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Tumba MC, Silva RL, Arevalo AB, Sattui SE. Current perspective on infections and mitigation strategies in primary systemic vasculitis. Curr Rheumatol Rep 2024; 26:279-289. [PMID: 38668813 DOI: 10.1007/s11926-024-01149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize and evaluate most recent evidence on the epidemiology of infections and associated risk factors in patients with primary systemic vasculitides (PSV), as well as discuss mitigation strategies including the risk of antibiotic prophylaxis. RECENT FINDINGS Infections remain one of the leading causes of mortality in patients with PSV, with rates of severe infection ranging from 16 to 40% in different cohorts. Older age, frailty, renal and pulmonary involvement, and higher burden of comorbidities have been recognized as important patient-associated risk factors. Treatments including higher cumulative doses of glucocorticoids are associated with an increased risk of infections, and recent studies show the potential benefit of interventions such as reduced-dose glucocorticoid regimens. Existing mitigation strategies include screening, vaccination, and infection prophylaxis. The latter remains particularly important for Pneumocystis jirovecii pneumonia; however, the benefit-risk ratio seems to be less clear outside of induction phase (i.e., high dose of glucocorticoids) and optimal treatment duration remains less clear. Patients with PSV are at increased risk of infections, due to disease itself, comorbidities, and treatment side effects. Awareness of the timing and types of infection, as well as mitigation strategies are imperative to ensure treatment success and survival for patients.
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Affiliation(s)
- Manuel Carpio Tumba
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raisa Lomanto Silva
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ana B Arevalo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Massachusetts, Boston, MA, USA
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
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Liu W, Tian G, Chen C, Zhang M, Chen Z, Chen T, Lin Z, Wu W, Wu Y, Wu K, Liu Q. Application of biological agents in the treatment of anti-neutrophil cytoplasmic antibody-associated vasculitis. Front Pharmacol 2024; 15:1378384. [PMID: 38831887 PMCID: PMC11144864 DOI: 10.3389/fphar.2024.1378384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/19/2024] [Indexed: 06/05/2024] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been traditionally treated using glucocorticoids and immunosuppressants. However, these treatment modes are associated with high recurrence AAV rates and adverse reactions. Therefore, treatment strategies for AAV need to be urgently optimized. The efficacy and safety of biological agents in the treatment of vasculitis have been clinically validated. This review comprehensively summarizes the evidence-based support for the clinical use of existing biological agents in AAV. The findings reveal that multiple biological agents not only effectively reduce the adverse reactions associated with glucocorticoids and immunosuppressants but also demonstrate significant therapeutic efficacy. Notably, rituximab, an anti-CD20 antibody, has emerged as a first-line treatment option for AAV. Mepolizumab has shown promising results in relapsed and refractory eosinophilic granulomatosis with polyangiitis. Other biological agents targeting cytokines, complement, and other pathways have also demonstrated clinical benefits in recent studies. The widespread application of biological agents provides new insights into the treatment of AAV and is expected to drive further clinical research. These advancements not only improve patient outcomes but also offer more possibilities and hope in the field of AAV treatment.
