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Kulkarni DH, Starick M, Aponte Alburquerque R, Kulkarni HS. Local complement activation and modulation in mucosal immunity. Mucosal Immunol 2024; 17:739-751. [PMID: 38838816 DOI: 10.1016/j.mucimm.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Abstract
The complement system is an evolutionarily conserved arm of innate immunity, which forms one of the first lines of host response to pathogens and assists in the clearance of debris. A deficiency in key activators/amplifiers of the cascade results in recurrent infection, whereas a deficiency in regulating the cascade predisposes to accelerated organ failure, as observed in colitis and transplant rejection. Given that there are over 60 proteins in this system, it has become an attractive target for immunotherapeutics, many of which are United States Food and Drug Administration-approved or in multiple phase 2/3 clinical trials. Moreover, there have been key advances in the last few years in the understanding of how the complement system operates locally in tissues, independent of its activities in circulation. In this review, we will put into perspective the abovementioned discoveries to optimally modulate the spatiotemporal nature of complement activation and regulation at mucosal surfaces.
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Affiliation(s)
- Devesha H Kulkarni
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Marick Starick
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Rafael Aponte Alburquerque
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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2
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Wang Y, Shang S, Jiang S, Zou G, Gao H, Li W. Complement C3a/C3aR and C5a/C5aR deposits accelerate the progression of advanced IgA nephropathy to end-stage renal disease. Clin Exp Med 2024; 24:139. [PMID: 38951265 PMCID: PMC11217045 DOI: 10.1007/s10238-024-01410-3] [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: 05/05/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
IgA nephropathy (IgAN) is still one of the leading causes of end-stage kidney disease (ESRD), and complement system activation is a key to the pathogenesis of IgAN. The role of complement C3a/C3aR and C5a/C5aR in late stage of IgAN remains unknown. Renal specimens of 75 IgAN patients at the stage 4 CKD were stained using immunofluorescence and immunohistochemistry. The primary outcome was a composite of end-stage renal disease (ESRD) and death. Associations of complement components with baseline clinicopathological characteristics and outcomes were assessed using multivariable Cox regression and Spearman analyses. During a median follow-up of 15.0 months, 27 patients progressed to ESRD and none died. Lower eGFR [hazards ratio (HR), 0.827, 95% confidence interval (CI), 0.732-0.935; P = 0.002] and glomerular C3 deposition (HR, 3.179, 95% CI, 1.079-9.363; P = 0.036) were predictive of time to ESRD in stage 4 CKD IgAN. Higher expression of C3a (P = 0.010), C3aR (P = 0.005), C5a (P = 0.015), and C5aR (P < 0.001) was identified in ESRD group than in non-ESRD group. Glomerular C3a/C3aR and C5a/C5aR deposits were both correlated with a lower baseline eGFR, higher baseline 24 h-urinary protein (24 h-UP) and faster decline of eGFR. Besides, C3a and C5a deposits were found in patients with high S (S1) and T (T1/2) scores, respectively. Complement C3a/C3aR and C5a/C5aR in IgAN patients with stage 4 CKD may portend a faster deterioration of kidney function.
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Affiliation(s)
- Ying Wang
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Shunlai Shang
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China.
| | - Shimin Jiang
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Guming Zou
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Hongmei Gao
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China.
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Chalkia A, Jayne D. ANCA-associated vasculitis-treatment standard. Nephrol Dial Transplant 2024; 39:944-955. [PMID: 37947275 PMCID: PMC11210069 DOI: 10.1093/ndt/gfad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 11/12/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are characterized by small-vessel necrotizing inflammation, and prior to the advent of immunosuppressive therapy frequently had a fatal outcome. Treatment has transformed AAV into a relapsing/remitting disease with increased drug-related toxicities and organ damage. The use of glucocorticoids, cyclophosphamide and immunosuppressives (including azathioprine, mycophenolate and methotrexate) was optimized through a sequence of clinical trials establishing a standard of care against which subsequent targeted therapies could be developed. Improved understanding of pathophysiology has supported the development of B-cell depletion and complement inhibition in granulomatosis with polyangiitis and microscopic polyangiitis, and interleukin 5 inhibition for eosinophilic granulomatosis with polyangiitis, leading to the approval of newer agents for these conditions. There has been an increased attention on minimizing the adverse effects of treatment and on understanding the epidemiology of comorbidities in AAV. This review will focus on recent evidence from clinical trials, especially with respect to glucocorticoids, avacopan, plasma exchange, rituximab and mepolizumab, and their interpretation in the 2022 management recommendations by the European League of Associations of Rheumatology.
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Affiliation(s)
- Aglaia Chalkia
- Department of Medicine, University of Cambridge, Cambridge, UK
- Nephrology Department, Hippokration General Hospital, Athens, Greece
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Renson T, Kelly MM, Benediktsson H, Grundhoefer N, Luca N, Miettunen P, Twilt M, Grisaru S, Wade A, Banks A, Fifi-Mah A, Hamiwka L, Benseler S. Non-invasive biomarkers of disease activity and organ damage in ANCA-associated vasculitis: a systematic review. RMD Open 2024; 10:e003579. [PMID: 38341193 PMCID: PMC10862256 DOI: 10.1136/rmdopen-2023-003579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/14/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND In anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), histopathological assessment of affected tissue is often necessary for diagnosis and assessment of disease extent. There is a requirement for validated non-invasive biomarkers to avoid the need for serial tissue biopsies. METHODS A systematic review of scientific databases from 2012 until present was performed to identify studies fulfilling the inclusion criteria. Studies were assessed for quality using the Strengthening the Reporting of Observational Studies in Epidemiology checklist for cohort, case-control and cross-sectional studies and the Risk of Bias Assessment tool for Non-randomised Studies, or the Cochrane Risk of Bias tool 2.0 for randomised controlled trials. A descriptive synthesis of the data for non-invasive (blood-based or urinary) biomarkers of AAV-related disease activity and organ damage was performed. RESULTS Twenty-two high quality studies were included. These articles reported the value of blood-based and urinary biomarkers including anti-neutrophil cytoplasmic antibodies, immune cells, complement factors, gene expression profiles, cytokines, chemokines and other proteins in the assessment of disease activity and/or organ damage in patients with AAV. Many of these biomarkers involve the alternative complement pathway, neutrophil activation and macrophage activation. CONCLUSION This is the first contemporary systematic review synthesising the value of non-invasive biomarkers of AAV-related disease activity and organ damage. The incorporation of individual markers in combined biomarker profiles might enhance clinical decision-making. Many unmet needs were identified; few studies involve oeosinophilic granulomatosis with polyangiitis and patients with childhood-onset AAV. Further validation of the candidate biomarkers is warranted in large prospective studies to bridge the existing knowledge gaps and apply precision health to systemic vasculitis.
