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Rodziewicz M, Mendoza-Pinto C, Dyball S, Munguía-Realpozo P, Parker B, Bruce IN. Predictors and prognostic factors influencing outcomes of anti-CD20 monoclonal antibodies in systemic lupus erythematosus: A systematic review update. Semin Arthritis Rheum 2024; 65:152346. [PMID: 38185077 DOI: 10.1016/j.semarthrit.2023.152346] [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: 08/13/2023] [Revised: 10/09/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Anti-C20 monoclonal antibodies (MAb), such as rituximab, are commonly used for the treatment of patients with severe or refractory systemic lupus erythematosus (SLE) but clinical outcomes are highly variable. We aimed to provide an update of a systematic review of predictive and prognostic factors of anti-CD20 MAb treatment in SLE. METHODS A systematic literature search was undertaken to identify predictive and prognostic factors of clinical response following treatment with anti-CD20 therapies in SLE patients. Studies examining rituximab published prior to 2015 were excluded. Risk of bias was assessed for randomized controlled trials (RCTs) using the Cochrane Collaboration (RoB2) tool for RCTs and the Quality In Prognosis Studies Tool (QUIPS) for cohort studies. A narrative synthesis of the evidence was undertaken and quality of evidence (QoE) was assessed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS From 850 studies identified, 17 studies met the inclusion criteria. A further 8 studies were identified and included through search updates. There were two post-hoc analyses of RCTs of rituximab, one RCT of ocrelizumab and one of obinutuzumab; and 16 cohort studies examining rituximab treatment. The overall QoE was low or very low. There was wide heterogeneity in definitions of clinical disease activity and outcome measures, non-standardized laboratory cut-offs, failure to account for confounders and multiple subgroup analyses of differing outcomes. B cell depletion as well as novel biomarkers, such as S100 proteins, FCGR genotype, anti-vimentin and anti-drug antibodies showed some evidence of prognostic value but QoE was limited due to moderate to high risk of bias, early phase of investigation and imprecision of results. CONCLUSION There has been no validation of previously identified prognostic factors to guide outcome in anti-CD20 treated lupus patients. Hypothesis-driven studies of several novel markers however, demonstrate prognostic value and require replication and validation to support their use in routine clinical practice. PROSPERO REGISTRATION NUMBER CRD42020220339.
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Affiliation(s)
- Mia Rodziewicz
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK.
| | - Claudia Mendoza-Pinto
- High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Rheumatology and Immunology, School of Medicine, Autonomous University of Puebla, Mexico
| | - Sarah Dyball
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK
| | - Pamela Munguía-Realpozo
- High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Rheumatology and Immunology, School of Medicine, Autonomous University of Puebla, Mexico
| | - Ben Parker
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK; Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University Hospitals Foundation Trust, Manchester Academic Health Science Centre Manchester, UK
| | - Ian N Bruce
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK; Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University Hospitals Foundation Trust, Manchester Academic Health Science Centre Manchester, UK
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Jayne DR, Steffgen J, Romero-Diaz J, Bajema I, Boumpas DT, Noppakun K, Amano H, Gomez HM, Satirapoj B, Avihingsanon Y, Chawanasuntorapoj R, Madero M, Naumnik B, Recto R, Fagan N, Revollo I, Wu J, Visvanathan S, Furie R. Clinical and Biomarker Responses to BI 655064, an Antagonistic Anti-CD40 Antibody, in Patients With Active Lupus Nephritis: A Randomized, Double-Blind, Placebo-Controlled, Phase II Trial. Arthritis Rheumatol 2023; 75:1983-1993. [PMID: 37192040 DOI: 10.1002/art.42557] [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: 03/17/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To characterize its dose-response relationship, BI 655064 (an anti-CD40 monoclonal antibody) was tested as an add-on to mycophenolate and glucocorticoids in patients with active lupus nephritis (LN). METHODS A total of 121 patients were randomized (2:1:1:2) to receive placebo or BI 655064 120, 180, or 240 mg and received a weekly loading dose for 3 weeks followed by dosing every 2 weeks for the 120 and 