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Xu M, Shu J, Qian S, Guo J, Gong Y, Huang R, Wang S, Zhou Z, Yuan G, Huang M, Lin LE, Lou S, Song Y, Liu Q, Zhou H, Mei H, Hu Y. Zuberitamab, an innovative anti-CD20 monoclonal antibody, for patients with primary immune thrombocytopenia in China: a randomized, double-blind, placebo-controlled, phase 2 study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 47:101096. [PMID: 38808021 PMCID: PMC11131054 DOI: 10.1016/j.lanwpc.2024.101096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/18/2024] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
Background Primary immune thrombocytopenia (ITP) is an autoimmune disease, and rituximab (RTX) induces long-term effect as second-line treatments. Zuberitamab is an innovative anti-CD20 monoclonal antibody, which was first developed in China and launched in diffuse large B lymphoma. This study aimed to investigate the safety, efficacy, and anticipated therapeutic dose of zuberitamab in Chinese ITP patients. Methods This randomised, double-blind, placebo-controlled, phase 2 study was conducted at 26 hospitals in China. Eligible patients were aged 18-70 years, had primary immune thrombocytopenia for more than 6 months, and did not respond or relapsed after previous treatment and had a pre-treatment platelet count of <30 × 109/L. Patients randomly received zuberitamab in a dose escalation (100/300/600 mg) or placebo once-weekly for 4 weeks and followed up to 24 weeks. The primary endpoint is the proportion of patients with a platelet count ≥50 × 109/L at week 8. Secondary endpoints include the proportion of patients with platelet counts ≥50 × 109/L or ≥100 × 109/L at least once within week 12/24, the proportion of patients experiencing platelets increased twice more than baseline as well as ≥30 × 109/L at least once during the treatment. Adverse events, pharmacokinetic, B cell depletion and immunogenicity were also assessed. This study is registered with https://www.chictr.org.cn/as ChiCTR2100050513. Findings From October 2021 to March 2023, 50 patients were screened for eligibility, of whom 32 patients were enrolled and randomly assigned to placebo (n = 4), zuberitamab 100 mg (n = 10), 300 mg (n = 8) and 600 mg (n = 10) groups. The primary endpoint (PLT ≥50 × 109/L at week 8) was achieved by 40% of patients in the 100 mg group, while none in the other groups. Within 12 weeks, the proportions of patients in each treatment group achieving at least one instance of platelet count ≥50 × 109/L or ≥100 × 109/L or an increase twice more than baseline as well as ≥30 × 109/L were (70%, 38%, 50%), (60%, 13%, 30%), and (80%, 50%, 70%) in zuberitamab 100/300/600 mg groups, respectively. By week 24, the proportions of patients achieving these secondary endpoints remained relatively stable or showed a mild increase of around 10%. The anticipated therapeutic dose of zuberitamab was 100 mg. The plasma concentration of zuberitamab showed an increasing trend with dose (100 mg-600 mg) and linear pharmacokinetic behavior. CD19+ B cells and CD20+ B lymphocytes rapidly declined to 0% within one week and consistently maintained reduced levels throughout the entire treatment phase in three groups. Adverse events occurred in all patients with most of them were mild to moderate, no severe infections occurred. A slight decrease in immunoglobulins was observed in the 600 mg group, but gradually recovered at week 20. Three patients (2 in 100 mg and 1 in 600 mg group) were tested positive for anti-zuberitamab antibodies. We also observed that women, disease duration <12 months, and MAIPA + patients may have higher response rates. Interpretation This study preliminarily confirmed that 100 mg zuberitamab was safe and effective in treating ITP and was recommended to support further investigation. Funding National Natural Science Foundation of China and Zhejiang Bioray Biopharmaceutical Co. Ltd.
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Affiliation(s)
- Min Xu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhui Shu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingming Guo
- Department of Hematology, The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang, China
| | - Yuping Gong
- Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Ruibin Huang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuye Wang
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zeping Zhou
- Department of Hematology, The Second Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Guolin Yuan
- Department of Hematology, Xiangyang Central Hospital, The Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Meijuan Huang
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Li-E Lin
- Department Hematology of Hainan Provincial People's Hospital, Haikou, China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanping Song
- Department of Hematology, Xi'an Central Hospital, Xi'an, China
| | - Qingchi Liu
- Department of Hematology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hu Zhou
- Department of Hematology, Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Zhang R, Zhao Y, Chen X, Zhuang Z, Li X, Shen E. Low-dose IL-2 therapy in autoimmune diseases: An update review. Int Rev Immunol 2024; 43:113-137. [PMID: 37882232 DOI: 10.1080/08830185.2023.2274574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023]
Abstract
Regulatory T (Treg) cells are essential for maintaining self-immune tolerance. Reduced numbers or functions of Treg cells have been involved in the pathogenesis of various autoimmune diseases and allograft rejection. Therefore, the approaches that increase the pool or suppressive function of Treg cells in vivo could be a general strategy to treat different autoimmune diseases and allograft rejection. Interleukin-2 (IL-2) is essential for the development, survival, maintenance, and function of Treg cells, constitutively expressing the high-affinity receptor of IL-2 and sensitive response to IL-2 in vivo. And low-dose IL-2 therapy in vivo could restore the imbalance between autoimmune response and self-tolerance toward self-tolerance via promoting Treg cell expansion and inhibiting follicular helper T (Tfh) and IL-17-producing helper T (Th17) cell differentiation. Currently, low-dose IL-2 treatment is receiving extensive attention in autoimmune disease and transplantation treatment. In this review, we summarize the biology of IL-2/IL-2 receptor, the mechanisms of low-dose IL-2 therapy in autoimmune diseases, the application in the progress of different autoimmune diseases, including Systemic Lupus Erythematosus (SLE), Type 1 Diabetes (T1D), Rheumatoid Arthritis (RA), Autoimmune Hepatitis (AIH), Alopecia Areata (AA), Immune Thrombocytopenia (ITP) and Chronic graft-versus-host-disease (GVHD). We also discuss the future directions to optimize low-dose IL-2 treatments.
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Affiliation(s)
- Ruizhi Zhang
- Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Yuyang Zhao
- Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangdong Provincial Key Laboratory of Allergy & Clinical Immunology, Guangzhou Medical University, Guangzhou, China
| | - Xiangming Chen
- Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangdong Provincial Key Laboratory of Allergy & Clinical Immunology, Guangzhou Medical University, Guangzhou, China
| | - Zhuoqing Zhuang
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Xiaomin Li
- Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Erxia Shen
- Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangdong Provincial Key Laboratory of Allergy & Clinical Immunology, Guangzhou Medical University, Guangzhou, China
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Protein Modification and Degradation, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
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Zhang Z, Markmann C, Yu M, Agarwal D, Rostami S, Wang W, Liu C, Zhao H, Ochoa T, Parvathaneni K, Xu X, Li E, Gonzalez V, Khadka R, Hoffmann J, Knox JJ, Scholler J, Marcellus B, Allman D, Fraietta JA, Samelson-Jones B, Milone MC, Monos D, Garfall AL, Naji A, Bhoj VG. Immunotherapy targeting B cells and long-lived plasma cells effectively eliminates pre-existing donor-specific allo-antibodies. Cell Rep Med 2023; 4:101336. [PMID: 38118406 PMCID: PMC10772570 DOI: 10.1016/j.xcrm.2023.101336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/22/2023] [Accepted: 11/21/2023] [Indexed: 12/22/2023]
Abstract
Pre-existing anti-human leukocyte antigen (HLA) allo-antibodies constitute a major barrier to transplantation. Current desensitization approaches fail due to ineffective depletion of allo-specific memory B cells (Bmems) and long-lived plasma cells (LLPCs). We evaluate the efficacy of chimeric antigen receptor (CAR) T cells targeting CD19 and B cell maturation antigen (BCMA) to eliminate allo-antibodies in a skin pre-sensitized murine model of islet allo-transplantation. We find that treatment of allo-sensitized hosts with CAR T cells targeting Bmems and LLPCs eliminates donor-specific allo-antibodies (DSAs) and mitigates hyperacute rejection of subsequent islet allografts. We then assess the clinical efficacy of the CAR T therapy for desensitization in patients with multiple myeloma (MM) with pre-existing HLA allo-antibodies who were treated with the combination of CART-BCMA and CART-19 (ClinicalTrials.gov: NCT03549442) and observe clinically meaningful allo-antibody reduction. These findings provide logical rationale for clinical evaluation of CAR T-based immunotherapy in highly sensitized candidates to promote successful transplantation.
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Affiliation(s)
- Zheng Zhang
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Department of Orthopaedic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Caroline Markmann
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Ming Yu
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Divyansh Agarwal
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Susan Rostami
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Wei Wang
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Chengyang Liu
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Huiwu Zhao
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Trini Ochoa
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Kalpana Parvathaneni
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Xiaoming Xu
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Eric Li
- Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Vanessa Gonzalez
- Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Roman Khadka
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jennifer Hoffmann
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - James J Knox
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - John Scholler
- Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Brooke Marcellus
- Department of Pathology & Laboratory Medicine, Immunogenetics Laboratory, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - David Allman
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Joseph A Fraietta
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Department of Microbiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Benjamin Samelson-Jones
- Division of Hematology, Children's Hospital of Philadelphia and University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Michael C Milone
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Dimitri Monos
- Department of Pathology & Laboratory Medicine, Immunogenetics Laboratory, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Alfred L Garfall
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Ali Naji
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA.
| | - Vijay G Bhoj
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Cellular Immunotherapies, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA.
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Xie D, Feng Z, Yang W, Wang Y, Li R, Zhang S, Zhou Z. A mAb to SIRPα downregulates the priming of naive CD4 + T cell in Primary immune thrombocytopenia. Cell Immunol 2023; 391-392:104757. [PMID: 37660478 DOI: 10.1016/j.cellimm.2023.104757] [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: 04/06/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
SIRPα is a transmembrane protein that binds the protein tyrosine phosphatases SHP-1 and SHP-2 through its cytoplasmic region and is abundantly expressed on monocytes, dendritic cells, and macrophages. Studies recently showed that SIRPα is essential for priming of CD4 + T cells by DCs and for development of Th17 cell-mediated autoimmune diseases. We have now further evaluated the importance of SIRPα and that of its ligand CD47 in primary immune thrombocytopenia (ITP). In this study, we show that there was a low expression state of SIRPα on the surface of monocytes. Treatment of cells culture from ITP patients with a mAb to SIRPα that blocks the binding of SIRPα to CD47 downregulated the ITP response. The abilities of monocytes from ITP patients to stimulate an allogenic MLR were reduced. The proliferation of, and production of IL-2, by CD4 + T cells from ITP patients were inhibited, the Treg cell numbers and the production of IL-10 pairs were upregulated, and the production of TGF-β not was inhibited, by a mAb to SIRPα. Moreover, a mAb to SIRPα, the expression of HLA-DR and CD86 were markedly inhibited and the expression of CD80 was slightly upregulated, on the surface of CD14 + monocytes from ITP patients as compared with healthy subjects. However, blockade of SIRPα increased the secretion of TLR-dependent cytokines TNF-α, IL-6 and IL-1β by PBMCs, which may be considered as a reserve in response to danger signals. These results suggest that SIRPα on monocytes is essential for the priming of naive T cells and the development of ITP. Therefore, SIRPα is a potential therapeutic target for ITP and other autoimmune diseases.