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Affiliation(s)
- Thomas Renson
- Rheumatology and Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Pediatric Nephrology and Rheumatology, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
- European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases, Ghent University Hospital, Ghent, Belgium
| | - Margaret M Kelly
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hallgrimur Benediktsson
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nele Grundhoefer
- Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Nadia Luca
- Rheumatology, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Paivi Miettunen
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Marinka Twilt
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Silviu Grisaru
- Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Wade
- Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Anke Banks
- Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Aurore Fifi-Mah
- Rheumatology, University of Calgary, Calgary, Alberta, Canada
| | - Lorraine Hamiwka
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Susanne Benseler
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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5
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Laffer B, Lenders M, Ehlers-Jeske E, Heidenreich K, Brand E, Köhl J. Complement activation and cellular inflammation in Fabry disease patients despite enzyme replacement therapy. Front Immunol 2024; 15:1307558. [PMID: 38304433 PMCID: PMC10830671 DOI: 10.3389/fimmu.2024.1307558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024] Open
Abstract
Defective α-galactosidase A (AGAL/GLA) due to missense or nonsense mutations in the GLA gene results in accumulation of the glycosphingolipids globotriaosylceramide (Gb3) and its deacylated derivate globotriaosylsphingosine (lyso-Gb3) in cells and body fluids. The aberrant glycosphingolipid metabolism leads to a progressive lysosomal storage disorder, i. e. Fabry disease (FD), characterized by chronic inflammation leading to multiorgan damage. Enzyme replacement therapy (ERT) with agalsidase-alfa or -beta is one of the main treatment options facilitating cellular Gb3 clearance. Proteome studies have shown changes in complement proteins during ERT. However, the direct activation of the complement system during FD has not been explored. Here, we demonstrate strong activation of the complement system in 17 classical male FD patients with either missense or nonsense mutations before and after ERT as evidenced by high C3a and C5a serum levels. In contrast to the strong reduction of lyso-Gb3 under ERT, C3a and C5a markedly increased in FD patients with nonsense mutations, most of whom developed anti-drug antibodies (ADA), whereas FD patients with missense mutations, which were ADA-negative, showed heterogenous C3a and C5a serum levels under treatment. In addition to the complement activation, we found increased IL-6, IL-10 and TGF-ß1 serum levels in FD patients. This increase was most prominent in patients with missense mutations under ERT, most of whom developed mild nephropathy with decreased estimated glomerular filtration rate. Together, our findings demonstrate strong complement activation in FD independent of ERT therapy, especially in males with nonsense mutations and the development of ADAs. In addition, our data suggest kidney cell-associated production of cytokines, which have a strong potential to drive renal damage. Thus, chronic inflammation as a driver of organ damage in FD seems to proceed despite ERT and may prove useful as a target to cope with progressive organ damage.
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Affiliation(s)
- Björn Laffer
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Malte Lenders
- Department of Internal Medicine D, University Hospital Münster, Münster, Germany
| | - Elvira Ehlers-Jeske
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | | | - Eva Brand
- Department of Internal Medicine D, University Hospital Münster, Münster, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
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6
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Lucientes-Continente L, Fernández-Juárez G, Márquez-Tirado B, Jiménez-Villegas L, Acevedo M, Cavero T, Cámara LS, Draibe J, Anton-Pampols P, Caravaca-Fontán F, Praga M, Villacorta J, Goicoechea de Jorge E. Complement alternative pathway determines disease susceptibility and severity in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Kidney Int 2024; 105:177-188. [PMID: 37923132 DOI: 10.1016/j.kint.2023.10.013] [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: 12/11/2022] [Revised: 09/27/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023]
Abstract
Activation of the alternative pathway (AP) of complement is involved in the pathogenesis of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), although the underlying molecular mechanisms are unclear. To gain insight into the role of the AP, common gene variants in CFH/CFHR1-5, CFB, C3 and MCP, and longitudinal determinations of plasma C3, C4, FH, FHR-1, FHR-2, FHR-5, FB, properdin and sC5b-9 levels were analyzed in a Spanish AAV cohort consisting of 102 patients; 54 with active AAV (active cohort) and 48 in remission not receiving immunosuppressants or dialysis therapy (remission cohort). The validation cohort consisted of 100 patients with ANCA-associated glomerulonephritis. Here, we demonstrated that common genetic variants in complement components of the AP are associated with disease susceptibility (CFB32Q/W) or severity of kidney damage in AAV (CFH-H1, CFH1H2 and ΔCFHR3/1). Plasma levels of complement components were significantly different between active and remission cohorts. In longitudinal observations, a high degree of AP activation at diagnosis was associated with worse disease outcome, while high basal FHR-1 levels and lower FH/FHR-1 ratios determined severe forms of kidney associated AAV. These genetic and plasmatic findings were confirmed in the validation cohort. Additionally, autoantibodies against FH and C3 convertase were identified in one and five active patients, respectively. Thus, our study identified key genetic and plasma components of the AP that determine disease susceptibility, prognosis, and severity in AAV. Our data also suggests that balance between FH and FHR-1 is critical and supports FHR-1 as a novel AP-specific therapeutic target in AAV.
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Affiliation(s)
- Laura Lucientes-Continente
- Department of Immunology, Ophthalmology and Otorhinolaryngology (ENT), Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Gema Fernández-Juárez
- Department of Nephrology, Hospital Universitario La Paz, Instituto de Investigación de la Paz (IdIPAZ), Madrid, Spain.
| | - Bárbara Márquez-Tirado
- Department of Immunology, Ophthalmology and Otorhinolaryngology (ENT), Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Laura Jiménez-Villegas
- Department of Immunology, Ophthalmology and Otorhinolaryngology (ENT), Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Mercedes Acevedo
- Department of Nephrology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Teresa Cavero
- Department of Nephrology, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Juliana Draibe
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; Biomedical Research Institute of Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Paula Anton-Pampols
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; Biomedical Research Institute of Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | | | - Manuel Praga
- Department of Nephrology, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain; Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Villacorta
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and Otorhinolaryngology (ENT), Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
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7
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Bulanov NM, Moiseev SV. [State-of-the-art trends in the treatment of immune-mediated inflammatory kidney diseases: Translation of the fundamental science into clinical practice. A review]. TERAPEVT ARKH 2023; 95:625329. [PMID: 38158941 DOI: 10.26442/00403660.2023.12.202502] [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: 12/26/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
Immune-mediated kidney diseases like glomerulonephritis and tubulointerstitial nephritis are not the most common cause of chronic kidney disease in the population, however the difficulties in their management, as well as a more rapid deterioration of kidney function, compared to diabetes mellitus and hypertension, justify the importance of this problem for internal medicine. Due to the fundamental discoveries in pathology and to the introduction of various methods of laboratory and instrumental investigation in the second half of the XX century substantial progress was made in the diagnostic approaches and treatment of these conditions. State-of-the-art diagnostic approach requires complex evaluation of the clinical, laboratory and morphological data to identify the nosological form of the disease. The accumulation of knowledge in the field of diseases' pathogenesis led to the revision of the current classification of glomerulonephritis that should be based on the immunopathogenesis of these conditions. The following phenotypes were suggested: autoimmunity-related, autoinflammation-related, alloimmunity-related, infections-related, and monoclonal gammopathy-related. The assessment of disease activity and chronicity in the kidney tissue should be mandatory. Personalized selection of the optimal treatment modality on the basis of the diagnosis, severity, and individual features of the patient is currently possible. The leading trends include rational prescription of glucocorticoids (steroid-sparing regimens) and cytotoxic agents, e.g. cyclophosphamide, as well as the introduction of multitarget regimens that include biologic agents or small molecules selectively suppressing B-cells or various complement pathways. Another mandatory component of treatment on par with immune suppression is nephroprotective therapy, which currently comprises not only traditional renin-angiotensin-aldosterone antagonists, but also endothelin receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Current guidelines emphasize the importance of the non-pharmacological interventions for the implementation of the nephroprotective strategy. Rational combination of the aforementioned approaches allows for the optimization of the management of patients with immune-mediated kidney diseases, although it requires high competencies and strict adherence to the principles of the evidence-based medicine from the healthcare providers.