180 mg groups, and 120 mg weekly for the 240 mg group. The primary endpoint was complete renal response (CRR) at week 52. Secondary endpoints included CRR at week 26. RESULTS A dose-response relationship with CRR at week 52 was not shown (BI 655064 120 mg, 38.3%; 180 mg, 45.0%; 240 mg, 44.6%; placebo, 48.3%). At week 26, 28.6% (120 mg), 50.0% (180 mg), 35.0% (240 mg), and 37.5% (placebo) achieved CRR. The unexpected high placebo response prompted a post hoc analysis evaluating confirmed CRR (cCRR, at weeks 46 and 52). cCRR was achieved in 22.5% (120 mg), 44.3% (180 mg), 38.2% (240 mg), and 29.1% (placebo) of patients. Most patients reported ≥1 adverse event (BI 655064, 85.7-95.0%; placebo, 97.5%), most frequently infections and infestations (BI 655064 61.9-75.0%; placebo 60%). Compared with other groups, higher rates of serious (20% vs. 7.5-10%) and severe infections (10% vs. 4.8-5.0%) were reported with 240 mg BI 655064. CONCLUSION The trial failed to demonstrate a dose-response relationship for the primary CRR endpoint. Post hoc analyses suggest a potential benefit of BI 655064 180 mg in patients with active LN.
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Affiliation(s)
- David R Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Juanita Romero-Diaz
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubiran", Mexico City, Mexico
| | - Ingeborg Bajema
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - Dimitrios T Boumpas
- Department of Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Hirofumi Amano
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | | | - Bancha Satirapoj
- Division of Nephrology, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | | | | | - Magdalena Madero
- National Institute of Cardiology Ignacio Chávez, Mexico City, Mexico
| | - Beata Naumnik
- Department of Nephrology and Transplantation with Dialysis Unit, Medical University of Bialystok, Bialystok, Poland
| | - Rhona Recto
- Mary Mediatrix Medical Center, Lipa City, Philippines
| | - Nora Fagan
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Ivette Revollo
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Jing Wu
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | | | - Richard Furie
- Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
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Gopal A, Kavadichanda C, Bairwa D, Shah S, Mehra S, Srinivas BH, Mariaselvam CM, Thabah MM, Negi VS. Performance of Clinical and Biochemical Parameters in Identifying Renal Histopathology and Predictors of One-Year Renal Outcome in Lupus Nephritis-A Single Centre Study from India. Diagnostics (Basel) 2022; 12:diagnostics12123163. [PMID: 36553169 PMCID: PMC9777017 DOI: 10.3390/diagnostics12123163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives: To assess the performance of clinical and biochemical parameters in identifying renal histopathology. To assess the performance of a combination of demographic, clinical, serological and histopathological parameters in determining renal response at one year. Methods: Data of biopsy-proven (ISN/RPS—2003 criteria) Lupus Nephritis (LN) were extracted from the institute database. Demographic, clinical and biochemical parameters at the time of biopsy were noted, and their associations with histopathological class, activity and chronicity scores were evaluated. Follow-up data at one year were collected. Complete, partial or no response (CR, PR, NR) for renal outcomes at one year and the predictors of NR were assessed. Results: Out of the 333 renal biopsies, 240 (71.8%) were Class III/IV. More patients with Class III/IV LN had hypertension (52.1%) and low eGFR (p < 0.001). Among Class III/IV, AS correlated weakly with UPCR (r = 0.31, p < 0.01), eGFR (r = −0.172; p < 0.01) and CS with eGFR (r = −0.212; p < 0.01). The presence of either hypertension, UPCR > 0.5 g/day, active urinary sediments or serum creatinine >1.3 g/dL had a sensitivity of >96% and specificity of <9% in detecting proliferative LN, crescents, interstitial inflammation and chronicity. NR was higher in males (aOR:3.9, 95% CI:1.4−11.0, p < 0.001), those with abnormal baseline creatinine (aOR: 1.9, 95% CI: 1.1−3.2, p < 0.001), higher renal SLEDAI (p < 0.05), higher AS, CS (p < 0.001) and interstitial inflammation (p < 0.005). In the binary logistic regression, the combination of male sex, baseline creatinine, UPCR and CS performed best in predicting NR (AUC: 0.762; 95% CI: 0.684−0.840, p < 0.001). Conclusions: Clinical and biochemical parameters alone have a poor specificity in identifying renal histopathology. A combination of demographic, clinical and histopathology parameters can better predict renal outcomes at one year.