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Affiliation(s)
- Dongmei Xie
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Zhihui Feng
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Wen Yang
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Yacan Wang
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Renxia Li
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Shiqi Zhang
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Zeping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Yunnan, China.
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5
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You M, Song Y, Chen J, Liu Y, Chen W, Cen Y, Zhao X, Tao Z, Yang G. Combined exposure to benzo(a)pyrene and dibutyl phthalate aggravates pro-inflammatory macrophage polarization in spleen via pyroptosis involving cathepsin B. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 881:163460. [PMID: 37061049 DOI: 10.1016/j.scitotenv.2023.163460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/23/2023] [Accepted: 04/08/2023] [Indexed: 06/01/2023]
Abstract
Humans are often simultaneously exposed to benzo(a)pyrene (BaP) and dibutyl phthalate (DBP) through consumption of food and water. Yet, direct evidence of the link between BaP and DBP co-exposure and the risk of splenic injury is lacking. In the present study, we established the rats and primary splenic macrophages models to evaluate the effects of BaP or/and DBP exposure on spleen and underlying mechanisms. Compared to the single exposure or control groups, the co-exposure group showed more severe spleen damage and higher production of pro-inflammatory cytokines. Co-exposure to BaP and DBP resulted in a 1.79-fold, 2.11-fold and 1.9-fold increase in the M1 macrophage markers iNOS, NLRP3 (pyroptosis marker protein) and cathepsin B (CTSB), respectively, and a 0.8-fold decrease in the M2 macrophage marker Arg1 in vivo. The more prominent effects in perturbation of imbalance in M1/M2 polarization (iNOS, 2.25-fold; Arg1, 0.55-fold), pyroptosis (NLRP3, 1.43-fold), and excess CTSB (1.07-fold) in macrophages caused by BaP and DBP co-exposure in vitro were also found. Notably, MCC950 (the NLRP3-specific inhibitor) treatment attenuated the pro-inflammatory macrophage polarization and following pro-inflammatory cytokine production triggered by BaP and DBP co-exposure. Furthermore, CA-074Me (the CTSB-specific inhibitor) suppressed the macrophages pyroptosis, pro-inflammatory macrophage polarization, and secretion of pro-inflammatory cytokine induced by BaP and DBP co-exposure. In conclusion, this study indicates co-exposure to BaP and DBP poses a higher risk of spleen injury. Pro-inflammatory macrophage polarization regulated by pyroptosis involving CTSB underlies the spleen injury caused by BaP and DBP co-exposure.
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Affiliation(s)
- Mingdan You
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 550025, China
| | - Yawen Song
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 550025, China
| | - Jing Chen
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 550025, China
| | - Yining Liu
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 550025, China
| | - Wenyan Chen
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 550025, China
| | - Yanli Cen
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 550025, China
| | - Xiaodeng Zhao
- Guizhou Center for Disease Control and Prevention, Guiyang, Guizhou 550004, China
| | - Zhongfa Tao
- Guizhou Center for Disease Control and Prevention, Guiyang, Guizhou 550004, China
| | - Ganghong Yang
- Guizhou Center for Disease Control and Prevention, Guiyang, Guizhou 550004, China; School of Public Health, Guizhou Medical University, Guiyang 550025, China.
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Zhang GC, Wu YJ, Liu FQ, Chen Q, Sun XY, Qu QY, Fu HX, Huang XJ, Zhang XH. β2-adrenergic receptor agonist corrects immune thrombocytopenia by reestablishing the homeostasis of T cell differentiation. J Thromb Haemost 2023; 21:1920-1933. [PMID: 36972787 DOI: 10.1016/j.jtha.2023.02.030] [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: 11/01/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The sympathetic nerve is known to regulate immune responses in autoimmunity. Aberrant T cell immunity plays a vital role in immune thrombocytopenia (ITP) pathogenesis. The spleen is the primary site of platelet destruction. However, little is known whether and how splenic sympathetic innervation and neuroimmune modulation contribute to ITP pathogenesis. OBJECTIVES To determine the sympathetic distribution in the spleen of ITP mice and the association between splenic sympathetic nerves and T cell immunity in ITP development, and to evaluate the treatment potential of β2-adrenergic receptor (β2-AR) in ITP. METHODS Chemical sympathectomy was performed in an ITP mouse model with 6-hydroxydopamine and treated with β2-AR agonists to evaluate the effects of sympathetic denervation and activation. RESULTS Decreased sympathetic innervation in the spleen of ITP mice was observed. Significantly increased percentages of Th1 and Tc1 cells and reduced percentages of regulatory T cells (Tregs) were also observed in ITP mice with chemical sympathectomy (ITP-syx mice) relative to mice without sympathectomy (controls). Expression of genes associated with Th1, including IFN-γ and IRF8, was significantly upregulated, whereas genes associated with Tregs, including Foxp3 and CTLA4, were significantly downregulated in ITP-syx mice compared with controls. Furthermore, β2-AR restored the percentage of Tregs and increased platelet counts at days 7 and 14 in ITP mice. CONCLUSION Our findings indicate that decreased sympathetic distribution contributes to ITP pathogenesis by disturbing the homeostasis of T cells and that β2-AR agonists have potential as a novel treatment for ITP.
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Affiliation(s)
- Gao-Chao Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ye-Jun Wu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feng-Qi Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qi Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xue-Yan Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qing-Yuan Qu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China.
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7
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Rivière E, Thiébaut R, Lazaro E, Guy A, James C, Mansier O, Blanco P, Viallard JF. Assessment of circulating blood lymphocytes in adult patients on rituximab to treat immune thrombocytopenia: Circulating number of NK cells is associated with the response at 6 months. Br J Haematol 2023. [PMID: 37081607 DOI: 10.1111/bjh.18818] [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: 11/30/2022] [Revised: 03/19/2023] [Accepted: 04/09/2023] [Indexed: 04/22/2023]
Abstract
Immune thrombocytopenia (ITP) is defined by a low platelet count that can trigger potentially life-threatening haemorrhages. Three-quarters of adult patients exhibit persistent or chronic disease and require second-line treatments. Among these, rituximab, an anti-CD20 antibody, has yielded valuable results, with global responses in 60% of patients at 6 months and complete responses in 30% at 5 years. Factors predictive of response to ITP therapy would help physicians choose optimal treatments. We retrospectively analysed clinical courses, biological markers and blood lymphocyte subset numbers of 72 patients on rituximab to treat persistent/chronic ITP followed-up in our department between 2007 and 2021, divided into three groups according to the platelet count at 6 months: complete, partial or no response. Among all studied parameters, a low number of CD3- CD16+ CD56+ circulating NK cells was associated with the complete response to rituximab. We also found that, after rituximab therapy, complete responders exhibited increased NK and decreased activated CD8+ T cell percentages. These results emphasize that the role played by NK cells in ITP remains incompletely known but that factors predictive of response to rituximab can be easily derived using blood lymphocyte subset data.
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Affiliation(s)
- Etienne Rivière
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
| | - Rodolphe Thiébaut
- Department of Public Health, University of Bordeaux, INSERM U1219 Bordeaux Population Health Research Centre, Inria SISTM, UMR 1219, Bordeaux, France
- Department of Medical Information, University Hospital Centre of Bordeaux, Bordeaux, France
| | - Estibaliz Lazaro
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- UMR CNRS 5164, ImmunoconcEpT & FHU ACRONIM, Bordeaux University, Bordeaux, France
| | - Alexandre Guy
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Chloé James
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Olivier Mansier
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Patrick Blanco
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- UMR CNRS 5164, ImmunoconcEpT & FHU ACRONIM, Bordeaux University, Bordeaux, France
| | - Jean-François Viallard
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
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8
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Ou Y, Zhan Y, Zhuang X, Shao X, Xu P, Li F, Chen H, Ji L, Cheng Y. A bibliometric analysis of primary immune thrombocytopenia from 2011 to 2021. Br J Haematol 2023; 201:954-970. [PMID: 36807900 DOI: 10.1111/bjh.18692] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/22/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia. This bibliometric analysis was applied to identify the characteristics of global scientific output, the hotspots, and frontiers of ITP over the past 10 years. We retrieved publications from 2011 to 2021 from the Web of Science Core Collection (WoSCC). Bibliometrix package, VOSviewer, and Citespace were used to analyse and visualize the trend, distribution, and hotspots of research on ITP. Altogether, there were 2084 papers, written by 9080 authors from 410 organizations in 70 countries/regions, published in 456 journals with 37 160 co-cited references. In the last decades, the most productive journal was British Journal of Haematology, China was the most productive country. and the most cited journal was Blood. Shandong University was the most productive institution in the field of ITP. NEUNERT C, 2011, BLOOD, CHENG G, 2011, LANCET, and PATEL VL, 2012, BLOOD were the top three most cited documents. "Thrombopoietin receptor agonist", "regulatory T cell" and "sialic acid" were three hotspots of the last decade. And "immature platelet fraction", "Th17", and "fostamatinib" would be research frontiers in the feature. The present study provided a novel insight for future research directions and scientific decision-making.
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Affiliation(s)
- Yang Ou
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xibing Zhuang
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xia Shao
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pengcheng Xu
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China
| | - Hao Chen
- Zhongshan Hospital Xuhui Branch, Department of Thoracic Surgery, Fudan University, Shanghai, China
| | - Lili Ji
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunfeng Cheng
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China.,Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai, China
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9
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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10
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Obinutuzumab Effectively Depletes Key B-cell Subsets in Blood and Tissue in End-stage Renal Disease Patients. Transplant Direct 2023; 9:e1436. [PMID: 36700064 PMCID: PMC9851678 DOI: 10.1097/txd.0000000000001436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 01/27/2023] Open
Abstract
The THEORY study evaluated the effects of single and multiple doses of obinutuzumab, a type 2 anti-CD20 antibody that induces antibody-dependent cell-mediated cytotoxicity and direct cell death, in combination with standard of care in patients with end-stage renal disease. Methods We measured B-cell subsets and protein biomarkers of B-cell activity in peripheral blood before and after obinutuzumab administration in THEORY patients, and B-cell subsets in lymph nodes in THEORY patients and an untreated comparator cohort. Results Obinutuzumab treatment resulted in a rapid loss of B-cell subsets (including naive B, memory B, double-negative, immunoglobulin D+ transitional cells, and plasmablasts/plasma cells) in peripheral blood and tissue. This loss of B cells was associated with increased B cell-activating factor and decreased CXCL13 levels in circulation. Conclusions Our data further characterize the mechanistic profile of obinutuzumab and suggest that it may elicit greater efficacy in indications such as lupus where B-cell targeting therapeutics are limited by the resistance of pathogenic tissue B cells to depletion.