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Affiliation(s)
- N M Bulanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S V Moiseev
- Sechenov First Moscow State Medical University (Sechenov University)
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8
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Moiseev S, Bulanov N, Crnogorac M, Direskeneli H, Galesic K, Gazel U, Geetha D, Guillevin L, Hrušková Z, Little MA, O'Neill L, Makarov E, McAdoo SP, Mohammad AJ, Moran S, Novikov P, Pusey CD, Rahmattulla C, Satrapová V, Silva J, Suvorov A, Tesar V, Terrier B, Willeit P, Zhao MH, Kronbichler A, Jayne DRW. Traditional and Disease-Specific Risk Factors for Cardiovascular Events in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Multinational Retrospective Study. J Rheumatol 2023; 50:1145-1151. [PMID: 36642436 DOI: 10.3899/jrheum.220851] [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] [Accepted: 11/25/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate the occurrence of cardiovascular events (CVEs) in a large cohort of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) across the European Union, China, Turkey, Russia, the United Kingdom, and the USA. METHODS Patients with a definite diagnosis of AAV who were followed for ≥ 3 months and had sufficient documentation were included. Data on myocardial infarction (MI) and stroke were collected retrospectively from tertiary vasculitis centers. Univariate and multivariate Cox regression models were used to estimate hazard ratios (HRs) and 95% CIs. RESULTS Over a median follow-up of 62.0 months (IQR 22.6-100.0), CVEs (mostly MIs) occurred in 245 (10.7%) of 2286 patients with AAV, with a higher frequency in China and the UK. On multivariate regression analysis, older age (55-64.9 yrs, HR 2.93, 95% CI 1.99-4.31), smoking (HR 1.98, 95% CI 1.48-2.64), Chinese origin (HR 4.24, 95% CI 3.07-5.85), and pulmonary (HR 1.50, 95% CI 1.09-2.06) and kidney (HR 3.02, 95% CI 2.08-4.37) involvement were independent variables associated with a higher occurrence of CVEs. CONCLUSION We showed that geographic region and both traditional and disease-specific (kidney involvement in particular) factors were independently associated with CVEs. Proper assessment and management of modifiable cardiovascular (CV) risk factors are essential for prevention of CV morbidity in patients with AAV.
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Affiliation(s)
- Sergey Moiseev
- S. Moiseev, MD, Professor, Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, and Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Nikolay Bulanov
- N. Bulanov, MD, P. Novikov, MD, Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Matija Crnogorac
- M. Crnogorac, MD, K. Galesic, MD, Professor, Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Haner Direskeneli
- H. Direskeneli, MD, Professor, U. Gazel, MD, Department of Internal Medicine, Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Kresimir Galesic
- M. Crnogorac, MD, K. Galesic, MD, Professor, Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Ummugulsum Gazel
- H. Direskeneli, MD, Professor, U. Gazel, MD, Department of Internal Medicine, Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Duvuru Geetha
- D. Geetha, MD, Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Loic Guillevin
- L. Guillevin, MD, Professor, B. Terrier, PhD, Professor, Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Zdenka Hrušková
- Z. Hrušková, MD, V. Satrapová, MD, V. Tesar, MD, Professor, Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Mark A Little
- M.A. Little, MD, Professor, Trinity Health Kidney Centre, Trinity Translational Medicine Institute, and Irish Centre for Vascular Biology, Tallaght University Hospital, Dublin, Ireland
| | - Liam O'Neill
- L. O'Neill, MD, University Hospital Galway, Dublin, Ireland
| | - Egor Makarov
- E. Makarov, MD, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Stephen P McAdoo
- S.P. McAdoo, PhD, C.D. Pusey, MD, Professor, J. Silva, MD, Department of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Aladdin J Mohammad
- A.J. Mohammad, MD, Department of Rheumatology, Clinical Sciences-Lund, Lund University, Lund, Sweden, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Sarah Moran
- S. Moran, MD, Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Pavel Novikov
- N. Bulanov, MD, P. Novikov, MD, Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- S.P. McAdoo, PhD, C.D. Pusey, MD, Professor, J. Silva, MD, Department of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Chinar Rahmattulla
- C. Rahmattulla, PhD, Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Veronika Satrapová
- Z. Hrušková, MD, V. Satrapová, MD, V. Tesar, MD, Professor, Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Joana Silva
- S.P. McAdoo, PhD, C.D. Pusey, MD, Professor, J. Silva, MD, Department of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Alexander Suvorov
- A. Suvorov, MD, Centre for Analysis of Complex Systems, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vladimír Tesar
- Z. Hrušková, MD, V. Satrapová, MD, V. Tesar, MD, Professor, Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Benjamin Terrier
- L. Guillevin, MD, Professor, B. Terrier, PhD, Professor, Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Peter Willeit
- P. Willeit, PhD, Professor, Clinical Epidemiology Team, Medical University of Innsbruck, Innsbruck, Austria, and Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ming-Hui Zhao
- M.H. Zhao, MD, Professor, Renal Division, Peking University First Hospital, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Andreas Kronbichler
- A. Kronbichler, PhD, D.R.W. Jayne, MD, Professor, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, and Department of Medicine, University of Cambridge, Cambridge, UK.
| | - David R W Jayne
- A. Kronbichler, PhD, D.R.W. Jayne, MD, Professor, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, and Department of Medicine, University of Cambridge, Cambridge, UK
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9
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Heras Benito M. [Complement in vasculitis associated with anti-neutrophil cytoplasm antibodies with renal involvement: pathogenic, prognostic and therapeutic implications]. Med Clin (Barc) 2023; 161:160-165. [PMID: 37236835 DOI: 10.1016/j.medcli.2023.04.007] [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: 02/20/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023]
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitides are primary vasculitides that affect small vessels in various organs, including the kidney. Renal involvement is characterized by the presence of glomerulonephritis with crescents and necrosis in light microscopy and a pauci-immune pattern in immunofluorescence. The participation of complement in the pathogenesis of these entities has been valued in recent years, initially in animal models and later in studies in humans, by demonstrating the presence of fragments of the alternative complement pathway, in plasma and urine, together with complement deposits in glomeruli and small vessels of patients affected by antineutrophil cytoplasmic antibody vasculitis. The presence of complement in these entities confers a worse general and renal prognosis.
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Affiliation(s)
- Manuel Heras Benito
- Servicio de Nefrología, Hospital Universitario de Salamanca, Salamanca, España.
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10
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Berti A, Cornec D, Dua AB. Treatment Approaches to Granulomatosis with Polyangiitis and Microscopic Polyangiitis. Rheum Dis Clin North Am 2023; 49:545-561. [PMID: 37331732 DOI: 10.1016/j.rdc.2023.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
We have made significant headway in our ability to induce and maintain remission in patients with granulomatosis with polyangiitis and microscopic polyangiitis. With increased understanding of the pathogenesis of antineutrophilic cytoplasmic antibody-associated vasculitides (AAV), therapeutic targets have been identified and studied in clinical trials. From initial induction strategies including glucocorticoids and cyclophosphamide, we have discovered effective induction regimens with rituximab and complement inhibition that can significantly decrease the glucocorticoid cumulative doses in patients with AAV. There are many trials underway evaluating management strategies for refractory patients and exploring new and old therapies that may help to continuously improve outcomes for patients with AAV.
