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Aziz KT, Best MJ, Skolasky RL, Ponnusamy KE, Sterling RS, Khanuja HS. Lupus and Perioperative Complications in Elective Primary Total Hip or Knee Arthroplasty. Clin Orthop Surg 2020; 12:37-42. [PMID: 32117536 PMCID: PMC7031438 DOI: 10.4055/cios.2020.12.1.37] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/30/2019] [Indexed: 01/30/2023] Open
Abstract
Background The number of patients with systemic lupus erythematosus (herein, lupus) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) is increasing. There is disagreement about the effect of lupus on perioperative complication rates. We hypothesized that lupus would be associated with higher complication rates in patients who undergo elective primary THA or TKA. Methods Records of more than 6.2 million patients from the National Inpatient Sample who underwent elective primary THA or TKA from 2000 to 2009 were reviewed. Patients with lupus (n = 38,644) were compared with those without lupus (n = 6,173,826). Major complications were death, pulmonary embolism, myocardial infarction, stroke, pneumonia, and acute renal failure. Minor complications were wound infection, seroma, deep vein thrombosis, hip dislocation, wound dehiscence, and hematoma. Patient age, sex, duration of hospital stay, and number of Elixhauser comorbidities were assessed for both groups. Multivariate logistic regression models using comorbidities, age, and sex as covariates were used to assess the association of lupus with major and minor perioperative complications. The alpha level was set to 0.001. Results Among patients who underwent THA, those with lupus were younger (mean age, 56 vs. 65 years), were more likely to be women (87% vs. 56%), had longer hospital stays (mean, 4.0 vs. 3.8 days), and had more comorbidities (mean, 2.5 vs. 1.4) than those without lupus (all p < 0.001). In patients with THA, lupus was independently associated with major complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7) and minor complications (OR, 1.2; 95% CI, 1.0 to 1.5). Similarly, among patients who underwent TKA, those with lupus were younger (mean, 62 vs. 67 years), were more likely to be women (93% vs. 64%), had longer hospital stays (mean, 3.8 vs. 3.7 days), and had more comorbidities (mean, 2.8 vs. 1.7) than those without lupus (all p < 0.001). However, in TKA patients, lupus was not associated with greater odds of major complications (OR, 1.2; 95% CI, 0.9 to 1.4) or minor complications (OR, 1.1; 95% CI, 0.9 to 1.3). Conclusions Lupus is an independent risk factor for major and minor perioperative complications in elective primary THA but not TKA.
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Affiliation(s)
- Keith T Aziz
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Karthik E Ponnusamy
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Basu N, Karabayas M, Pusey C. Prognosis and future developments in vasculitis. Best Pract Res Clin Rheumatol 2018; 32:148-165. [PMID: 30526894 DOI: 10.1016/j.berh.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/07/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022]
Abstract
The prognosis of ANCA-associated vasculitis has been transformed in recent years. Once it was a set of invariably acute and fatal conditions, but these disorders are currently considered to be chronic diseases. This change is largely attributable to earlier diagnosis and the careful application of immunotherapeutics. However, patients still experience premature mortality, relapse, comorbid ill health and poor quality of life. Mortality rates in large-vessel vasculitis are not comparable; however, morbidity and poor patient outcomes prevail. Toxicity secondary to glucocorticoids represents a common driver of poor outcomes across systemic vasculitis. The main thrust of future treatment strategies is to reduce if not eliminate exposure to these agents.
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Affiliation(s)
- N Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, United Kingdom.