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Affiliation(s)
- Aishwarya Gopal
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
- Correspondence:
| | - Devender Bairwa
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
- Department of General Medicine, All India Institute of Medical Sciences, Bilaspur 174001, India
| | - Sanket Shah
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
- GCS Medical College, Ahmedabad 380025, India
| | - Sonal Mehra
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
- Centre for Spine and Rheumatology, Delhi 110058, India
| | - Bheemanathi Hanuman Srinivas
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Christina Mary Mariaselvam
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Molly Mary Thabah
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
- All India Institute of Medical Sciences, Bilaspur 174001, India
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Cooley I, Derebail VK, Gibson KL, Álvarez C, Poulton CJ, Blazek LN, Love A, Hogan SL, Jennette JC, Falk RJ, Sheikh SZ. Association of Lupus Nephritis Histopathologic Classification With Venous Thromboembolism-Modification by Age at Biopsy. Kidney Int Rep 2021; 6:1653-1660. [PMID: 34169206 PMCID: PMC8207328 DOI: 10.1016/j.ekir.2021.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/21/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Lupus nephritis (LN) is an independent risk factor for venous thromboembolism (VTE). The risk of VTE has not been analyzed by International Society of Nephrology/Renal Pathology Society or World Health Organization LN class. Study goals were to measure VTE incidence in an LN patient cohort, to evaluate associations between VTE and LN class, and to investigate factors modifying associations between VTE and LN class. METHODS A retrospective analysis was performed using Glomerular Disease Collaborative Network data. Image-confirmed VTE was compared between patients with any LN class V lesion and patients with only LN class III or IV. Logistic regression was used to calculate odds ratios and 95% confidence intervals. Effect modification was assessed between main effect and covariates. RESULTS Our cohort consisted of 534 LN patients, 310 (58%) with class III/IV and 224 (42%) with class V with or without class III/IV, including 106 with class V alone. The VTE incidence was 62 of 534 (11.6%). The odds of VTE were not significantly different between patients with class III/IV and class V in adjusted analyses (odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.45-1.48). An age interaction was observed (P = 0.009), with increased odds of VTE with class III/IV diagnosed at a younger age (2.75, 0.90-8.41 estimated at age 16 years) and decreased odds with class III/IV diagnosed at an older age (0.23, 0.07-0.72 estimated at age 46 years), compared to class V. CONCLUSIONS The VTE incidence was similar among patients with LN classes III/IV and V, suggesting that VTE risk is not limited to class V-related nephrotic syndrome and that age may modulate LN class-specific VTE risk.
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Affiliation(s)
- Ian Cooley
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Keisha L. Gibson
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carolina Álvarez
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lauren N. Blazek
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrew Love
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Saira Z. Sheikh
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Chapel Hill Alliance Promoting Excellence in Lupus (CHAPEL) group of investigators
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Nephrotic syndrome in the course of type 1 diabetes mellitus and systemic lupus erythematosus with secondary antiphospholipid syndrome - diagnostic and therapeutic problems. Reumatologia 2020; 58:331-334. [PMID: 33227048 PMCID: PMC7667945 DOI: 10.5114/reum.2020.100105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/21/2020] [Indexed: 12/05/2022] Open
Abstract
Nephrotic syndrome (NS) can be a symptom of many autoimmune, metabolic, or infectious diseases. Kidney involvement is often observed in the course of diabetes mellitus (DM) and systemic lupus erythematosus (SLE). The development of NS with coexisting SLE and DM generates serious diagnostic problems. In this paper, the authors present diagnostic and therapeutic dilemmas in a patient with long-lasting DM, SLE, and secondary antiphospholipid syndrome, in whom NS symptoms appeared. Histopathological examination of the kidney confirmed the diagnosis of lupus nephritis. Immunosuppressive and anticoagulant drugs were used. The authors demonstrated that the character of morphologic lesions in the kidney biopsy can help in diagnosis, nephropathy classification, and further therapeutic decisions, which are distinct in both diseases.
