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Robinson CH, Hart-Matyas M, Morgenstern DA, Noone D, Campisi P. Renal Implications of Long-Term Systemic Bevacizumab for Recurrent Respiratory Papillomatosis. Ann Otol Rhinol Laryngol 2024; 133:119-123. [PMID: 37439024 PMCID: PMC10759239 DOI: 10.1177/00034894231184942] [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] [Indexed: 07/14/2023]
Abstract
BACKGROUND Bevacizumab is a vascular endothelial growth factor (VEGF) inhibitor that is used off-label for select cases of recurrent respiratory papillomatosis (RRP) that are severe, involve the distal airway or lung parenchyma, and refractory to other forms of adjuvant therapy. However, there is limited safety data for the use of bevacizumab in children and VEGF inhibitors are reported to have a range of adverse renal effects, including hypertension, proteinuria, and thrombotic microangiopathy (TMA). CASE-DIAGNOSIS/TREATMENT This report describes a case of severe juvenile-onset RRP that had an exceptionally high operative burden that was refractory to several adjuvant treatment strategies (including intralesional cidofovir and subcutaneous pegylated interferon). Bevacizumab treatment resulted in a dramatic and sustained improvement in disease control over a 5-year period. However, after 3 years of treatment, the patient developed hypertension and proteinuria and was found to have evidence of a glomerular TMA on kidney biopsy. These complications were successfully managed with a reduction in bevacizumab frequency and angiotensin-converting enzyme inhibitor initiation. CONCLUSIONS Clinicians caring for children treated with VEGF inhibitors should be aware of the potential renal complications and their management.
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Affiliation(s)
- Cal H. Robinson
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael Hart-Matyas
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel A. Morgenstern
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Damien Noone
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paolo Campisi
- Department of Otolaryngology – Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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2
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You ZY, Wu MF, Li H, Ye YF, Wang LJ, Lin ZQ, Li J. A phase I dose-finding trial of hyperthermic intraperitoneal docetaxel combined with cisplatin in patients with advanced-stage ovarian cancer. J Gynecol Oncol 2024; 35:e1. [PMID: 37477105 PMCID: PMC10792218 DOI: 10.3802/jgo.2024.35.e1] [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: 02/09/2023] [Revised: 05/11/2023] [Accepted: 06/24/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVE To identify the maximum tolerated dose (MTD) of docetaxel combined with a fixed dose of cisplatin (75 mg/m²) delivered as hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with ovarian cancer. METHODS In this phase I trial, a time-to-event Bayesian optimal interval design was used. Docetaxel was given at a starting dose of 60 mg/m² and was increased in 5 mg/m² increments until the MTD was determined or the maximum dose level of 75 mg/m² was reached. The dose-limiting toxicity (DLT) rate was set at 25%, with a total sample size of 30 patients. HIPEC was delivered immediately following debulking surgery at a target temperature of 43°C for 90 minutes. RESULTS From August 2022 to November 2022, 30 patients were enrolled. Among the patients who received a dose of docetaxel ≤65 mg/m², no DLT was reported. DLTs were observed in one patient who received 70 mg/m² docetaxel (grade 3 anaemia) and in three patients who received 75 mg/m² docetaxel (one case of grade 3 anaemia, one case of grade 3 hepatic impairment and one case of grade 4 thrombocytopenia). Patients treated with docetaxel 75 mg/m² in combination with cisplatin 75 mg/m² had an estimated DLT rate of 25%, which was the closest to the target DLT rate and was therefore chosen as the MTD. CONCLUSION Docetaxel, in combination with a fixed dose of cisplatin (75 mg/m²), can be used safely at intraperitoneal doses of 75 mg/m² in ovarian cancer patients who received HIPEC (43°C, 90 minutes) following debulking surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05410483.
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Affiliation(s)
- Zhi-Yao You
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Miao-Fang Wu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hui Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan-Fang Ye
- Clinical research design division, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li-Juan Wang
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhong-Qiu Lin
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gynecology, Shenshan Medical Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Shanwei, China.
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3
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Ko HC, Lee HP, Wu JD, Ma TL, Shen CH, Lin CT, Cheng MC, Jou YC. Sunitinib-related high-grade proteinuria and allograft dysfunction in a kidney recipient: a rare case report. BMC Nephrol 2022; 23:150. [PMID: 35436872 PMCID: PMC9014636 DOI: 10.1186/s12882-022-02789-5] [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: 02/24/2022] [Accepted: 04/11/2022] [Indexed: 12/21/2022] Open
Abstract
Background Sunitinib-induced high-grade proteinuria and irreversible renal allograft dysfunction are rare conditions. Here, we present a patient who had received renal allograft and later developed metastatic clear cell renal cell carcinoma(cc-mRCC), for which he was prescribed sunitinib. High-grade proteinuria, hypoalbuminemia, peripheral edema and renal allograft dysfunction (manifesting as an increase in the serum creatinine concentration) occurred 5 months after sunitinib prescription. Case presentation The patient was a 58-year-old male who had end-stage renal disease with regular hemodialysis through arteriovenous fistula for 17 years since 1998 and received a renal allograft from a deceased kidney donor in 2015. Unfortunately, in 2019, the patient developed cc-mRCC originating from the left native kidney. We suggested a needle biopsy on left native kidney or radical left nephrectomy, but the patient refused. Sunitinib was prescribed. Follow-up urine analysis showed proteinuria (500 mg/dL) 2 weeks after sunitinib prescription. He was hospitalized 5 months later because of body weight gain, decreased urine output, pitting edema of both lower extremities, and shortness of breath. The image studies showed progression in his cc-mRCC. His serum creatinine level and spot urine protein at admission increased to 4.26 mg/dL and 300 mg/dL, respectively. He agreed on a biopsy for the renal allograft and the pathology studies showed focal segmental glomerulosclerosis, acute interstitial nephritis, and acute tubular injury. Based on the time sequence of clinical presentations with the laboratory and pathological findings, sunitinib-induced renal allograft dysfunction secondary to high-grade proteinuria was most likely. Despite of discontinuation of sunitinib and increased dose of everolimus, renal impairment progressed. Thus, he had to receive hemodialysis starting 2 week after hospitalization. Unfortunately, the patient died of advanced metastasis despite of aggressive medical treatments 3 weeks after admission. Conclusion This case report is a reminder that renal allograft dysfunction can happen secondary to proteinuria after taking sunitinib. Hence, clinicians must regularly check renal function and urine protein for renal allograft recipients. Monitoring and modifying drug prescription, especially sunitinib, is necessary if persistent proteinuria accompanied by deteriorating serum creatinine level occurs. Renal biopsy may be considered if more evidence is required to make a differential diagnosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02789-5.
