1
|
Alghamdi AH. Overlap of Primary Membranous Nephropathy, IgA Nephropathy, and Diabetic Nephropathy: A Case Report. Cureus 2023; 15:e49598. [PMID: 38161828 PMCID: PMC10754713 DOI: 10.7759/cureus.49598] [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] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
The coexistence of primary membranous nephropathy (PMN), immunoglobulin A nephropathy (IgAN), and diabetic nephropathy (DN) in the same patient has been a subject of clinical and pathological investigation, yielding inconclusive results. The limited availability of cases and resource materials has hindered a comprehensive understanding of this phenomenon. We present the case of a 70-year-old Saudi Arabian man diagnosed with type 2 diabetes mellitus and nephrotic syndrome. A kidney biopsy revealed the coexistence of PMN, IgAN, and DN. The patient presented with an unusual and rare combination of PMN, IgAN, and DN. To address his condition, the patient consented to rituximab therapy and planned follow-up with the kidney transplant team. However, before the first dose of rituximab could be administered, the patient experienced severe septic shock secondary to pneumonia, which tragically led to his demise. The simultaneous occurrence of PMN, IgAN, and DN represents a rare and scarcely documented condition. The purpose of this article is to report this exceptional case, emphasizing the significance of further research to deepen the understanding of the underlying pathology behind these concurrent renal disorders. This report aims to shed light on the complexities of managing such complex cases and advancing therapeutic approaches in the future.
Collapse
|
2
|
Du W, Han M, Zhu X, Xiao F, Huang E, Che N, Tang X, Zou H, Jiang Q, Lu L. The Multiple Roles of B Cells in the Pathogenesis of Sjögren's Syndrome. Front Immunol 2021; 12:684999. [PMID: 34168653 PMCID: PMC8217880 DOI: 10.3389/fimmu.2021.684999] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022] Open
Abstract
Primary Sjögren’s syndrome (pSS) is a chronic autoimmune disease characterized by lymphocytic infiltration and tissue destruction of exocrine glands such as salivary glands. Although the formation of ectopic lymphoid tissue in exocrine glands and overproduction of autoantibodies by autoreactive B cells highlight the critical involvement of B cells in disease development, the precise roles of various B cell subsets in pSS pathogenesis remain partially understood. Current studies have identified several novel B cell subsets with multiple functions in pSS, among which autoreactive age-associated B cells, and plasma cells with augmented autoantibody production contribute to the disease progression. In addition, tissue-resident Fc Receptor-Like 4 (FcRL4)+ B cell subset with enhanced pro-inflammatory cytokine production serves as a key driver in pSS patients with mucosa-associated lymphoid tissue (MALT)-lymphomas. Recently, regulatory B (Breg) cells with impaired immunosuppressive functions are found negatively correlated with T follicular helper (Tfh) cells in pSS patients. Further studies have revealed a pivotal role of Breg cells in constraining Tfh response in autoimmune pathogenesis. This review provides an overview of recent advances in the identification of pathogenic B cell subsets and Breg cells, as well as new development of B-cell targeted therapies in pSS patients.
Collapse
Affiliation(s)
- Wenhan Du
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China
| | - Man Han
- Division of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaoxia Zhu
- Department of Rheumatology, Huashan Hospital and Fudan University, Shanghai, China
| | - Fan Xiao
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China.,Chongqing International Institute for Immunology, Chongqing, China
| | - Enyu Huang
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China.,Chongqing International Institute for Immunology, Chongqing, China
| | - Nan Che
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu, China
| | - Xiaopo Tang
- Division of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hejian Zou
- Department of Rheumatology, Huashan Hospital and Fudan University, Shanghai, China
| | - Quan Jiang
- Division of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liwei Lu
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China.,Chongqing International Institute for Immunology, Chongqing, China
| |
Collapse
|
3
|
Hydrogen deuterium exchange mass spectrometry identifies the dominant paratope in CD20 antigen binding to the NCD1.2 monoclonal antibody. Biochem J 2021; 478:99-120. [PMID: 33284343 PMCID: PMC7813475 DOI: 10.1042/bcj20200674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 11/17/2022]
Abstract
A comparative canine–human therapeutics model is being developed in B-cell lymphoma through the generation of a hybridoma cell that produces a murine monoclonal antibody specific for canine CD20. The hybridoma cell produces two light chains, light chain-3, and light chain-7. However, the contribution of either light chain to the authentic full-length hybridoma derived IgG is undefined. Mass spectrometry was used to identify only one of the two light chains, light chain-7, as predominating in the full-length IgG. Gene synthesis created a recombinant murine–canine chimeric monoclonal antibody expressing light chain-7 that reconstituted the IgG binding to CD20. Using light chain-7 as a reference sequence, hydrogen deuterium exchange mass spectrometry was used to identify the dominant CDR region implicated in CD20 antigen binding. Early in the deuteration reaction, the CD20 antigen suppressed deuteration at CDR3 (VH). In later time points, deuterium suppression occurred at CDR2 (VH) and CDR2 (VL), with the maintenance of the CDR3 (VH) interaction. These data suggest that CDR3 (VH) functions as the dominant antigen docking motif and that antibody aggregation is induced at later time points after antigen binding. These approaches define a methodology for fine mapping of CDR contacts using nested enzymatic reactions and hydrogen deuterium exchange mass spectrometry. These data support the further development of an engineered, synthetic canine–murine monoclonal antibody, focused on CDR3 (VH), for use as a canine lymphoma therapeutic that mimics the human–murine chimeric anti-CD20 antibody Rituximab.