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11
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Elsayh KI, Saad K, Osman NS, Mahmoud KH, Ahmad FA, Khalaf SM, Sayed NG, Zahran ZAM, Ghandour AMA, Elhoufey AA, Bedir T, Zahran A. Regulatory T-lymphocyte subsets in children with chronic immune thrombocytopenia after high-dose of dexamethasone. Pediatr Res 2022; 92:1432-1436. [PMID: 35173302 PMCID: PMC9700518 DOI: 10.1038/s41390-022-01978-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/19/2022] [Accepted: 01/23/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is an acquired autoimmune disease. This study's objective was to estimate the variations in the population of CD4+CD25+High FoxP3+ cells (CD4+ regulatory T-lymphocytes; Tregs) in previously untreated children with chronic ITP managed in Assiut University Hospitals, as well as to evaluate the efficacy of high-dose dexamethasone (HD-DXM) in these patients. METHODS In this study, we investigated the frequencies of T-lymphocyte subsets in 27 untreated children with chronic ITP. RESULTS Prior to treatment, the percentages of CD4+CD25High cells and Tregs were significantly lower in the chronic ITP group compared to the control group (p = 0.018 and p < 0.0001, respectively). After treatment with HD-DXM, Tregs and platelets were significantly increased in these patients (p < 0.0001 for both). CONCLUSIONS Our results suggest that Tregs are deficient in children with chronic ITP and that HD-DXM immunosuppressive therapy can restore the levels of these cells. IMPACT CD4+CD25High cells and Tregs were significantly lower in children chronic ITP compared to healthy control. HD-DXM treatment led to significantly increased Tregs and platelets in these patients. Our results suggest that Tregs are deficient in children with chronic ITP and that HD-DXM immunosuppressive therapy can restore the levels of these cells.
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Affiliation(s)
| | - Khaled Saad
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Naglaa Samy Osman
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Faisal A Ahmad
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Shaimaa M Khalaf
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Noha G Sayed
- Department of clinical pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Aliaa M A Ghandour
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Amira A Elhoufey
- Department of Community Health Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
- Department of Community Health Nursing, Alddrab University College, Jazan University, Jazan, Saudi Arabia
| | - Tamer Bedir
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Asmaa Zahran
- Department of Clinical Pathology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
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12
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Mischlinger J, Jaeger VK, Ciurea A, Gabay C, Hasler P, Mueller RB, Siegrist CA, Villiger P, Walker UA, Hatz C, Bühler S. Long-term persistence of antibodies after diphtheria/tetanus vaccination in immunosuppressed patients with inflammatory rheumatic diseases and healthy controls. Vaccine 2022; 40:4897-4904. [PMID: 35810064 DOI: 10.1016/j.vaccine.2022.06.013] [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: 12/22/2021] [Revised: 05/16/2022] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Abstract
Many vaccines demonstrate high effectiveness for years. This prospective multicentre study was conducted in Switzerland to assess the long-term persistence of antibodies to the diphtheria/tetanus (dT)-vaccine in adult patients with rheumatic diseases (PRDs). 163 PRDs and 169 controls were included in the study. The median age of all participants was 50 years (range: 18-83 years) and 56% were female. After a median time interval of 16 years after vaccination, the median anti-vaccine antibody concentrations were lower in PRDs than in controls for tetanus (1.68 vs 2.01; p = 0.049) and diphtheria (0.05 vs 0.22; p = 0.002). Based on the currently accepted seroprotection threshold (antibody concentration ≥ 0.1 IU/ml), PRDs had lower proportions of short-term tetanus and diphtheria protection as demonstrated by crude odds ratios (OR) of 0.30 (p = 0.017) and OR: 0.52 (p = 0.004), respectively. After adjusting for 'age' and 'time since last dT vaccination', the strength of associations became weaker; for tetanus, borderline evidence remained for a true difference between PRDs and controls (OR: 0.36 [p = 0.098]), however, not for diphtheria (OR: 0.86 [p = 0.58]). We hypothesize that in the presence of rheumatic diseases and its immunosuppressive treatment, vaccine-specific long-lived plasma cells (LLPCs) may be diminished or competitively displaced by rheumatism-specific LLPCs, a process which may decrease the persistence of vaccine-specific antibodies. Novel studies should be designed by incorporating methodologies allowing to determine the attributable fraction of immunosuppressive/immunomodulatory medications and rheumatic disease itself on long-lasting vaccine-specific antibody persistence, as well as, further study the role of LLPCs.
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Affiliation(s)
- Johannes Mischlinger
- Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I. Department of Medicine University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Veronika K Jaeger
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland; Institute of Epidemiology and Social Medicine, University of Münster, Germany
| | - Adrian Ciurea
- Department of Rheumatology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Cem Gabay
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | - Paul Hasler
- Division of Rheumatology, University Department of Medicine, University of Basel Medical Faculty, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Ruediger B Mueller
- Division of Rheumatology, University Department of Medicine, University of Basel Medical Faculty, Cantonal Hospital Aarau, Aarau, Switzerland; Division of Rheumatology, Department of Internal Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland; Division of Rheumatology and Clinical Immunology, Department of Internal Medicine Ludwig-Maximilians-University Munich, Germany
| | - Claire Ann Siegrist
- Center for Vaccinology, University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Peter Villiger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, Bern, Switzerland
| | - Ulrich A Walker
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Christoph Hatz
- Department of Public Health / Division of Infectious Diseases, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Department of Medicine and Diagnostics, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Switzerland; Division of Infectious Diseases & Hospital Epidemiology, Kantonsspital St. Gallen, Switzerland
| | - Silja Bühler
- Department of Public Health / Division of Infectious Diseases, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Division of Hygiene and Infectious Diseases, Institute for Hygiene and Environment, Hamburg, Germany.
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13
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Canales-Herrerias P, Crickx E, Broketa M, Sokal A, Chenon G, Azzaoui I, Vandenberghe A, Perima A, Iannascoli B, Richard-Le Goff O, Castrillon C, Mottet G, Sterlin D, Robbins A, Michel M, England P, Millot GA, Eyer K, Baudry J, Mahevas M, Bruhns P. High-affinity autoreactive plasma cells disseminate through multiple organs in patients with immune thrombocytopenic purpura. J Clin Invest 2022; 132:153580. [PMID: 35503254 PMCID: PMC9197514 DOI: 10.1172/jci153580] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
The major therapeutic goal for immune thrombocytopenic purpura (ITP) is to restore normal platelet counts using drugs to promote platelet production or by interfering with mechanisms responsible for platelet destruction. Eighty percent of patients with ITP possess anti–integrin αIIbβ3 IgG autoantibodies that cause platelet opsonization and phagocytosis. The spleen is considered the primary site of autoantibody production by autoreactive B cells and platelet destruction. The immediate failure in approximately 50% of patients to recover a normal platelet count after anti-CD20 rituximab-mediated B cell depletion and splenectomy suggests that autoreactive, rituximab-resistant, IgG-secreting B cells (IgG-SCs) reside in other anatomical compartments. We analyzed more than 3,300 single IgG-SCs from spleen, bone marrow, and/or blood of 27 patients with ITP, revealing high interindividual variability in affinity for αIIbβ3, with variations over 3 logs. IgG-SC dissemination and range of affinities were, however, similar for each patient. Longitudinal analysis of autoreactive IgG-SCs upon treatment with the anti-CD38 mAb daratumumab demonstrated variable outcomes, from complete remission to failure with persistence of high-affinity anti–αIIbβ3 IgG-SCs in the bone marrow. This study demonstrates the existence and dissemination of high-affinity autoreactive plasma cells in multiple anatomical compartments of patients with ITP that may cause the failure of current therapies.
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Affiliation(s)
| | - Etienne Crickx
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
| | - Matteo Broketa
- Department of Immunology, Institut Pasteur, Paris, France
| | - Aurélien Sokal
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
| | - Guilhem Chenon
- Laboratoire Colloïdes et Matériaux Divisés (LCMD), ESPCI, Paris, France
| | - Imane Azzaoui
- Service de Médecine Interne, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Paris, France
| | - Alexis Vandenberghe
- Service de Médecine Interne, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Paris, France
| | - Angga Perima
- Department of Immunology, Institut Pasteur, Paris, France
| | | | | | | | | | | | - Ailsa Robbins
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunolo, Robert Debré Hospital, Reims University Hospitals, Reims, France
| | - Marc Michel
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Créteil, France
| | - Patrick England
- Plateforme de Biophysique Moléculaire, Institut Pasteur, Paris, France
| | - Gael A Millot
- Hub Bioinformatique et Biostatistique, Institut Pasteur, Paris, France
| | - Klaus Eyer
- Laboratory for Functional Immune Repertoire Analysis, ETH Zurich, Zurich, Switzerland
| | - Jean Baudry
- Laboratoire Colloïdes et Matériaux Divisés (LCMD), ESPCI, Paris, France
| | - Matthieu Mahevas
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
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14
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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15
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Zhang G, Yang P, Liu X, Liu H, Wang J, Wang J, Xiao J, Nie D, Ma L. HMGB1 is increased in patients with immune thrombocytopenia and negatively associates with Tregs. Thromb Res 2022; 213:128-136. [DOI: 10.1016/j.thromres.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 12/24/2022]
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16
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Maitland HS. Avatrombopag Effectively Maintained Platelet Counts in a Patient with Immune Thrombocytopenia Who Was Intolerant to Tyrosine Kinase Inhibitor Therapy. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933788. [PMID: 34862358 PMCID: PMC8656289 DOI: 10.12659/ajcr.933788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient: Female, 47-year-old
Final Diagnosis: Idiopathic thrombocytopenia
Symptoms: Bruising • diarhea • thrombocytopenia
Medication: —
Clinical Procedure: —
Specialty: Hematology
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Affiliation(s)
- Hillary S Maitland
- Division of Hematology/Oncology, Department of Medicine, Emily Couric Clinical Cancer Center, University of Virginia, Charlottesville, VA, USA
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17
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Markmann C, Bhoj VG. On the road to eliminating long-lived plasma cells-"are we there yet?". Immunol Rev 2021; 303:154-167. [PMID: 34351644 DOI: 10.1111/imr.13015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 01/19/2023]
Abstract
Central to protective humoral immunity is the activation of B cells and their terminal differentiation into antibody-secreting plasma cells. Long-lived plasma cells (LLPC) may survive for years to decades. Such long-lived plasma cells are also responsible for producing pathogenic antibodies that cause a variety of challenges such as autoimmunity, allograft rejection, and drug neutralization. Up to now, various therapeutic strategies aimed at durably eliminating pathogenic antibodies have failed, in large part due to their inability to efficiently target LLPCs. Several antibody-based therapies have recently gained regulatory approval or are in clinical phases of development for the treatment of multiple myeloma, a malignancy of plasma cells. We discuss the exciting potential of using these emerging cancer immunotherapies to solve the antibody problem.