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Affiliation(s)
- Hsu-Cheng Ko
- Department of Urology, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Huai-Pao Lee
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jiann-Der Wu
- Department of Pathology and Laboratory Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Tsung-Liang Ma
- Department of Nephrology, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Cheng-Huang Shen
- Department of Urology, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Chang-Te Lin
- Department of Urology, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Ming-Chin Cheng
- Department of Urology, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yeong-Chin Jou
- Department of Urology, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan. .,Department of Health and Nutrition Biotechnology, Asian University, Taichung, Taiwan.
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4
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Sterner RC, Rose WN. Unique Presentation of Bortezomib-Associated Thrombotic Microangiopathy Responsive to Therapeutic Plasma Exchange and Eculizumab Therapy. Hematol Rep 2022; 14:119-125. [PMID: 35466182 PMCID: PMC9036209 DOI: 10.3390/hematolrep14020018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/26/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic microangiopathies (TMA) are a rare group of life-threatening hematological conditions characterized by thrombocytopenia and microangiopathic hemolytic anemia. Although our understanding of the pathophysiology and the availability of diagnostic testing has improved for primary TMAs, such as thrombotic thrombocytopenic purpura, the pathophysiology underlying secondary TMAs, including drug-induced TMAs (DITMAs), remains less clear. In this case report, we present the unique case of a patient with a history of multiple myeloma that presented four months after the initiation of bortezomib therapy with a bortezomib-associated TMA that responded to therapeutic plasma exchange (TPE) with plasma replacement and eculizumab therapy. This case demonstrates the possible utility of TPE with plasma replacement and eculizumab therapy in DITMA patients that fail to respond following a trial of holding the suspected medication.
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5
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Clou E, Luque Y. [Angiogenesis inhibitors: mechanism of action and nephrotoxicity]. Nephrol Ther 2021; 18:1-6. [PMID: 34838486 DOI: 10.1016/j.nephro.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 07/16/2021] [Accepted: 08/18/2021] [Indexed: 10/19/2022]
Abstract
Tumoral angiogenesis is a key mechanism involved in the growth and spread of cancer cells. The development of angiogenesis inhibitors, particularly those targeting the Vascular Endothelial Growth Factor (VEGF) pathway, has improved the prognosis and survival of many cancer patients since they were approved in 2005 in France. Vascular Endothelial Growth Factor inhibitors have different mechanisms of action, targeting either the ligand (e.g. bevacizumab, anti-Vascular Endothelial Growth Factor monoclonal antibody; aflibercept, recombinant anti-Vascular Endothelial Growth Factor fusion protein), or its receptors such as tyrosine kinase inhibitors (e.g. sunitinib or sorafenib). These treatments can be combined with conventional chemotherapy, or other anti-cancer therapies, and are associated with variable tolerance depending on the patient's clinical condition and comorbidities. Additionally, angiogenesis inhibition may be associated with cardiovascular and/or kidney toxicity and therefore special monitoring is needed during the treatment duration. Development of hypertension and proteinuria are the commonest renal side effects; these are generally manageable and reversible when treatment is stopped. However, more severe toxicities have been reported such as acute kidney injury, glomerular and/or vascular insults such as thrombotic microangiopathy, and more rarely tubulointerstitial damage. The prescribing physician should be aware of these potentially serious. This article describes the mechanisms of action of antiangiogenic agents and their potential toxicities, with particular respect to the kidneys.
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Affiliation(s)
- Emmanuelle Clou
- Soins Intensifs néphrologiques et rein aigu, département de néphrologie, hôpital Tenon, assistance publique, hôpitaux de Paris, Inserm UMR_S1155, Sorbonne université, Paris, France.
| | - Yosu Luque
- Inserm UMR_S1155, Urgences néphrologiques et transplantation rénale, hôpital Tenon, Sorbonne Université, Paris, France.
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6
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Intravitreal vascular endothelial growth factors hypertension, proteinuria, and renal injury: a concise review. Curr Opin Nephrol Hypertens 2021; 31:47-56. [PMID: 34750330 DOI: 10.1097/mnh.0000000000000760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Nearly 20 years ago, vascular endothelial growth factor (VEGF)inhibitors (VEGFi) were adapted from systemic use from antiangiogenesis roles to intravitreal uses. Initially bevacizumab a murine immunoglobulin was injected 'off label' as a treatment for diabetic macular edema and age-related macular degeneration. Throughout the following decade aflibercept and finally ranibizumab were adapted and obtained Food and Drug Administration approval for intravitreal use. Initially systemic absorption was thought to be quite low after intravitreal injections and was quoted as being 200-fold lower than levels postulated to induce significant VEGF inhibition. Pharmacodynamic studies obtained in 2014 and again in 2017 revealed significant systemic absorption and detectable VEGF inhibition, this has since been confirmed in multiple subsequent studies. RECENT FINDINGS A few case reports of renal dysfunction and glomerular disease related to VEGFi were initially identified. Mixed findings on effects on blood pressure were noted in studies. More recently, 32 cases of de-novo glomerular disease and/or proteinuria exacerbation were identified. New studies have corroborated increased blood pressure, proteinuria exacerbation in patients with pre-existing nephrotic syndrome, and systemic VEGF depletion. Further, the most common lesion of systemic VEGFi nephrotoxicity, thrombotic microangiopathy, has recently been reported by our group. SUMMARY We will review the pharmacokinetic, translational, and epidemiological data that year upon year establish the finite-yet real risk of intravitreal VEGFi.
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7
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Phadke G, Hanna RM, Ferrey A, Torres EA, Singla A, Kaushal A, Kalantar-Zadeh K, Kurtz I, Jhaveri KD. Review of intravitreal VEGF inhibitor toxicity and report of collapsing FSGS with TMA in a patient with age-related macular degeneration. Clin Kidney J 2021; 14:2158-2165. [PMID: 34603693 PMCID: PMC8483684 DOI: 10.1093/ckj/sfab066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 03/16/2021] [Indexed: 01/04/2023] Open
Abstract
Intravitreal vascular endothelial growth factor (VEGF) receptor blockade is used for a variety of retinal pathologies. These include age-related macular degeneration (AMD), diabetic macular edema (DME) and central retinal vein obstruction. Reports of absorption of intravitreal agents into systemic circulation have increased in number and confirmation of depletion of VEGF has been confirmed. Increasingly there are studies and case reports showing worsening hypertension, proteinuria, renal dysfunction and glomerular disease. The pathognomonic findings of systemic VEGF blockade, thrombotic microangiopathies (TMAs), are also being increasingly reported. One lesion that occurs in conjunction with TMAs that has been described is collapsing focal segmental glomerulosclerosis (cFSGS). cFSGS has been postulated to occur due to TMA-induced chronic glomerular hypoxia. In this updated review we discuss the mechanistic, pharmacological, epidemiological and clinical evidence of intravitreal VEGF toxicity. We review cases of biopsy-proven toxicity presented by our group and other investigators. We also present the third reported case of cFSGS in the setting of intravitreal VEGF blockade with a chronic TMA component that was crucially found on biopsy. This patient is a 74-year-old nondiabetic male receiving aflibercept for AMD. Of the two prior cases of cFSGS in the setting of VEGF blockade, one had AMD and the other had DME. This case solidifies the finding of cFSGS and its association with chronic TMA as a lesion that may be frequently encountered in patients receiving intravitreal VEGF inhibitors.