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Affiliation(s)
- Weijun Liu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Guanyuan Tian
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Chao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Mingying Zhang
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Zhanmao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Tietao Chen
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Zhibin Lin
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Wuzhong Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Yiqaing Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Kefei Wu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
| | - Qinghua Liu
- Department of Nephrology, Jieyang People’s Hospital, Jieyang, China
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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Durel CA, Thervet ES, Chauveau D, Schmidt A, Terrier B, Bataille PM. Evolution of therapeutic management of patients with ANCA associated vasculitis in France after licensing Rituximab use. BMC Rheumatol 2024; 8:16. [PMID: 38679737 PMCID: PMC11056056 DOI: 10.1186/s41927-024-00385-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/10/2024] [Indexed: 05/01/2024] Open
Abstract
INTRODUCTION In 2013, rituximab was approved in France for the treatment of ANCA-associated vasculitis (AAV). The aim of the study was to compare the treatment and health events of adult incident patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), included before rituximab approval (over 2010-2012, Group 1) and those included after rituximab approval (over 2014-2017, Group 2). METHOD Data were extracted from the French National Health Insurance database (SNDS) including outpatient health care consumption and hospital discharge forms. Comparisons between inclusion periods were performed using Wilcoxon and χ² tests. Kaplan-Meier method was used to model the duration of treatment induction, maintenance, and off-drug periods. Fine and Gray tests were used to compare treatment phase durations. RESULTS A total of 694 GPA and 283 MPA patients were included in Group 1, while 668 GPA and 463 MPA patients were included in Group 2. Between the two inclusion periods, the proportions of patients treated with rituximab increased in the induction and maintenance phases whereas treatment with azathioprine declined. These proportions remained stable in the case of methotrexate, cyclophosphamide, and glucocorticoid-treated patients. Frequency of first-time hospitalized infections, diabetes and renal failure during the first year after inclusion increased for both groups. LIMITATIONS OF THE STUDY This is a retrospective study based on claims data including only 76% of people covered by health insurance in France. The period studied includes the learning phase of using rituximab. This study lacks biological data and precise quantitative analysis for the use of steroids, therefore the criteria for establishing diagnosis and therapeutic choice were unknown. CONCLUSIONS Introduction of rituximab reduced the use of azathioprine without affecting the use of glucocorticoids or cyclophosphamide.
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Omura S, Kida T, Noma H, Sunaga A, Kusuoka H, Kadoya M, Nakagomi D, Abe Y, Takizawa N, Nomura A, Kukida Y, Kondo N, Yamano Y, Yanagida T, Endo K, Hirata S, Matsui K, Takeuchi T, Ichinose K, Kato M, Yanai R, Matsuo Y, Shimojima Y, Nishioka R, Okazaki R, Takata T, Ito T, Moriyama M, Takatani A, Miyawaki Y, Ito-Ihara T, Yajima N, Kawaguchi T, Fukuda W, Kawahito Y. Association between hypogammaglobulinaemia and severe infections during induction therapy in ANCA-associated vasculitis: from J-CANVAS study. Rheumatology (Oxford) 2023; 62:3924-3931. [PMID: 36961329 DOI: 10.1093/rheumatology/kead138] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023] Open
Abstract
OBJECTIVES To investigate the association between decreased serum IgG levels caused by remission-induction immunosuppressive therapy of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and the development of severe infections. METHODS We conducted a retrospective cohort study of patients with new-onset or severe relapsing AAV enrolled in the J-CANVAS registry, which was established at 24 referral sites in Japan. The minimum serum IgG levels up to 24 weeks and the incidence of severe infection up to 48 weeks after treatment initiation were evaluated. After multiple imputations for all explanatory variables, we performed the multivariate analysis using a Fine-Gray model to assess the association between low IgG (the minimum IgG levels <500 mg/dl) and severe infections. In addition, the association was expressed as a restricted cubic spline (RCS) and analysed by treatment subgroups. RESULTS Of 657 included patients (microscopic polyangiitis, 392; granulomatosis with polyangiitis, 139; eosinophilic granulomatosis with polyangiitis, 126), 111 (16.9%) developed severe infections. The minimum serum IgG levels were measured in 510 patients, of whom 77 (15.1%) had low IgG. After multiple imputations, the confounder-adjusted hazard ratio of low IgG for the incidence of severe infections was 1.75 (95% confidence interval: 1.03-3.00). The RCS revealed a U-shaped association between serum IgG levels and the incidence of severe infection with serum IgG 946 mg/dl as the lowest point. Subgroup analysis showed no obvious heterogeneity between treatment regimens. CONCLUSION Regardless of treatment regimens, low IgG after remission-induction treatment was associated with the development of severe infections up to 48 weeks after treatment initiation.