Collapse
|
4
|
Marrack P. Obsessive-Compulsive Behavior Isn't Necessarily a Bad Thing. Annu Rev Immunol 2020; 38:1-21. [PMID: 31594433 DOI: 10.1146/annurev-immunol-072319-033325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is difficult to believe that in about 1960 practically nothing was known about the thymus and some of its products, T cells bearing αβ receptors for antigen. Thus I was lucky to join the field of T cell biology almost at its beginning, when knowledge about the cells was just getting off the ground and there was so much to discover. This article describes findings about these cells made by others and myself that led us all from ignorance, via complete confusion, to our current state of knowledge. I believe I was fortunate to practice science in very supportive institutions and with very collaborative colleagues in two countries that both encourage independent research by independent scientists, while simultaneously ignoring or somehow being able to avoid some of the difficulties of being a woman in what was, at the time, a male-dominated profession.
Collapse
Affiliation(s)
- Philippa Marrack
- Department of Biomedical Research, National Jewish Health, Denver, Colorado 80206, USA; .,Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| |
Collapse
|
5
|
Koç R, Sönmez HE, Çakan M, Karadağ ŞG, Tanatar A, Çakmak F, Aktay Ayaz N. Drug reactions in children with rheumatic diseases receiving parenteral therapies: 9 years’ experience of a tertiary pediatric rheumatology center. Rheumatol Int 2019; 40:771-776. [DOI: 10.1007/s00296-019-04498-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022]
|
6
|
A Neurologist's Perspective on Understanding Myasthenia Gravis: Clinical Perspectives of Etiologic Factors, Diagnosis, and Preoperative Treatment. Thorac Surg Clin 2019; 29:133-141. [PMID: 30927994 DOI: 10.1016/j.thorsurg.2018.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Myasthenia gravis (MG) is a disease of neuromuscular transmission caused by antibodies directed toward proteins concentrated at the neuromuscular junction. Mild to life-threatening weakness varies in severity over time and with level of activity. Therefore, clinical diagnosis is often challenging. MG may be categorized by autoantibody type, thymic pathologic condition, and age of onset. Treatments are tailored for each group. A key management concern is severe exacerbation of weakness resulting from infections or exposure to certain medications, including antibiotics, which may be severe enough to produce respiratory decompensation. The article reviews key diagnostic issues and treatment options.
Collapse
|
7
|
Age (autoimmunity) associated B cells (ABCs) and their relatives. Curr Opin Immunol 2018; 55:75-80. [DOI: 10.1016/j.coi.2018.09.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
|
8
|
Efficacy and safety of biological DMARDs modulating B cells in primary Sjögren's syndrome: Systematic review and meta-analysis. Joint Bone Spine 2018; 85:15-22. [DOI: 10.1016/j.jbspin.2017.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/21/2017] [Indexed: 02/06/2023]
|
9
|
Warren RB, Weatherhead SC, Smith CH, Exton LS, Mohd Mustapa MF, Kirby B, Yesudian PD. British Association of Dermatologists' guidelines for the safe and effective prescribing of methotrexate for skin disease 2016. Br J Dermatol 2017; 175:23-44. [PMID: 27484275 DOI: 10.1111/bjd.14816] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 12/25/2022]
Affiliation(s)
- R B Warren
- The Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M6 8HD, U.K
| | - S C Weatherhead
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - B Kirby
- St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - P D Yesudian
- Glan Clwyd Hospital, Sarn Lane, Rhyl, LL18 5UJ, U.K
| |
Collapse
|
10
|
Abstract
Objective: To review published literature evaluating the use of rituximab for treatment of acquired hemophilia. Data Sources: An English-language literature search was conducted using MEDLINE (1966–January 2006). References of identified articles were subsequently reviewed for additional data. Search terms included rituximab, acquired hemophilia, and inhibitors. Data Synthesis: Available data suggest that B-cell depletion by rituximab in patients with acquired hemophilia may contribute to the eradication of inhibitors to coagulation factors. B-cells have been shown to be essential in the development of autoimmunity or an acquired immune response. Beneficial effects of rituximab, after failure of established therapies, have been reported in case reports and one small, open-label trial. Conclusions: Although data are limited, administration of rituximab appears to be an effective option for treatment of patients with acquired hemophilia after established therapies have failed. Patients given rituximab experienced cessation of recurrent bleeding, normalization of factor VIII activity, and eradication of inhibitors. A complete response to rituximab (undetectable inhibitors, normalization of factor levels) generally occurred several weeks to months after initiation of therapy.
