) are extremely effective in eradicating hepatitis C virus (HCV) in chronically infected patients. However, the protective role of the sustained virologic response (SVR) achieved by second- and third-generation DAAs against the onset of hepatocellular carcinoma (HCC) and mortality is less well established.
AIM To examine the occurrence of HCC or death from any cause in a retrospective-prospective study of patients treated with DAAs.
METHODS Patients were enrolled from a tertiary academic hospital center for liver disease management that collects subject data mainly from northeastern Italy. The study was conducted in 380 patients (age: 60 ± 13 years, 224 males, 32% with cirrhosis) treated with DAAs with or without SVR (95/5%), with a median follow up of 58 wk (interquartile range: 38-117). The baseline anthropometric features, HCV viral load, severity of liver disease, presence of extra-hepatic complications, coinfection with HIV and/or HBV, alcohol consumption, previous interferon use, alpha-fetoprotein levels, and renal function were considered to be confounders.
RESULTS The incidence rate of HCC in patients with and without SVR was 1.3 and 59 per 100 person-years, respectively (incidence rate ratio: 44, 95%CI: 15-136, P < 0.001). Considering the combined endpoint of HCC or death from any cause, the hazard ratio (HR) for the SVR patients was 0.070 (95%CI: 0.025-0.194, P < 0.001). Other independent predictors of HCC or death were low HCV viremia (HR: 0.808, P = 0.030), low platelet count (HR: 0.910, P = 0.041), and presence of mixed cryoglobulinemia (HR: 3.460, P = 0.044). Considering SVR in a multi-state model, the independent predictors of SVR achievement were absence of cirrhosis (HR: 0.521, P < 0.001) and high platelet count (HR: 1.019, P = 0.026). Mixed cryoglobulinemia predicted the combined endpoint in patients with and without SVR (HR: 5.982, P = 0.028 and HR: 5.633, P = 0.047, respectively).
CONCLUSION DAA treatment is effective in inducing SVR and protecting against HCC or death. A residual risk of HCC persists in patients with advanced liver disease or with complications, such as mixed cryoglobulinemia or renal failure.
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Affiliation(s)
| | - Debora Donnini
- Department of Medicine, University of Udine, Udine 33100, Italy
| | | | - Silvia Maier
- Department of Medicine, University of Udine, Udine 33100, Italy
| | - Luca Valenti
- Department of Medicine, University of Udine, Udine 33100, Italy
| | | | | | | | - Giorgio Soardo
- Department of Medicine, University of Udine, Udine 33100, Italy
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11
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Zignego AL, Pawlotsky JM, Bondin M, Cacoub P. Expert opinion on managing chronic HCV in patients with mixed cryoglobulinaemia vasculitis. Antivir Ther 2019; 23:1-9. [PMID: 30451151 DOI: 10.3851/imp3246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/11/2022]
Abstract
Mixed cryoglobulinaemia vasculitis (CryoVas) is a small-vessel systemic vasculitis caused by deposition of mixed cryoglobulins and is characterized by a wide range of clinical symptoms. HCV is the primary cause of CryoVas, which is associated with significant morbidity and mortality. The mortality rate among patients with HCV-associated CryoVas is 3× that of the general population, with a 63% 10-year survival rate. First-line treatment for CryoVas is anti-HCV therapy because viral clearance is associated with clinical improvement. The introduction of highly effective, interferon-free, direct-acting antiviral regimens provides additional treatment options for these patients. Here, we review recent studies investigating the effect of antiviral therapy on HCV-associated CryoVas and provide expert opinion for health-care professionals managing these patients.
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Affiliation(s)
- Anna Linda Zignego
- Department of Clinical and Experimental Medicine, Interdepartmental Hepatology Center MASVE, University of Florence, Florence, Italy
| | - Jean-Michel Pawlotsky
- National Reference Center for Viral Hepatitis B, C and D, Department of Virology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France.,INSERM U955, Créteil, France
| | | | - Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, F-75013, Paris, France.,CNRS, FRE3632, F-75005, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France
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12
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Clinical practice: hepatitis C virus infection, cryoglobulinemia and cryoglobulinemic vasculitis. Clin Exp Med 2018; 19:1-21. [PMID: 30430284 DOI: 10.1007/s10238-018-0536-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/25/2018] [Indexed: 02/06/2023]
Abstract
Cryoglobulins are circulating immunoglobulins that reversibly precipitate at temperatures below 37 °C. Type-II cryoglobulins consist of monoclonal IgM/polyclonal IgG immune complexes (ICs), whereas in type-III cryoglobulins both IgM and IgG are polyclonal. The clinical condition resulting from the presence of cryoglobulins in the blood is called mixed cryoglobulinemia (MC), which can be asymptomatic or manifest as cryoglobulinemic vasculitis (CV). Type-I cryoglobulins, consisting of a single monoclonal isotype, are detected in patients with lymphoproliferative disorders. It is now established that > 90% of MCs are associated with HCV infection. Clinically, the spectrum of symptoms may range in severity from occasional purpuric eruptions to life-threatening features. In addition to the development of liver cirrhosis and hepatocellular carcinoma, the possible progression of HCV-positive CV patients to B-cell non-Hodgkin lymphoma (B-NHL) has been reported. The pathogenetic role played by HCV infection in the onset of B-NHL is suggested by regression of the latter following the achievement of a sustained virologic response (SVR). For several years, interferon-α alone or combined with ribavirin has been the standard of care. However, the rates of clinical, biochemical, and virologic responses have been low, and the occurrence of relapse frequent. The addition of rituximab has resulted in a higher rate of responses. With the advent of direct-acting antiviral agents, SVR has been achieved in ~ 95% of CV patients. However, in a minority of patients, despite SVR, CV may persist or reappear over variable lengths of time from the completion of therapy. The eventual appearance of B-NHL is also possible.