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Affiliation(s)
- Alvise Berti
- Center for Medical Sciences (CISMed), Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, and Division of Rheumatology, Santa Chiara Hospital, APSS Trento, Italy
| | - Divi Cornec
- Rheumatology Department, INSERM UMR1227 LBAI, Lymphocytes B, Autoimmunité et Immunothérapies, University of Brest, National Reference Center for Rare Systemic Autoimmune Diseases CERAINO, CHRU Brest, Brest, France.
| | - Anisha B Dua
- Division of Rheumatology, Northwestern University Feinberg School of Medicine, 675 North Saint Clair Street, Suite 14-100, Chicago, IL 60611, USA
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11
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Aqeel F, Zonozi R, Jeyabalan A, Sauvage G, Niles JL, Geetha D. Outcomes of COVID-19 in patients with ANCA-associated vasculitis receiving avacopan. RMD Open 2023; 9:e003435. [PMID: 37640515 PMCID: PMC10462954 DOI: 10.1136/rmdopen-2023-003435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Faten Aqeel
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Reza Zonozi
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Anushya Jeyabalan
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel Sauvage
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John L Niles
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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12
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Levit E, Leon J, Lincoln MR. Pearls & Oy-sters: Homozygous Complement Factor I Deficiency Presenting as Fulminant Relapsing Complement-Mediated CNS Vasculitis. Neurology 2023; 101:e220-e223. [PMID: 36941072 PMCID: PMC10351560 DOI: 10.1212/wnl.0000000000207079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 01/05/2023] [Indexed: 03/23/2023] Open
Abstract
A 36-year-old man presented multiple times with fever, headache, alteration of mental status, and focal neurologic deficits. MRI revealed extensive white matter lesions that were partially reversed between episodes. Workup revealed persistently low complement factor C3, low factor B, and absent alternative complement pathway activity. Biopsy revealed neutrophilic vasculitis. Genetic testing revealed a homozygous variant in complement factor I (CFI), which was thought to be pathogenic. CFI regulates complement-mediated inflammation, and deficiency in this factor leads to unchecked alternative pathway activity and decrease in C3 and factor B through consumption. The patient has remained stable since starting IL-1β inhibition. Complement factor I is a rare disorder that should be considered in patients with atypical relapsing neurologic disease associated with neutrophilic pleocytosis.
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Affiliation(s)
- Elle Levit
- From the Yale University School of Medicine (E.L.), New Haven, CT; Miami VA Healthcare System (J.L.), Veterans Health Administration, Miami, FL; Division of Neurology, Department of Medicine (M.R.L.), University of Toronto, ON; Keenan Research Centre for Biomedical Science (M.R.L.), Toronto, ON, Canada.
| | - Janice Leon
- From the Yale University School of Medicine (E.L.), New Haven, CT; Miami VA Healthcare System (J.L.), Veterans Health Administration, Miami, FL; Division of Neurology, Department of Medicine (M.R.L.), University of Toronto, ON; Keenan Research Centre for Biomedical Science (M.R.L.), Toronto, ON, Canada
| | - Matthew R Lincoln
- From the Yale University School of Medicine (E.L.), New Haven, CT; Miami VA Healthcare System (J.L.), Veterans Health Administration, Miami, FL; Division of Neurology, Department of Medicine (M.R.L.), University of Toronto, ON; Keenan Research Centre for Biomedical Science (M.R.L.), Toronto, ON, Canada
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13
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Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
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Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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14
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Kojima T, Oda T. Role of complement activation in anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. Front Med (Lausanne) 2022; 9:1031445. [DOI: 10.3389/fmed.2022.1031445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune disease characterized by necrotizing inflammation of small or medium vessels, causing ANCA associated glomerulonephritis (AAGN). AAGN is defined as pauci-immune glomerulonephritis with no or little immune deposition; hence, activation of the complement system in AAV was overlooked until recently. However, many studies in mice and humans have revealed a crucial role for complement system activation in the development of AAGN. Circulating and urinary detection of various complement components associated with AP activation, which have been broadly correlated with the clinical activity of AAGN, has been reported and may be useful for predicting renal outcome at the time of diagnosis and setting up personalized treatments. Moreover, recent investigations have suggested the possible contribution of the complement classical or lectin pathway activation in the development of AAGN. Thus, as therapeutic options targeting complement components are making rapid strides, the primary complement pathway involved in AAGN disease progression remains to be elucidated: this will directly impact the development of novel therapeutic strategies with high specificity and reduced side effects. This review summarizes and discusses the most recent evidence on the crucial roles of the complement system in the development of AAGN and possible therapeutic strategies that target complement components for disease management.
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15
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Scurt FG, Bose K, Hammoud B, Brandt S, Bernhardt A, Gross C, Mertens PR, Chatzikyrkou C. Old known and possible new biomarkers of ANCA-associated vasculitis. J Autoimmun 2022; 133:102953. [PMID: 36410262 DOI: 10.1016/j.jaut.2022.102953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/06/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises a group of multisystem disorders involving severe, systemic, small-vessel vasculitis with short- and long term serious and life-threating complications. Despite the simplification of treatment, fundamental aspects concerning assessment of its efficacy and its adaptation to encountered complications or to the relapsing/remitting/subclinical disease course remain still unknown. The pathogenesis of AAV is complex and unique, and despite the progress achieved in the last years, much has not to be learnt. Foremost, there is still no accurate marker enabling us to monitoring disease and guide therapy. Therefore, the disease management relays often on clinical judgment and follows a" trial and error approach". In the recent years, an increasing number of new molecules s have been explored and used for this purpose including genomics, B- and T-cell subpopulations, complement system factors, cytokines, metabolomics, biospectroscopy and components of our microbiome. The aim of this review is to discuss both the role of known historical and clinically established biomarkers of AAV, as well as to highlight potential new ones, which could be used for timely diagnosis and monitoring of this devastating disease, with the goal to improve the effectiveness and ameliorate the complications of its demanding therapy.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany.
| | - K Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - S Brandt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - A Bernhardt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - C Gross
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Peter R Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
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16
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Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [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: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
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Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
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17
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Soliman SA, Stanley S, Vanarsa K, Ismail F, Mok CC, Mohan C. Exploring urine:serum fractional excretion ratios as potential biomarkers for lupus nephritis. Front Immunol 2022; 13:910993. [PMID: 36091001 PMCID: PMC9449537 DOI: 10.3389/fimmu.2022.910993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives The goal of this exploratory study is to determine if urine:serum fractional excretion ratios can outperform the corresponding urinary biomarker proteins in identifying active renal disease in systemic lupus erythematosus (SLE). Methods Thirty-six adult SLE patients and twelve healthy controls were examined for serum and urine levels of 8 protein markers, namely ALCAM, calpastatin, hemopexin, peroxiredoxin 6 (PRDX6), platelet factor 4 (PF4), properdin, TFPI and VCAM-1, by ELISA. Fractional excretion of analyzed biomarkers was calculated after normalizing both the urine and serum biomarker levels against creatinine. A further validation cohort of fifty SLE patients was included to validate the initial findings. Results The FE ratios of all 8 proteins interrogated outperformed conventional disease activity markers such as anti-dsDNA, C3 and C4 in identifying renal disease activity. All but VCAM-1FE were superior to the corresponding urine biomarkers levels in differentiating LN activity, exhibiting positive correlation with renal SLEDAI. ALCAMFE, PF4FE and properdinFE ratios exhibited the highest accuracy (AUC>0.9) in distinguishing active LN from inactive SLE. Four of the FE ratios exhibited perfect sensitivity (calpastatin, PRDX6, PF4 and properdin), while ALCAMFE, PF4FE and properdinFE exhibited the highest specificity values for active LN. In addition, several of these novel biomarkers were associated with higher renal pathology activity indices. In the validation cohort ALCAMFE, PF4FE and properdinFE once again exhibited higher accuracy metrics, surpassing corresponding urine and serum biomarkers levels, with ALCAMFE exhibiting 95% accuracy in distinguishing active LN from inactive SLE. Conclusions With most of the tested proteins, urine:serum fractional excretion ratios outperformed corresponding urine and serum protein measurements in identifying active renal involvement in SLE. Hence, this novel class of biomarkers in SLE ought to be systemically evaluated in larger independent cohorts for their diagnostic utility in LN assessment.