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Affiliation(s)
- Gautam Phadke
- Metrolina Nephrology Associates, Charlotte, NC, USA.,Department of Medicine, Division of Nephrology, Fargo School of Medicine, University of North Dakota, Grand Forks, ND, USA
| | - Ramy M Hanna
- Department of Medicine, Division of Nephrology, University of California, Irvine, Orange, CA, USA
| | - Antoney Ferrey
- Department of Medicine, Division of Nephrology, University of California, Irvine, Orange, CA, USA
| | | | | | - Amit Kaushal
- Sanford Health, Fargo, ND, USA.,Department of Medicine, Fargo School of Medicine, University of North Dakota, Grand Forks, ND, USA
| | - Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology, University of California, Irvine, Orange, CA, USA
| | - Ira Kurtz
- Department of Medicine, Division of Nephrology, University of California, Los Angeles, Westwood, CA, USA.,Brain Research Institute, Westwood, CA, USA
| | - Kenar D Jhaveri
- Northwell Health, Hofstra School of Medicine, New York, NY, USA
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8
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van Dorst DCH, Dobbin SJH, Neves KB, Herrmann J, Herrmann SM, Versmissen J, Mathijssen RHJ, Danser AHJ, Lang NN. Hypertension and Prohypertensive Antineoplastic Therapies in Cancer Patients. Circ Res 2021; 128:1040-1061. [PMID: 33793337 PMCID: PMC8011349 DOI: 10.1161/circresaha.121.318051] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The development of a wide range of novel antineoplastic therapies has improved the prognosis for patients with a wide range of malignancies, which has increased the number of cancer survivors substantially. Despite the oncological benefit, cancer survivors are exposed to short- and long-term adverse cardiovascular toxicities associated with anticancer therapies. Systemic hypertension, the most common comorbidity among cancer patients, is a major contributor to the increased risk for developing these adverse cardiovascular events. Cancer and hypertension have common risk factors, have overlapping pathophysiological mechanisms and hypertension may also be a risk factor for some tumor types. Many cancer therapies have prohypertensive effects. Although some of the mechanisms by which these antineoplastic agents lead to hypertension have been characterized, further preclinical and clinical studies are required to investigate the exact pathophysiology and the optimal management of hypertension associated with anticancer therapy. In this way, monitoring and management of hypertension before, during, and after cancer treatment can be improved to minimize cardiovascular risks. This is vital to optimize cardiovascular health in patients with cancer and survivors, and to ensure that advances in terms of cancer survivorship do not come at the expense of increased cardiovascular toxicities.
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Affiliation(s)
- Daan C H van Dorst
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (D.C.H.v.D., J.V., A.H.J.D.), Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute (D.C.H.v.D., R.H.J.M.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stephen J H Dobbin
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (S.J.H.D., K.B.N., N.N.L.)
| | - Karla B Neves
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (S.J.H.D., K.B.N., N.N.L.)
| | - Joerg Herrmann
- Department of Cardiovascular Medicine (J.H.), Mayo Clinic, Rochester, MN
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension (S.M.H.), Mayo Clinic, Rochester, MN
| | - Jorie Versmissen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (D.C.H.v.D., J.V., A.H.J.D.), Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy (J.V.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute (D.C.H.v.D., R.H.J.M.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (D.C.H.v.D., J.V., A.H.J.D.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ninian N Lang
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (S.J.H.D., K.B.N., N.N.L.)
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9
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Chan CY, Li H, Wu MF, Liu CH, Lu HW, Lin ZQ, Li J. A Dose-Finding Trial for Hyperthermic Intraperitoneal Cisplatin in Gynecological Cancer Patients Receiving Hyperthermic Intraperitoneal Chemotherapy. Front Oncol 2021; 11:616264. [PMID: 33777754 PMCID: PMC7991782 DOI: 10.3389/fonc.2021.616264] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background: To identify the maximum tolerated dose (MTD) of hyperthermic intraperitoneal cisplatin at 43°C among gynecological cancer patients. Methods: In this Phase I dose-finding trial, Bayesian optimal interval (BOIN) design was used. We sought to explore the MTD with a target dose-limiting toxicity (DLT) rate of 20%, 4 prespecified doses (70 mg/m2, 75 mg/m2, 80 mg/m2 and 85 mg/m2), and 30 patients. Results: Between 2019 and 2020, 30 gynecologic cancer patients were enrolled. No patients received bevacizumab in subsequent treatment. The most common adverse events related to cisplatin were nausea and vomiting (100%), followed by tinnitus (26.7%) and kidney injury (23.3%). Of the seven patients with kidney injury, four had persistent renal impairment, and finally progressed into chronic kidney injury. DLTs were noted only in the dose level 4 group (85 mg/m2) and included acute kidney injury, pulmonary embolism, anemia, and neutropenia. When cisplatin was given at dose level four (85 mg/m2), the isotonic estimate of the DLT rate (22%) was closest to the target DLT rate of 20%. Therefore, 85 mg/m2 was selected as the MTD, with a 51% probability that the toxicity probability was greater than the target DLT rate. Conclusions: For gynecological cancer patients who received HIPEC for peritoneal metastases, the MTD of cisplatin in HIPEC at 43°C was 85 mg/m2. Our findings apply to patients who do not receive bevacizumab (ChiCTR1900021555).
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Affiliation(s)
- Chui-Ying Chan
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hui Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Miao-Fang Wu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chang-Hao Liu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huai-Wu Lu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhong-Qiu Lin
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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10
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Angiogenesis Inhibitors as Anti-Cancer Therapy Following Renal Transplantation: A Case Report and Review of the Literature. Curr Oncol 2021; 28:661-670. [PMID: 33499164 PMCID: PMC7924357 DOI: 10.3390/curroncol28010064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/20/2022] Open
Abstract
Solid organ transplant recipients on long-term immunosuppressive medication are at increased risk of developing malignancy, and treatment of advanced cancers with angiogenesis inhibitors in this context has not been widely studied. We present a case of recurrent high-grade serous ovarian carcinoma treated with paclitaxel and bevacizumab in the context of prior renal transplantation where the patient responded well to treatment with controlled toxicities, discussing the potential for increased rates of adverse events and drug interactions in this select population.