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13
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Batsaikhan B, Huang CI, Yeh ML, Huang CF, Liang PC, Hsieh MY, Huang JF, Yu ML, Chuang WL, Lee JC, Lee PL, Dai CY. Association between cryoglobulinemia and liver fibrosis in chronic hepatitis C patients. J Gastroenterol Hepatol 2018; 33:1897-1903. [PMID: 29737561 DOI: 10.1111/jgh.14275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/11/2018] [Accepted: 04/23/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM The prevalence of mixed cryoglobulinemia is 15-50% in chronic hepatitis C (CHC) patients, and these patients are in an increased risk of liver fibrosis and cirrhosis, but it is controversial. This study aimed to reveal the prevalence of mixed cryoglobulinemia in Asian population and to determine the relationship between presence of serum cryoglobulinemia and liver fibrosis in CHC patients with or without liver biopsy. METHODS In total, 2255 treatment-naïve patients retrospectively enrolled in our study. Serum cryoglobulinemia precipitation, liver biopsy, and four indexes of fibrosis (FIB4) were assessed to detect the associated factors. RESULTS Three hundred sixty-four (32%) out of 1135 liver biopsy patients and 341 (30.4%) out of 1120 non-biopsy patients were positive for serum cryoglobulinemia. Multivariate analysis revealed that male gender, hepatitis C virus RNA, platelet and advanced fibrosis (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.05-1.87, P = 0.021) were significantly associated with the presence of cryoglobulinemia in the liver biopsy proven patients. The presence of serum cryoglobulinemia (OR 1.43, 95% CI 1.04-1.96, P = 0.026) was associated with advanced liver fibrosis (F3 and F4) by multivariate logistic regression analysis. In patients without liver biopsy, FIB4 (OR 1.72, 95% CI 1.30-2.27, P = 0.0001) was associated with the presence of serum cryoglobulinemia, and also cryoglobulinemia (OR 1.74, 95% CI 1.32-2.30, P = 0.0001) was associated with high FIB4 (≥ 3.25) patients. CONCLUSION The prevalence of the presence of serum cryoglobulinemia is 30.4-32% in CHC patients and associated with advanced fibrosis in liver biopsy proven patients and high-FIB4 (≥ 3.25) patients without liver biopsy.
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Affiliation(s)
- Batbold Batsaikhan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Ching-I Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lun Yeh
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Feng Huang
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Cheng Liang
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Yen Hsieh
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lung Yu
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jin-Ching Lee
- Department of Biotechnology, College of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Chia-Yen Dai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Hepatobiliary Section, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Health Management Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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14
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Zubkin ML, Chervinko VI, Ovchinnikov YV, Kryukov EV, Kotenko ON. [Chronic hepatitis C virus infection: An internist's opinion (Part 1)]. TERAPEVT ARKH 2018. [PMID: 28635859 DOI: 10.17116/terarkh2016886105-113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Hepatitis C virus (HCV) infection results in not only chronic hepatitis and subsequent complications as liver cirrhosis and hepatocellular carcinoma, but also in a significant number of other diseases, the so-called extrahepatic manifestations of chronic HCV infection. This is because of viral hepatotropicity and lymphotropicity. The most striking example of the course of chronic HCV infection, in which the infectious and inflammatory processes are concurrent with autoimmune disorders and carcinogenesis, is mixed cryoglobulinemia and B-cell non-Hodgkin's lymphoma. The pathogenesis of these diseases is based on the clonal expansion of B cells, which occurs under their prolonged stimulation with the virus or viral proteins. Part 1 of this review is devoted to the analysis of a correlation of chronic HCV infection with lymphoproliferative and autoimmune disorders, as well as its association with kidney injury.
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Affiliation(s)
- M L Zubkin
- G.N. Gabrichevsky Moscow Research Institute for Epidemiology and Microbiology, Russian Federal Service for Supervision of Consumer Rights Protection and Human Welfare, Moscow, Russia; Branch, S.M. Kirov Military Medical Academy, Moscow, Russia
| | - V I Chervinko
- Branch, S.M. Kirov Military Medical Academy, Moscow, Russia
| | | | - E V Kryukov
- N.N. Burdenko Main Military Clinical Hospital, Moscow, Russia
| | - O N Kotenko
- City Clinical Hospital Fifty-Two, Moscow Healthcare Department, Moscow, Russia
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15
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Marson P, Monti G, Montani F, Riva A, Mascia MT, Castelnovo L, Filippini D, Capuzzo E, Moretto M, D'Alessandri G, Marenchino D, Zani R, Fraticelli P, Ferri C, Quartuccio L, De Silvestro G, Oreni L, Accorsi P, Galli M. Apheresis treatment of cryoglobulinemic vasculitis: A multicentre cohort study of 159 patients. Transfus Apher Sci 2018; 57:639-645. [PMID: 30228046 DOI: 10.1016/j.transci.2018.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess the effectiveness of apheresis therapy (AT) in treating the clinical manifestations of patients with complicated cryoglobulinemic vasculitis (CV). METHODS A retrospective cohort study of 159 CV patients attending 22 Italian Centers who underwent at least one AT session between 2005 and 2015. The response to AT was evaluated on the basis of a defined grading system. RESULTS Peripheral neuropathy was the most frequent clinical condition leading to AT. Therapeutic plasma exchange was used in 70.4% of cases. The outcome of AT was rated very good in 19 cases, good in 64, partial/transient in 40, and absent/not assessable in 36. Life-threatening CV-related emergencies and renal impairment independently correlated with failure to respond to AT. The independent variables associated with an increased risk of death were age at the time of the first AT session, multi-organ life-threatening CV, the presence of renal impairment and failure to respond to AT. The time-dependent probability of surviving until CV-related death in the second year was 84%, with an AHR in patients with absent/not assessable response to AT of 11.25. CONCLUSION In this study AT is confirmed to be a safe procedure in patients with CV. Early AT should be considered in patients with severe CV, especially in cases with impending renal involvement, in order to prevent irreversible kidney damage. Although its efficacy in patients with multi-organ failure is limited, AT is the only treatment that can rapidly remove circulating cryoglobulins, and should be considered an emergency treatment.