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Affiliation(s)
- Caroline Markmann
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Vijay G Bhoj
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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18
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Crickx E, Chappert P, Sokal A, Weller S, Azzaoui I, Vandenberghe A, Bonnard G, Rossi G, Fadeev T, Storck S, Fadlallah J, Meignin V, Rivière E, Audia S, Godeau B, Michel M, Weill JC, Reynaud CA, Mahévas M. Rituximab-resistant splenic memory B cells and newly engaged naive B cells fuel relapses in patients with immune thrombocytopenia. Sci Transl Med 2021; 13:13/589/eabc3961. [PMID: 33853929 DOI: 10.1126/scitranslmed.abc3961] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/29/2020] [Accepted: 03/22/2021] [Indexed: 01/19/2023]
Abstract
Rituximab (RTX), an antibody targeting CD20, is widely used as a first-line therapeutic strategy in B cell-mediated autoimmune diseases. However, a large proportion of patients either do not respond to the treatment or relapse during B cell reconstitution. Here, we characterize the cellular basis responsible for disease relapse in secondary lymphoid organs in humans, taking advantage of the opportunity offered by therapeutic splenectomy in patients with relapsing immune thrombocytopenia. By analyzing the B and plasma cell immunoglobulin gene repertoire at bulk and antigen-specific single-cell level, we demonstrate that relapses are associated with two responses coexisting in germinal centers and involving preexisting mutated memory B cells that survived RTX treatment and naive B cells generated upon reconstitution of the B cell compartment. To identify distinctive characteristics of the memory B cells that escaped RTX-mediated depletion, we analyzed RTX refractory patients who did not respond to treatment at the time of B cell depletion. We identified, by single-cell RNA sequencing (scRNA-seq) analysis, a population of quiescent splenic memory B cells that present a unique, yet reversible, RTX-shaped phenotype characterized by down-modulation of B cell-specific factors and expression of prosurvival genes. Our results clearly demonstrate that these RTX-resistant autoreactive memory B cells reactivate as RTX is cleared and give rise to plasma cells and further germinal center reactions. Their continued surface expression of CD19 makes them efficient targets for current anti-CD19 therapies. This study thus identifies a pathogenic contributor to autoimmune diseases that can be targeted by available therapeutic agents.
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Affiliation(s)
- Etienne Crickx
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France.,Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Pascal Chappert
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France.,Inovarion, 75005 Paris, France
| | - Aurélien Sokal
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Sandra Weller
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Imane Azzaoui
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Alexis Vandenberghe
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Guillaume Bonnard
- INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Geoffrey Rossi
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Tatiana Fadeev
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Sébastien Storck
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Jehane Fadlallah
- Service d'immunologie clinique, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, 75010 Paris, France
| | - Véronique Meignin
- Service d'anatomopathologie, Hôpital Saint-Louis (AP-HP), 75010 Paris, France
| | - Etienne Rivière
- Service de médecine interne, Hôpital Haut-Lévêque, 33604 Pessac, France
| | - Sylvain Audia
- Service de médecine interne, Hôpital du Bocage, 21000 Dijon, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Jean-Claude Weill
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Claude-Agnès Reynaud
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Matthieu Mahévas
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France. .,Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
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19
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Vaccine response following anti-CD20 therapy: a systematic review and meta-analysis of 905 patients. Blood Adv 2021; 5:2624-2643. [PMID: 34152403 PMCID: PMC8216656 DOI: 10.1182/bloodadvances.2021004629] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/23/2021] [Indexed: 11/20/2022] Open
Abstract
The objective of this study was to perform a systematic review of the literature on vaccine responsiveness in patients who have received anti-CD20 therapy. PubMed and EMBASE were searched up to 4 January 2021 to identify studies of vaccine immunogenicity in patients treated with anti-CD20 therapy, including patients with hematologic malignancy or autoimmune disease. The primary outcomes were seroprotection (SP), seroconversion (SC), and/or seroresponse rates for each type of vaccine reported. As the pandemic influenza vaccine (2009 H1N1) has standardized definitions for SP and SC, and represented a novel primary antigen similar to the COVID-19 vaccine, meta-analysis was conducted for SC of studies of this vaccine. Pooled estimates, relative benefit ratios (RBs), and 95% confidence intervals (CIs) were calculated using a random-effects model. Thirty-eight studies (905 patients treated with anti-CD20 therapy) were included (19 studies of patients with hematologic malignancies). Patients on active (<3 months since last dose) anti-CD20 therapy had poor responses to all types of vaccines. The pooled estimate for SC after 1 pandemic influenza vaccine dose in these patients was 3% (95% CI, 0% to 9%), with an RB of 0.05 (95% CI, 0-0.73) compared with healthy controls and 0.22 (95% CI, 0.09-0.56) compared with disease controls. SC compared with controls seems abrogated for at least 6 months following treatment (3-6 months post anti-CD20 therapy with an RB of 0.50 [95% CI, 0.24-1.06] compared with healthy and of 0.44 [95% CI, 0.23-0.84] compared with disease controls). For all vaccine types, response to vaccination improves incrementally over time, but may not reach the level of healthy controls even 12 months after therapy.
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20
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Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. Hemasphere 2021; 5:e574. [PMID: 34095758 PMCID: PMC8171374 DOI: 10.1097/hs9.0000000000000574] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to both a peripheral destruction of platelets and an inappropriate bone marrow production. Although the primary triggering factors of ITP remain unknown, a loss of immune tolerance-mostly represented by a regulatory T-cell defect-allows T follicular helper cells to stimulate autoreactive splenic B cells that differentiate into antiplatelet antibody-producing plasma cells. Glycoprotein IIb/IIIa is the main target of antiplatelet antibodies leading to platelet phagocytosis by splenic macrophages, through interactions with Fc gamma receptors (FcγRs) and complement receptors. This allows macrophages to activate autoreactive T cells by their antigen-presenting functions. Moreover, the activation of the classical complement pathway participates to platelet opsonization and also to their destruction by complement-dependent cytotoxicity. Platelet destruction is also mediated by a FcγR-independent pathway, involving platelet desialylation that favors their binding to the Ashwell-Morell receptor and their clearance in the liver. Cytotoxic T cells also contribute to ITP pathogenesis by mediating cytotoxicity against megakaryocytes and peripheral platelets. The deficient megakaryopoiesis resulting from both the humoral and the cytotoxic immune responses is sustained by inappropriate levels of thrombopoietin, the major growth factor of megakaryocytes. The better understanding of ITP pathogenesis has provided important therapeutic advances. B cell-targeting therapies and thrombopoietin-receptor agonists (TPO-RAs) have been used for years. New emerging therapeutic strategies that inhibit FcγR signaling, the neonatal Fc receptor or the classical complement pathway, will deeply modify the management of ITP in the near future.
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21
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Successful treatment of thrombocytopenia with daratumumab after allogeneic transplant: a case report and literature review. Blood Adv 2021; 4:815-818. [PMID: 32119735 DOI: 10.1182/bloodadvances.2019001215] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/03/2020] [Indexed: 11/20/2022] Open
Abstract
Key Points
A source of treatment refractoriness in immune cytopenias appears to be residual CD138/38-positive lymphocyte populations. A short course of daratumumab is a novel treatment of refractory thrombocytopenia after failure of standard treatment options.
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22
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Stable HLA antibodies following sustained CD19+ cell depletion implicate a long-lived plasma cell source. Blood Adv 2021; 4:4292-4295. [PMID: 32915973 DOI: 10.1182/bloodadvances.2020002435] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/12/2020] [Indexed: 11/20/2022] Open
Abstract
Key Points
HLA-specific alloantibodies can be maintained despite profound CD19+ cell aplasia, likely due to production by CD19− plasma cells.
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23
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Zian Z, Berry SPDG, Bahmaie N, Ghotbi D, Kashif A, Madkaikar M, Bargir UA, Abdullahi H, Khan H, Azizi G. The clinical efficacy of Rituximab administration in autoimmunity disorders, primary immunodeficiency diseases and malignancies. Int Immunopharmacol 2021; 95:107565. [PMID: 33773205 DOI: 10.1016/j.intimp.2021.107565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Rituximab (RTX), as a monoclonal antibody-based immunotherapeutic intervention targeting CD20 on B cells, has proven efficacy in the treatment of patients with some immune-mediated diseases. In the present review, we provided information on the immunobiological mechanisms of signaling for RTX and its clinical applications, according to the immune-pathophysiology involved in the microenvironment of multiple diseases. We highlighted combination therapy, dose schedules, and laboratory monitoring, as well as the associated common and rare side effects to avoid. We also discussed the efficacy and safety of RTX-based therapeutic strategies and whether RTX therapy can be used as a promising treatment regimen for autoimmune diseases, primary immunodeficiency diseases, and malignancies. Our review highlights and supports the importance of collaboration between basic medical researchers and clinical specialists when considering the use of RTX in the treatment of various immune-mediated disorders.
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Affiliation(s)
- Zeineb Zian
- Biomedical Genomics and Oncogenetics Research Laboratory, Faculty of Sciences and Techniques of Tangier, P.B. 416, Abdelmalek Essaadi University, Tetouan, Morocco
| | - S P Déo-Gracias Berry
- Centre de Recherches Médicales (CERMEL) de Lambaréné, B.P: 242, Gabon; Technical University of Munich, 80333, Germany
| | - Nazila Bahmaie
- Department of Allergy and Immunology, Faculty of Medicine, Graduate School of Health Science, Near East University (NEU), Nicosia, 99138, Northern Cyprus, Cyprus
| | - Dana Ghotbi
- Faculty of Biological Sciences, University of Kharazmi, Tehran 14911-15719, Iran
| | - Ali Kashif
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Manisha Madkaikar
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology, Mumbai 400070, India
| | - Umair Ahmed Bargir
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology, Mumbai 400070, India
| | - Hamisu Abdullahi
- Department of Immunology, School of Medical Laboratory Sciences, Usmanu Danfodiyo University Sokoto, 840232, Nigeria
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj 3149779453, Iran.
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24
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Lin X, Xu A, Zhou L, Zhao N, Zhang X, Xu J, Feng S, Zheng C. Imbalance of T Lymphocyte Subsets in Adult Immune Thrombocytopenia. Int J Gen Med 2021; 14:937-947. [PMID: 33776472 PMCID: PMC7989055 DOI: 10.2147/ijgm.s298888] [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: 12/30/2020] [Accepted: 02/08/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Primary immune thrombocytopenia (ITP) is defined as an acquired autoimmune disease characterized by isolated thrombocytopenia. This work is to further clarify the relationship between T cell immune dysfunction and the pathogenesis of ITP. METHODS 37 adult patients with ITP were selected and were classified into newly diagnosed ITP (nITP, n = 13), persistent ITP (pITP, n = 6) and chronic ITP (cITP n = 18). The frequency of cytotoxic T lymphocytes (Tc1, Tc2, and Tc17) and helper T cells (Th1, Th2, and Th17), Tregs, and the expression of chemokine receptors and PD-1 on CD4+ T cells were investigated by flow cytometry. Plasma levels of T cell-related cytokines (IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, IL-17) were measured by cytometric beads array (CBA). RESULTS The percentage of Tc1 in cITP was greatly higher than nITP and healthy controls (p < 0.05, p < 0.01). The percentage of Treg in nITP and cITP groups was remarkably lower than those in healthy control group (p < 0.05, p < 0.001); and according to platelet count analysis (PLT<50x109/L or PLT>50x109/L), Treg cells in ITP group were significantly lower than those in healthy control group (p < 0.001, p < 0.05). The percentage of CD4+CXCR3+ of cITP was significantly higher than healthy controls and nITP (p < 0.01, p < 0.05). The percentage of CD4+CCR6+ in cITP was significantly higher than healthy controls and nITP (p < 0.001, p < 0.05). The expression of PD-1 in cITP patients was higher than healthy control (p < 0.05), but there was no significant difference among nITP, pITP and cITP (p = 0.25). The levels of IL-2, IFN-γ and TNFα in nITP group and cITP group were significantly higher than those in healthy control group (p < 0.01, p < 0.05; p < 0.01, p < 0.05; p < 0.05, p < 0.05), and the level of IL-10 in nITP group was significantly higher than that in pITP group (p < 0.05). CONCLUSION Our results suggest that T lymphocyte immune dysfunction does exist in adult ITP patients and plays an important role in the pathogenesis of ITP.