Collapse
Affiliation(s)
- Joan M Stachnik
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Medical Center at Chicago, 60612-7229, USA.
| |
Collapse
|
11
|
Combined Use of Rituximab and Intravenous Immunoglobulin for Severe Autoimmune Cicatricial Conjunctivitis—An Interventional Case Series. Cornea 2016; 35:1611-1614. [DOI: 10.1097/ico.0000000000001024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Abstract
Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease characterized by dryness and systemic involvement in more than a third of the patients. Patient management has suffered from the lack of effective treatments. However, progresses made in the understanding of pSS pathogenesis have allowed a move to a more targeted approach to therapeutic intervention. Given the key role of chronic B cell activation, B cell-targeted therapies were the first candidate. New pathways are currently investigated including costimulation and ectopic germinal centre formation. In this review, we have summarized the new tools available in clinical research in the field of pSS, the current evidence regarding B cell-targeted therapies and an overview of the promising drugs in the pipeline.
Collapse
|
13
|
Jain S, Aresu L, Comazzi S, Shi J, Worrall E, Clayton J, Humphries W, Hemmington S, Davis P, Murray E, Limeneh AA, Ball K, Ruckova E, Muller P, Vojtesek B, Fahraeus R, Argyle D, Hupp TR. The Development of a Recombinant scFv Monoclonal Antibody Targeting Canine CD20 for Use in Comparative Medicine. PLoS One 2016; 11:e0148366. [PMID: 26894679 PMCID: PMC4760772 DOI: 10.1371/journal.pone.0148366] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 01/19/2016] [Indexed: 01/08/2023] Open
Abstract
Monoclonal antibodies are leading agents for therapeutic treatment of human diseases, but are limited in use by the paucity of clinically relevant models for validation. Sporadic canine tumours mimic the features of some human equivalents. Developing canine immunotherapeutics can be an approach for modeling human disease responses. Rituximab is a pioneering agent used to treat human hematological malignancies. Biologic mimics that target canine CD20 are just being developed by the biotechnology industry. Towards a comparative canine-human model system, we have developed a novel anti-CD20 monoclonal antibody (NCD1.2) that binds both human and canine CD20. NCD1.2 has a sub-nanomolar Kd as defined by an octet red binding assay. Using FACS, NCD1.2 binds to clinically derived canine cells including B-cells in peripheral blood and in different histotypes of B-cell lymphoma. Immunohistochemical staining of canine tissues indicates that the NCD1.2 binds to membrane localized cells in Diffuse Large B-cell lymphoma, Marginal Zone Lymphoma, and other canine B-cell lymphomas. We cloned the heavy and light chains of NCD1.2 from hybridomas to determine whether active scaffolds can be acquired as future biologics tools. The VH and VL genes from the hybridomas were cloned using degenerate primers and packaged as single chains (scFv) into a phage-display library. Surprisingly, we identified two scFv (scFv-3 and scFv-7) isolated from the hybridoma with bioactivity towards CD20. The two scFv had identical VH genes but different VL genes and identical CDR3s, indicating that at least two light chain mRNAs are encoded by NCD1.2 hybridoma cells. Both scFv-3 and scFv-7 were cloned into mammalian vectors for secretion in CHO cells and the antibodies were bioactive towards recombinant CD20 protein or peptide. The scFv-3 and scFv-7 were cloned into an ADEPT-CPG2 bioconjugate vector where bioactivity was retained when expressed in bacterial systems. These data identify a recombinant anti-CD20 scFv that might form a useful tool for evaluation in bioconjugate-directed anti-CD20 immunotherapies in comparative medicine.