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Affiliation(s)
- P Marson
- Apheresis Unit, Department of Transfusion Medicine, University Hospital of Padova, Padova, Italy
| | - G Monti
- Internal Medicine, Hospital of Saronno, Saronno, Italy
| | - F Montani
- Blood Transfusion Service, Hospital of Saronno, Saronno, Italy
| | - A Riva
- Infectious Disease Unit, Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Italy
| | - M T Mascia
- Immune-Rheumatology Unit, Department of Diagnostic and Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - L Castelnovo
- Internal Medicine, Hospital of Saronno, Saronno, Italy
| | - D Filippini
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - E Capuzzo
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | - M Moretto
- Immunohematology and Transfusion Medicine Unit, Hospital of Piacenza, Piacenza, Italy
| | - G D'Alessandri
- Immunohematology and Transfusion Medicine, ASL3, Pistoia, Italy
| | - D Marenchino
- Immunohematology and Transfusion Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
| | - R Zani
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - P Fraticelli
- Department of Clinical and Molecular Sciences, Clinical Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - C Ferri
- Immune-Rheumatology Unit, Department of Diagnostic and Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - L Quartuccio
- Rheumatology Clinic, DPMSC, University of Udine, Italy
| | - G De Silvestro
- Apheresis Unit, Department of Transfusion Medicine, University Hospital of Padova, Padova, Italy
| | - L Oreni
- Infectious Disease Unit, Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Italy
| | - P Accorsi
- Blood Transfusion Service, Azienda Ospedaliera Santo Spirito, Pescara, Italy
| | - M Galli
- Infectious Disease Unit, Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Italy.
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16
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Russi S, Sansonno D, Monaco S, Mariotto S, Ferrari S, Pavone F, Lauletta G, Dammacco F. HCV RNA Genomic sequences and HCV-E2 glycoprotein in sural nerve biopsies from HCV-infected patients with peripheral neuropathy. Neuropathol Appl Neurobiol 2017; 44:427-438. [PMID: 28543916 DOI: 10.1111/nan.12413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 12/24/2022]
Abstract
AIMS Peripheral neuropathy (PN), the major neurological complication of chronic HCV infection, is frequently associated with mixed cryoglobulinaemia (MC) and small-vessel systemic vasculitis. While humoral and cell-mediated immune mechanisms are suspected to act together in an aberrant immune response that results in peripheral nerve damage, the role of HCV remains largely speculative. The possible demonstration of HCV in peripheral nerve tissue would obviously assume important pathogenic implications. METHODS We studied sural nerve biopsies from 11 HCV-positive patients with neuropathic symptoms: five with and six without MC. In situ hybridization (ISH) and immunofluorescence studies were carried out to detect genomic and antigenomic HCV RNA sequences and HCV-encoded E2-glycoprotein, respectively. RESULTS Epineurial vascular deposits of E2-glycoprotein were found in four (80%) MC and in two (33.3%) non-MC patients, respectively. These findings were enhanced by the perivascular deposition of positive-, though not negative-strand replicative RNA, as also found in the nerve extracts of all patients. Mild inflammatory cell infiltrates with no deposits of immunoglobulins and/or complement proteins were revealed around small vessels, without distinct vasculitis changes between MC and non-MC patients. CONCLUSIONS These results indicate that nerve vascular HCV RNA/E2 deposits associated to perivascular inflammatory infiltrates were similar in chronically HCV-infected patients, regardless of cryoglobulin occurrence. Given the failure to demonstrate HCV productive infection in the examined sural nerve biopsies, nerve damage is likely to result from virus-triggered immune-mediated mechanisms.
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Affiliation(s)
- S Russi
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - D Sansonno
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - S Monaco
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - S Mariotto
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - S Ferrari
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - F Pavone
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - G Lauletta
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - F Dammacco
- Liver Unit, Division of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
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17
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Lauletta G, Russi S, Pavone F, Vacca A, Dammacco F. Direct-acting antiviral agents in the therapy of hepatitis C virus-related mixed cryoglobulinaemia: a single-centre experience. Arthritis Res Ther 2017; 19:74. [PMID: 28388935 PMCID: PMC5385046 DOI: 10.1186/s13075-017-1280-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/09/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The efficacy and safety of direct-acting antiviral agents (DAAs) were evaluated in a cohort of prospectively enrolled patients with hepatitis C virus (HCV)-related mixed cryoglobulinaemia (MC), an immune complex-mediated vasculitis of small and medium vessels in which the pathogenetic role of HCV has been clearly established. METHODS Twenty-two patients received DAAs. Clinical and laboratory features were recorded at baseline, every 4 weeks until the end of treatment (EoT), and 12 weeks afterwards. Primary efficacy endpoints were (a) sustained virological response 12 weeks after therapy completion (SVR12), (b) regression of symptomatology (clinical response) and (c) cryoglobulin disappearance or cryocrit reduction ≥50% (immunological response). Complete response (CR) was defined as the occurrence of all three primary endpoints; partial response (PR) was defined as the occurrence of SVR12, with or without either immunological or clinical response; and no response was defined as missing the achievement of all three endpoints. RESULTS All patients reached SVR12. Compared with basal values, mean cryocrit values were significantly decreased at EoT and SVR12. A significant reduction of alanine transaminase and a parallel increase of complement component C4 levels were also detected. Rheumatoid factor activity was significantly reduced at EoT but not at SVR12. At SVR12, a CR was established in 14 patients (63.7%) and a PR in 8 patients (36.3%). In one patient with small lymphocytic lymphoma, the tumour progressed despite viral clearance. Mild adverse events were recorded in nine patients (40.9%). CONCLUSIONS The response rates induced by the use of DAAs in patients with MC were remarkably higher than those previously achieved with pegylated interferon-α/ribavirin, with or without rituximab. A much longer follow-up is desirable to achieve useful information in terms of persistent viral clearance and clinical response.