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Affiliation(s)
- Satoshi Omura
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Takashi Kida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Atsuhiko Sunaga
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hiroaki Kusuoka
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University, Tokyo, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Naoya Kondo
- Department of Nephrology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan
| | - Takuya Yanagida
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
- Department of Hematology and Rheumatology, Kagoshima University Hospital, Kagoshima, Japan
| | - Koji Endo
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kiyoshi Matsui
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo Medical University School of Medicine, Hyogo, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Matsuo
- Department of Rheumatology, Tokyo Kyosai Hospital, Tokyo, Japan
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Ryota Okazaki
- Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tomoaki Takata
- Division of Gastroenterology and Nephrology, Tottori University, Yonago, Japan
| | - Takafumi Ito
- Division of Nephrology, Shimane University Hospital, Shimane, Japan
| | - Mayuko Moriyama
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Ayuko Takatani
- Rheumatic Disease Center, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuyuki Yajima
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Wataru Fukuda
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Schirmer JH, Sanchez-Alamo B, Hellmich B, Jayne D, Monti S, Luqmani RA, Tomasson G. Systematic literature review informing the 2022 update of the EULAR recommendations for the management of ANCA-associated vasculitis (AAV): part 1-treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:e003082. [PMID: 37479496 PMCID: PMC10364171 DOI: 10.1136/rmdopen-2023-003082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/16/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To summarise and update evidence to inform the 2022 update of the EULAR recommendations for the management of antineutrophil cytoplasm antibody-associated vasculitis (AAV). METHODS A systematic literature review (SLR) was performed to identify current evidence regarding treatment of AAV. PubMed, EMBASE and the Cochrane library were searched from 1 February 2015 to 25 February 2022. The evidence presented here is focused on the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RESULTS 3517 articles were screened and 175 assessed by full-text review. Ninety articles were included in the final evidence synthesis. Cyclophosphamide and rituximab (RTX) show similar efficacy for remission induction (level of evidence (LoE) 1a) but RTX is more effective in relapsing disease (LoE 1b). Glucocorticoid (GC) protocols with faster tapering result in similar remission rates but lower rates of serious infections (LoE 1b). Avacopan can be used to rapidly taper and replace GC (LoE 1b). Data on plasma exchange are inconsistent depending on the analysed trial populations but meta-analyses based on randomised controlled trials demonstrate a reduction of the risk of end-stage kidney disease at 1 year but not during long-term follow-up (LoE 1a). Use of RTX for maintenance of remission is associated with lower relapse rates compared with azathioprine (AZA, LoE 1b). Prolonged maintenance treatment results in lower relapse rates for both, AZA (LoE 1b) and RTX (LoE 1b). CONCLUSION This SLR provides current evidence to inform the 2022 update of the EULAR recommendations for the management of AAV.
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Affiliation(s)
- Jan Henrik Schirmer
- Clinic for Internal Medicine I, Rheumatology and Clinical Immunology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Beatriz Sanchez-Alamo
- Nephrology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
- Nephrology, Skåne University Hospital, Lund, Sweden
| | - Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken Kirchheim/Teck, University Tübingen, Kirchheim-Teck, Germany
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, University of Pavia; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raashid Ahmed Luqmani
- Oxford NIHR Biomedical Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gunnar Tomasson
- Faculty of Medicine, University of Iceland, Landspitali University Hospital, Reykjavik, Iceland
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Outcomes in ANCA-associated vasculitis patients with end-stage kidney disease on renal replacement therapy-A meta-analysis. Semin Arthritis Rheum 2023; 60:152189. [PMID: 36931168 DOI: 10.1016/j.semarthrit.2023.152189] [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: 11/26/2022] [Revised: 02/11/2023] [Accepted: 02/27/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND End-stage kidney disease (ESKD) is associated with poor prognosis in patients with anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This study summarizes the existing evidence regarding outcomes in AAV patients with ESKD on renal replacement therapy. METHODS Searches of the MEDLINE and Embase databases were performed from inception until December 2021. Any study reporting outcomes after ESKD in patients with AAV on haemodialysis or peritoneal dialysis was included. The mortality rate per 100 person-years (100 py) calculated with a random-effects meta-analysis model was the primary outcome. Rates of infections and relapses were secondary outcomes. RESULTS 2470 citations were found; 22 studies of 952 adult patients with over 3600 person-years of follow-up were included. The pooled mortality rate was 10.90 per 100 py (95% CI: 7.11 - 14.68, I2 = 90.8%). The pooled 1-year survival was 80.9% (95% CI: 75.6 - 86.1%, I2 = 86.1%) while the pooled 5-year survival was 61.0% (95% CI: 46.0 - 76.0%, I2 = 0.0%). The pooled severe infection rate was 66.57 per 100 py (95% CI: 13.64 - 119.50, I2 = 99.6%). The pooled relapse rate was 6.22 per 100 py (95% CI: 4.64 - 7.80, I2 = 46.6%). Only 1 paediatric study met the inclusion criteria and reported a mortality rate of 11.7 ± 1.9 deaths per 100 py (95% CI: 0.23 - 23.20) amongst 9 patients. CONCLUSIONS Patients with AAV and ESKD have a lower risk of relapse, but higher infection and mortality rates. More prospective research exploring the role of immunosuppression after ESKD is needed.