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11
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Monteith BE, Venner CP, Reece DE, Kew AK, Lalancette M, Garland JS, Shepherd LE, Pater JL, Hay AE. Drug-induced Thrombotic Microangiopathy with Concurrent Proteasome Inhibitor Use in the Treatment of Multiple Myeloma: A Case Series and Review of the Literature. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e791-e800. [DOI: 10.1016/j.clml.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 01/29/2023]
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12
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Hanna RM, Tran NT, Patel SS, Hou J, Jhaveri KD, Parikh R, Selamet U, Ghobry L, Wassef O, Barsoum M, Bijol V, Kalantar-Zadeh K, Pai A, Amin A, Kupperman B, Kurtz IB. Thrombotic Microangiopathy and Acute Kidney Injury Induced After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors VEGF Blockade-Related TMA After Intravitreal Use. Front Med (Lausanne) 2020; 7:579603. [PMID: 33117836 PMCID: PMC7577346 DOI: 10.3389/fmed.2020.579603] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/14/2020] [Indexed: 12/12/2022] Open
Abstract
Vascular endothelial growth factor (VEGF) inhibition can cause worsening hypertension, proteinuria, chronic kidney injury, and glomerular disease. Thrombotic microangiopathy (TMA) and other nephrotic disorders have been reported with systemic VEGF blockade. These same agents are given intravitreally for age-related macular degeneration (AMD) and diabetic retinopathy (DR), albeit at lower doses than those given for systemic indications. Systemic absorption of anti-VEGF agents when given intravitreally has been shown consistently along with evidence of significant intravascular VEGF suppression. While worsening hypertension has only been seen in some large-scale studies, case reports show worsening proteinuria and diverse glomerular diseases. These include TMA-associated lesions like focal and segmental glomerulosclerosis with collapsing features (cFSGS). In this paper, we report three cases of TMA likely associated with the use of intravitreal anti-VEGF therapy. These patients developed the signature lesion of VEGF blockade in a 6 to 11 month time frame after starting intravitreal VEGF inhibitors. The literature is reviewed showing similar cases. Intravitreal VEGF blockade may cause these adverse events in a hitherto unidentified subgroup of patients. Well-controlled prospective observational trials are needed to determine the event rate and identify which subgroups of patients are at increased risk. A registry for patients who develop worsening hypertension, proteinuria exacerbation, and glomerular diseases from intravitreal VEGF blockade is proposed.
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Affiliation(s)
- Ramy M. Hanna
- Division of Nephrology, Department of Medicine, University of California (UC) Irvine School of Medicine, Orange, CA, United States
| | - Ngoc-Tram Tran
- Division of Nephrology, Department of Medicine, Long Beach Memorial Medical Center, Long Beach, CA, United States
| | - Sapna S. Patel
- Division of Nephrology, Department of Medicine, Long Beach Memorial Medical Center, Long Beach, CA, United States
| | - Jean Hou
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States
| | - Rushang Parikh
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States
| | - Umut Selamet
- Division of Renal Medicine, Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Lena Ghobry
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Olivia Wassef
- Division of Nephrology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Marina Barsoum
- Keck School of Science and Technology, School of Pharmacy, Chapman University, Orange, CA, United States
| | - Vanesa Bijol
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of Medicine, University of California (UC) Irvine School of Medicine, Orange, CA, United States
| | - Alex Pai
- Division of Nephrology, Department of Medicine, University of California (UC) Irvine School of Medicine, Orange, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California (UC) Irvine, Orange, CA, United States
| | - Baruch Kupperman
- Herbert Gavin Eye Institute, Department of Ophthalmology, University of California (UC) Irvine, Irvine, CA, United States
| | - Ira B. Kurtz
- Division of Nephrology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Brain Research Institute, University of California Los Angeles (UCLA), Los Angeles, CA, United States
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13
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Morimoto M, Arai T, Matsuura M, Ono Y. Bevacizumab-associated glomerular microangiopathy that occurred after postoperative chemotherapy for ovarian cancer. CEN Case Rep 2020; 10:6-11. [PMID: 32642991 DOI: 10.1007/s13730-020-00504-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/28/2020] [Indexed: 11/26/2022] Open
Abstract
Bevacizumab is a monoclonal antibody against vascular endothelial growth factor (VEGF) that is used to treat patients with various cancers. However, it is known to be associated with adverse events, such as hypertension and proteinuria. The histology of bevacizumab-induced nephropathy is known as thrombotic microangiopathy or minimal change nephrotic syndrome. Recently, however, the terms "bevacizumab-associated glomerular microangiopathy" and "anti-VEGF therapy-induced glomerular microangiopathy" have been proposed. We present a case of a 68-year-old woman who was administered postoperative chemotherapy (carboplatin, paclitaxel, and bevacizumab) for stage IV ovarian cancer. Proteinuria and hypertension appeared after three courses; however, six courses were completed. Then, gemcitabine and carboplatin were administered for recurrence of her cancer. She was diagnosed with nephrotic syndrome after eight courses. Renal biopsy showed accumulation of periodic acid-Schiff (PAS)-positive substances in the capillary walls and para-mesangial areas. Double contouring of basement membranes was also observed. Immunofluorescence microscopy revealed positive staining for IgG, IgA, IgM, C3, C4, and C1q. Immunosuppressive therapy was administered, but was ineffective. Further examination by electron microscopy and immunostaining led to a diagnosis of bevacizumab-associated glomerular microangiopathy.
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Affiliation(s)
- Madoka Morimoto
- Division of Nephrology, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, Japan.
| | - Tatsuya Arai
- Division of Nephrology, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, Japan
| | - Motoo Matsuura
- Division of Nephrology, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, Japan
| | - Yuko Ono
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, Japan
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14
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Rapidly progressive glomerulonephritis caused by tegafur/gimeracil/oteracil resulted in diabetes nephropathy, in a patient with minor risk of diabetes nephropathy: a case report. CEN Case Rep 2020; 9:347-353. [PMID: 32378178 DOI: 10.1007/s13730-020-00485-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022] Open
Abstract
A 79-year-old Japanese male with a history of type 2 diabetes mellitus (T2DM) for 16 years was admitted to evaluate possible renal disease. The T2DM was well controlled in this patient using nutrition therapy without the need for any diabetes medication, and both diabetes retinopathy and proteinuria were negative. At the age of 78 advanced colorectal cancer (stage IIIa) was diagnosed and laparoscopic-assisted colectomy was performed. Following this procedure, the patient began treatment with tegafur/gimeracil/oteracil (S-1), 80 mg twice daily for 28 days of 42-day cycle. The patient received S-1 for 6 months, during which time, serum albumin decreased from 3.0 g/dL to 1.1 g/dL, urinary protein increased from negative to 3.0 g/day, and serum creatinine increased from 0.9 mg/dL to 2.1 mg/dL. Treatment with S-1 was discontinued, and furosemide 180 mg and prednisolone 30 mg treatment was initiated; however, serum creatinine levels continued to increase to 7.2 mg/dL and proteinuria continued to increase reaching a nephrotic range. A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity was decreased to 27.0%. Renal biopsy showed Kimmelstiel-Wilson nodules, while immunofluorescence intensity of IgG subclass was IgG1 dominant, which was not compatible with diabetic nephropathy (DN). Plasma exchange was not affected. However, hemodialysis was initiated.The results of this investigation suggest that when S-1 monotherapy is performed in the case with DN, rapidly progressive glomerulonephritis (RPGN) may develop due to a condition similar to thrombotic microangiopathy, even in patients with a minor risk factor of DN.