| | - M Karabayas
- Department of Rheumatology, NHS Grampian, United Kingdom
| | - C Pusey
- Department of Medicine, Imperial College London, United Kingdom
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Grygiel-Górniak B, Limphaibool N, Perkowska K, Puszczewicz M. Clinical manifestations of granulomatosis with polyangiitis: key considerations and major features. Postgrad Med 2018; 130:581-596. [PMID: 30071173 DOI: 10.1080/00325481.2018.1503920] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) presents a wide spectrum of manifestations from the common respiratory symptoms to infrequent neurological and cardiac complications. The challenge in diagnosis and management makes the rapidly progressive disorder one of the most challenging dilemmas in clinical medicine. METHOD An extensive electronic literature search was done using multiple databases (e.g. PubMed) from January 2007 to August 2017 to gather information on the etiopathogenesis, clinical presentation, and current treatment management plan of GPA. The language used was English. Search items included 'Granulomatosis with Polyangiitis symptoms,' 'Wegener's Granulomatosis,' and 'Treatment of Granulomatosis with Polyangiitis' for the databases. Inclusion criteria consisted of published articles in the English language which reported on the clinical manifestations of GPA, as well as on the treatment of the disease. Exclusion criteria included articles that: (1) did not specifically report on GPA vasculitis but also focused on discussion of other vasculitis such as MPA or Churg-Strauss; (2) reported on treatment/symptoms of GPA prior to 2007. RESULT This review provides an overview of work undertaken in key areas of GPA research, including its complex multifactorial etiology, clinical manifestations, treatment strategies, and treatment-related adverse effects. CONCLUSION Major advances in the understanding and treatment of GPA over recent decades have contributed to the notable decline in morbidity and mortality of patients. The ultimate goal is an improved prognosis through outcome measures which assesses the disease control with minimal adverse effects of intensive immunosuppressive regimens, an integral part of the clinical approach to improve the quality of life of GPA patients.
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Affiliation(s)
- Bogna Grygiel-Górniak
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Nattakarn Limphaibool
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Katarzyna Perkowska
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Mariusz Puszczewicz
- a Department of Rheumatology and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
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Jardel S, Puéchal X, Le Quellec A, Pagnoux C, Hamidou M, Maurier F, Aumaitre O, Aouba A, Quemeneur T, Subra JF, Cottin V, Sibilia J, Godmer P, Cacoub P, Fauchais AL, Hachulla E, Maucort-Boulch D, Guillevin L, Lega JC. Mortality in systemic necrotizing vasculitides: A retrospective analysis of the French Vasculitis Study Group registry. Autoimmun Rev 2018; 17:653-659. [PMID: 29730524 DOI: 10.1016/j.autrev.2018.01.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/07/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of the study was to describe the evolution of mortality and cause-specific mortality over time in patients with systemic necrotizing vasculitides (SNV), including polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Patients with SNV from the French Vasculitis Study Group registry were divided into 5 groups according to the date of diagnosis: <1980, 1980-1989, 1990-1999, 2000-2010, and ≥ 2010. The causes of death were classified as vasculitis, infection, cardiovascular, malignancy, miscellaneous, or unknown. RESULTS Among the 2217 patients included (PAN 16.1%, GPA 41.7%, EGPA 22.6%, MPA 19.6%), overall incidence of death was 2.26 per 100 person-years. The overall survival improved during each period considered. The 5-year survival rate increased from 72.2% (95% confidence interval [CI] 59.7-87.2) for patients diagnosed before 1980 to 94.5% (95% CI 90.4-98.8) after 2010 (p < 0.001). Periods of diagnosis, age, and male gender were independently associated with a poor survival with a non-significant difference between vasculitis. The incidence of mortality between the 1980s and after 2010 significantly decreased for vasculitis-related (p = 0.03) and cardiovascular-related deaths (p = 0.04). Incidence of death by infection remained stable between the 1980s and the 2000s but no death by infection occurred after 2010. The incidence of death by malignancy remained stable over time. CONCLUSION Overall survival of SNV patients has improved since the 1980s with the decrease of vasculitis- and cardiovascular-related deaths, but cancer-related mortality remained stable. These results highlight malignancy as the current target to improve the overall prognosis.