Collapse
Affiliation(s)
- Saurabh Jain
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
| | - Luca Aresu
- Dipartimento di Biomedicina Comparata e Alimentazione (BCA) Department of Comparative Biomedicine and Food Science, Università di Padova 35020 Legnaro (PD), Italy
| | - Stefano Comazzi
- Dipartimento di Scienze Veterinarie e Sanità Pubblica, Università degli Studi di Milano, via Celoria 10, 20133 Milano, Italy
| | - Jianguo Shi
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
| | - Erin Worrall
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
| | - John Clayton
- Mologic, Ltd, Bedford Technology Park, Thurleigh, Bedford, MK44 2YP, United Kingdom
| | - William Humphries
- Mologic, Ltd, Bedford Technology Park, Thurleigh, Bedford, MK44 2YP, United Kingdom
| | - Sandra Hemmington
- Mologic, Ltd, Bedford Technology Park, Thurleigh, Bedford, MK44 2YP, United Kingdom
| | - Paul Davis
- Mologic, Ltd, Bedford Technology Park, Thurleigh, Bedford, MK44 2YP, United Kingdom
| | - Euan Murray
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
- INSERM Unité 940, Institut de Génétique Moléculaire, Université Paris 7, Hôpital St Louis, 27 rue Juliette Dodu, Paris, France
| | - Asmare A. Limeneh
- Bahit Dar University College of Medicine and Health Sciences Department of Medical Biochemistry and Molecular Biology, Bahir Dar, Ethiopia
| | - Kathryn Ball
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
| | - Eva Ruckova
- Regional Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, 656 53 Brno, Czech Republic
| | - Petr Muller
- Regional Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, 656 53 Brno, Czech Republic
| | - Borek Vojtesek
- Regional Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, 656 53 Brno, Czech Republic
| | - Robin Fahraeus
- INSERM Unité 940, Institut de Génétique Moléculaire, Université Paris 7, Hôpital St Louis, 27 rue Juliette Dodu, Paris, France
| | - David Argyle
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
| | - Ted R. Hupp
- University of Edinburgh, Institute of Genetic and Molecular Medicine and School of Veterinary Medicine, Edinburgh, EH4 2XR, United Kingdom
- * E-mail:
| |
Collapse
|
14
|
Fettke F, Schumacher A, Costa SD, Zenclussen AC. B cells: the old new players in reproductive immunology. Front Immunol 2014; 5:285. [PMID: 25002862 PMCID: PMC4066365 DOI: 10.3389/fimmu.2014.00285] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 06/02/2014] [Indexed: 12/30/2022] Open
Abstract
Reproductive immunology research has long focused on T cell responses to paternal antigens and tolerance mechanisms supporting fetal well-being. The participation of B cells herein was not widely studied. Because of the fascinating immunological uniqueness of pregnancy, it is however to be expected that such pleiotropic cells play a considerable role. In fact, on the one hand B cells contribute toward pregnancy tolerance by secreting the immunomodulatory cytokine IL-10 but on the other hand can seriously harm pregnancy because of their capacity of producing autoantibodies. As for protective B cells, new evidences in mouse models arise suggesting that IL-10 producing B cells, the so-called B10 cells, help in maintaining tolerance toward semi-allogenic fetal antigens. They may be also important to fight danger signals at the fetal-maternal interface as, e.g., in the case of infections with the aim to restore the disrupted fetal tolerance. In human pregnancies, IL-10 producing B cells increase with pregnancy onset but not in the case of spontaneous abortions. In vitro, they are able to suppress TNF-α production by T cells from pregnant individuals. Their generation and functionality will be discussed throughout this review article. B cells can be deleterious to pregnancy as well. Aberrant B cell compartment is associated with obstetric pathologies. In particular, the capacity of B2 cells to produce specific autoantibodies or of B-1a B cells to secrete natural autoantibodies that can turn autoreactive will be discussed herein.
Collapse
Affiliation(s)
- Franziska Fettke
- Department of Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University , Magdeburg , Germany
| | - Anne Schumacher
- Department of Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University , Magdeburg , Germany
| | - Serban-Dan Costa
- University Women's Clinic, Otto-von-Guericke University , Magdeburg , Germany
| | - Ana Claudia Zenclussen
- Department of Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University , Magdeburg , Germany
| |
Collapse
|
15
|
Turner-Stokes T, Sandhu E, Pepper RJ, Stolagiewicz NE, Ashley C, Dinneen D, Howie AJ, Salama AD, Burns A, Little MA. Induction treatment of ANCA-associated vasculitis with a single dose of rituximab. Rheumatology (Oxford) 2014; 53:1395-403. [DOI: 10.1093/rheumatology/ket489] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
16
|
|
17
|
Sangle SR, Lutalo PMK, Davies RJ, Khamashta MA, D'Cruz DP. B-cell depletion therapy and pregnancy outcome in severe, refractory systemic autoimmune diseases. J Autoimmun 2013; 43:55-9. [PMID: 23608146 DOI: 10.1016/j.jaut.2013.03.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 02/26/2013] [Accepted: 03/05/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To study the pregnancy outcome following Rituximab treatment before conception in patients with refractory autoimmune rheumatic diseases. METHODOLOGY Five women with systemic lupus erythematosus (SLE) and 1 woman with ANCA positive vasculitis fulfilling the respective ACR classification criteria were studied retrospectively when they became pregnant following rituximab treatment for refractory disease. Rituximab was given as a 1 g infusion together with 500 mg Methylprednisolone, on day 1 and day 15 after written informed consent. RESULTS The median age was 34 (range 32-39) years and median disease duration was 10 (range 5-16) years. All the patients achieved complete B-cell depletion < 1 cell/μL at 1 month and <5 cells/μL at 6 months with prolonged B-cell depletion. Four women had successful pregnancies with median gestational age of 38 (range 31-40) weeks; median weight of the new born was 3.25 (range1.17-3.3) kg with no documented adverse neonatal events. One patient with lupus nephritis (LN) had a premature delivery and increasing proteinuria in the third trimester. One other patient with LN had a premature delivery and the new born had oesophageal atresia. CONCLUSION We report a child with oesophageal atresia born to a mother with lupus nephritis who had received Rituximab 12 months prior to conception, while four other pregnancies in women with SLE resulted in morphologically normal children. We also describe the first report, to our knowledge, of a successful pregnancy outcome in a woman with granulomatosis with polyangiitis treated with rituximab.