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Affiliation(s)
- Xiuxiu Lin
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Anhui Xu
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Li Zhou
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Na Zhao
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Xinhui Zhang
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, People’s Republic of China
| | - Jin Xu
- Wannan Medical College, Wuhu, People’s Republic of China
| | - Shanglong Feng
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, People’s Republic of China
| | - Changcheng Zheng
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
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25
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Emerging Therapies in Immune Thrombocytopenia. J Clin Med 2021; 10:jcm10051004. [PMID: 33801294 PMCID: PMC7958340 DOI: 10.3390/jcm10051004] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder caused by peripheral platelet destruction and inappropriate bone marrow production. The management of ITP is based on the utilization of steroids, intravenous immunoglobulins, rituximab, thrombopoietin receptor agonists (TPO-RAs), immunosuppressants and splenectomy. Recent advances in the understanding of its pathogenesis have opened new fields of therapeutic interventions. The phagocytosis of platelets by splenic macrophages could be inhibited by spleen tyrosine kinase (Syk) or Bruton tyrosine kinase (BTK) inhibitors. The clearance of antiplatelet antibodies could be accelerated by blocking the neonatal Fc receptor (FcRn), while new strategies targeting B cells and/or plasma cells could improve the reduction of pathogenic autoantibodies. The inhibition of the classical complement pathway that participates in platelet destruction also represents a new target. Platelet desialylation has emerged as a new mechanism of platelet destruction in ITP, and the inhibition of neuraminidase could dampen this phenomenon. T cells that support the autoimmune B cell response also represent an interesting target. Beyond the inhibition of the autoimmune response, new TPO-RAs that stimulate platelet production have been developed. The upcoming challenges will be the determination of predictive factors of response to treatments at a patient scale to optimize their management.
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26
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Adams H, Meek B, van de Garde EMW, van Moorsel CHM, Vugts DJ, Keijsers RG, Grutters JC. Altered splenic [ 89Zr]Zr-rituximab uptake in patients with interstitial lung disease not responding to rituximab: could this indicate a splenic immune-mediated mechanism? AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2020; 10:168-177. [PMID: 32929395 PMCID: PMC7486548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
Rituximab (RTX) for immune-mediated inflammatory disease (IMID) with interstitial pneumonitis (IP) results in non-response in about a third of patients for reasons not well understood. Complete peripheral B-cell depletion in IMID-IP does not seem to correlate with successful treatment outcome. A hypothesis is that splenic B cells might play a role in B-cell recovery and attraction of naïve B cells in non-responsive patients. The aim of this post hoc analysis of clinical trial data is to search for indicators in [89Zr]Zr-rituximab PET/CT data from the spleen that might explain non-responsiveness. PET/CT data of 20 patients with IMID-IP, who were enrolled in a phase II trial and treated with RTX were analyzed. Clinical outcome was categorized into responders (RSP) and non-responders (NR) after 6 months of initial RTX by two independent pulmonologists. Patients were examined separately to search for associations between clinical outcome, splenic activity on PET/CT, lymphocyte counts and other biomarkers. Treatment failure was found in 6/20 patients (30%) while all patients exhibited B-cell depletion from the circulation. NR patients demonstrated significantly higher splenic activity than RSP patients (non-preload protocol: SUV 4.9±1.96 and SUV 2.3±1.08 respectively, P=0.025). No correlations between treatment outcome and serum lymphocyte subsets were found. Our findings suggest a potential splenic mechanism in IMID-IP patients non-responding to RTX and warrant further consideration and investigation.
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Affiliation(s)
- Human Adams
- Department of Pulmonology, ILD Center of Excellence, St. Antonius HospitalNieuwegein, The Netherlands
- Department of Nuclear Medicine, Groene Hart HospitalThe Netherlands
| | - Bob Meek
- Department of Medical Microbiology & Immunology, St Antonius HospitalNieuwegein, The Netherlands
| | | | - Coline HM van Moorsel
- Department of Pulmonology, ILD Center of Excellence, St. Antonius HospitalNieuwegein, The Netherlands
| | - Danielle J Vugts
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands Radiology and Nuclear Medicine, VU Medical Center, Amsterdam, The Netherlands Radiology and Nuclear Medicine, VU Medical CenterAmsterdam, The Netherlands
| | - Ruth G Keijsers
- Department of Nuclear Medicine, St Antonius HospitalNieuwegein, The Netherlands
| | - Jan C Grutters
- Department of Pulmonology, ILD Center of Excellence, St. Antonius HospitalNieuwegein, The Netherlands
- Division of Heart & Lung, University Medical Center UtrechtThe Netherlands
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27
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Audia S, Mahevas M, Bonnotte B. [Immune thrombocytopenia: From pathogenesis to treatment]. Rev Med Interne 2020; 42:16-24. [PMID: 32741715 DOI: 10.1016/j.revmed.2020.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/29/2020] [Accepted: 06/20/2020] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to an immune peripheral destruction of platelets and an inappropriate platelet production. The pathogenesis of ITP is now better understood: it involves a humoral immune response which dependents on the stimulation of B cells by specific T cells called T follicular helper cells, leading to their differentiation into plasma cells that produce antiplatelet antibodies thus promoting the phagocytosis of platelets mainly by splenic macrophages. The deciphering of ITP pathogenesis has led to a better understanding of the inefficiency of treatments such as rituximab, although it has not provided yet the determination of biological predictive factor of response to treatments. Moreover, new therapeutic perspectives have been opened in the last few years with the development of molecules targeting Fcγ receptor signalling such as Syk inhibitor, or molecules increasing the clearance of pathogenic autoantibodies such as inhibitors of the neonatal Fc receptor (FcRn).
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Affiliation(s)
- S Audia
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France.
| | - M Mahevas
- 1 Service de Médecine Interne, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France; IMRB - U955 - Equipe n°2 "Transfusion et maladies du globule rouge" EFS Île-de-France, Hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, France
| | - B Bonnotte
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France
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28
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Rituximab and immune thrombocytopenia in adults: The state of knowledge 20 years later. Rev Med Interne 2020; 42:32-37. [PMID: 32680716 DOI: 10.1016/j.revmed.2020.05.016] [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: 03/05/2020] [Accepted: 05/23/2020] [Indexed: 01/19/2023]
Abstract
Rituximab has been used for immune thrombocytopenia (ITP) for almost 20 years and is now considered a valid off-label second-line treatment. About 60% to 70% of patients with ITP show initial response to rituximab, but in half of these patients, the disease will eventually relapse. Therefore, in 30% of patients with persistent or chronic ITP, one course of rituximab at 375 mg/m2/week for 4 weeks or 2 fixed 1000-mg rituximab infusions allows for a sustained response rate at 5 years. Unfortunately, to date, no robust predictor of long-term sustained response has been found to assist the physician in deciding to treat with rituximab on an individual basis, and the choice of rituximab or another second-line treatment must be individualized and shared with the patient. Retreatment with rituximab has been found efficient, with a similar or higher magnitude and duration of response in most patients. Rituximab is usually well tolerated, with mainly mild and easily manageable infusion-related adverse events. Severe infections are uncommon, including in the long-term, and occur in patients with at least another contributing factor in more than two thirds. Several issues remain to be resolved. Indeed, head-to-head comparisons with other and new treatments in ITP and robust predictors of long-term response are urgently needed to better determine the position of rituximab in the therapeutic armamentarium for adult ITP. Additionally, the place of combination therapies, maintenance therapy with rituximab and rituximab in newly-diagnosed ITP deserve additional studies.
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29
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Anti-CD20–mediated B-cell depletion in autoimmune diseases: successes, failures and future perspectives. Kidney Int 2020; 97:885-893. [DOI: 10.1016/j.kint.2019.12.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/09/2019] [Accepted: 12/12/2019] [Indexed: 12/11/2022]
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30
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CD4 + T cell phenotypes in the pathogenesis of immune thrombocytopenia. Cell Immunol 2020; 351:104096. [PMID: 32199587 DOI: 10.1016/j.cellimm.2020.104096] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/14/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by low platelet counts due to enhanced platelet clearance and compromised production. Traditionally, ITP was regarded a B cell mediated disorder as anti-platelet antibodies are detected in most patients. The very nature of self-antigens, evident processes of isotype switching and the affinity maturation of anti-platelet antibodies indicate that B cells in order to mount anti-platelet immune response require assistance of auto-reactive CD4+ T cells. For a long time, ITP pathogenesis has been exclusively reviewed through the prism of the disturbed balance between Th1 and Th2 subsets of CD4+ T cells, however, more recently new subsets of these cells have been described including Th17, Th9, Th22, T follicular helper and regulatory T cells. In this paper, we review the current understanding of the role and immunological mechanisms by which CD4+ T cells contribute to the pathogenesis of ITP.
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31
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Durozard P, Rico A, Boutiere C, Maarouf A, Lacroix R, Cointe S, Fritz S, Brunet C, Pelletier J, Marignier R, Audoin B. Comparison of the Response to Rituximab between Myelin Oligodendrocyte Glycoprotein and Aquaporin-4 Antibody Diseases. Ann Neurol 2019; 87:256-266. [PMID: 31725931 DOI: 10.1002/ana.25648] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To compare response to rituximab (RTX) between adult patients positive for myelin oligodendrocyte glycoprotein (MOG) and aquaporin-4 (AQP4) antibodies. METHODS We prospectively studied adult patients with MOG or AQP4 antibodies who received RTX under an individualized dosing schedule adapted to the biological effect of RTX monitored by memory B-cell measurement. Memory B cells were counted monthly and when relapse occurred. The biological effect of RTX was considered significant with <0.05% memory B cells in peripheral blood lymphocytes. RESULTS In 16 patients with MOG antibodies and 29 with AQP4 antibodies, mean follow-up was 19 (range = 9-38) and 38 (13-79) months. Under RTX, 10 relapses occurred in 6 of 16 (37.5%) patients with MOG antibodies, and 13 occurred in 7 of 29 (24%) with AQP4 antibodies. The median time of relapse after the most recent infusion was 2.6 (0.6-5.8) and 7 (0.8-13) months, respectively (p < 0.001). Memory B cells had reemerged in 2 of 10 (20%) relapses in patients with MOG antibodies and 12 of 13 (92.5%) with AQP4 antibodies (p < 0.001). INTERPRETATION In AQP4 antibody-associated disorder, relapse mostly occurs when the biological effect of RTX decreases, which argues for treatment efficacy. In MOG antibody-associated disorder, the efficacy of RTX is not constant, because one-third of patients showed relapse despite an effective biological effect of RTX. In this subpopulation, memory B-cell depletion was unable to prevent relapse, which was probably caused by different immunological mechanisms. These findings should be used to improve treatment strategies for MOG antibody-associated disorder. ANN NEUROL 2020;87:256-266.