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Affiliation(s)
- Gianfranco Lauletta
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Sabino Russi
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Fabio Pavone
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza G. Cesare, 11-70124, Bari, Italy
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18
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Bonacci M, Lens S, Londoño MC, Mariño Z, Cid MC, Ramos-Casals M, Sánchez-Tapias JM, Forns X, Hernández-Rodríguez J. Virologic, Clinical, and Immune Response Outcomes of Patients With Hepatitis C Virus-Associated Cryoglobulinemia Treated With Direct-Acting Antivirals. Clin Gastroenterol Hepatol 2017; 15:575-583.e1. [PMID: 27725289 DOI: 10.1016/j.cgh.2016.09.158] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cryoglobulins (circulating immune complexes of polyclonal IgG, monoclonal IgM, and rheumatoid factor) are detected in the circulation of 40% to 60% of patients with chronic hepatitis C virus infection, and cryoglobulinemic vasculitis (CV) is observed in approximately 10% of patients. We aimed to assess the clinical and immune effects of direct-acting antiviral treatment. METHODS We performed a prospective study of 64 patients with HCV infection with circulating cryoglobulins receiving direct-acting antiviral therapy at a single center in Barcelona, Spain, from January 2014 through April 2016. Patients were classified as having CV (n = 35) or asymptomatic circulating cryoglobulins (ACC, n = 29). Clinical response was considered complete if a patient's Birmingham Vasculitis Activity Score (version 3) was 0, or if all affected organs improved 12 weeks after the end of therapy. A complete immunologic response (CIR) was defined as no detection of circulating cryoglobulins and normalized levels of complement and/or rheumatoid factor. RESULTS Clinical manifestations of CV included purpura (65%), weakness (70%), arthralgia (31%), myalgia (20%), peripheral neuropathy (50%), and renal involvement (20%). At baseline, patients with CV had significantly higher levels of rheumatoid factor and lower levels of C4 complement than patients with ACC, whereas cryocrits were similar between groups (3.2% vs 2.6%). Overall, 60 patients (94%) had a sustained viral response 12 weeks after therapy. Among patients with CV, the median Birmingham Vasculitis Activity Score (version 3) decreased from 9 (range, 2-31) to 3 (range, 0-12) (P < .001). Twenty-five patients with CV (71%) achieved a complete clinical response. Immune-suppressive therapy was reduced for 4 of 13 patients and withdrawn for 6 of 13. Overall, 48% of patients achieved a CIR. A low baseline cryocrit level (<2.7%) was the only factor associated with CIR (odds ratio, 9.8; 95% confidence interval, 2.2-44; P = .03). CONCLUSIONS Viral eradication was associated with clinical improvement in most patients with CV. Markers of immune activation, including circulating cryoglobulins, persisted in 52% of patients with CV or ACC, despite a sustained viral response 12 weeks after therapy. A longer follow-up period after viral eradication might be necessary to ensure a normal immune response.
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Affiliation(s)
- Martín Bonacci
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Sabela Lens
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - María-Carlota Londoño
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Zoe Mariño
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Maria C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomédiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, Hospital Clínic, Laboratory of Autoimmune Diseases Josep Font, Institut d'Investigacions Biomédiques August Pi i Sunyer-CELLEX, University of Barcelona, Barcelona, Spain
| | - Jose María Sánchez-Tapias
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi i Sunyer, Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain.
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomédiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Mihăilă RG. Hepatitis C virus - associated B cell non-Hodgkin's lymphoma. World J Gastroenterol 2016; 22:6214-6223. [PMID: 27468211 PMCID: PMC4945980 DOI: 10.3748/wjg.v22.i27.6214] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 05/26/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
The hepatitis C virus (HCV) infected patients are prone to develop bone marrow or various tissue infiltrates with monoclonal B cells, monoclonal B lymphocytosis or different types of B cell non-Hodgkin’s lymphoma (BCNHL), of which the most common are splenic marginal zone BCNHL, diffuse large BCNHL and follicular lymphoma. The association between chronic HCV infection and non Hodgkin’s lymphoma has been observed especially in areas with high prevalence of this viral infection. Outside the limitations of some studies that have been conducted, there are also geographic, environmental, and genetic factors that contribute to the epidemiological differences. Various microenvironmental signals, such as cytokines, viral antigenic external stimulation of lymphocyte receptors by HCV antigens, and intercellular interactions contribute to B cell proliferation. HCV lymphotropism and chronic antigenic stimulation are involved in B-lymphocyte expansion, as mixted cryoglobulinemia or monoclonal gammopathy of undetermined significance, which can progress to BCNHL. HCV replication in B lymphocytes has oncogenic effect mediated by intracellular HCV proteins. It is also involved in an important induction of reactive oxygen species that can lead to permanent B lymphocyte damage, as DNA mutations, after binding to surface B-cell receptors. Post-transplant lymphoproliferative disorder could appear and it has a multiclonal potentiality that may develop into different types of lymphomas. The hematopoietic stem cell transplant made for lymphoma in HCV-infected patients can increase the risk of earlier progression to liver fibrosis and cirrhosis. HCV infected patients with indolent BCNHL who receive antiviral therapy can be potentially cured. Viral clearance was related to lymphoma response, fact that highlights the probable involvement