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15
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Toriu N, Sekine A, Mizuno H, Hasegawa E, Yamanouchi M, Hiramatsu R, Hayami N, Hoshino J, Kawada M, Suwabe T, Sumida K, Sawa N, Takaichi K, Ohashi K, Fujii T, Matoba S, Ubara Y. Renal-Limited Thrombotic Microangiopathy due to Bevacizumab Therapy for Metastatic Colorectal Cancer: A Case Report. Case Rep Oncol 2019; 12:391-400. [PMID: 31244641 PMCID: PMC6587198 DOI: 10.1159/000500716] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 12/13/2022] Open
Abstract
An 88-year-old Japanese man received bevacizumab for colorectal cancer with liver and peritoneal metastasis, during which nephrotic range proteinuria occurred (7.66 g/day). Renal biopsy showed endothelial damage with subendothelial swelling and a double contour of the glomerular basement membrane, which indicated a diagnosis of thrombotic microangiopathy (TMA). After bevacizumab was stopped, proteinuria decreased to 1 g/day. During the clinical course, this patient had no extrarenal manifestations. This case suggests that renal injury induced by bevacizumab is characterized by nephrotic range proteinuria and histological TMA, and is a renal-limited condition that differs from systemic TMA related to thrombotic thrombocytopenic purpura.
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Affiliation(s)
- Naoya Toriu
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Akinari Sekine
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Hiroki Mizuno
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Eiko Hasegawa
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Masayuki Yamanouchi
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Rikako Hiramatsu
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Noriko Hayami
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Junichi Hoshino
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Masahiro Kawada
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Tatsuya Suwabe
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Keiichi Sumida
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Naoki Sawa
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Kenmei Takaichi
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan.,Department of Pathology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Takeshi Fujii
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | - Shuichiro Matoba
- Department of Digestive Surgery, Colorectal Surgery Unit, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Nephrology Center and Department of Rheumatology, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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16
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Tsai JP, Hsieh KLC, Yeh TH, Lee YJ, Wei CR. The Occurrence of Metronidazole-Induced Encephalopathy in Cancer Patients: A Hospital-Based Retrospective Study. Ann Indian Acad Neurol 2019; 22:344-348. [PMID: 31359955 PMCID: PMC6613425 DOI: 10.4103/aian.aian_523_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Metronidazole-induced encephalopathy (MIE) is a rare but serious complication caused by metronidazole, a widely used antianaerobic drug. Previous studies prescribed MIE including dysarthria, cerebellar ataxia, and confusion after long-term use of metronidazole. Malignancy has been proposed one of the predisposing conditions for MIE. However, the occurrence of MIE in cancer patients remains unknown. Methodology: We investigated the occurrence of MIE and analyzed retrospectively by hospital-based data of 4160 cancer patients from January 2014 to December 2016. Results: Findings in 793 cancer patients who underwent metronidazole therapy for anaerobic infection revealed two cases of MIE. One had renal cell carcinoma and the other had bladder urothelial carcinoma. Both of their initial presentation were cerebellar dysfunction. The occurrence of MIE was 8.6% for cases who received >30 g of cumulative dose. Hypertension was the most common comorbidity, followed by chronic renal disease and diabetes mellitus. Conclusion: In cancer patients, MIE should be monitored in those with genitourinary cancer, especially with renal dysfunction. Longer duration with more cumulative dose also has a greater risk of MIE. Early consideration of MIE with prompt cessation of metronidazole may result in better outcome.
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Affiliation(s)
- Jui-Ping Tsai
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C), Taipei, Taiwan
| | - Kevin Li-Chun Hsieh
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C), Taipei, Taiwan.,Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tu-Hsueh Yeh
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C), Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yuarn-Jang Lee
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, Division of Infectious Diseases, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Ren Wei
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C), Taipei, Taiwan
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17
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Ma TKW, McAdoo SP, Tam FWK. Targeting the tyrosine kinase signalling pathways for treatment of immune-mediated glomerulonephritis: from bench to bedside and beyond. Nephrol Dial Transplant 2017; 32:i129-i138. [PMID: 28391340 PMCID: PMC5410974 DOI: 10.1093/ndt/gfw336] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/18/2016] [Indexed: 12/25/2022] Open
Abstract
Glomerulonephritis (GN) affects patients of all ages and is an important cause of morbidity and mortality. Non-selective immunosuppressive drugs have been used in immune-mediated GN but often result in systemic side effects and occasionally fatal infective complications. There is increasing evidence from both preclinical and clinical studies that abnormal activation of receptor and non-receptor tyrosine kinase signalling pathways are implicated in the pathogenesis of immune-mediated GN. Activation of spleen tyrosine kinase (SYK), Bruton's tyrosine kinase (BTK), platelet-derived growth factor receptor (PDGFR), epidermal growth factor receptor (EGFR) and discoidin domain receptor 1 (DDR1) have been demonstrated in anti-GBM disease. SYK is implicated in the pathogenesis of ANCA-associated GN. SYK, BTK, PDGFR, EFGR, DDR1 and Janus kinase are implicated in the pathogenesis of lupus nephritis. A representative animal model of IgA nephropathy (IgAN) is lacking. Based on the results from in vitro and human renal biopsy study results, a phase II clinical trial is ongoing to evaluate the efficacy and safety of fostamatinib (an oral SYK inhibitor) in high-risk IgAN patient. Various tyrosine kinase inhibitors (TKIs) have been approved for cancer treatment. Clinical trials of TKIs in GN may be justified given their long-term safety data. In this review we will discuss the current unmet medical needs in GN treatment and research as well as the current stage of development of TKIs in GN treatment and propose an accelerated translational research approach to investigate whether selective inhibition of tyrosine kinase provides a safer and more efficacious option for GN treatment.