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Affiliation(s)
- Pierre Durozard
- Public Assistance Hospitals of Marseille, Department of Neurology, Timone Hospital, Marseille.,Aix-Marseille University, Center for Magnetic Resonance in Biology and Medicine, French National Center for Scientific Research, Marseille
| | - Audrey Rico
- Public Assistance Hospitals of Marseille, Department of Neurology, Timone Hospital, Marseille.,Aix-Marseille University, Center for Magnetic Resonance in Biology and Medicine, French National Center for Scientific Research, Marseille
| | - Clémence Boutiere
- Public Assistance Hospitals of Marseille, Department of Neurology, Timone Hospital, Marseille.,Aix-Marseille University, Center for Magnetic Resonance in Biology and Medicine, French National Center for Scientific Research, Marseille
| | - Adil Maarouf
- Public Assistance Hospitals of Marseille, Department of Neurology, Timone Hospital, Marseille.,Aix-Marseille University, Center for Magnetic Resonance in Biology and Medicine, French National Center for Scientific Research, Marseille
| | - Romaric Lacroix
- Public Assistance Hospitals of Marseille, Laboratory of Hematology and Vascular Biology, La Conception Hospital, Marseille.,Aix-Marseille University, Center for Cardiovascular and Nutrition Research, French National Institute of Health, National Institute of Agricultural Research, Faculty of Pharmacy, Marseille
| | - Sylvie Cointe
- Public Assistance Hospitals of Marseille, Laboratory of Hematology and Vascular Biology, La Conception Hospital, Marseille.,Aix-Marseille University, Center for Cardiovascular and Nutrition Research, French National Institute of Health, National Institute of Agricultural Research, Faculty of Pharmacy, Marseille
| | - Shirley Fritz
- Public Assistance Hospitals of Marseille, Laboratory of Hematology and Vascular Biology, La Conception Hospital, Marseille.,Aix-Marseille University, Center for Cardiovascular and Nutrition Research, French National Institute of Health, National Institute of Agricultural Research, Faculty of Pharmacy, Marseille
| | - Corinne Brunet
- Public Assistance Hospitals of Marseille, Laboratory of Hematology and Vascular Biology, La Conception Hospital, Marseille.,Aix-Marseille University, Center for Cardiovascular and Nutrition Research, French National Institute of Health, National Institute of Agricultural Research, Faculty of Pharmacy, Marseille
| | - Jean Pelletier
- Public Assistance Hospitals of Marseille, Department of Neurology, Timone Hospital, Marseille.,Aix-Marseille University, Center for Magnetic Resonance in Biology and Medicine, French National Center for Scientific Research, Marseille
| | - Romain Marignier
- Lyon Civil Hospices, Department of Neurology, Neurologic and Neurosurgical Hospital Pierre Wertheimer, Bron, France
| | - Bertrand Audoin
- Public Assistance Hospitals of Marseille, Department of Neurology, Timone Hospital, Marseille
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Baker D, Pryce G, Amor S, Giovannoni G, Schmierer K. Learning from other autoimmunities to understand targeting of B cells to control multiple sclerosis. Brain 2019; 141:2834-2847. [PMID: 30212896 DOI: 10.1093/brain/awy239] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/01/2018] [Indexed: 12/15/2022] Open
Abstract
Although many suspected autoimmune diseases are thought to be T cell-mediated, the response to therapy indicates that depletion of B cells consistently inhibits disease activity. In multiple sclerosis, it appears that disease suppression is associated with the long-term reduction of memory B cells, which serves as a biomarker for disease activity in many other CD20+ B cell depletion-sensitive, autoimmune diseases. Following B cell depletion, the rapid repopulation by transitional (immature) and naïve (mature) B cells from the bone marrow masks the marked depletion and slow repopulation of lymphoid tissue-derived, memory B cells. This can provide long-term protection from a short treatment cycle. It seems that memory B cells, possibly via T cell stimulation, drive relapsing disease. However, their sequestration in ectopic follicles and the chronic activity of B cells and plasma cells in the central nervous system may drive progressive neurodegeneration directly via antigen-specific mechanisms or indirectly via glial-dependent mechanisms. While unproven, Epstein-Barr virus may be an aetiological trigger of multiple sclerosis. This infects mature B cells, drives the production of memory B cells and possibly provides co-stimulatory signals promoting T cell-independent activation that breaks immune tolerance to generate autoreactivity. Thus, a memory B cell centric mechanism can integrate: potential aetiology, genetics, pathology and response to therapy in multiple sclerosis and other autoimmune conditions with ectopic B cell activation that are responsive to memory B cell-depleting strategies.
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Affiliation(s)
- David Baker
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gareth Pryce
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sandra Amor
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Pathology Department, Free University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Gavin Giovannoni
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
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Lucchini E, Zaja F, Bussel J. Rituximab in the treatment of immune thrombocytopenia: what is the role of this agent in 2019? Haematologica 2019; 104:1124-1135. [PMID: 31126963 PMCID: PMC6545833 DOI: 10.3324/haematol.2019.218883] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/09/2019] [Indexed: 01/19/2023] Open
Abstract
The use of rituximab for the treatment of immune thrombocytopenia was greeted enthusiastically: it led to up to 60% response rates, making it, nearly 20 years ago, the main alternative to splenectomy, with far fewer side effects. However, long-term follow-up data showed that only 20-30% of patients maintained the remission. No significant changes have been registered using different dose schedules and timing of administration, while the combination with other drugs seemed promising. Higher response rates have been observed in young women before the chronic phase, but apart from that, other clinical factors or biomarkers predictive of response are still lacking. In this review we examine the historical and current role of rituximab in the management of immune thrombocytopenia, 20 years after its first use for the treatment of autoimmune diseases.
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Affiliation(s)
- Elisa Lucchini
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
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Pecoraro A, Crescenzi L, Galdiero MR, Marone G, Rivellese F, Rossi FW, de Paulis A, Genovese A, Spadaro G. Immunosuppressive therapy with rituximab in common variable immunodeficiency. Clin Mol Allergy 2019; 17:9. [PMID: 31080365 PMCID: PMC6501382 DOI: 10.1186/s12948-019-0113-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 12/23/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequent symptomatic primary antibody deficiency in adulthood and is characterized by the marked reduction of IgG and IgA serum levels. Thanks to the successful use of polyvalent immunoglobulin replacement therapy to treat and prevent recurrent infections, non-infectious complications, including autoimmunity, polyclonal lymphoproliferation and malignancies, have progressively become the major cause of morbidity and mortality in CVID patients. The management of these complications is particularly challenging, often requiring multiple lines of immunosuppressive treatments. Over the last 5–10 years, the anti-CD20 monoclonal antibody (i.e., rituximab) has been increasingly used for the treatment of both autoimmune and non-malignant lymphoproliferative manifestations associated with CVID. This review illustrates the evidence on the use of rituximab in CVID. For this purpose, first we discuss the mechanisms proposed for the rituximab mediated B-cell depletion; then, we analyze the literature data regarding the CVID-related complications for which rituximab has been used, focusing on autoimmune cytopenias, granulomatous lymphocytic interstitial lung disease (GLILD) and non-malignant lymphoproliferative syndromes. The cumulative data suggest that in the vast majority of the studies, rituximab has proven to be an effective and relatively safe therapeutic option. However, there are currently no data on the long-term efficacy and side effects of rituximab and other second-line therapeutic options. Further randomized controlled trials are needed to optimize the management strategies of non-infectious complications of CVID.
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Affiliation(s)
- Antonio Pecoraro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Ludovica Crescenzi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Rosaria Galdiero
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giancarlo Marone
- 2Department of Public Health, University of Naples Federico II, Naples, Italy.,3Monaldi Hospital Pharmacy, Naples, Italy
| | - Felice Rivellese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy.,4Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Francesca Wanda Rossi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Amato de Paulis
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Arturo Genovese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giuseppe Spadaro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
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Slifka MK, Amanna IJ. Role of Multivalency and Antigenic Threshold in Generating Protective Antibody Responses. Front Immunol 2019; 10:956. [PMID: 31118935 PMCID: PMC6504826 DOI: 10.3389/fimmu.2019.00956] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/15/2019] [Indexed: 12/03/2022] Open
Abstract
Vaccines play a vital role in protecting our communities against infectious disease. Unfortunately, some vaccines provide only partial protection or in some cases vaccine-mediated immunity may wane rapidly, resulting in either increased susceptibility to that disease or a requirement for more booster vaccinations in order to maintain immunity above a protective level. The durability of antibody responses after infection or vaccination appears to be intrinsically determined by the structural biology of the antigen, with multivalent protein antigens often providing more long-lived immunity than monovalent antigens. This forms the basis for the Imprinted Lifespan model describing the differential survival of long-lived plasma cell populations. There are, however, exceptions to this rule with examples of highly attenuated live virus vaccines that are rapidly cleared and elicit only short-lived immunity despite the expression of multivalent surface epitopes. These exceptions have led to the concept that multivalency alone may not reliably determine the duration of protective humoral immune responses unless a minimum number of long-lived plasma cells are generated by reaching an appropriate antigenic threshold of B cell stimulation. Examples of long-term and in some cases, potentially lifelong antibody responses following immunization against human papilloma virus (HPV), Japanese encephalitis virus (JEV), Hepatitis B virus (HBV), and Hepatitis A virus (HAV) provide several lessons in understanding durable serological memory in human subjects. Moreover, studies involving influenza vaccination provide the unique opportunity to compare the durability of hemagglutinin (HA)-specific antibody titers mounted in response to antigenically repetitive whole virus (i.e., multivalent HA), or detergent-disrupted “split” virus, in comparison to the long-term immune responses induced by natural influenza infection. Here, we discuss the underlying mechanisms that may be associated with the induction of protective immunity by long-lived plasma cells and their importance in future vaccine design.
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Affiliation(s)
- Mark K Slifka
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, United States
| | - Ian J Amanna
- Najít Technologies, Inc., Beaverton, OR, United States
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Transplantation of bone-marrow-derived mesenchymal stem cells into a murine model of immune thrombocytopenia. Blood Coagul Fibrinolysis 2018; 28:596-601. [PMID: 28562430 DOI: 10.1097/mbc.0000000000000642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
: Several reports have demonstrated T regulatory cells may play an important role in the pathophysiology of immune thrombocytopenia (ITP). As the immunomodulator, bone-marrow-derived mesenchymal stem cells (MSCs) (BM-MSCs) regulate T regulatory cells and show therapeutic effects on autoimmune diseases. However, it is not clear how BM-MSCs affect ITP. In this study, we explored the specific effects of BM-MSCs on ITP in mice. Using a murine model of ITP, mice were randomly divided into three groups: normal control group, ITP control group and ITP and BM-MSCs group. Platelet (PLT) levels were monitored by an automatic blood cell counter, and T regulatory cells were analyzed by flow cytometry. Compared with the untreated ITP mice, the PLT level of the ITP mice was significantly increased after BM-MSCs treatment. In the BM-MSCs group, T regulatory cells were significantly decreased. These findings demonstrate that bone-marrow-derived MSCs are effective in improving PLT levels and reducing the T regulatory cells mediating proinflammatory response in ITP mice.