of HCV in lymphomagenesis. Direct acting antiviral drugs could be a solution for the patients who did not tolerate or respond to interferon, as they seem to be safe and highly effective. The use of chemotherapy in combination with rituximab for the treatment of BCNHL in patients infected with HCV can produce liver dysfunction. The addition of immunotherapy with rituximab can increase the viral replication, and severe complications can occure especially in patients co-infected with hepatitis B virus or immune immunodeficiency virus, in those with hepatocarcinoma, cirrhosis, or liver cytolysis. But the final result of standard immunochemotherapy applied to diffuse large BCNHL patients with HCV infection is not notably worse than in those without this viral infection. The treatment of patients chronically infected with HCV and having BCNHL is complex and requires a multidisciplinary approach and the risk / benefit ratio of rituximab treatment must be evaluated especially in those with liver cytolysis.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Antiviral Agents/therapeutic use
- B-Lymphocytes/immunology
- Cell Proliferation
- Hematopoietic Stem Cell Transplantation
- Hepatitis C Antigens/immunology
- Hepatitis C, Chronic/immunology
- Hepatitis C, Chronic/therapy
- Humans
- Liver Transplantation
- Lymphoma, B-Cell/immunology
- Lymphoma, B-Cell/therapy
- Lymphoma, B-Cell, Marginal Zone/immunology
- Lymphoma, B-Cell, Marginal Zone/therapy
- Lymphoma, Follicular/immunology
- Lymphoma, Follicular/therapy
- Lymphoma, Large B-Cell, Diffuse/immunology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Non-Hodgkin/immunology
- Lymphoma, Non-Hodgkin/therapy
- Rituximab/therapeutic use
- Splenic Neoplasms/immunology
- Splenic Neoplasms/therapy
- Virus Replication/immunology
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Ogishi M, Yotsuyanagi H, Moriya K, Koike K. Delineation of autoantibody repertoire through differential proteogenomics in hepatitis C virus-induced cryoglobulinemia. Sci Rep 2016; 6:29532. [PMID: 27403724 PMCID: PMC4941579 DOI: 10.1038/srep29532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/17/2016] [Indexed: 12/21/2022] Open
Abstract
Antibodies cross-reactive to pathogens and autoantigens are considered pivotal in both infection control and accompanying autoimmunity. However, the pathogenic roles of autoantibodies largely remain elusive without a priori knowledge of disease-specific autoantigens. Here, through a novel quantitative proteogenomics approach, we demonstrated a successful identification of immunoglobulin variable heavy chain (VH) sequences highly enriched in pathological immune complex from clinical specimens obtained from a patient with hepatitis C virus-induced cryoglobulinemia (HCV-CG). Reconstructed single-domain antibodies were reactive to both HCV antigens and potentially liver-derived human proteins. Moreover, over the course of antiviral therapy, a substantial "de-evolution" of a distinct sub-repertoire was discovered, to which proteomically identified cryoprecipitation-prone autoantibodies belonged. This sub-repertoire was characterized by IGHJ6*03-derived, long, hydrophobic complementarity determining region (CDR-H3). This study provides a proof-of-concept of de novo mining of autoantibodies and corresponding autoantigen candidates in a disease-specific context in human, thus facilitating future reverse-translational research for the discovery of novel biomarkers and the development of antigen-specific immunotherapy against various autoantibody-related disorders.
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Affiliation(s)
- Masato Ogishi
- Department of Infectious Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yotsuyanagi
- Department of Infectious Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infectious Control and Prevention, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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The expanding spectrum of HCV-related cryoglobulinemic vasculitis: a narrative review. Clin Exp Med 2016; 16:233-42. [PMID: 26935415 DOI: 10.1007/s10238-016-0410-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/10/2016] [Indexed: 02/06/2023]
Abstract
Cryoglobulinemic vasculitis (CV) is a small-to-medium-vessel vasculitis that appears in 10-15 % of patients chronically infected with hepatitis C virus (HCV). The classic symptom triad of CV, purpura/asthenia/arthralgia, is accompanied by clinical features that include glomerulonephritis, neuropathy, interstitial pneumonitis, and cardiomyopathy, ranging in their severity from mild to life threatening. The risk of developing non-Hodgkin lymphoma is also higher. The cumulative 10-year survival rate of CV patients is significantly lower than in the age- and sex-matched general population, with death typically caused by nephropathy, malignancies, liver involvement, and severe infections. Unfailing serological stigmata include both a cryoglobulin IgM fraction with rheumatoid factor activity and decreased complement C4 levels. On peripheral B cells, the expression of the CD81 B cell receptor is reduced while that of the CD19 receptor is increased. A monoclonal B cell lymphocytosis develops in almost one-third of patients. HCV-related proteins (but not HCV-RNA genomic sequences) can be detected on biopsy samples by immunofluorescence and immunohistochemistry and involve the vessel lumen, vessel walls, and the perivascular spaces of the skin, kidney, and peripheral nerves, supporting the pathogenetic role of HCV in the onset of a widespread microvasculitis. Based on the demonstration of HCV infection in the large majority of CV patients, a therapeutic regimen consisting of once-weekly pegylated interferon-α and the daily administration of ribavirin results in a sustained virologic response in ~50 % of patients. In those with refractory and relapsing disease, addition of the anti-CD20 monoclonal antibody rituximab has significantly increased the overall response rates. The extension to CV of latest-generation direct-acting antivirals, strikingly successful in non-CV HCV-positive patients, has yielded high complete response rates according to the few studies published thus far.