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Affiliation(s)
- Terry King-Wing Ma
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK.,Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Stephen P McAdoo
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Frederick Wai Keung Tam
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
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18
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Keir LS, Firth R, Aponik L, Feitelberg D, Sakimoto S, Aguilar E, Welsh GI, Richards A, Usui Y, Satchell SC, Kuzmuk V, Coward RJ, Goult J, Bull KR, Sharma R, Bharti K, Westenskow PD, Michael IP, Saleem MA, Friedlander M. VEGF regulates local inhibitory complement proteins in the eye and kidney. J Clin Invest 2017; 127:199-214. [PMID: 27918307 PMCID: PMC5199702 DOI: 10.1172/jci86418] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 10/28/2016] [Indexed: 12/15/2022] Open
Abstract
Outer retinal and renal glomerular functions rely on specialized vasculature maintained by VEGF that is produced by neighboring epithelial cells, the retinal pigment epithelium (RPE) and podocytes, respectively. Dysregulation of RPE- and podocyte-derived VEGF is associated with neovascularization in wet age-related macular degeneration (ARMD), choriocapillaris degeneration, and glomerular thrombotic microangiopathy (TMA). Since complement activation and genetic variants in inhibitory complement factor H (CFH) are also features of both ARMD and TMA, we hypothesized that VEGF and CFH interact. Here, we demonstrated that VEGF inhibition decreases local CFH and other complement regulators in the eye and kidney through reduced VEGFR2/PKC-α/CREB signaling. Patient podocytes and RPE cells carrying disease-associated CFH genetic variants had more alternative complement pathway deposits than controls. These deposits were increased by VEGF antagonism, a common wet ARMD treatment, suggesting that VEGF inhibition could reduce cellular complement regulatory capacity. VEGF antagonism also increased markers of endothelial cell activation, which was partially reduced by genetic complement inhibition. Together, these results suggest that VEGF protects the retinal and glomerular microvasculature, not only through VEGFR2-mediated vasculotrophism, but also through modulation of local complement proteins that could protect against complement-mediated damage. Though further study is warranted, these findings could be relevant for patients receiving VEGF antagonists.
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Affiliation(s)
- Lindsay S. Keir
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Rachel Firth
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Lyndsey Aponik
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
| | - Daniel Feitelberg
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
| | - Susumu Sakimoto
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
| | - Edith Aguilar
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
| | - Gavin I. Welsh
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Anna Richards
- Queens Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Yoshihiko Usui
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
- Tokyo Medical University Hospital, Tokyo, Japan
| | - Simon C. Satchell
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Valeryia Kuzmuk
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Richard J. Coward
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Jonathan Goult
- Centre for Cellular and Molecular Physiology, University of Oxford, United Kingdom
| | - Katherine R. Bull
- Centre for Cellular and Molecular Physiology, University of Oxford, United Kingdom
| | - Ruchi Sharma
- National Eye Institute, NIH, Bethesda, Maryland, USA
| | - Kapil Bharti
- National Eye Institute, NIH, Bethesda, Maryland, USA
| | - Peter D. Westenskow
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
- The Lowy Medical Research Institute, La Jolla, California, USA
| | | | - Moin A. Saleem
- Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Martin Friedlander
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California, USA
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19
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Voss MH, Bhatt RS, Plimack ER, Rini BI, Alter RS, Beck JT, Wilson D, Zhang X, Mutyaba M, Glasser C, Attie KM, Sherman ML, Pandya SS, Atkins MB. The DART Study: Results from the Dose-Escalation and Expansion Cohorts Evaluating the Combination of Dalantercept plus Axitinib in Advanced Renal Cell Carcinoma. Clin Cancer Res 2016; 23:3557-3565. [PMID: 28031424 DOI: 10.1158/1078-0432.ccr-16-2395] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/30/2016] [Accepted: 12/15/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Activin receptor-like kinase 1 (ALK1) is a novel target in angiogenesis. Concurrent targeting of ALK1 and VEGF signaling results in augmented inhibition of tumor growth in renal cell carcinoma (RCC) xenograft models. Dalantercept is an ALK1-receptor fusion protein that acts as a ligand trap for bone morphogenetic proteins 9 and 10. The DART Study evaluated the safety, tolerability, pharmacokinetics, pharmacodynamics, and antitumor activity of dalantercept plus axitinib in patients with advanced RCC and determined the optimal dose for further testing.Experimental Design: Patients received dalantercept 0.6, 0.9, or 1.2 mg/kg subcutaneously every 3 weeks plus axitinib 5 mg by mouth twice daily until disease progression or intolerance.Results: Twenty-nine patients were enrolled in the dose escalation (n = 15) and expansion (n = 14) cohorts. There were no dose-limiting toxicities or grade 4/5 treatment-related adverse events. In addition to common VEGFR tyrosine kinase inhibitor effects, such as fatigue and diarrhea, commonly seen treatment-related adverse events were peripheral edema, epistaxis, pericardial effusion, and telangiectasia. The objective response rate by RECIST v1.1 was 25% with responses seen at all dose levels. The overall median progression-free survival was 8.3 months.Conclusions: The combination of dalantercept plus axitinib is well tolerated and associated with clinical activity. On the basis of safety and efficacy results, the 0.9 mg/kg dose level was chosen for further study in a randomized phase II trial of dalantercept plus axitinib versus placebo plus axitinib. Clin Cancer Res; 23(14); 3557-65. ©2016 AACR.
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Affiliation(s)
- Martin H Voss
- Memorial Sloan Kettering Cancer Center, New York, New York.
- Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | - Rupal S Bhatt
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Brian I Rini
- Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Robert S Alter
- John Theurer Cancer Center Hackensack UMC, Hackensack, New Jersey
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20
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Alirahimi E, Ashkiyan A, Kazemi-Lomedasht F, Azadmanesh K, Hosseininejad-Chafi M, Habibi-Anbouhi M, Moazami R, Behdani M. Intrabody targeting vascular endothelial growth factor receptor-2 mediates downregulation of surface localization. Cancer Gene Ther 2016; 24:33-37. [PMID: 27982020 DOI: 10.1038/cgt.2016.76] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/02/2016] [Accepted: 11/08/2016] [Indexed: 12/22/2022]
Abstract
Angiogenesis is among the most important mechanisms that helps cancer cells to survive, grow and undergo metastasis. Therefore, inhibiting angiogenesis will suppress tumor growth. Vascular endothelial growth factor (VEGF) and its receptor (VEGFR) are believed to be important players of angiogenesis. The goal of this study was to evaluate the success of a novel nanobody against VEGFR2 in tethering its target inside the endoplasmic reticulum and preventing its transport to the cell membrane. Nanobody sequence was cloned in a mammalian vector in fusion with green fluorescent protein and a KDEL retention signal. After transfection of 293KDR cells with this expression vector, surface localization of VEGFR2 was monitored by flow cytometry. This study demonstrates that our intrananobody is effective in targeting VEGFR2 receptor, and therefore, it is a powerful tool to downregulate a surface-exposed target protein, and in this capacity, it has potential to be used as a therapeutic protein to inhibit growth of tumors.