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Swinkels M, Rijkers M, Voorberg J, Vidarsson G, Leebeek FWG, Jansen AJG. Emerging Concepts in Immune Thrombocytopenia. Front Immunol 2018; 9:880. [PMID: 29760702 PMCID: PMC5937051 DOI: 10.3389/fimmu.2018.00880] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/09/2018] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease defined by low platelet counts which presents with an increased bleeding risk. Several genetic risk factors (e.g., polymorphisms in immunity-related genes) predispose to ITP. Autoantibodies and cytotoxic CD8+ T cells (Tc) mediate the anti-platelet response leading to thrombocytopenia. Both effector arms enhance platelet clearance through phagocytosis by splenic macrophages or dendritic cells and by induction of apoptosis. Meanwhile, platelet production is inhibited by CD8+ Tc targeting megakaryocytes in the bone marrow. CD4+ T helper cells are important for B cell differentiation into autoantibody secreting plasma cells. Regulatory Tc are essential to secure immune tolerance, and reduced levels have been implicated in the development of ITP. Both Fcγ-receptor-dependent and -independent pathways are involved in the etiology of ITP. In this review, we present a simplified model for the pathogenesis of ITP, in which exposure of platelet surface antigens and a loss of tolerance are required for development of chronic anti-platelet responses. We also suggest that infections may comprise an important trigger for the development of auto-immunity against platelets in ITP. Post-translational modification of autoantigens has been firmly implicated in the development of autoimmune disorders like rheumatoid arthritis and type 1 diabetes. Based on these findings, we propose that post-translational modifications of platelet antigens may also contribute to the pathogenesis of ITP.
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Affiliation(s)
- Maurice Swinkels
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maaike Rijkers
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Jan Voorberg
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands.,Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
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Sacco KA, Abraham RS. Consequences of B-cell-depleting therapy: hypogammaglobulinemia and impaired B-cell reconstitution. Immunotherapy 2018; 10:713-728. [PMID: 29569510 DOI: 10.2217/imt-2017-0178] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Rituximab is a chimeric monoclonal antibody used to treat hematologic and autoimmune diseases by depleting CD20-expressing B cells. Patients may develop hypogammaglobulinemia following treatment, with some demonstrating failure of B-cell recovery. The true frequency of hypogammaglobulinemia and/or impaired B-cell reconstitution post rituximab is unknown due to the lack of prospective studies in different patient cohorts. The clinical significance remains controversial; some patients have recurrent infections while others are relatively asymptomatic. The aim of this review is to describe the prevalence of hypogammaglobulinemia and the associated risk for developing severe infection, in patients with differing underlying clinical conditions treated with rituximab. This may facilitate classification and prognostication of patients who develop these conditions and identify patients who may be at high risk of developing these complications, including those who may benefit from immunoglobulin replacement therapy.
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Affiliation(s)
- Keith A Sacco
- Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Roshini S Abraham
- Department of Laboratory Medicine & Pathology & Medicine, Mayo Clinic, Rochester, MN 55905, USA
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40
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Zhang J, Zhang Q, Li Y, Tao L, Wu F, Shen Y, Tao Q, Xu X, Wu C, Ruan Y, Wang J, Wang J, Wang Y, Zhai Z. Immune dysregulation in primary immune thrombocytopenia patients. ACTA ACUST UNITED AC 2018; 23:510-516. [PMID: 29409398 DOI: 10.1080/10245332.2018.1435021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To explore the immunological abnormalities in patients with primary immune thrombocytopenia (ITP), and analyze its relationship with treatment. METHODS Proportion of different immune cell subsets were detected in the peripheral blood of 124 ITP patients at different time points and 45 normal controls by flow cytometry. The treatments included glucocorticoids, intravenous IgG as first-line treatment and second-line drugs. RESULTS Elevated CD4/CD8 ratio and decreased the proportion of NK and CD4 + CD25 + CD127low regulatory T cells (Tregs) were found in pre-treated ITP patients than healthy controls. The newly diagnosed group had a significantly higher CD4/CD8 ratio than the relapsed group, but no differences in the proportion of B cells, NK cells and Tregs. No relationships were found between the curative effect and the pre-treated cell subsets within both the effective and ineffective groups. Furthermore, compared with the ineffective group, the effective group had higher Tregs and lower CD4/CD8 ratio post-treatment, but no significant differences in NK and B cells. CONCLUSION ITP patients presented with a high CD4/CD8 ratio and low levels of Tregs and NK cells, suggesting that immune deregulation was involved in the pathogenesis of ITP. The pre-treated immune status of ITP patients may not be related to the curative effect. Tregs significantly increased in the effective group post-treatment, highlighting that the mechanism of restoring Tregs may be involved in the treatment of ITP. However, whether or not the targeted regulation of Tregs is an effective treatment for ITP still requires further studies.
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Affiliation(s)
- Jiakui Zhang
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Qiuye Zhang
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Yingwei Li
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Lili Tao
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Fan Wu
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Yuanyuan Shen
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Qianshan Tao
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Xuanxuan Xu
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Can Wu
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Yanjie Ruan
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Jiyu Wang
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
| | - Jeffrey Wang
- b Centre for Transplant and Renal Research , Westmead Institute for Medical Research at University of Sydney , Sydney , New South Wales , Australia
| | - Yiping Wang
- b Centre for Transplant and Renal Research , Westmead Institute for Medical Research at University of Sydney , Sydney , New South Wales , Australia
| | - Zhimin Zhai
- a Department of Hematology, Hematological Research Center , The Second Affiliated Hospital of Anhui Medical University , Hefei , Anhui , People's Republic of China
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Plasma cell survival in the absence of B cell memory. Nat Commun 2017; 8:1781. [PMID: 29176567 PMCID: PMC5701209 DOI: 10.1038/s41467-017-01901-w] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/24/2017] [Indexed: 01/28/2023] Open
Abstract
Pre-existing serum antibodies play an important role in vaccine-mediated protection against infection but the underlying mechanisms of immune memory are unclear. Clinical studies indicate that antigen-specific antibody responses can be maintained for many years, leading to theories that reactivation/differentiation of memory B cells into plasma cells is required to sustain long-term antibody production. Here, we present a decade-long study in which we demonstrate site-specific survival of bone marrow-derived plasma cells and durable antibody responses to multiple virus and vaccine antigens in rhesus macaques for years after sustained memory B cell depletion. Moreover, BrdU+ cells with plasma cell morphology can be detected for 10 years after vaccination/BrdU administration, indicating that plasma cells may persist for a prolonged period of time in the absence of cell division. On the basis of these results, long-lived plasma cells represent a key cell population responsible for long-term antibody production and serological memory. The long-term maintenance of antibody-secreting plasma cells and the requirement for memory B cells are unclear. Here, the authors show that plasma cells and the antibodies secreted are long-lived and maintained over a decade in the absence of memory B cells in non-human primates.
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Cho A, Bradley B, Kauffman R, Priyamvada L, Kovalenkov Y, Feldman R, Wrammert J. Robust memory responses against influenza vaccination in pemphigus patients previously treated with rituximab. JCI Insight 2017; 2:93222. [PMID: 28614800 PMCID: PMC5470882 DOI: 10.1172/jci.insight.93222] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/16/2017] [Indexed: 12/21/2022] Open
Abstract
Rituximab is a therapeutic anti-CD20 monoclonal antibody widely used to treat B cell lymphoma and autoimmune diseases, such as rheumatic arthritis, systemic lupus erythematosus, and autoimmune blistering skin diseases (AIBD). While rituximab fully depletes peripheral blood B cells, it remains unclear whether some preexisting B cell memory to pathogens or vaccines may survive depletion, especially in lymphoid tissues, and if these memory B cells can undergo homeostatic expansion during recovery from depletion. The limited data available on vaccine efficacy in this setting have been derived from rituximab-treated patients receiving concomitant chemotherapy or other potent immunosuppressants. Here, we present an in-depth analysis of seasonal influenza vaccine responses in AIBD patients previously treated with rituximab, who generally did not receive additional therapeutic interventions. We found that, despite a lack of influenza-specific memory B cells in the blood, patients mount robust recall responses to vaccination, comparable to healthy controls, both at a cellular and a serological level. Repertoire analyses of plasmablast responses suggest that they likely derive from a diverse pool of tissue-resident memory cells, refractory to depletion. Overall, these data have important implications for establishing an effective vaccine schedule for AIBD patients and the clinical care of rituximab-treated patients in general and contribute to our basic understanding of maintenance of normal and pathogenic human B cell memory.
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Affiliation(s)
- Alice Cho
- Department of Pediatrics, Division of Infectious Disease.,Emory Vaccine Center, and
| | - Bridget Bradley
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert Kauffman
- Department of Pediatrics, Division of Infectious Disease.,Emory Vaccine Center, and
| | - Lalita Priyamvada
- Department of Pediatrics, Division of Infectious Disease.,Emory Vaccine Center, and
| | - Yevgeniy Kovalenkov
- Department of Pediatrics, Division of Infectious Disease.,Emory Vaccine Center, and
| | - Ron Feldman
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jens Wrammert
- Department of Pediatrics, Division of Infectious Disease.,Emory Vaccine Center, and
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Emerging Role of the Spleen in the Pharmacokinetics of Monoclonal Antibodies, Nanoparticles and Exosomes. Int J Mol Sci 2017; 18:ijms18061249. [PMID: 28604595 PMCID: PMC5486072 DOI: 10.3390/ijms18061249] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 01/19/2023] Open
Abstract
After being absorbed, drugs distribute in the body in part to reach target tissues, in part to be disposed in tissues where they do not exert clinically-relevant effects. Therapeutically-relevant effects are usually terminated by drug metabolism and/or elimination. The role that has been traditionally ascribed to the spleen in these fundamental pharmacokinetic processes was definitely marginal. However, due to its high blood flow and to the characteristics of its microcirculation, this organ would be expected to be significantly exposed to large, new generation drugs that can hardly penetrate in other tissues with tight endothelial barriers. In the present review, we examine the involvement of the spleen in the disposition of monoclonal antibodies, nanoparticles and exosomes and the possible implications for their therapeutic efficacy and toxicity. The data that we will review lead to the conclusion that a new role is emerging for the spleen in the pharmacokinetics of new generation drugs, hence suggesting that this small, neglected organ will certainly deserve stronger attention by pharmacologists in the future.
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Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev 2017; 16:620-632. [DOI: 10.1016/j.autrev.2017.04.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023]
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Rituximab for Recurrence of Primary Focal Segmental Glomerulosclerosis After Kidney Transplantation: Clinical Outcomes. Transplantation 2017; 101:649-656. [PMID: 27043407 DOI: 10.1097/tp.0000000000001160] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rituximab has shown encouraging results for the treatment of kidney transplantation recipients with focal segmental glomerulosclerosis (FSGS) recurrence. However, the correct, opportune, and safe use of rituximab for this indication remains to be determined. METHODS This multicenter retrospective study reports on 19 new cases aged 35 (15-66) years who developed FSGS recurrence at 12 (1.5-27) days posttransplantation. Initial treatment consisted of plasma exchanges (PE), high doses of calcineurin inhibitors, and steroids. Rituximab was introduced either immediately (N = 6) or after failure of the initial treatment (N = 10) or failed attempted weaning from PE (N = 3). RESULTS Overall, we observed 9 of 19 complete remissions and 3 of 19 partial remissions. Estimated glomerular filtration rates (Modification of Diet in Renal Disease 4) were significantly higher in the responding patients than in nonresponding patients at month (M)12, M36, and M60. Overall, kidney survival at 5 years was 77.4% (95% range, 41.9-92.7). The 5-year graft survival rates in the responding patients and the nonresponding patients were 100% and 36.5%, respectively (P = 0.01). A further course of rituximab was required for 4 patients as a result of FSGS relapse, with good results. During the first year after renal transplantation, 14 patients developed severe infections (16 bacterial, 4 viral, 1 parasitic). CONCLUSIONS In kidney transplantation recipients with recurrent FSGS, rituximab therapy may be a recommended treatment for cases that have failed either the initial treatment or weaning from PE.