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Affiliation(s)
- Sabine Jardel
- National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
| | - Xavier Puéchal
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Alain Le Quellec
- Department of Internal Medicine, Centre Hospitalier Régional Universitaire de Montpellier, Hôpital St. Eloi, Montpellier 1 University, Montpellier, France
| | - Christian Pagnoux
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | - François Maurier
- Department of Internal medicine and Clinical Immunology, Site Belle Isle, Metz, France
| | - Olivier Aumaitre
- Department of Internal Medicine, Centre Hospitalier Universitaire, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Achille Aouba
- Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Caen, France
| | - Thomas Quemeneur
- Department of Internal Medicine, Centre Hospitalier, Valenciennes, France
| | - Jean-François Subra
- Department of Internal Medicine, Centre Hospitalier Universitaire d' Angers, Angers, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Jean Sibilia
- Department of Rheumatology, National Reference Center for rare Systemic Autoimmune Diseases, Strasbourg University Hospital, Strasbourg University, Strasbourg, France
| | - Pascal Godmer
- Department of Internal Medicine, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France; INSERM, UMRS 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France
| | - Anne Laure Fauchais
- Department of Internal Medicine, Hôpital Dupuytren, Centre Hospitalier Universitaire de Limoges Limoges University, Limoges, France
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, University of Lille, Lille, France
| | - Delphine Maucort-Boulch
- Department of Biostatistics and bioinformatics, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon Claude Bernard University Lyon 1, Lyon, France
| | - Loïc Guillevin
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Jean-Christophe Lega
- National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France.
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Castellani M, Felaco P, Pandolfp F, Salini V, De Amicis D, Vecchiet J, Tetè S, Ciampoli C, Conti F, Cerulli G, Caraffa A, Antinolfi P, Cuccurullo C, Perrella A, Theoharides T, De Lutiis M, Kempuraj D, Shaik Y. Inflammatory Compounds: Neuropeptide Substance Pand Cytokines. EUR J INFLAMM 2017. [DOI: 10.1177/1721727x0900700202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Inflammatory diseases represent one of the major causes of morbidity and mortality throughout the world and they affect the functions of several tissues. The pathophysiology of these diseases involves release of many pro-inflammatory mediators such as cytokines/chemokines, histamine, C3a, C5a (complement components), bradykinin, leukotrienes (LTC4, LTD4, LTE4), PAF, and substance P, in addition to anti-inflammatory molecules. Recently, it has been demonstrated that neuroimmune interactions are important in the initiation and progress of inflammatory processes. Substance P is an 11-amino acid neuropeptide that is released from nerve endings in many tissues. It acts via membrane-bound NK1 receptors (NK1R). Inflammatory and neuropeptides such as substance P stimulate the release of chemokines, in particular IL-8, a potent neutrophil chemoattractant. Expression of IL-8 is regulated mainly by the transcription factors NF-kappaB, activating protein-1. Substance P plays an important role in immunological and inflammatory states, and it is a mediator of tissue injury, asthma, arthritis, allergy and autoimmune diseases. In this article, our studies revisited the interrelationship between these two powerful inflammatory compounds: substance P and cytokines. These observations suggest that these inflammatory molecules may represent a potential therapeutic target to treat several inflammatory states.
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Affiliation(s)
- M.L. Castellani
- Immunology Division, Medical School, University of Chieti-Pescara, Italy
| | - P. Felaco
- Division of Nephrology, University of Chieti, Italy
| | - F. Pandolfp
- Immunology Division, Medical School, University of Chieti-Pescara, Italy
| | - V. Salini
- Department of Human Dynamic, University of Chieti-Pescara, Italy
| | - D. De Amicis
- Department of Human Dynamic, University of Chieti-Pescara, Italy
| | - J. Vecchiet
- Clinic of Infectious Diseases, Medical School, University of Chieti-Pescara, Italy
| | - S. Tetè
- Dental School, University of Chieti-Pescara, Italy
| | - C. Ciampoli
- Dental School, University of Chieti-Pescara, Italy
| | - F. Conti
- Gynecology Division, University of Chieti, Italy
| | - G. Cerulli
- Orthopeadic Division, University of Perugia, Italy
| | - A. Caraffa
- Orthopeadic Division, University of Perugia, Italy
| | - P. Antinolfi
- Orthopeadic Division, University of Perugia, Italy
| | - C. Cuccurullo
- Division of Medical Pathology, University of Chieti, Italy
| | - A. Perrella
- Department of Infectious Diseases, Cotugno Hospital, Naples, Italy
| | - T.C. Theoharides
- Department of Pharmacology and Experimental Therapeutics, Biochemistry and Internal Medicine Tufts University School of Medicine, Tufts-New England Medical Center, Boston, MA, USA
| | - M.A. De Lutiis
- Department of Biology, University of Chieti, Chieti, Italy
| | - D. Kempuraj