Collapse
Affiliation(s)
- Shirish R Sangle
- Graham Hughes Research Laboratory, The Rayne Institute, St Thomas' Hospital, Guy's, St Thomas' Hospital and King's College Medical School, London SE1 7EH, UK
| | | | | | | | | |
Collapse
|
18
|
Yang JA, Lee SJ, Park JW, Kwon HM, Moon JY, Ko DJ, Chang SH, Park JK, Lee EB, Song YW, Lee EY. Rituximab Treatment for the Patients with Refractory Inflammatory Myopathy. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.5.303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Ji Ae Yang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Jin Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Mi Kwon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Young Moon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Jin Ko
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hae Chang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
19
|
Pollard RPE, Pijpe J, Bootsma H, Spijkervet FKL, Kluin PM, Roodenburg JLN, Kallenberg CGM, Vissink A, van Imhoff GW. Treatment of mucosa-associated lymphoid tissue lymphoma in Sjogren's syndrome: a retrospective clinical study. J Rheumatol 2011; 38:2198-208. [PMID: 21844152 DOI: 10.3899/jrheum.110077] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To retrospectively analyze the clinical course of patients with mucosa-associated lymphoid tissue (MALT)-type lymphoma of the parotid gland and associated Sjögren's syndrome (SS). METHODS All consecutive patients with SS and MALT lymphoma (MALT-SS) diagnosed in the University Medical Center Groningen between January 1997 and January 2009 were analyzed. Clinical course and treatment outcome of SS and MALT lymphoma were evaluated. RESULTS From a total of 329 patients with SS, 35 MALT-SS patients were identified, with a median followup of 76 months (range 16-153 mo). MALT lymphoma was localized in the parotid gland in all cases. Treatment consisted of "watchful waiting" (n = 10), surgery (n = 3), radiotherapy (n = 1), surgery combined with radiotherapy (n = 2), rituximab only (n = 13), or rituximab combined with chemotherapy (n = 6). Complete response was observed in 14 patients, partial response in 1 patient, and stable disease in 20 patients. In 6 of 7 patients with initially high SS disease activity (M-protein, cryoglobulins, IgM rheumatoid factor > 100 KIU/l, severe extraglandular manifestations), MALT lymphoma progressed and/or SS disease activity increased after a median followup of 39 months (range 4-98 mo), necessitating retreatment. Only 1 patient with MALT who had low SS disease activity showed progression of lymphoma when left untreated. CONCLUSION An initially high SS disease activity likely constitutes an adverse prognostic factor for progression of lymphoma and/or SS. Such patients may require treatment for both MALT lymphoma and SS. In SS patients with localized asymptomatic MALT lymphoma and low SS disease activity, a "watchful waiting" strategy seems justified.
Collapse
Affiliation(s)
- Rodney P E Pollard
- Department of Hematology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Meiners PM, Vissink A, Kallenberg CGM, Kroese FGM, Bootsma H. Treatment of primary Sjögren's syndrome with anti-CD20 therapy (rituximab). A feasible approach or just a starting point? Expert Opin Biol Ther 2011; 11:1381-94. [PMID: 21819314 DOI: 10.1517/14712598.2011.605352] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In vitro and in vivo experimental data have suggested new immunopathogenic mechanisms in primary Sjögren's syndrome (pSS). The availability of targeted treatment modalities has opened new ways to selectively target these mechanistic pathways in vivo. Amongst these new treatment modalities, monoclonal antibodies specific for the B-cell surface molecule CD20 have been shown to be the most promising treatment option to date. AREAS COVERED A search of the Pubmed, MEDLINE, EMBASE, Cochrane and Ovid databases was performed to review literature on the efficacy and safety profile of anti-CD20 therapy in pSS patients. EXPERT OPINION A single course of the chimeric humanized anti-CD20 antibody rituximab was effective in reducing disease activity in pSS patients for about six to nine months. Retreatment of responders resulted in a similar effect to initial treatment. When combined with corticosteroids during infusion, rituximab was shown to be a safe drug to administer. Thus, anti-CD20 therapy can be considered an effective treatment option in pSS patients. However, large randomized controlled trials with anti-CD20 therapy, for example rituximab, are warranted in order to: 1) assess long-term effects of such treatment, 2) determine which pSS patients will benefit most from anti-CD20 treatment and 3) assess which retreatment schedule should be followed.