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Affiliation(s)
- E Alirahimi
- Biotechnology Research Center, Venom & Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Tehran, Iran
| | - A Ashkiyan
- Biotechnology Research Center, Venom & Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Tehran, Iran
| | - F Kazemi-Lomedasht
- Biotechnology Research Center, Venom & Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Tehran, Iran
| | - K Azadmanesh
- Virology Department, Pasteur Institute of Iran, Tehran, Iran
| | - M Hosseininejad-Chafi
- Biotechnology Research Center, Venom & Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Tehran, Iran
| | | | - R Moazami
- Biotechnology Research Center, Venom & Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Tehran, Iran
| | - M Behdani
- Biotechnology Research Center, Venom & Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Tehran, Iran
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21
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Yui JC, Van Keer J, Weiss BM, Waxman AJ, Palmer MB, D'Agati VD, Kastritis E, Dimopoulos MA, Vij R, Bansal D, Dingli D, Nasr SH, Leung N. Proteasome inhibitor associated thrombotic microangiopathy. Am J Hematol 2016; 91:E348-52. [PMID: 27286661 DOI: 10.1002/ajh.24447] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/03/2016] [Accepted: 06/07/2016] [Indexed: 12/21/2022]
Abstract
A variety of medications have been implicated in the causation of thrombotic microangiopathy (TMA). Recently, a few case reports have emerged of TMA attributed to the proteasome inhibitors (PI) bortezomib and carfilzomib in patients with multiple myeloma. The aim of this case series was to better characterize the role of PI in the etiology of drug-induced TMA. We describe eleven patients from six medical centers from around the world who developed TMA while being treated with PI. The median time between medication initiation and diagnosis of TMA was 21 days (range 5 days to 17 months). Median laboratory values at diagnosis included hemoglobin-7.5 g dL(-1) , platelet count-20 × 10(9) /L, LDH-698 U L(-1) , creatinine-3.12 mg dL(-1) . No patient had any other cause of TMA, including ADAMTS13 inhibition, other malignancy or use of any other medication previously associated with TMA. Nine patients had resolution of TMA without evidence of hemolysis after withdrawal of PI. Two patients had stabilization of laboratory values but persistent evidence of hemolysis despite medication withdrawal. One patient had recurrence of TMA with rechallenge of PI. There is a strong level of evidence that PI can cause DITMA. In evaluating patients with suspected TMA, PI use should be recognized as a potential etiology, and these medications should be discontinued promptly if thought to be the cause of TMA. Am. J. Hematol. 91:E348-E352, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Jan Van Keer
- Department of Cardiology; University Hospitals Leuven; Leuven Belgium
| | - Brendan M. Weiss
- Division of Hematology and Oncology, Abramson Cancer Center; University of Pennsylvania; Philadelphia Pennsylvania
| | - Adam J. Waxman
- Division of Hematology and Oncology, Abramson Cancer Center; University of Pennsylvania; Philadelphia Pennsylvania
| | - Matthew B. Palmer
- Department of Pathology and Laboratory Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Vivette D. D'Agati
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Efstathios Kastritis
- Department of Clinical Therapeutics; National and Kapodistrian, University of Athens, School of Medicine; Athens Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics; National and Kapodistrian, University of Athens, School of Medicine; Athens Greece
| | - Ravi Vij
- Division of Hematology and Oncology; Washington University School of Medicine; St. Louis Missouri
| | - Dhruv Bansal
- Division of Hematology and Oncology; Washington University School of Medicine; St. Louis Missouri
| | - David Dingli
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Samih H. Nasr
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
| | - Nelson Leung
- Division of Hematology; Mayo Clinic; Rochester Minnesota
- Division of Nephrology and Hypertension; Mayo Clinic; Rochester Minnesota
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22
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Deray G, Janus N, Aloy B, Launay-Vacher V. [Renovascular effects of antiangiogenic drugs]. Bull Cancer 2016; 103:662-6. [PMID: 27318610 DOI: 10.1016/j.bulcan.2016.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/31/2016] [Accepted: 05/13/2016] [Indexed: 11/24/2022]
Abstract
During the last decade, inhibitors of the vascular endothelial growth factor (VEGF) were developed for the treatment of cancer. Many anti-VEGF are available but the issue is still the same: to inhibit the effect of the VEGF on their receptors. There are two main classes, depending on the mechanism of action by blocking the binding of the ligand on the receptor (VEGF trap or monoclonal antibody) or by affecting directly the receptor (tyrosine kinase inhibitor [TKI], monoclonal antibody directed against the VEGF receptor). These selective agents are safe. Nevertheless, side effects were described, in particular renal and vascular effects. In this article, we analyze the frequency of these renovascular complications, their clinical aspects and the interest of these indexes as a marker of treatment efficacy.
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Affiliation(s)
- Gilbert Deray
- Groupe hospitalier Pitié-Salpêtrière, service ICAR, 83, boulevard de l'Hôpital, 75013 Paris, France; Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France
| | - Nicolas Janus
- Groupe hospitalier Pitié-Salpêtrière, service ICAR, 83, boulevard de l'Hôpital, 75013 Paris, France; Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Blandine Aloy
- Groupe hospitalier Pitié-Salpêtrière, service ICAR, 83, boulevard de l'Hôpital, 75013 Paris, France; Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France
| | - Vincent Launay-Vacher
- Groupe hospitalier Pitié-Salpêtrière, service ICAR, 83, boulevard de l'Hôpital, 75013 Paris, France; Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France
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McClung EC, Wenham RM. Profile of bevacizumab in the treatment of platinum-resistant ovarian cancer: current perspectives. Int J Womens Health 2016; 8:59-75. [PMID: 27051317 PMCID: PMC4803258 DOI: 10.2147/ijwh.s78101] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients with platinum-resistant ovarian cancer have progression of disease within 6 months of completing platinum-based chemotherapy. While several chemotherapeutic options exist for the treatment of platinum-resistant ovarian cancer, the overall response to any of these therapies is ~10%, with a median progression-free survival of 3–4 months and a median overall survival of 9–12 months. Bevacizumab (Avastin), a humanized, monoclonal antivascular endothelial growth factor antibody, has demonstrated antitumor activity in the platinum-resistant setting and was recently approved by US Food and Drug Administration for combination therapy with weekly paclitaxel, pegylated liposomal doxorubicin, or topotecan. This review summarizes key clinical trials investigating bevacizumab for recurrent, platinum-resistant ovarian cancer and provides an overview of efficacy, safety, and quality of life data relevant in this setting. While bevacizumab is currently the most studied and clinically available antiangiogenic therapy, we summarize recent studies highlighting novel alternatives, including vascular endothelial growth factor-trap, tyrosine kinase inhibitors, and angiopoietin inhibitor trebananib, and discuss their application for the treatment of platinum-resistant ovarian cancer.