- Department of Pharmacology and Experimental Therapeutics, Biochemistry and Internal Medicine Tufts University School of Medicine, Tufts-New England Medical Center, Boston, MA, USA
| | - Y.B. Shaik
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Rhee RL, Hogan SL, Poulton CJ, McGregor JAG, Landis JR, Falk RJ, Merkel PA. Trends in Long-Term Outcomes Among Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Renal Disease. Arthritis Rheumatol 2017; 68:1711-20. [PMID: 26814428 DOI: 10.1002/art.39614] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 01/21/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE It is still not clear how advances in the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have impacted long-term outcomes. We undertook this study to examine changes over 25 years in long-term clinical outcomes, including the impact of renal function at diagnosis (a potential marker of time to disease detection) and the duration of cyclophosphamide use in AAV patients with renal involvement. METHODS We included ANCA-positive patients with biopsy-proven AAV diagnosed between 1985 and 2009 who were followed up in the Glomerular Disease Collaborative Network inception cohort. Outcomes included the composite outcome of end-stage renal disease (ESRD) or death as well as relapse. Cox proportional hazards or competing risks regression models were adjusted for potential baseline confounders. RESULTS Data from 554 patients were included in the analysis. There was a decreasing 5-year risk of ESRD or death over time (P < 0.001 by log rank test for trend). After adjustment for baseline characteristics, the risk of relapse was similar across the time periods (P = 0.45 by test for trend). Serum creatinine level at baseline was the only significant predictor of an increased risk of ESRD or death (hazard ratio 1.11 per 1 mg/dl of serum creatinine [95% confidence interval 1.04-1.18], P = 0.002). CONCLUSION In patients with renal disease secondary to AAV, over 25 years the risk of ESRD or death has decreased but the risk of relapse has not changed. A higher serum creatinine level at diagnosis is associated with a higher risk of ESRD or death, suggesting that earlier disease detection is potentially an important measure to improve outcomes in AAV.
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Solans-Laqué R, Fraile G, Rodriguez-Carballeira M, Caminal L, Castillo MJ, Martínez-Valle F, Sáez L, Rios JJ, Solanich X, Oristrell J, Pasquau F, Fonseca E, Zamora M, Callejas JL, Frutos B, Abdilla M, Fanlo P, García-Sánchez I, López-Dupla M, Sopeña B, Pérez-Iglesias A, Bosch JA. Clinical characteristics and outcome of Spanish patients with ANCA-associated vasculitides: Impact of the vasculitis type, ANCA specificity, and treatment on mortality and morbidity. Medicine (Baltimore) 2017; 96:e6083. [PMID: 28225490 PMCID: PMC5569416 DOI: 10.1097/md.0000000000006083] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The aim of this study was to describe the clinical characteristics of ANCA-associated vasculitides (AAV) at presentation, in a wide cohort of Spanish patients, and to analyze the impact of the vasculitis type, ANCA specificity, prognostic factors, and treatments administered at diagnosis, in the outcome.A total of 450 patients diagnosed between January 1990 and January 2014 in 20 Hospitals from Spain were included. Altogether, 40.9% had granulomatosis with polyangiitis (GPA), 37.1% microscopic polyangiitis (MPA), and 22% eosinophilic granulomatosis with polyangiitis (EGPA). The mean age at diagnosis was 55.6 ± 17.3 years, patients with MPA being significantly older (P < 0.001). Fever, arthralgia, weight loss, respiratory, and ear-nose-throat (ENT) symptoms, were the most common at disease onset. ANCAs tested positive in 86.4% of cases: 36.2% C-ANCA-PR3 and 50.2% P-ANCA-MPO. P-ANCA-MPO was significantly associated with an increased risk for renal disease (OR 2.6, P < 0.001) and alveolar hemorrhage (OR 2, P = 0.010), while C-ANCA-PR3 was significantly associated with an increased risk for ENT (OR 3.4, P < 0.001) and ocular involvement (OR 2.3, P = 0.002). All patients received corticosteroids (CS) and 74.9% cyclophosphamide (CYC). The median follow-up was 82 months (IQR 100.4). Over this period 39.9% of patients suffered bacterial infections and 14.6% opportunistic infections, both being most prevalent in patients with high-cumulated doses of CYC and CS (P < 0.001). Relapses were recorded in 36.4% of cases with a mean rate of 2.5 ± 2.3, and were more frequent in patients with C-ANCA-PR3 (P = 0.012). The initial disease severity was significantly associated with mortality but not with the occurrence of relapses. One hundred twenty-nine (28.7%) patients (74 MPA, 41 GPA, 14 EGPA) died. The mean survival was 58 months (IQR 105) and was significantly lower for patients with MPA (P < 0.001). Factors independently related to death were renal involvement (P = 0.010), cardiac failure (P = 0.029) and age over 65 years old (P < 0.001) at disease onset, and bacterial infections (P < 0.001). An improved outcome with significant decrease in mortality and treatment-related morbidity was observed in patients diagnosed after 2000, and was related to the implementation of less toxic regimens adapted to the disease activity and stage, and a drastic reduction in the cumulated CYC and CS dose.