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Affiliation(s)
- Samar A. Soliman
- Department of Rheumatology & Rehabilitation, Faculty of Medicine, Minia University, Minia, Egypt
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Samantha Stanley
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Kamala Vanarsa
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Faten Ismail
- Department of Rheumatology & Rehabilitation, Faculty of Medicine, Minia University, Minia, Egypt
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong SAR, China
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
- *Correspondence: Chandra Mohan,
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18
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Tesar V, Hruskova Z. Complement Inhibition in ANCA-Associated Vasculitis. Front Immunol 2022; 13:888816. [PMID: 35880179 PMCID: PMC9307875 DOI: 10.3389/fimmu.2022.888816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Efficacy of immunosuppressive treatment of Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is complicated by its toxicity. With the replacement of cyclophosphamide with rituximab, serious adverse events seem to be associated especially with high-dose corticosteroids. Activation of alternative complement pathway plays an important role in the pathogenesis of AAV. Avacopan (C5a receptor inhibitor) was demonstrated to have at least similar efficacy and better safety (in terms of corticosteroid-related adverse events) compared with high-dose corticosteroids in the induction treatment of AAV. Other modes of the inhibition of alternative complement pathway are currently tested in AAV or could be considered on the basis of the experience in other glomerular diseases.
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19
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Molnár A, Studinger P, Ledó N. Diagnostic and Therapeutic Approach in ANCA-Associated Glomerulonephritis: A Review on Management Strategies. Front Med (Lausanne) 2022; 9:884188. [PMID: 35721093 PMCID: PMC9205443 DOI: 10.3389/fmed.2022.884188] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is a destructive small vessel vasculitis affecting multiple organs. Renal involvement often leads to end-stage renal disease and increases mortality. Prompt diagnosis and initiation of adequate immunosuppressive therapy are critical for the best patient and kidney outcomes. However, considerable heterogeneity in symptoms and severity across the patients frequently hinder the diagnosis and management. The objective of this review is to emphasize the heterogeneity of the ANCA-associated vasculitis, facilitate the recognition and give guidance to the therapeutical possibilities. We present epidemiologic and risk factors, pathogenesis, and provide comprehensive clinical features of the disease. This article also focuses on the currently available therapeutic options and emerging cellular and molecular targets for the management of systemic and especially renal disease. We conducted extensive literature research published on PubMed and Google Scholar. We systematically reviewed, analyzed, and assembled databases, covering a broad spectrum of aspects of the disease. We compared and summarized the recommendations of two recent guidelines on ANCA-associated vasculitis. The incidence of ANCA-associated vasculitis, hence glomerulonephritis shows a steady increase. Familiarity with the presenting symptoms and laboratory abnormalities are necessary for rapid diagnosis. Early initiation of treatment is the key aspect for favorable patient and renal outcomes. A better understanding of the pathogenesis constantly leads to more targeted and therefore more efficient and less toxic treatment.
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Affiliation(s)
| | | | - Nóra Ledó
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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20
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Cavalli S, Lonati PA, Gerosa M, Caporali R, Cimaz R, Chighizola CB. Beyond Systemic Lupus Erythematosus and Anti-Phospholipid Syndrome: The Relevance of Complement From Pathogenesis to Pregnancy Outcome in Other Systemic Rheumatologic Diseases. Front Pharmacol 2022; 13:841785. [PMID: 35242041 PMCID: PMC8886148 DOI: 10.3389/fphar.2022.841785] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/27/2022] [Indexed: 12/17/2022] Open
Abstract
Evidence about the relevance of the complement system, a highly conserved constituent of the innate immunity response that orchestrates the elimination of pathogens and the inflammatory processes, has been recently accumulated in many different rheumatologic conditions. In rheumatoid arthritis, complement, mainly the classical pathway, contributes to tissue damage especially in seropositive subjects, with complement activation occurring in the joint. Data about complement pathways in psoriatic arthritis are dated and poorly consistent; among patients with Sjögren syndrome, hypocomplementemia exerts a prognostic role, identifying patients at risk of extra-glandular manifestations. Hints about complement involvement in systemic sclerosis have been recently raised, following the evidence of complement deposition in affected skin and in renal samples from patients with scleroderma renal crisis. In vasculitides, complement plays a dual role: on one hand, stimulation of neutrophils with anti-neutrophil cytoplasmic antibodies (ANCA) results in the activation of the alternative pathway, on the other, C5a induces translocation of ANCA antigens, favouring the detrimental role of antibodies. Complement deposition in the kidneys identifies patients with more aggressive renal disease; patients with active disease display low serum levels of C3 and C4. Even though in dermatomyositis sC5b-9 deposits are invariably present in affected muscles, data on C3 and C4 fluctuation during disease course are scarce. C3 and C1q serum levels have been explored as potential markers of disease activity in Takayasu arteritis, whereas data in Behçet disease are limited to in vitro observations. Pregnancies in women with rheumatologic conditions are still burdened by a higher rate of pregnancy complications, thus the early identification of women at risk would be invaluable. A fine-tuning of complement activation is required from a physiological progression of pregnancy, from pre-implantation stages, through placentation to labour. Complement deregulation has been implicated in several pregnancy complications, such as recurrent abortion, eclampsia and premature birth; low complement levels have been shown to reliably identify women at risk of complications. Given its physiologic role in orchestrating pregnancy progression and its involvement as pathogenic effector in several rheumatologic conditions, complement system is an attractive candidate biomarker to stratify the obstetric risk among women with rheumatologic conditions.
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Affiliation(s)
- Silvia Cavalli
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy.,Clinical Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
| | - Paola Adele Lonati
- Experimental Laboratory of Immunorheumatological Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy.,Clinical Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy.,Clinical Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy.,Pediatric Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
| | - Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy.,Pediatric Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
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21
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Deng X, Gao J, Zhao F. Identification of differentially expressed genes and pathways in kidney of ANCA-associated vasculitis by integrated bioinformatics analysis. Ren Fail 2022; 44:204-216. [PMID: 35172670 PMCID: PMC8856091 DOI: 10.1080/0886022x.2022.2030755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systematic of relatively rare autoimmune diseases with unknown cause. Kidney involvement is one of the most common clinical manifestations, and the degree of renal damage is closely associated with the development and prognosis of AAV. In this study, we utilized the Robust Rank Aggreg (RRA) method in R to integrate GSE104948, GSE104954, GSE108109, GSE108112, and GSE108113 profile datasets loaded from Gene Expression Omnibus (GEO) database and identified a set of differentially expressed genes (DEGs) in kidney between AAV patients and living donors. Then, the results of gene ontology (GO) functional annotation showed that immunity and metabolism involved process of AAV both in glomerulus and tubulointerstitial. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis revealed that following pathways, such as complement and coagulation cascades pathway; Staphylococcus aureus infection; disease-COVID-19; and systemic lupus erythematosus (SLE) pathway play a crucial role in AAV. Next, the results analyzed by protein–protein interaction (PPI) network and Cytoscape software exhibited the hub genes ALB, TYROBP, and CYBB existed in both glomerular and tubulointerstitial compartments datasets. Finally, KEGG analysis using genes of two most important modules also further validated complement and coagulation cascades pathway and S. aureus infection existed both in glomerulus and tubulointerstitial compartments datasets. In conclusion, this study identified key genes and pathways involved in kidney of AAV, which was benefit to further uncover the mechanisms underlying the development and progress of AAV, biomarkers, and potential therapeutic targets as well.