Collapse
Affiliation(s)
- Petra M Meiners
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, The Netherlands
| | | | | | | | | |
Collapse
|
21
|
Negrea GO, Elstrom R, Allen SL, Rai KR, Abbasi RM, Farber CM, Teoh N, Horne H, Wegener WA, Goldenberg DM. Subcutaneous injections of low-dose veltuzumab (humanized anti-CD20 antibody) are safe and active in patients with indolent non-Hodgkin's lymphoma. Haematologica 2010; 96:567-73. [PMID: 21173095 DOI: 10.3324/haematol.2010.037390] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Subcutaneous injections of anti-CD20 antibodies may offer benefits to both patients and the healthcare system for treatment of B-cell malignancies. DESIGN AND METHODS A pilot study was undertaken to evaluate the potential for subcutaneous dosing with 2(nd) generation anti-CD20 antibody veltuzumab in patients with CD20(+) indolent non-Hodgkin's lymphoma. Patients with previously untreated or relapsed disease received 4 doses of 80, 160, or 320 mg veltuzumab injected subcutaneously every two weeks. Responses were assessed by computed tomography scans, with other evaluations including adverse events, safety laboratories, B-cell blood levels, serum veltuzumab levels, and human anti-veltuzumab antibody (HAHA) titers. RESULTS Seventeen patients (14 follicular lymphoma; 13 stage III or IV disease; 5 treatment-naive) completed treatment with only occasional, mild-moderate, transient injection reactions and no other safety issues. Subcutaneous veltuzumab demonstrated a slow release pattern over several days, achieving a mean Cmax of 19, 25 and 63 μg/mL at 80, 160, and 320 mg doses for a total of 4 administrations, respectively. Depletion of circulating B cells occurred after the first injection. The objective response rate (partial responses plus complete responses plus complete responses unconfirmed) was 47% (8/17) with a complete response/complete response unconfirmed rate of 24% (4/17); 4 of 8 objective responses continued for 60 weeks or more. All serum samples evaluated for human anti-veltuzumab antibody were negative. CONCLUSIONS Subcutaneous injections of low-dose veltuzumab are convenient, well tolerated, and capable of achieving sustained serum levels, B-cell depletion, and durable objective responses in indolent non-Hodgkin's lymphoma. (Clinicaltrials.gov identifier: NCT00546793).
Collapse
|
22
|
Abstract
IMPORTANCE OF THE FIELD The use of biologics as immune modulators in several autoimmune diseases has provided new tools to the physician's therapeutic armamentiarium and has led to improved patients' outcomes and quality of life. By producing autoantibodies, B cells in systemic lupus erythematosus (SLE) are key players in the pathogenesis of the disease and in its clinical manifestations. Therefore, biologics that target B cells in SLE aim at reducing the activity of these cells for the induction of remissions and/or amelioration of disease activity, reduction of organ involvement, and limitation of the complications and side effects caused by immunosuppressive therapies. AREAS COVERED IN THIS REVIEW This review describes the past and current clinical trials with B-cell-targeted biologics in SLE, to provide a historical perspective and the state-of-the-art on the topic. WHAT THE READER WILL GAIN We review how the disappointment in the field from promising agents has been instrumental in providing valuable lessons leading to an improved design of new trials that are now giving encouraging results. TAKE HOME MESSAGE In systemic lupus erythematosus (SLE), the use of B-cell-based biologics in clinical trials has shown both disappointment and promise.
Collapse
Affiliation(s)
- Antonio La Cava
- Lupus Research Laboratory, Division of Rheumatology, Department of Medicine, University of California Los Angeles, 1000 Veteran Avenue 32-59, Los Angeles, CA 90095-1670, USA.
| |
Collapse
|
23
|
Tew GW, Rabbee N, Wolslegel K, Hsieh HJ, Monroe JG, Behrens TW, Brunetta PG, Keir ME. Baseline autoantibody profiles predict normalization of complement and anti-dsDNA autoantibody levels following rituximab treatment in systemic lupus erythematosus. Lupus 2009; 19:146-57. [PMID: 19946034 DOI: 10.1177/0961203309350752] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
B cells are thought to play a major role in the pathogenesis of systemic lupus erythematosus (SLE). Rituximab (RTX), a chimeric anti-CD20 mAb, effectively depletes CD20( +) peripheral B cells. Recent results from EXPLORER, a placebo-controlled trial of RTX in addition to aggressive prednisone and immunosuppressive therapy, showed similar levels of clinical benefit in patients with active extra-renal SLE despite effective B cell depletion. We performed further data analyses to determine whether significant changes in disease activity biomarkers occurred in the absence of clinical benefit. We found that RTX-treated patients with baseline autoantibodies (autoAbs) had decreased anti-dsDNA and anti-cardiolipin autoAbs and increased complement levels. Patients with anti-dsDNA autoAb who lacked baseline RNA binding protein (RBP) autoAbs showed increased complement and decreased anti-dsDNA autoAb in response to RTX. Other biomarkers, such as baseline BAFF levels or IFN signature status did not predict enhanced effects of RTX therapy on complement or anti-dsDNA autoAb levels. Finally, platelet levels normalized in RTX-treated patients who entered the study with low baseline counts. Together, these findings demonstrate clear biologic activity of RTX in subsets of SLE patients, despite an overall lack of incremental clinical benefit with RTX in the EXPLORER trial.