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Moroni G, Gatto M, Tamborini F, Quaglini S, Radice F, Saccon F, Frontini G, Alberici F, Sacchi L, Binda V, Trezzi B, Vaglio A, Messa P, Sinico RA, Doria A. Lack of EULAR/ERA-EDTA response at 1 year predicts poor long-term renal outcome in patients with lupus nephritis. Ann Rheum Dis 2020; 79:1077-1083. [PMID: 32503858 DOI: 10.1136/annrheumdis-2020-216965] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/09/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Short-term predictive endpoints of chronic kidney disease (CKD) are needed in lupus nephritis (LN). We tested response to therapy at 1 year. METHODS We considered patients with LN who underwent renal biopsy followed by induction therapy between January 1970 and December 2016. LN was assessed using the International Society of Nephrology/Renal Pathology Society (2003) criteria and the National Institute of Health (NIH) activity and chronicity index. The renal outcome was CKD. Response was defined according to EULAR/European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations: complete: proteinuria <0.5 g/24 hours, (near) normal estimated glomerular filtration rate (eGFR); partial: ≥50% proteinuria reduction to subnephrotic levels, (near) normal eGFR; and no response: all the other cases. Logistic regression analysis was employed for 12-month response and Cox regression for CKD prediction. RESULTS We studied 381 patients (90.5% Caucasians). After 12-month therapy, 58%, 26% and 16% of patients achieved complete, partial and no response, respectively, according to EULAR/ERA-EDTA. During a median follow-up of 10.7 (IQR: 4.97-18.80) years, 53 patients developed CKD. At 15 years, CKD-free survival rate was 95.2%, 87.6% and 55.4% in patients with complete, partial and no response at 12 months, respectively (p<0.0001). CKD-free survival rates did not differ between complete and partial responders (p=0.067). Serum creatinine (HR: 1.485, 95% CI 1.276 to 1.625), eGFR (HR 0.967, 95% CI 0.957 to 0.977) and proteinuria at 12 months (HR 1.234, 95% CI 1.111 to 1.379) were associated with CKD, yet no reliable cut-offs were identified on the receiver operating characteristic curve. In multivariable analysis, no EULAR/ERA-EDTA response at 12 months (HR 5.165, 95% CI 2.770 to 7.628), low C4 (HR 1.053, 95% CI 1.019 to 1.089) and persistent arterial hypertension (HR 3.154, 95% CI 1.500 to 4.547) independently predicted CKD. CONCLUSIONS Lack of EULAR/ERA-EDTA response at 12 months predicts CKD.
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Affiliation(s)
- Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Francesco Tamborini
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Francesca Radice
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy.,Nephrology Unit, ASST-Monza, Ospedale San Gerardo, Milano, Italy
| | - Francesca Saccon
- Division of Rheumatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Giulia Frontini
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Federico Alberici
- Nephrology Unit - Immunology Clinic, ASST Santo Paolo e Carlo - San Carlo Borromeo Hospital, Milano, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Valentina Binda
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Barbara Trezzi
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy.,Nephrology Unit, ASST-Monza, Ospedale San Gerardo, Milano, Italy
| | - Augusto Vaglio
- Department of Biomedical Clinical and Experimental Sciences "Mario Serio", Meyer Children's Hospital, University of Florence, Firenze, Italy
| | - Piergiorgio Messa
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Renato Alberto Sinico
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy.,Nephrology Unit, ASST-Monza, Ospedale San Gerardo, Milano, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
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Affiliation(s)
- Ronald van Vollenhoven
- Amsterdam University Medical Center, Amsterdam, The Netherlands.,Department of Rheumatology, Amsterdam Rheumatology Center, Amsterdam, The Netherlands
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