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Affiliation(s)
- Xu Deng
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, P. R. China
| | - Junying Gao
- Department of Human Anantomy, Nanjing Medical University, Nanjing, P. R. China
| | - Fei Zhao
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, P. R. China
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22
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Cortes C, Desler C, Mazzoli A, Chen JY, Ferreira VP. The role of properdin and Factor H in disease. Adv Immunol 2022; 153:1-90. [PMID: 35469595 DOI: 10.1016/bs.ai.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The complement system consists of three pathways (alternative, classical, and lectin) that play a fundamental role in immunity and homeostasis. The multifunctional role of the complement system includes direct lysis of pathogens, tagging pathogens for phagocytosis, promotion of inflammatory responses to control infection, regulation of adaptive cellular immune responses, and removal of apoptotic/dead cells and immune complexes from circulation. A tight regulation of the complement system is essential to avoid unwanted complement-mediated damage to the host. This regulation is ensured by a set of proteins called complement regulatory proteins. Deficiencies or malfunction of these regulatory proteins may lead to pro-thrombotic hematological diseases, renal and ocular diseases, and autoimmune diseases, among others. This review focuses on the importance of two complement regulatory proteins of the alternative pathway, Factor H and properdin, and their role in human diseases with an emphasis on: (a) characterizing the main mechanism of action of Factor H and properdin in regulating the complement system and protecting the host from complement-mediated attack, (b) describing the dysregulation of the alternative pathway as a result of deficiencies, or mutations, in Factor H and properdin, (c) outlining the clinical findings, management and treatment of diseases associated with mutations and deficiencies in Factor H, and (d) defining the unwanted and inadequate functioning of properdin in disease, through a discussion of various experimental research findings utilizing in vitro, mouse and human models.
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Affiliation(s)
- Claudio Cortes
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, United States.
| | - Caroline Desler
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Amanda Mazzoli
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Jin Y Chen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States.
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23
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Warren K, Vu K, Shergill K, Watson B, Faris M. Rare complication of a commonly used antihypertensive agent: A case of hydralazine-induced ANCA-associated vasculitis presenting as rapidly progressive glomerulonephritis. Clin Case Rep 2022; 10:e05411. [PMID: 35154727 PMCID: PMC8819714 DOI: 10.1002/ccr3.5411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 12/28/2022] Open
Abstract
Hydralazine-induced ANCA-associated vasculitis is a rare clinical entity, with complications including rapidly progressive glomerulonephritis, pulmonary hemorrhage, and pulmonary-renal syndrome. We present this case to highlight the clinical features that support this challenging diagnosis and to emphasize the importance of prompt recognition and aggressive intervention given its significant morbidity and mortality.
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Affiliation(s)
- Kayle Warren
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Khiem Vu
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Karandeep Shergill
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Brian Watson
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Mohamed Faris
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
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24
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Johansson L, Berglin E, Eriksson O, Mohammad AJ, Dahlqvist J, Rantapää-Dahlqvist S. Complement activation prior to symptom onset in myeloperoxidase ANCA-associated vasculitis but not proteinase 3 ANCA associated vasculitis - A Swedish biobank study. Scand J Rheumatol 2022; 51:214-219. [PMID: 35048784 DOI: 10.1080/03009742.2021.1989814] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Increased soluble levels of complement effectors have been demonstrated in active anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), but the timing of complement activation in the autoimmune inflammation remains elusive. This study investigated whether the complement system is activated before onset of symptoms in AAV. METHOD The Swedish National Patient Register and Cause of Death register were linked to registers of five biobanks to identify individuals sampled before AAV symptom onset. Diagnosis of AAV and time-point for symptom onset were confirmed by reviewing medical records. We identified 64 presymptomatic individuals with serum samples > 1 month < 10 years from AAV symptom onset and 122 matched controls. Complement factors (C2, C5) and activation markers (C5a, C4b) were measured using Luminex technology. RESULTS Presymptomatic individuals had higher levels of C5 up to 6.5 years before symptom onset, compared with controls [median (IQR) 80.7 (131.9) vs 46.6 (63.4) µg/mL, p = 0.05]. Levels of C5a increased significantly during the pre-dating time (p = 0.033) until symptom onset. The complement levels were significantly higher in presymptomatic myeloperoxidase (MPO)-ANCA+ individuals versus MPO-ANCA- and proteinase-3-ANCA+ individuals. C5 was significantly increased in cases with renal involvement at diagnosis versus controls (p = 0.022), whereas levels of both C5 and C5a were significantly increased in presymptomatic individuals diagnosed with microscopic polyangiitis after onset compared with controls (C5: p = 0.027; C5a: p = 0.027). CONCLUSION Activation of the complement system is an early event in the pathogenesis of AAV and is mainly associated with MPO-ANCA+ AAV and with microscopic polyangiitis.
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Affiliation(s)
- L Johansson
- Department of Public Health and Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - E Berglin
- Department of Public Health and Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - O Eriksson
- Department of Immunology, Genetics & Pathology, Uppsala University, Uppsala, Sweden
| | - A J Mohammad
- Department of Clinical Sciences/Rheumatology, Lund University, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - J Dahlqvist
- Department of Medical Sciences, and Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - S Rantapää-Dahlqvist
- Department of Public Health and Medicine/Rheumatology, Umeå University, Umeå, Sweden
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25
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Koike H, Nishi R, Ohyama K, Morozumi S, Kawagashira Y, Furukawa S, Mouri N, Fukami Y, Iijima M, Sobue G, Katsuno M. ANCA-Associated Vasculitic Neuropathies: A Review. Neurol Ther 2022; 11:21-38. [PMID: 35044596 PMCID: PMC8857368 DOI: 10.1007/s40120-021-00315-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/08/2021] [Indexed: 01/21/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a systemic disorder that frequently affects the peripheral nervous system and consists of three distinct conditions: microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA, previously Wegener’s granulomatosis), and eosinophilic granulomatosis with polyangiitis (EGPA, previously Churg-Strauss syndrome). The neuropathic features associated with this condition usually include mononeuritis multiplex, which reflects the locality of lesions. Findings suggestive of vasculitis are usually found in the epineurium and occur diffusely throughout the nerve trunk. Nerve fiber degeneration resulting from ischemia is sometimes focal or asymmetric and tends to become conspicuous at the middle portion of the nerve trunk. The attachment of neutrophils to endothelial cells in the epineurial vessels is frequently observed in patients with ANCA-associated vasculitis; neutrophils play an important role in vascular inflammation by binding of ANCA. The positivity rate of ANCA in EGPA is lower than that in MPA and GPA, and intravascular and tissue eosinophils appear to participate in neuropathy. Immunotherapy for ANCA-associated vasculitis involves the induction and maintenance of remission to prevent the relapse of the disease. A combination of glucocorticoids along with cyclophosphamide, rituximab, methotrexate, or mycophenolate mofetil is considered depending on the severity of the condition of the organ to induce remission. A combination of low-dose glucocorticoids and azathioprine, rituximab, methotrexate, or mycophenolate mofetil is recommended to maintain remission. The efficacy of anti-interleukin-5 therapy (i.e., mepolizumab) was demonstrated in the case of refractory or relapsing EGPA. Several other new agents, including avacopan, vilobelimab, and abatacept, are under development for the treatment of ANCA-associated vasculitis. Multidisciplinary approaches are required for the diagnosis and management of the disorder because of its systemic nature. Furthermore, active participation of neurologists is required because the associated neuropathic symptoms can significantly disrupt the day-to-day functioning and quality of life of patients with ANCA-associated vasculitis.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Ryoji Nishi