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Herlyn K, Buckert F, Gross WL, Reinhold-Keller E. Doubled prevalence rates of ANCA-associated vasculitides and giant cell arteritis between 1994 and 2006 in northern Germany. Rheumatology (Oxford) 2014; 53:882-9. [DOI: 10.1093/rheumatology/ket440] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Silva-Fernández L, Loza E, Martínez-Taboada VM, Blanco R, Rúa-Figueroa I, Pego-Reigosa JM, Muñoz-Fernández S. Biological therapy for systemic vasculitis: a systematic review. Semin Arthritis Rheum 2013; 43:542-57. [PMID: 23978781 DOI: 10.1016/j.semarthrit.2013.07.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Relapses and failure are frequent in systemic vasculitis (SV) patients. Biological agents have been prescribed as rescue therapies. The aim of this systematic review is to analyze the current evidence on the therapeutic use of biological agents for SV. METHODS MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched up to the end of April 2013. Systematic reviews and meta-analysis, clinical trials, cohort studies, and case series with >3 patients were included. Independent article review and study quality assessment was done by 2 investigators with consensus resolution of discrepancies. RESULTS Of 3447 citations, abstracts, and hand-searched studies screened, 90 were included. Most of the studies included ANCA-associated vasculitis (AAV) patients and only a few included large vessel vasculitis (LVV) patients. Rituximab was the most used agent, having demonstrated efficacy for remission induction in patients with AAV. A number of studies used different anti-TNFα agents with contrasting results. A few uncontrolled studies on the use of abatacept, alemtuzumab, mepolizumab, and tocilizumab were found. CONCLUSION Current evidence on the use of biological therapies for SV is mainly based on uncontrolled, observational data. Rituximab is not inferior to cyclophosphamide for remission induction in AAV and might be superior in relapsing disease. Infliximab and adalimumab are effective as steroid-sparing agents. Etanercept is not effective to maintain remission in patients with granulomatosis with polyangiitis, and serious adverse events have been reported. For LVV, both infliximab and etanercept had a role as steroid-sparing agents, and tocilizumab might be effective also for remission induction in LVV.