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Audia S, Santegoets K, Laarhoven AG, Vidarsson G, Facy O, Ortega‐Deballon P, Samson M, Janikashvili N, Saas P, Bonnotte B, Radstake TR. Fcγ receptor expression on splenic macrophages in adult immune thrombocytopenia. Clin Exp Immunol 2017; 188:275-282. [PMID: 28142207 PMCID: PMC5383444 DOI: 10.1111/cei.12935] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 01/21/2023] Open
Abstract
Splenic macrophages play a key role in immune thrombocytopenia (ITP) pathogenesis by clearing opsonized platelets. Fcγ receptors (FcγR) participate in this phenomenon, but their expression on splenic macrophages and their modulation by treatment have scarcely been studied in human ITP. We aimed to compare the phenotype and function of splenic macrophages between six controls and 24 ITP patients and between ITP patients according to the treatments they received prior to splenectomy. CD86, human leucocyte antigen D-related (HLA-DR) and FcγR expression were measured by flow cytometry on splenic macrophages. The major FcγR polymorphisms were determined and splenic macrophage function was assessed by a phagocytosis assay. The expression of the activation markers CD86 and HLA-DR was higher on splenic macrophages during ITP compared to controls. While the expression of FcγR was not different between ITP and controls, the phagocytic function of splenic macrophages was reduced in ITP patients treated with intravenous immunoglobulin (IVIg) within the 2 weeks prior to splenectomy. The FCGR3A (158V/F) polymorphism, known to increase the affinity of FcγRIII to IgG, was over-represented in ITP patients. Thus, these are the first results arguing for the fact that the therapeutic use of IVIg during human chronic ITP does not modulate FcγR expression on splenic macrophages but decreases their phagocytic capabilities.
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Affiliation(s)
- S. Audia
- CR INSERM 1098University of Bourgogne/Franche‐ComtéDijonFrance
- Department of Internal Medicine and Clinical ImmunologyCompetence Centre for Auto‐Immune CytopeniaDijonFrance
- Laboratory of Translational ImmunologyUniversity Medical CentreUtrecht
| | - K. Santegoets
- Laboratory of Translational ImmunologyUniversity Medical CentreUtrecht
| | - A. G. Laarhoven
- Experimental Immunohematology, Sanquin ResearchAmsterdamthe Netherlands
| | - G. Vidarsson
- Experimental Immunohematology, Sanquin ResearchAmsterdamthe Netherlands
| | - O. Facy
- Department of SurgeryUniversity HospitalDijonFrance
| | | | - M. Samson
- CR INSERM 1098University of Bourgogne/Franche‐ComtéDijonFrance
- Department of Internal Medicine and Clinical ImmunologyCompetence Centre for Auto‐Immune CytopeniaDijonFrance
| | - N. Janikashvili
- CR INSERM 1098University of Bourgogne/Franche‐ComtéDijonFrance
| | - P. Saas
- CR INSERM 1098University of Bourgogne/Franche‐ComtéDijonFrance
| | - B. Bonnotte
- CR INSERM 1098University of Bourgogne/Franche‐ComtéDijonFrance
- Department of Internal Medicine and Clinical ImmunologyCompetence Centre for Auto‐Immune CytopeniaDijonFrance
| | - T. R. Radstake
- Laboratory of Translational ImmunologyUniversity Medical CentreUtrecht
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Cines DB, Wasser J, Rodeghiero F, Chong BH, Steurer M, Provan D, Lyons R, Garcia-Chavez J, Carpenter N, Wang X, Eisen M. Safety and efficacy of romiplostim in splenectomized and nonsplenectomized patients with primary immune thrombocytopenia. Haematologica 2017; 102:1342-1351. [PMID: 28411254 PMCID: PMC5541869 DOI: 10.3324/haematol.2016.161968] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/12/2017] [Indexed: 02/02/2023] Open
Abstract
Primary immune thrombocytopenia is an autoimmune disorder characterized by increased platelet destruction and insufficient platelet production without another identified underlying disorder. Splenectomy may alter responsiveness to treatment and/or increase the risk of thrombosis, infection, and pulmonary hypertension. The analysis herein evaluated the safety and efficacy of the thrombopoietin receptor agonist romiplostim in splenectomized and nonsplenectomized adults with primary immune thrombocytopenia. Data were pooled across 13 completed clinical studies in adults with immune thrombocytopenia from 2002-2014. Adverse event rates were adjusted for time of exposure. Results were considered different when 95% confidence intervals were non-overlapping. Safety was analyzed for 1111 patients (395 splenectomized; 716 nonsplenectomized) who received romiplostim or control (placebo or standard of care). At baseline, splenectomized patients had a longer median duration of immune thrombocytopenia and a lower median platelet count, as well as a higher proportion with >3 prior immune thrombocytopenia treatments versus nonsplenectomized patients. In each treatment group, splenectomized patients used rescue medications more often than nonsplenectomized patients. Platelet response rates (≥50×109/L) for romiplostim were 82% (310/376) for splenectomized and 91% (592/648) for nonsplenectomized patients (P<0.001 by Cochran-Mantel-Haenszel test). Platelet responses were stable over time in both subgroups. Exposure-adjusted adverse event rates were higher for control versus romiplostim for both splenectomized (1857 versus 1226 per 100 patient-years) and nonsplenectomized patients (1052 versus 852 per 100 patient-years). In conclusion, responses to romiplostim were seen in both splenectomized and nonsplenectomized patients, and romiplostim was not associated with an increase in the risk of adverse events in splenectomized patients. clinicaltrials.gov Identifier: 00111475(A)(B), 00117143, 00305435, 01143038, 00102323, 00102336, 00415532, 00603642, 00508820, 00907478, 00116688, and 00440037.
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Affiliation(s)
- Douglas B Cines
- Perelman University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Jeffrey Wasser
- University of Connecticut Health Center, Farmington, CT, USA
| | - Francesco Rodeghiero
- Hematology Project Foundation, Vicenza, Italy.,San Bortolo Hospital, Vicenza, Italy
| | - Beng H Chong
- St George Hospital/University of New South Wales, Sydney, Australia
| | | | - Drew Provan
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Roger Lyons
- Texas Oncology and US ONCOLOGY Research, San Antonio, TX
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Absence of Intragraft B Cells in Rejection Biopsies After Rituximab Induction Therapy: Consequences for Clinical Outcome. Transplant Direct 2017; 3:e143. [PMID: 28405599 PMCID: PMC5381736 DOI: 10.1097/txd.0000000000000659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 01/19/2023] Open
Abstract
Background The pathophysiological role of intragraft B cells during renal allograft rejection is unclear. Methods We studied B-cell infiltration during acute rejection in 53 patients who participated in a clinical trial in which adult renal transplant patients were randomized between a single intraoperative dose of rituximab (375 mg/m2) or placebo as induction therapy. Two independent pathologists scored all biopsies in a blinded fashion according to the Banff classification and scored for the presence of B cells and plasma cells using CD79a and CD138 as markers. Results The majority of acute rejections were T cell–mediated. The proportion of acute rejections with an antibody-mediated component tended to be lower in rituximab-treated patients (4/23, 17.4%) than in placebo-treated patients (11/30, 36.7%; P = 0.14). Biopsies of rituximab-treated patients had significantly lower scores for B cells (0.00; range, 0.00-0.50 vs 1.70; range, 0.60-3.30; P < 0.0001) and plasma cells (0.10; range, 0.00-1.90 vs 0.40; range, 0.00-7.50; P = 0.006). During acute rejection, intragraft clusters of B cells were not observed after rituximab induction therapy. However, the depletion of intragraft B cells during acute rejection did not affect steroid resistance, proteinuria, graft function at 2 years follow-up, or patient and graft survival at a median follow-up of 4.1 years (range, 2.0-6.2 years). Conclusions These data do not support a harmful influence of intragraft B cells present during acute allograft rejection on the clinical course within the first few years after renal transplantation.
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Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med 2017; 6:jcm6020016. [PMID: 28208757 PMCID: PMC5332920 DOI: 10.3390/jcm6020016] [Citation(s) in RCA: 281] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/04/2017] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a complex autoimmune disease characterized by low platelet counts. The pathogenesis of ITP remains unclear although both antibody-mediated and/or T cell-mediated platelet destruction are key processes. In addition, impairment of T cells, cytokine imbalances, and the contribution of the bone marrow niche have now been recognized to be important. Treatment strategies are aimed at the restoration of platelet counts compatible with adequate hemostasis rather than achieving physiological platelet counts. The first line treatments focus on the inhibition of autoantibody production and platelet degradation, whereas second-line treatments include immunosuppressive drugs, such as Rituximab, and splenectomy. Finally, third-line treatments aim to stimulate platelet production by megakaryocytes. This review discusses the pathophysiology of ITP and how the different treatment modalities affect the pathogenic mechanisms.
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Affiliation(s)
- Anne Zufferey
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
| | - Rick Kapur
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- Canadian Blood Services, Toronto, ON M5B 1W8, Canada.
| | - John W Semple
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- Canadian Blood Services, Toronto, ON M5B 1W8, Canada.
- Department of Pharmacology, Medicine, and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada.
- Division of Hematology and Transfusion Medicine, Lund University, 221 84 Lund, Sweden.
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Zhang J, Ruan Y, Shen Y, Tao Q, Wang H, Tao L, Pan Y, Fang H, Wang Y, Zhai Z. Low dose IL-2 increase regulatory T cells and elevate platelets in a patient with immune thrombocytopenia. CYTOMETRY PART B-CLINICAL CYTOMETRY 2016; 94:400-404. [PMID: 27862977 DOI: 10.1002/cyto.b.21494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/13/2016] [Accepted: 11/07/2016] [Indexed: 12/20/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder in which its immune system destroys platelets and leads to haemorrhage symptom. Recent studies have found that regulatory T cells (Tregs) in peripheral blood, bone marrow, and spleen were reduced in ITP patients and recovered after effective ITP therapy. Low-dose Interleukin-2 (IL-2) has been reported recently to increase Tregs and used to treat autoimmune disease including graft-versus-host disease (GVHD) after organ transplantation and HCV-related autoimmune vasculitis. However, it is unknown whether IL-2 is able to treat ITP. We have used low-dose IL-2 (1.0 million IU/day) on 5 consecutive days per week for 4 weeks in a 36-year-old patient with ITP. The result has shown that low-dose IL-2 induces expansion of Tregs significantly and increase platelet count was gradually from 36 × 109 /L to maximum 85 × 109 /L. No side effects of IL-2 have been found. This result suggested that low-dose of IL-2 may have therapeutic potential for ITP. © 2016 International Clinical Cytometry Society.
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Affiliation(s)
- Jiakui Zhang
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Yanjie Ruan
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Yuanyuan Shen
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Qianshan Tao
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Huiping Wang
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Lili Tao
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Yin Pan
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Huizi Fang
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
| | - Yiping Wang
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research at University of Sydney, Sydney, Australia
| | - Zhimin Zhai
- Department of Hematology, Hamatological Research Center, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, People's Republic of China
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