Collapse
Affiliation(s)
- G W Tew
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080-4990, USA
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Helpman L, Katz BZ, Safra T, Schreiber L, Levine Z, Nemzer S, Kinar Y, Grisaru D. Systematic antigenic profiling of hematopoietic antigens on ovarian carcinoma cells identifies membrane proteins for targeted therapy development. Am J Obstet Gynecol 2009; 201:196.e1-7. [PMID: 19646570 DOI: 10.1016/j.ajog.2009.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 03/17/2009] [Accepted: 05/10/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We studied ovarian cancers for the expression of membrane markers of hematopoietic origin. STUDY DESIGN We used flow cytometry to systematically characterize the expression of more than 30 hematologic antigens on ovarian carcinoma cell lines and to assess their stability under estrogen exposure. The expression of the antigens was validated by a bioinformatics survey and immunohistochemical staining of ovarian cancer specimens. RESULTS Several antigens were expressed by the majority of the cells, such as CD15, CD71, and CD138, whereas others were found on small and distinct cellular subpopulations. The expression patterns of the different markers were unaffected by estrogen exposure, indicating their stability. CONCLUSION The antigens described in our work may serve as potential targets for new and existing targeted drugs.
Collapse
MESH Headings
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Surface/genetics
- Antigens, Surface/metabolism
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Cell Line, Tumor
- Computational Biology
- Drug Design
- Female
- Flow Cytometry
- Gene Expression Regulation, Neoplastic
- Hematopoiesis
- Humans
- Immunohistochemistry
- Lewis X Antigen/genetics
- Lewis X Antigen/metabolism
- Ovarian Neoplasms/metabolism
- Ovarian Neoplasms/therapy
- Receptors, Transferrin/genetics
- Receptors, Transferrin/metabolism
- Syndecan-1/genetics
- Syndecan-1/metabolism
Collapse
Affiliation(s)
- Limor Helpman
- Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Rothstein TL, Guo B. Receptor crosstalk: reprogramming B cell receptor signalling to an alternate pathway results in expression and secretion of the autoimmunity-associated cytokine, osteopontin. J Intern Med 2009; 265:632-43. [PMID: 19493057 PMCID: PMC2774770 DOI: 10.1111/j.1365-2796.2009.02103.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Receptor crosstalk: reprogramming B cell receptor signalling to an alternate pathway results in expression and secretion of the autoimmunity-associated cytokine, osteopontin (Review). J Intern Med 2009; 265: 632-643.Intracellular signalling emanating from the B-cell antigen receptor is considered to follow a discrete course that requires participation by a set of mediators, grouped together as the signalosome, in order for downstream events to occur. Recent work indicates that this paradigm is true only for naïve B cells. Following engagement of the IL-4 receptor, a new, alternate pathway for B-cell receptor (BCR)-triggered intracellular signalling is established that bypasses the need for signalosome elements and operates in parallel with the classical, signalosome-dependent pathway. Reliance on Lyn and sensitivity to rottlerin by the former, but not the latter, distinguishes these two pathways. The advent of alternate pathway signalling leads to production and secretion by B cells of osteopontin (Opn). As Opn is a polyclonal B-cell activator that is strongly associated with a number of autoimmune diseases including lupus and rheumatoid arthritis, this novel finding is likely to be clinically relevant. Our results highlight the potential role of B-cell-derived Opn in immunity and autoimmunity and suggest that stress-related IL-4 expression might act to strengthen immunoglobulin secretion at the risk of autoantibody formation. Further, these results illustrate receptor crosstalk in the form of reprogramming, whereby engagement of one receptor (IL-4R) produces an effect that persists after the original ligand (IL-4) is removed and results in alteration of the pathway, and outcome, of signalling via a second receptor (BCR) following its activation.