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Affiliation(s)
| | | | - Víctor M Martínez-Taboada
- Rheumatology Department, Hospital Universitario Marqués de Valdecilla, Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - Ricardo Blanco
- Rheumatology Department, Hospital Universitario Marqués de Valdecilla, Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - Iñigo Rúa-Figueroa
- Rheumatology Department, Hospital Universitario Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - José María Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, Instituto de Investigación Biomédica de Vigo, Vigo, Spain
| | - Santiago Muñoz-Fernández
- Rheumatology Department, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
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10
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L43. Seropositive and negative ANCA-associated vasculitis, anti-MPO and PR3-vasculitis: different outcomes? Presse Med 2013; 42:616-9. [PMID: 23481358 DOI: 10.1016/j.lpm.2013.01.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Holle JU, Reinhold-Keller E, Gross WL. [Update on granulomatosis with polyangitis (GPA, Wegener's granulomatosis)]. Z Rheumatol 2012; 71:745-53. [PMID: 23138551 DOI: 10.1007/s00393-012-0982-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Granulomatosis with polyangitis (GPA, Wegener's granulomatosis) is characterized by a granulomatous inflammation of the respiratory tract and a necrotizing ANCA-associated small to medium-size vessel vasculitis with a predilection for the lungs (pulmonary capillaritis) and kidneys (necrotizing glomerulonephritis). The disease evolves stage-wise and typically starts as inflammation of the respiratory tract followed by development of systemic vasculitis manifestations. Today, treatment is evidence-based and adapted according to activity and disease stage which has resulted in a significant improvement in long-term outcome. Early mortality during the first year of treatment poses one of the main problems and is a result of infections under immunosuppressive treatment. Furthermore, treatment of refractory disease activity which is often represented by granulomatous manifestations is still a challenge and may result in significant organ damage if not treated successfully.
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Affiliation(s)
- J U Holle
- UKSH, Campus Lübeck, Poliklinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander Str. 26, 24576, Bad Bramstedt, Deutschland.
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Abstract
The antineutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitides (AASVs) include granulomatosis with polyangiitis and microscopic polyangiitis. These conditions are characterized by small-vessel inflammation and necrosis, predominantly in pulmonary and renal vascular beds. Untreated AASV has a poor prognosis, although the advent of effective immunosuppressive therapy (the mainstay of which remains cyclophosphamide with high-dose corticosteroids) has markedly improved patients' survival (78% at 5 years). Patients with AASV, however, continue to have an increased mortality compared to the general population. Mortality is greatest in the first year after diagnosis and remains consistently elevated in subsequent years. Patients with AASV also experience increased rates of infections, malignancies and cardiovascular events as compared to the general population. Current treatments for AASV, although effective in controlling the aggressive systemic disease, incur substantial long-term toxic effects. Long-term immunosuppressive therapy also has notable deleterious effects on bone health and fertility. The long-term safety profiles of biological therapies (such as rituximab) are yet to be evaluated in patients with AASV, but represent a promising treatment option. The challenge for the future is to develop specific therapies with improved safety profiles that can cure these diseases.
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Abstract
The outcome of ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis (AAV) has been significantly improved due to the combined use of cyclophosphamide (CYC) and glucocorticosteroids. Recent studies demonstrated a normalization of life expectancy for several subgroups of AAV patients. Mortality is highest in the first year after diagnosis and infections are the most frequent cause of death. Older age and renal failure are associated with worse outcome. The use of Pneumocystis jiroveci prophylaxis and subsequent activity-adapted GC dose reduction (target: below 10 mg per day) can substantially reduce the risk of severe infections. Late sequelae of CYC medication, such as cystitis and malignancy should be recognized and can be minimized by the usage of uroprotection with mesna and avoidance of high cumulative CYC doses.
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14
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Díaz-Orta MA, Rojas-Serrano J. [Biologic therapies in the systemic vasculitides]. ACTA ACUST UNITED AC 2011; 7 Suppl 3:S33-6. [PMID: 22152288 DOI: 10.1016/j.reuma.2011.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 09/28/2011] [Indexed: 11/27/2022]
Abstract
Several biological therapies have been evaluated in systemic vasculitis. Anti TNF-α agents may have a role in the treatment of Takayasu's arteritis and probably in giant cell arteritis. In Kawasaki's disease, infliximab is an option in subjects with intravenous immunoglobulin-resistant disease. Anti TNF-α cannot be recommended to treat ANCA-associated vasculitis. Anti-T lymphocyte globulin and alemtuzumab could have a role in the treatment of ANCA associated vasculitis, although current information about these two biological treatments comes from conventional resistant treatment cases, so the high incidence of complications and relapses observed with these treatment may be intrinsic to the severity of the disease and not related to the biological agents.