- Department of Neurology, Daido Hospital, Nagoya, Japan
| | - Ken Ohyama
- Department of Neurology, Okazaki City Hospital, Okazaki, Japan
| | - Saori Morozumi
- Department of Neurology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | | | - Soma Furukawa
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Naohiro Mouri
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Gen Sobue
- Aichi Medical University, Nagakute, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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26
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Toraman A, Soysal Gündüz Ö. Predictors of renal and patient outcomes in anti-neutrophil cytoplasmic antibody-associated vasculitis: Our single-center, tertiary care experience. Arch Rheumatol 2021; 36:445-457. [PMID: 34870177 PMCID: PMC8612491 DOI: 10.46497/archrheumatol.2021.8687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives
This study aims to assess the different predictors of renal and patient prognosis in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) patients with and without renal involvement. Patients and methods
A total of 79 patients (51 males, 28 females; mean age: 57.3±14.2 years; range, 18 to 71 years) with AAV between January 2006 and November 2019 were retrospectively analyzed. Demographic and laboratory data including the complement 3 (C3) serum levels and renal biopsy findings were extracted from the electronic and printed medical records of the hospital registry. Survival, renal survival, remission, and relapse outcomes were analyzed. Results
A total of 35% of the patients with renal involvement progressed to end-stage renal disease (ESRD). The dialysis requirement at the time of admission (hazard ratio [HR]: 21.95 [2.93-164.22]; p=0.003), estimated glomerular filtration rate (eGFR) (HR: 0.97 [0.94-0.99]; p=0.024) and Five-Factor Score (FFS) ≥2 at the time of diagnosis (HR: 3.59 [1.08-11.94]; p=0.037) were the predictors of ESRD. The five-year patient survival rate was 87.1%. The only predictor of mortality was age (HR: 1.07 [1.01-1.14]; p=0.024). The patients with hypocomplementemia (22%) had a lower remission rate (p=0.049), FFS ≥2 at the time of diagnosis (p=0.026), and higher levels of hematuria (p=0.004) and proteinuria (p=0.037). The FFS ≥2 at the time of diagnosis was an independent predictor of relapse (HR: 8.9 [1.02-77.36]; p=0.047). Conclusion
Our study suggests that the baseline renal function and FFS ≥2 at the time of diagnosis are the major prognostic factors for progression to ESRD in AAV patients. In addition, AAV patients with hypocomplementemia may have a lower remission rate.
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Affiliation(s)
- Aysun Toraman
- Department of Internal Medicine, Division of Nephrology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Özgül Soysal Gündüz
- Department of Internal Medicine, Division of Rheumatology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
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27
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The COVID-19 pandemic and ANCA-associated vasculitis - reports from the EUVAS meeting and EUVAS education forum. Autoimmun Rev 2021; 20:102986. [PMID: 34718165 PMCID: PMC8552556 DOI: 10.1016/j.autrev.2021.102986] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/24/2021] [Indexed: 01/17/2023]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic influenced the management of patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. A paucity of data exists on outcome of patients with vasculitis following COVID-19, but mortality is higher than in the general population and comparable to patients undergoing haemodialysis or kidney transplant recipients (reported mortality rates of 20-25%). Delays in diagnosis have been reported, which are associated with sequelae such as dialysis-dependency. Management of ANCA-associated vasculitis has not changed with the aim to suppress disease activity and reduce burden of disease. The use of rituximab, an important and widely used agent, is associated with a more severe hospital course of COVID-19 and absence of antibodies following severe acute respiratory syndrome (SARS)-CoV-2 infections, which prone patients to re-infection. Reports on vaccine antibody response are scarce at the moment, but preliminary findings point towards an impaired immune response, especially when patients receive rituximab as part of their treatment. Seropositivity was reported in less than 20% of patients when rituximab was administered within the prior six months, and the antibody response correlated with CD19+ B-cell repopulation. A delay in maintenance doses, if disease activity allows, has been suggested using a CD19+ B-cell guided strategy. Other immunosuppressive measures, which are used in ANCA-associated vasculitis, also impair humoral and cellular vaccine responses. Regular measurements of vaccine response or a healthcare-policy time-based strategy are indicated to provide additional doses ("booster") of COVID-19 vaccines. This review summarizes a recent educational forum and a recent virtual meeting of the European Vasculitis Society (EUVAS) focusing on COVID-19.
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28
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Lu Q, Hou Q, Cao K, Sun X, Liang Y, Gu M, Xue X, Zhao AZ, Dai C. Complement factor B in high glucose-induced podocyte injury and diabetic kidney disease. JCI Insight 2021; 6:147716. [PMID: 34622800 PMCID: PMC8525650 DOI: 10.1172/jci.insight.147716] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
The role and mechanisms for upregulating complement factor B (CFB) expression in podocyte dysfunction in diabetic kidney disease (DKD) are not fully understood. Here, analyzing Gene Expression Omnibus GSE30528 data, we identified genes enriched in mTORC1 signaling, CFB, and complement alternative pathways in podocytes from patients with DKD. In mouse models, podocyte mTOR complex 1 (mTORC1) signaling activation was induced, while blockade of mTORC1 signaling reduced CFB upregulation, alternative complement pathway activation, and podocyte injury in the glomeruli. Knocking down CFB remarkably alleviated alternative complement pathway activation and DKD in diabetic mice. In cultured podocytes, high glucose treatment activated mTORC1 signaling, stimulated STAT1 phosphorylation, and upregulated CFB expression, while blockade of mTORC1 or STAT1 signaling abolished high glucose–upregulated CFB expression. Additionally, high glucose levels downregulated protein phosphatase 2Acα (PP2Acα) expression, while PP2Acα deficiency enhanced high glucose–induced mTORC1/STAT1 activation, CFB induction, and podocyte injury. Taken together, these findings uncover a mechanism by which CFB mediates podocyte injury in DKD.
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Affiliation(s)
| | | | - Kai Cao
- Center for Kidney Disease and
| | - Xiaoli Sun
- Department of Clinical Genetics, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | | | | | - Xian Xue
- Department of Clinical Genetics, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Allan Zijian Zhao
- Institute of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, China
| | - Chunsun Dai
- Center for Kidney Disease and.,Department of Clinical Genetics, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
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29
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Barratt J, Weitz I. Complement Factor D as a Strategic Target for Regulating the Alternative Complement Pathway. Front Immunol 2021; 12:712572. [PMID: 34566967 PMCID: PMC8458797 DOI: 10.3389/fimmu.2021.712572] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/18/2021] [Indexed: 11/20/2022] Open
Abstract
The complement system is central to first-line defense against invading pathogens. However, excessive complement activation and/or the loss of complement regulation contributes to the development of autoimmune diseases, systemic inflammation, and thrombosis. One of the three pathways of the complement system, the alternative complement pathway, plays a vital role in amplifying complement activation and pathway signaling. Complement factor D, a serine protease of this pathway that is required for the formation of C3 convertase, is the rate-limiting enzyme. In this review, we discuss the function of factor D within the alternative pathway and its implication in both healthy physiology and disease. Because the alternative pathway has a role in many diseases that are characterized by excessive or poorly mediated complement activation, this pathway is an enticing target for effective therapeutic intervention. Nonetheless, although the underlying disease mechanisms of many of these complement-driven diseases are quite well understood, some of the diseases have limited treatment options or no approved treatments at all. Therefore, in this review we explore factor D as a strategic target for advancing therapeutic control of pathological complement activation.