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Russi S, Dammacco F, Sansonno S, Pavone F, Sansonno D. Activation-induced cytidine deaminase in B cells of hepatits C virus-related cryoglobulinaemic vasculitis. Clin Exp Immunol 2015. [PMID: 26219420 DOI: 10.1111/cei.12690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Immunoglobulin variable region heavy chain (IgVH ) somatic gene diversification is instrumental in the transformation process that characterizes hepatitis C virus (HCV)-related B cell lymphoproliferative disorders. However, the extent to which activation-induced cytidine deaminase (AID), an enzyme essential for IgV gene somatic hypermutation (SHM), is active in cryoglobulinaemic vasculitis (CV) remains unclear. AID mRNA expression in the peripheral blood of 102 chronically hepatitis C virus (HCV)-infected patients (58 with and 44 without CV) and 26 healthy subjects was investigated using real-time reverse transcription-polymerase chain reaction (RT-PCR). The features of activation-induced cytidine deaminase (AID) protein and mRNA transcripts were explored in liver tissue biopsies and portal tracts isolated using laser capture microdissection. In chronically HCV-infected patients, AID mRNA expression was almost threefold higher in those with than in those without CV and sevenfold higher than in healthy subjects (median-fold: 6.68 versus 2.54, P = 0.03 and versus 0.95, P = 0.0003). AID transcript levels were significantly higher in polyclonal than in clonally restricted B cell preparations in either CV or non-CV patients (median-fold, 15.0 versus 2.70, P = 0.009 and 3.46 versus 1.58, P = 0.02, respectively). AID gene expression was found to be related negatively to age and virological parameters. AID protein was found in portal tracts containing inflammatory cells that, in several instances, expressed AID mRNA transcripts. Our data indicate that the aberrant expression of AID may reflect continuous B cell activation and sustained survival signals in HCV-related CV patients.
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Affiliation(s)
- S Russi
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - F Dammacco
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - S Sansonno
- Institute of Internal Medicine, Department of Medical and Surgical Sciences, University of Foggia Medical School, Foggia, Italy
| | - F Pavone
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - D Sansonno
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
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Sansonno D, Russi S, Sansonno S, Pavone F, Dammacco F. Thymic stromal lymphopoietin in hepatitis C virus-related cryoglobulinemic vasculitis: gene expression level and protein distribution. Arthritis Res Ther 2015; 17:62. [PMID: 25889007 PMCID: PMC4391143 DOI: 10.1186/s13075-015-0581-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/23/2015] [Indexed: 12/16/2022] Open
Abstract
Introduction Hepatitis C virus (HCV) infection can be detected in virtually all patients with cryoglobulinemic vasculitis (CV). Among its many effects, the virus is able to stimulate the production of thymic stromal lymphopoietin (TSLP) by infected hepatocytes. In this study, we assessed the systemic levels and tissue distribution of TSLP in 60 chronically HCV-infected patients, 36 with and 24 without CV. Methods Serum TSLP levels were measured by an enzyme-linked immunosorbent assay (ELISA) method. TSLP mRNA was assessed in patient samples by real-time reverse transcriptase-polymerase chain reaction (RT-PCR). TSLP protein in liver and skin biopsy samples was revealed by indirect immunofluorescence. All other methods were carried out according to standardized procedures. Results Serum TSLP levels were significantly higher in patients with than in those without CV and in healthy individuals. Higher TSLP levels paralleled specific mRNA expression and the up-regulation of TSLP protein in liver tissue. Compared with non-CV patients, higher TSLP levels in CV were accompanied by a higher frequency of circulating mono/oligoclonal B-cell expansions (8% vs. 92%, p < 0.0001) and a higher number of peripheral CD20+ B-cells (10.3% vs. 15.5% p = 0.04). In addition, TSLP mRNA expression in the liver of CV patients was lower than in their correspondent skin tissue and paralleled specific immune deposits of TSLP protein in keratinocytes. Conclusion Overall, this study shows that TSLP secreted by hepatocytes and keratinocytes of HCV-infected patients with CV is involved in the pathogenesis of vasculitis and may possibly support the therapeutic use of TSLP-targeted monoclonal antibodies.
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Affiliation(s)
- Domenico Sansonno
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, 11 Piazza G. Cesare, 70124, Bari, Italy.
| | - Sabino Russi
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, 11 Piazza G. Cesare, 70124, Bari, Italy.
| | - Silvia Sansonno
- Institute of Internal Medicine, Department of Medical and Surgical Sciences, University of Foggia Medical School, 1 viale L. Pinto, 71122, Foggia, Italy.
| | - Fabio Pavone
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, 11 Piazza G. Cesare, 70124, Bari, Italy.
| | - Franco Dammacco
- Liver Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, 11 Piazza G. Cesare, 70124, Bari, Italy.