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Affiliation(s)
- Mariano Arturo Díaz-Orta
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Facultad de Medicina de Universidad Nacional Autónoma de México, México DF, México
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15
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Holle JU, Gross WL, Latza U, Nölle B, Ambrosch P, Heller M, Fertmann R, Reinhold-Keller E. Improved outcome in 445 patients with Wegener's granulomatosis in a German vasculitis center over four decades. ACTA ACUST UNITED AC 2010; 63:257-66. [PMID: 20862686 DOI: 10.1002/art.27763] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Julia U Holle
- University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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16
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Holle JU, Wieczorek S, Gross WL. The Future of ANCA-associated Vasculitis. Rheum Dis Clin North Am 2010; 36:609-21. [DOI: 10.1016/j.rdc.2010.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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17
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Holle JU, Laudien M, Gross WL. Clinical Manifestations and Treatment of Wegener's Granulomatosis. Rheum Dis Clin North Am 2010; 36:507-26. [DOI: 10.1016/j.rdc.2010.05.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Rúa-Figueroa Fernández de Larrinoa I, Erausquin Arruabarrena C. Tratamiento de las vasculitis sistémicas asociadas a ANCA. ACTA ACUST UNITED AC 2010; 6:161-72. [DOI: 10.1016/j.reuma.2009.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 01/15/2009] [Indexed: 11/30/2022]
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19
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Stratta P, Mesiano P, Campo A, Grill A, Ferrero S, Santi S, Besso L, Mazzucco G, Rosso S, Spitale A, Fop F, Ciccone G. Life Expectancy of Women with Lupus Nephritis Now Approaches That of the General Population. Int J Immunopathol Pharmacol 2009; 22:1135-41. [DOI: 10.1177/039463200902200432] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Immunosuppressive treatment has changed the prognosis of Lupus nephritis over time, but improvement in prognosis is difficult to analyze in different historical periods, and should be better demonstrated in comparison with life expectancy of sex-and age-matched people. Long-term patient and renal survival of 90 patients diagnosed with Lupus nephritis at our center from 1968 to 2001 with a follow-up time of 14±8 years was retrospectively evaluated. Patient and kidney survival significantly increased over time. Multivariate analyses show that risks of patient and renal death decreased by 8% at each year of follow-up, and increased by more than 5 time in patients aged > 30 years at diagnosis. As only 14 patients were men, relative survival as compared to that of the sex- and age-matched general population of the Piedmont Region was calculated for the 76 women. Improvement in the survival of the cohort of women was seen at any time of follow-up: in particular, it was sharply lower in the first period (relative survival at 5,10 and 15 years = 0.784, 0.665, and 0.620, respectively) and increased in the second (relative survival at 5,10 and 15 years = 0.939, 0.921, and 0.850, respectively) nearly approaching that expected for the general population, i.e. 0.993, 0.983 and 0.967, respectively. Taken together, our data allow us to draw the conclusion that life expectancy in women with Lupus nephritis has improved over time, paralleling an improved awareness of the disease and a significant increase in steroid pulse therapy as induction/remission phase. Improvement in survival is for the first time demonstrated to cover the gap with life expectancy of the general population for women with Lupus nephritis.
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Affiliation(s)
- P. Stratta
- Departments of Clinical and Experimental Medicine, Nephrology and Transplantation & International Research Center Autoimmune Diseases (IRCAD) of the Amedeo Avogadro University, Maggiore Hospital, Novara
| | - P. Mesiano
- Renal Care Units of Ciriè Hospital, Section of Nephrology, Molinette Hospital, Torino
| | - A. Campo
- Alba Hospital, Section of Nephrology, Molinette Hospital, Torino
| | - A. Grill
- Rivoli Hospital, Section of Nephrology, Molinette Hospital, Torino
| | - S. Ferrero
- Rivoli Hospital, Section of Nephrology, Molinette Hospital, Torino
| | - S. Santi
- Chivasso Hospital, Section of Nephrology, Molinette Hospital, Torino
| | - L. Besso
- Departments of Internal Medicine, Section of Nephrology, Molinette Hospital, Torino
| | - G. Mazzucco
- Biomedical Science and Human Oncology, Sections Pathology, Italy
| | - S. Rosso
- CPO-Piemonte Cancer Registry, Italy
| | | | - F. Fop
- Departments of Internal Medicine, Section of Nephrology, Molinette Hospital, Torino
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