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Affiliation(s)
- Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, United Kingdom
| | - Ilene Weitz
- Jane Anne Nohl Division of Hematology, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
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30
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Windpessl M, Bettac EL, Gauckler P, Shin JI, Geetha D, Kronbichler A. ANCA Status or Clinical Phenotype - What Counts More? Curr Rheumatol Rep 2021; 23:37. [PMID: 33909191 PMCID: PMC8081707 DOI: 10.1007/s11926-021-01002-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW There is ongoing debate concerning the classification of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. That is, whether classification should be based on the serotype (proteinase 3 (PR3)- or myeloperoxidase (MPO)-ANCA) or on the clinical phenotype (granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)). To add clarity, this review focused on integration of the most recent literature. RECENT FINDINGS Large clinical trials have provided evidence that a serology-based risk assessment for relapses is more predictive than distinction based on the phenotype. Research conducted in the past decade indicated that a serology-based approach more closely resembles the genetic associations, the clinical presentation (i.e., lung involvement), biomarker biology, treatment response, and is also predicting comorbidities (such as cardiovascular death). Our review highlights that a serology-based approach could replace a phenotype-based approach to classify ANCA-associated vasculitides. In future, clinical trials and observational studies will presumably focus on this distinction and, as such, translate into a "personalized medicine."
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Affiliation(s)
- Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstrasse 42, 4600, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Erica L Bettac
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Avenue, Vancouver, WA, USA
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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31
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Moiseev S, Kronbichler A, Makarov E, Bulanov N, Crnogorac M, Direskeneli H, Galesic K, Gazel U, Geetha D, Guillevin L, Hrušková Z, Little MA, Ahmed A, McAdoo SP, Mohammad AJ, Moran S, Novikov P, Pusey CD, Rahmattulla C, Satrapová V, Silva J, Terrier B, Tesař V, Westman K, Jayne DRW. Association of venous thromboembolic events with skin, pulmonary and kidney involvement in ANCA-associated vasculitis: a multinational study. Rheumatology (Oxford) 2021; 60:4654-4661. [PMID: 33523099 DOI: 10.1093/rheumatology/keab071] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/24/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To investigate the occurrence of venous thromboembolic events (VTE) in a large cohort of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) across the European Union, Turkey, Russia, UK, and North America. METHODS Patients with a definite diagnosis of AAV who were followed for at least 3 months and had sufficient documentation were included. Data on VTE, including either deep vein thrombosis or pulmonary embolism, were collected retrospectively from tertiary vasculitis centers. Univariate and multivariate regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Over a median follow up of 63 (29; 101) months, VTE occurred in 278 (9.7%) of 2869 AAV patients with a similar frequency across different countries (from 6.3% to 13.7%), and AAV subtype (granulomatosis with polyangiitis: 9.8%; 95% CI 8.3-11.6, microscopic polyangiitis: 9.6%; 95% CI 7.9-11.4, and eosinophilic granulomatosis with polyangiitis: 9.8%; 95% CI 7.0-13.3). Most VTE (65.6%) were reported in the first-year post diagnosis. Multiple factor logistic regression analysis adjusted for sex and age showed that skin (OR 1.71, 95% CI 1.01-2.92), pulmonary (OR 1.78, 95% CI 1.04-3.14) and kidney involvement (eGFR 15-60 mL/min/1.73 m2, OR 2.86, 95% CI 1.27-6.47; eGFR < 15 mL/min/1.73 m2, OR 6.71, 95% CI 2.94-15.33) were independent variables associated with a higher occurrence of VTE. CONCLUSION Two thirds of VTE occurred during the initial phase of active disease. We confirmed previous findings from smaller studies that a decrease in kidney function, skin involvement and pulmonary disease are independently associated with VTE.
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Affiliation(s)
- Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.,Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Egor Makarov
- Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Nikolay Bulanov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Haner Direskeneli
- Department of Internal Medicine, Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Kresimir Galesic
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Ummugulsum Gazel
- Department of Internal Medicine, Division of Rheumatology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Loic Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Zdenka Hrušková
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Prague, Czech Republic, in
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland.,Irish Centre for Vascular Biology, Tallaght University Hospital, Dublin, Ireland
| | | | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Aladdin J Mohammad
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden, Vasculitis and Lupus Clinic, Addenbrooke's Hospital Cambridge University Hospitals, Cambridge, UK
| | - Sarah Moran
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Chinar Rahmattulla
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Veronika Satrapová
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Prague, Czech Republic, in
| | - Joana Silva
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Prague, Czech Republic, in
| | - Kerstin Westman
- Department of Clinical Sciences Lund, Nephrology, Lund University, Lund, Sweden
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Trivioli G, Vaglio A. The rise of complement in ANCA-associated vasculitis: from marginal player to target of modern therapy. Clin Exp Immunol 2020; 202:403-406. [PMID: 32946609 DOI: 10.1111/cei.13515] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/18/2022] Open
Abstract
The complement system plays a central role in autoimmune diseases, including anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Although complement deposition is scarce in AAV pathological samples, complement activation is required for the development of necrotizing crescentic glomerulonephritis (NCGN) in mouse models of AAV and occurs via the alternative pathway. The anaphylatoxin C5a, produced by the final complement pathway, is determinant to drive the disease in animal models. C5a primes human neutrophils and enhances their activation induced by ANCA; activated neutrophils, in turn, release factors that lead to C5a generation, establishing a self-amplifying loop. C5a is also significantly increased in the serum of AAV patients with active disease compared to those in remission or healthy controls. Inhibition of the C5a receptor with avacopan is an emerging therapy that will probably allow AAV treatment with glucocorticoid-free regimens.
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Affiliation(s)
- G Trivioli
- Nephrology Unit, Meyer Children's Hospital, Firenze, Italy.,Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Firenze, Italy
| | - A Vaglio
- Nephrology Unit, Meyer Children's Hospital, Firenze, Italy.,Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Firenze, Italy
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Immunopathogenesis of ANCA-Associated Vasculitis. Int J Mol Sci 2020; 21:ijms21197319. [PMID: 33023023 PMCID: PMC7584042 DOI: 10.3390/ijms21197319] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune disorder which affects small- and, to a lesser degree, medium-sized vessels. ANCA-associated vasculitis encompasses three disease phenotypes: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). This classification is largely based on clinical presentations and has several limitations. Recent research provided evidence that genetic background, risk of relapse, prognosis, and co-morbidities are more closely related to the ANCA serotype, proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, compared to the disease phenotypes GPA or MPA. This finding has been extended to the investigation of biomarkers predicting disease activity, which again more closely relate to the ANCA serotype. Discoveries related to the immunopathogenesis translated into clinical practice as targeted therapies are on the rise. This review will summarize the current understanding of the immunopathogenesis of ANCA-associated vasculitis and the interplay between ANCA serotype and proposed disease biomarkers and illustrate how the extending knowledge of the immunopathogenesis will likely translate into development of a personalized medicine approach in the management of ANCA-associated vasculitis.
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