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Odler B, Riedl R, Gauckler P, Shin JI, Leierer J, Merkel PA, St Clair W, Fervenza F, Geetha D, Monach P, Jayne D, Smith RM, Rosenkranz A, Specks U, Stone JH, Kronbichler A. Risk factors for serious infections in ANCA-associated vasculitis. Ann Rheum Dis 2023; 82:681-687. [PMID: 36702528 PMCID: PMC10176387 DOI: 10.1136/ard-2022-223401] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Severe infections contribute to morbidity and mortality in antineutrophil cytoplasm antibody-associated vasculitis (AAV). This study aimed to identify risk factors associated with severe infections in participants of the Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial. METHODS Data on 197 patients recruited into the RAVE trial were analysed. Participants received either rituximab (RTX) or cyclophosphamide (CYC), followed by azathioprine (AZA). Clinical and laboratory data of patients with and without severe infections (≥grade 3, according to the Common Terminology Criteria for Adverse Events version 3.0) were compared. Risk factors for severe infections were investigated using Cox-regression models. RESULTS Eighteen of 22 (82%) severe infections occurred within 6 months after trial entry, most commonly respiratory tract infections (15/22, 68%). At baseline, lower absolute numbers of CD19+ cells were observed in patients with severe infections either receiving RTX or CYC/AZA at baseline, while CD5+B and CD3+T cells did not differ between groups. In Cox-regression analysis, higher baseline serum immunoglobulin M levels were associated with the risk of severe infections, whereby a higher baseline total CD19+B cell number and prophylaxis against Pneumocystis jirovecii with trimethoprim-sulfamethoxazole (TMP/SMX) with decreased risk of severe infections. Use of TMP/SMX was associated with lower risk of severe infections in both groups, receiving either RTX or CYC/AZA. CONCLUSIONS The use of low-dose TMP/SMX is associated with reduced risk of severe infections in patients with AAV treated with either RTX or CYC/AZA. Reduced B cell subpopulations at start of treatment might be a useful correlate of reduced immunocompetence.