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Michot JM, Canioni D, Driss H, Alric L, Cacoub P, Suarez F, Sibon D, Thieblemont C, Dupuis J, Terrier B, Feray C, Tilly H, Pol S, Leblond V, Settegrana C, Rabiega P, Barthe Y, Hendel-Chavez H, Nguyen-Khac F, Merle-Béral H, Berger F, Molina T, Charlotte F, Carrat F, Davi F, Hermine O, Besson C. Antiviral therapy is associated with a better survival in patients with hepatitis C virus and B-cell non-Hodgkin lymphomas, ANRS HC-13 lympho-C study. Am J Hematol 2015; 90:197-203. [PMID: 25417909 DOI: 10.1002/ajh.23889] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 10/28/2014] [Accepted: 10/30/2014] [Indexed: 12/16/2022]
Abstract
Hepatitis C virus (HCV) infection increases the risk of B-cell non-Hodgkin lymphomas (B-NHL). Antiviral treatment (AT) can induce hematological responses in patients with marginal zone lymphomas (MZL). The ANRS HC-13 Lympho-C study aimed at a better understanding of the impact of AT on HCV associated B-NHL. This multicentric study enrolled 116 HCV-positive patients with B-NHL between 2006 and 2012. Cytological and histological samples were collected for centralized review. At lymphoma diagnosis, median age was 61 years and gender ratio M/F was 1. Cytohistological distribution was marginal zone lymphoma (MZL) n = 45 (39%), diffuse large B-cell lymphoma (DLBCL) n = 45 (39%), and other types n = 26 (22%). MZL patients had more frequent detection of rheumatoid factor (68% vs. 35%; P = 0.001) and more frequently mixed cryoglobulinemia (74% vs. 44%; P = 0.021) than patients with DLBCL. Among patients receiving AT, a sustained virologic response was achieved in 23 of 38 (61%) patients with MZL and in 9 of 17 (53%) with DLBCL (P = 0.42). Three-year overall survival (OS) and progression-free survival were 78% 95%CI [63-88] and 64% [48-76], respectively, without difference between cytohistological groups. Outcome analysis showed a favorable association between OS and AT in all patients (P = 0.05) and in the subgroup of MZL patients only (P = 0.04). Our data support that AT improves the outcomes of HCV-associated NHLs. The impact of new AT regimen with protease inhibitor needs to be investigated in this setting. [clinicalTrials.gov Identification number NCT01545544]
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Affiliation(s)
- Jean-Marie Michot
- Department of Internal Medicine and Clinical Immunology; Paris Sud University; AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre France
| | - Danielle Canioni
- Department of Pathology; Paris 5 Descartes University; AP-HP, Hôpital Necker Paris France
| | - Henda Driss
- Epidemiology of Infectious Diseases INSERM Unité 707; Paris 6 Pierre et Marie Curie University; Paris France
| | - Laurent Alric
- Department of Internal Medicine and Digestive Diseases; Toulouse 3 University; UMR 152 IRD, Hôpital Purpan Toulouse France
| | - Patrice Cacoub
- Department of Internal Medicine; APHP; Hôpital Pitié-Salpétrière; Paris 6 Pierre et Marie Curie University; UMR 7211, INSERM, UMR S 959, CNRS Paris France
| | - Felipe Suarez
- Department of Adult Hematology; Paris 5 Descartes University; AP-HP, Hôpital Necker Paris France
- Imagine Institute; Université Sorbonne Paris Cité; INSERM U 1163, CNRS ERL 8254 Paris France
| | - David Sibon
- Department of Adult Hematology; Paris 5 Descartes University; AP-HP, Hôpital Necker Paris France
- Imagine Institute; Université Sorbonne Paris Cité; INSERM U 1163, CNRS ERL 8254 Paris France
| | - Catherine Thieblemont
- Service d'hémato-oncologie; Université Paris Sorbonne P7; INSERM U728, AP-HP, Hôpital Saint-Louis Paris France
| | - Jehan Dupuis
- Department of Lymphoid Malignancies and Clinical Hematology; Paris 12 Est Créteil University; AP-HP, Hôpital Henri-Mondor Créteil France
| | - Benjamin Terrier
- Department of Internal Medicine; APHP; Hôpital Pitié-Salpétrière; Paris 6 Pierre et Marie Curie University; UMR 7211, INSERM, UMR S 959, CNRS Paris France
| | - Cyrille Feray
- Department of Hepatology; Nantes University; Hôpital de Nantes Nantes France
| | - Hervé Tilly
- Department of Hematology; Rouen University; Centre Henri Becquerel Rouen France
| | - Stanislas Pol
- Department of Hepatology; Paris 5 Descartes University; INSERM U-1016, AP-HP, Hôpital Cochin Paris France
| | - Véronique Leblond
- Department of Clinical Hematology; Paris 6 Pierre et Marie Curie University; AP-HP, Hôpital Pitié-Salpêtrière Paris France
| | - Catherine Settegrana
- Department of Biological Hematology and Cytogenetic; Paris 6 Pierre et Marie Curie University; AP-HP, Hôpital Pitié-Salpêtrière Paris France
| | - Pascaline Rabiega
- Epidemiology of Infectious Diseases INSERM Unité 707; Paris 6 Pierre et Marie Curie University; Paris France
| | - Yoann Barthe
- Epidemiology of Infectious Diseases INSERM Unité 707; Paris 6 Pierre et Marie Curie University; Paris France
| | - Houria Hendel-Chavez
- Department of Biological Immunology and Hematology; Paris 11 Sud University; AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre France
| | - Florence Nguyen-Khac
- Department of Biological Hematology and Cytogenetic; Paris 6 Pierre et Marie Curie University; AP-HP, Hôpital Pitié-Salpêtrière Paris France
| | - Hélène Merle-Béral
- Department of Biological Hematology and Cytogenetic; Paris 6 Pierre et Marie Curie University; AP-HP, Hôpital Pitié-Salpêtrière Paris France
| | - Françoise Berger
- Department of Pathology; Lyon Sud University, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud; Lyon France
| | - Thierry Molina
- Department of Pathology; Paris 5 Descartes University; AP-HP, Hôpital Necker Paris France
| | - Frédéric Charlotte
- Department of Pathology; Paris 6 Pierre et Marie Curie University; AP-HP, Hôpital Pitié-Salpêtrière Paris France
| | - Fabrice Carrat
- Epidemiology of Infectious Diseases INSERM Unité 707; Paris 6 Pierre et Marie Curie University; Paris France
| | - Frédéric Davi
- Department of Biological Hematology and Cytogenetic; Paris 6 Pierre et Marie Curie University; AP-HP, Hôpital Pitié-Salpêtrière Paris France
| | - Olivier Hermine
- Department of Adult Hematology; Paris 5 Descartes University; AP-HP, Hôpital Necker Paris France
- Imagine Institute; Université Sorbonne Paris Cité; INSERM U 1163, CNRS ERL 8254 Paris France
| | - Caroline Besson
- Department of Internal Medicine and Clinical Immunology; Paris Sud University; AP-HP, Hôpital Bicêtre Le Kremlin-Bicêtre France