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Affiliation(s)
- E Clair McClung
- Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Robert M Wenham
- Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Hanna RM, Lopez E, Wilson J, Barathan S, Cohen AH. Minimal change disease onset observed after bevacizumab administration. Clin Kidney J 2015; 9:239-44. [PMID: 26985375 PMCID: PMC4792614 DOI: 10.1093/ckj/sfv139] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 11/17/2015] [Indexed: 01/24/2023] Open
Abstract
This is a report of a patient with minimal change disease (MCD) onset after bevacizumab administration. A 72-year-old man with inoperable Grade 3 astrocytoma was treated with a combination of temozolomide and the vascular endothelial growth factor monoclonal antibody bevacizumab. After two biweekly treatments, he developed nephrotic syndrome. Despite cessation of bevacizumab, his renal function deteriorated and a renal biopsy disclosed MCD. Thereafter, he was started on high-dose oral prednisone and renal function immediately improved. Within weeks, the nephrotic syndrome resolved. Although rare, biologic agents can cause various glomerulopathies that can have important therapeutic implications. MCD should be considered in patients who develop nephrotic syndrome while exposed to antiangiogenic agents.
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Affiliation(s)
- Ramy M Hanna
- Department of Medicine, Division of Nephrology, Cedars Sinai Medical Center-Office Towers, Los Angeles, CA, USA
| | - Eduardo Lopez
- Department of Nephrology, Kaiser Permanente, Panorama City, CA, USA
| | - James Wilson
- Surgical Consultative Nephrology, UCLA David Geffen School of Medicine, Director UCLA Stone Center, Los Angeles, CA, USA
| | - Shrinath Barathan
- Department of Medicine, Division of Nephrology, Cedars Sinai Medical Center-Office Towers, Los Angeles, CA, USA
| | - Arthur H Cohen
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, CA, USA
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The endothelium as the common denominator in malignant hypertension and thrombotic microangiopathy. ACTA ACUST UNITED AC 2015; 10:352-9. [PMID: 26778772 DOI: 10.1016/j.jash.2015.12.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/02/2015] [Accepted: 12/07/2015] [Indexed: 11/24/2022]
Abstract
The endothelium plays a pivotal role in vascular biology. The endothelium is the primary site of injury in thrombotic microangiopathies including malignant hypertension. Endothelial injury in thrombotic microangiopathies is the result of increased shear stress, toxins, and/or dysregulated complement activation. Endothelial injury can lead to microvascular thrombosis resulting in ischemia and organ dysfunction, the clinical hallmarks of thrombotic microangiopathies. Currently, available therapies target the underlying mechanisms that lead to endothelial injury in these conditions. Ongoing investigations aim at identifying drugs that protect the endothelium.
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Launay-Vacher V, Janus N, Beuzeboc P, Daniel C, Ray-Coquard I, Selle F, Rey JB, Jouannaud C, Spano JP, Thery JC, Morere JF, Goldwasser F, Mir O, Oudard S, Scotté F, Dorent R, Ludwig L, Deray G, Gligorov J. [Renovascular safety of bevacizumab in breast cancer patients. The prognostic value of hypertension and proteinuria]. Bull Cancer 2015; 102:906-14. [PMID: 26603517 DOI: 10.1016/j.bulcan.2015.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/02/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The potential prognostic value of hypertension and proteinuria of anti-vascular endothelial growth factor (VEGF) drugs has not been assessed in routine clinical practice so far in breast cancer. The objectives of the MARS study were to assess the prevalence of proteinuria and hypertension at baseline, their incidence under anti-VEGF treatment, and to evaluate a possible link with overall survival. METHODS Patients from 8 centres were included between 2009 and 2011 with a follow-up of 1 year. They were naive of any previous anti-VEGF treatment and planned to be started on one. The results of the group of patients with breast cancer receiving bevacizumab are presented. RESULTS Four hundred and two patients with breast cancer and treated with bevacizumab were included. At inclusion, hypertension prevalence was 12.4%, proteinuria 23.9%. The incidence of de novo proteinuria and hypertension during the follow-up was 61.7% and 16.8%, respectively. Among patients with de novo proteinuria, 62.2% afterwards improved/normalized. No thrombotic microangiopathy was reported. Baseline or de novo proteinuria/hypertension were not associated with overall survival in breast cancer patients treated with bevacizumab. DISCUSSION These results on the renovascular safety of bevacizumab in breast cancer patients showed that the prevalence of hypertension and proteinuria was high at baseline and, moreover, patients treated with bevacizumab frequently developed de novo hypertension and/or proteinuria. Finally, neither hypertension, nor proteinuria, neither at baseline, nor de novo, were associated with overall survival in our cohort of "real-life'' patients
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Coucha M, Elshaer SL, Eldahshan WS, Mysona BA, El-Remessy AB. Molecular mechanisms of diabetic retinopathy: potential therapeutic targets. Middle East Afr J Ophthalmol 2015; 22:135-44. [PMID: 25949069 PMCID: PMC4411608 DOI: 10.4103/0974-9233.154386] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Diabetic retinopathy (DR) is the leading cause of blindness in working-age adults in United States. Research indicates an association between oxidative stress and the development of diabetes complications. However, clinical trials with general antioxidants have failed to prove effective in diabetic patients. Mounting evidence from experimental studies that continue to elucidate the damaging effects of oxidative stress and inflammation in both vascular and neural retina suggest its critical role in the pathogenesis of DR. This review will outline the current management of DR as well as present potential experimental therapeutic interventions, focusing on molecules that link oxidative stress to inflammation to provide potential therapeutic targets for treatment or prevention of DR. Understanding the biochemical changes and the molecular events under diabetic conditions could provide new effective therapeutic tools to combat the disease.
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Affiliation(s)
- Maha Coucha
- Department of Clinical Pharmacy, Program in Clinical and Experimental Therapeutics, University of Georgia, Georgia, USA ; Culver Vision Discovery Institute, Georgia Regents University, Georgia, USA ; Research Service, Charlie Norwood VA Medical Center, Augusta 30912, Georgia, USA
| | - Sally L Elshaer
- Department of Clinical Pharmacy, Program in Clinical and Experimental Therapeutics, University of Georgia, Georgia, USA ; Culver Vision Discovery Institute, Georgia Regents University, Georgia, USA ; Research Service, Charlie Norwood VA Medical Center, Augusta 30912, Georgia, USA
| | - Wael S Eldahshan
- Department of Clinical Pharmacy, Program in Clinical and Experimental Therapeutics, University of Georgia, Georgia, USA ; Culver Vision Discovery Institute, Georgia Regents University, Georgia, USA ; Research Service, Charlie Norwood VA Medical Center, Augusta 30912, Georgia, USA
| | - Barbara A Mysona
- Department of Clinical Pharmacy, Program in Clinical and Experimental Therapeutics, University of Georgia, Georgia, USA ; Culver Vision Discovery Institute, Georgia Regents University, Georgia, USA ; Research Service, Charlie Norwood VA Medical Center, Augusta 30912, Georgia, USA
| | - Azza B El-Remessy
- Department of Clinical Pharmacy, Program in Clinical and Experimental Therapeutics, University of Georgia, Georgia, USA ; Culver Vision Discovery Institute, Georgia Regents University, Georgia, USA ; Research Service, Charlie Norwood VA Medical Center, Augusta 30912, Georgia, USA
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