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Affiliation(s)
- Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, UK.,Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Philipp Gauckler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Yonsei University College of Medicine and Severance Children's Hospital, Seoul, Republic of Korea
| | - Johannes Leierer
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William St Clair
- Division of Rheumatology and Immunology, Duke University, Durham, North Carolina, USA
| | - Fernando Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Paul Monach
- VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rona M Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Alexander Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John H Stone
- Division of Rheumatology Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Vassilopoulos A, Vassilopoulos S, Kalligeros M, Shehadeh F, Mylonakis E. Incidence of serious infections in patients with ANCA-associated vasculitis receiving immunosuppressive therapy: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1110548. [PMID: 36936221 PMCID: PMC10014619 DOI: 10.3389/fmed.2023.1110548] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 03/05/2023] Open
Abstract
Introduction Rituximab and azathioprine are used to induce or maintain remission in patients with ANCA-associated vasculitis (AAV). We evaluated the incidence of serious infections and infection-related deaths in patients with AAV treated with rituximab and azathioprine, during the maintenance of remission period. Methods We searched PubMed and EMBASE for randomized clinical trials (RCTs) and observational studies evaluating immunosuppressive agents in patients with AAV. We defined serious or severe infections according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The study was registered on PROSPERO (CRD42022366269). Results From 1,265 abstracts, we identified 21 studies (7 RCTs and 14 observational), with relevant data. We included data from 1,284 and 2,938 individuals for assessment in our primary and secondary outcomes, respectively. The overall cumulative incidence of serious infections was 15.99% (CI 95%: 6.95-27.53%) during the total follow-up period (induction and maintenance) and 7.62% (CI 95%: 4.43-11.43%) during the maintenance period. Additionally, we found a 0.49% overall case fatality rate (CI 95%: 0.02-1.37%) and a 0.09% infection-related mortality rate (CI 95%: 0.00-0.51%) during maintenance treatment. Notably, we found a 14.61% (CI 95%: 10.19-19.61%) cumulative incidence of serious infections among patients who received rituximab and a 5.93% (CI 95%: 1.19-13.26%) cumulative incidence of serious infections among patients who received azathioprine during maintenance. Moreover, the cumulative incidence of serious infections during the total follow-up period (induction and maintenance) was 20.81% (CI 95%:4.56-43.70%) for the combination of cyclophosphamide and azathioprine and 14.12% (CI 95%: 5.20-26.00%) for rituximab. Discussion The cumulative incidence of serious infections during total follow-up and maintenance was within expected limits, while fatal infections during maintenance treatment were uncommon. Additionally, treatment with rituximab for both induction and maintenance did not exceed the anticipated by previous studies incidence of serious infections. Clinical practice and long-term follow up data are needed to corroborate these findings. Systematic review registration Identifier: PROSPERO (CRD42022366269).
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Affiliation(s)
- Athanasios Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Stephanos Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Markos Kalligeros
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Fadi Shehadeh
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- *Correspondence: Eleftherios Mylonakis
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Ge S, Zhu X, Xu Q, Wang J, An C, Hu Y, Yang F, Wang X, Yang Y, Chen S, Jin R, Li H, Peng X, Liu Y, Xu J, Zhu M, Shuai Z. Neutrophils in ANCA-associated vasculitis: Mechanisms and implications for management. Front Pharmacol 2022; 13:957660. [PMID: 36210838 PMCID: PMC9545605 DOI: 10.3389/fphar.2022.957660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of systemic autoimmune diseases, which is typified by inflammatory necrosis predominantly affecting the small vessels and often accompanied by positive ANCA. Clinically, AAV primarily includes microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA). It has been found that in AAV pathogenesis, both innate and adaptive immunity are related to neutrophil function mutually. Many proteins, such as myeloperoxidase (MPO) and proteinase 3 (PR3), in neutrophil cytoplasm lead to the production of proteins such as MPO-ANCA and PR3-ANCA by activating adaptive immunity. In addition, through the process of neutrophil extracellular trap (NET) formation, activation of an alternative complement pathway and the respiratory burst can stimulate the neutrophils close to vascular endothelial cells and will participate the vessel inflammation. This review aims to reveal the potential mechanisms regulating the association between the neutrophils and various types of AAVs and to emphasize the results of recent findings on these interactions. Moreover, multiple underlying signaling pathways involved in the regulation of neutrophils during AAV processes have also been discussed. The ultimate goal of this review is to identify novel biomarkers and therapeutic targets for AAV management in the future.
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Affiliation(s)
- Shangqing Ge
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xingyu Zhu
- National Institute of Clinical Drug Trials, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Qinyao Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Junyan Wang
- Department of Clinical Medical, The Second Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Cheng An
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ying Hu
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
| | - Fan Yang
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Xinyi Wang
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Yipin Yang
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Shuwen Chen
- Department of Clinical Medical, The First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Ruimin Jin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Haiyan Li
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xinchen Peng
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yue Liu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Junnan Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Minhui Zhu
- National Institute of Clinical Drug Trials, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Zongwen Shuai,
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