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Bunchorntavakul C, Maneerattanaporn M, Chavalitdhamrong D. Management of patients with hepatitis C infection and renal disease. World J Hepatol 2015; 7:213-25. [PMID: 25729476 PMCID: PMC4342603 DOI: 10.4254/wjh.v7.i2.213] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/10/2014] [Accepted: 11/17/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) is associated with more rapid liver disease progression and reduced renal graft and patients' survival following kidney transplantation. Evaluations and management of HCV in patients with renal disease are challenging. The pharmacokinetics of interferons (IFN), ribavirin (RBV) and some direct acting antiviral (DAA), such as sofosbuvir, are altered in patients with ESRD. With dose adjustment and careful monitoring, treatment of HCV in patients with ESRD can be associated with sustained virological response (SVR) rates nearly comparable to that of patients with normal renal function. DAA-based regimens, especially the IFN-free and RBV-free regimens, are theoretically preferred for patients with ESRD and KT in order to increase SVR rates and to reduce treatment side effects. However, based on the data for pharmacokinetics, dosing safety and efficacy of DAA for patients with severe renal impairment are lacking. This review will be focused on the evaluations, available pharmacologic data, and management of HCV in patients with severe renal impairment, patients who underwent KT, and those who suffered from HCV-related renal disease, according to the available treatment options, including DAA.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Monthira Maneerattanaporn
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Disaya Chavalitdhamrong
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
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Evaluation of the liver condition in chronic hepatitis C virus patients with and without vasculitis. THE EGYPTIAN RHEUMATOLOGIST 2014. [DOI: 10.1016/j.ejr.2014.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Russi S, Sansonno D, Mariggiò MA, Vinella A, Pavone F, Lauletta G, Sansonno S, Dammacco F. Assessment of total hepatitis C virus (HCV) core protein in HCV-related mixed cryoglobulinemia. Arthritis Res Ther 2014; 16:R73. [PMID: 24636026 PMCID: PMC4060364 DOI: 10.1186/ar4513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 03/04/2014] [Indexed: 12/17/2022] Open
Abstract
Introduction In hepatitis C virus (HCV)-related mixed cryoglobulinemia (MCG), the nonenveloped HCV core protein (HCV-Cp) is a constituent of the characteristic cold-precipitating immune complexes (ICs). A possible correlation between HCV-Cp, virologic, laboratory, and clinical parameters in both untreated MCG patients and those undergoing specific treatment was explored. Methods HCV-Cp was quantified by a fully automated immune assay. Correlations between HCV-Cp and HCV RNA, cryocrit, and virus genotype (gt) were investigated in 102 chronically HCV-infected MCG patients. Results HCV-Cp concentrations strongly correlated with HCV RNA levels in baseline samples. An average ratio of 1,425 IU and 12,850 IU HCV RNA per picogram HCV-Cp was estimated in HCV gt-1 and gt-2 patients, respectively. This equation allowed us to estimate that, on average, HCV-Cp was associated with the viral genome in only 3.4% of the former and in 35% of the latter group of patients. The direct relation between HCV-Cp and the cryocrit level suggests that the protein directly influences the amount of cryoprecipitate. Although the therapy with rituximab (RTX) as a single agent resulted in the enhancement of HCV-Cp levels, in patients treated with RTX in combination with a specific antiviral therapy (pegylated interferon-α plus ribavirin), the prompt and effective clearance of HCV-Cp was documented. Conclusions Our data provide evidence that HCV-Cp has a direct effect on the cold-precipitation process in a virus genotype-dependence in HCV-related MCG patients.
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Sansonno D, Russi S, Serviddio G, Conteduca V, D'Andrea G, Sansonno L, Pavone F, Lauletta G, Mariggiò MA, Dammacco F. Interleukin 28B gene polymorphisms in hepatitis C virus-related cryoglobulinemic vasculitis. J Rheumatol 2014; 41:91-8. [PMID: 24293567 DOI: 10.3899/jrheum.130527] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Single-nucleotide polymorphisms (SNP) in the interleukin 28B (IL-28B) gene region are strongly predictive of the response of infected patients to antiviral therapy for hepatitis C virus (HCV). We sought to determine the prevalence of SNP IL-28B rs12979860 C/C and non-C/C (C/T plus T/T) genotypes in HCV-related cryoglobulinemic vasculitis (CV), as compared with HCV-positive patients without CV. We also searched for their association with peculiar clinical manifestations of CV and potential influence on the complete response (virological, molecular, and immunological) to the therapy. METHODS The study cohort comprised 159 and 172 HCV-infected patients with and without CV, respectively, prospectively followed starting from 1990. SNP rs12979860 genotyping was performed by Taq-Man allelic discrimination. In 106 patients (66.6%) with CV, the profile of circulating B cell clonalities was determined as well. All patients with CV were treated with pegylated interferon-α/ribavirin-based antiviral therapy. RESULTS The T/T IL-28B genotype was more common in patients with CV than in those without (17% vs 8.1%, p = 0.02). In patients with CV, compared with non-C/C variants, the IL-28B C/C genotype was associated with a higher rate of complete response (52.6% vs 39.2%, p = 0.13), whereas a treatment response of 61.4% was demonstrated when solely virological response was considered (p = 0.008). A higher frequency of expanded B cell clonalities in the circulation (84.2% vs 55.9%; p = 0.005), kidney involvement (21% vs 2.9%; p = 0.003), and B cell non-Hodgkin lymphoma (17.5% vs 6.8%; p = 0.048), were also observed. CONCLUSION In HCV-positive patients with CV, the IL-28B C/C genotype is distinguished biologically by a higher frequency of restriction of B cell response and clinically by a higher risk of cryoglobulinemic nephropathy and B cell malignancies, while acting as an independent predictor of a sustained virological response to antiviral therapy. In addition, we found that IL-28B T/T variant was more prevalent in patients with CV than in those without.
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Affiliation(s)
- Domenico Sansonno
- From the Section of Internal Medicine and Clinical Oncology, Laboratory of General Pathology and Experimental Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari; Section of Internal Medicine, Department of Medical Sciences, and Section of Medical Genetics, Department of Biomedical Sciences, University of Foggia, Foggia, Italy
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