Collapse
Affiliation(s)
- T L Rothstein
- Center for Oncology and Cell Biology, The Feinstein Institute for Medical Research, Manhasset, NY 11030, USA.
| | | |
Collapse
|
26
|
Morschhauser F, Leonard JP, Fayad L, Coiffier B, Petillon MO, Coleman M, Schuster SJ, Dyer MJS, Horne H, Teoh N, Wegener WA, Goldenberg DM. Humanized anti-CD20 antibody, veltuzumab, in refractory/recurrent non-Hodgkin's lymphoma: phase I/II results. J Clin Oncol 2009; 27:3346-53. [PMID: 19451441 DOI: 10.1200/jco.2008.19.9117] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE This is a multicenter phase I/II dose-finding study in relapsed/refractory B-cell non-Hodgkin's lymphoma (NHL) evaluating veltuzumab, a humanized anti-CD20 antibody with structure-function differences from chimeric rituximab. PATIENTS AND METHODS Eighty-two patients (median age, 64 years; 79% stage III/IV, one to nine prior treatments) received four once-weekly doses of 80 to 750 mg/m(2) of veltuzumab and were assessed for safety, efficacy, pharmacodynamics, pharmacokinetics, and immunogenicity. RESULTS Veltuzumab was well tolerated, with no grade 3 to 4 drug-related adverse events despite short infusion times (typically 2 hours initially, 1 hour subsequently at doses < 375 mg/m(2)). In follicular lymphoma, 24 (44%) of 55 patients had objective responses (OR), with 15 (27%) complete responses (CRs) or CRs unconfirmed (CRus) by International Working Group criteria, and with some responses occurring despite two to five prior rituximab-containing regimens, less favorable prognosis (elevated lactate dehydrogenase, tumors > 5 cm, and Follicular Lymphoma International Prognostic Index > or = 2), and at all dose levels. The CRs/CRus were durable (median duration, 19.7 months), with five patients still ongoing (15.9 to 37.6 months duration). In marginal zone lymphoma, five (83%) of six patients had ORs, with two CRs/CRus (33%), and in diffuse large B-cell lymphoma, three (43%) of seven patients achieved partial responses. At all dose levels studied, B cells were depleted after the first infusion, veltuzumab serum half-lives were similar after the fourth infusion, and mean antibody serum levels exceeded values considered important for anti-CD20 therapy (ie, 25 microg/mL). CONCLUSION Veltuzumab appeared safe and active at all tested doses, encouraging further study, including dose levels less than those typically used with rituximab.
Collapse
|
27
|
Perry DK, Burns JM, Pollinger HS, Amiot BP, Gloor JM, Gores GJ, Stegall MD. Proteasome inhibition causes apoptosis of normal human plasma cells preventing alloantibody production. Am J Transplant 2009; 9:201-9. [PMID: 18976291 DOI: 10.1111/j.1600-6143.2008.02461.x] [Citation(s) in RCA: 243] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody production by normal plasma cells (PCs) against human leukocyte antigens (HLA) can be a major barrier to successful transplantation. We tested four reagents with possible activity against PCs (rituximab, polyclonal rabbit antithymocyte globulin (rATG), intravenous immunoglobulin (IVIG) and the proteasome inhibitor, bortezomib) to determine their ability to cause apoptosis of human bone marrow-derived PCs and subsequently block IgG secretion in vitro. IVIG, rituximab and rATG all failed to cause apoptosis of PCs and neither rituximab nor rATG blocked antibody production. In contrast, bortezomib treatment led to PC apoptosis and thereby blocked anti-HLA and antitetanus IgG secretion in vitro. Two patients treated with bortezomib for humoral rejection after allogeneic kidney transplantation demonstrated a transient decrease in bone marrow PCs in vivo and persistent alterations in alloantibody specificities. Total IgG levels were unchanged. We conclude that proteasome activity is important for PC longevity and its inhibition may lead to new techniques of controlling antibody production in vivo.
Collapse
Affiliation(s)
- D K Perry
- Division of Transplantation Surgery, Department of Surgery, von Leibig Transplant Center, Mayo CLinic College of Medicine, Rochester, MN, USA
| | | | | | | | | | | | | |
Collapse
|
28
|
Illa I, Diaz-Manera J, Rojas-Garcia R, Pradas J, Rey A, Blesa R, Juarez C, Gallardo E. Sustained response to Rituximab in anti-AChR and anti-MuSK positive Myasthenia Gravis patients. J Neuroimmunol 2008; 201-202:90-4. [PMID: 18653247 DOI: 10.1016/j.jneuroim.2008.04.039] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 04/15/2008] [Accepted: 04/18/2008] [Indexed: 11/24/2022]
Abstract
We report the results of treatment with Rituximab in six severe, non-responder MG patients. We treated three AChR+MG and three MuSK+MG patients, representing 2% and 20% of the respective groups of our series. Patients were assessed according to the Myasthenia Gravis Foundation of America (MGFA) recommendations. Antibody titers to AChR and MuSK, Ig levels, and IgG subclasses, were tested before treatment and during a follow-up of 9-22 months. All patients, one class V and five class IVB, improved dramatically, with no side effects. Antibody titers declined in all patients (p=0.006). The decline was significantly better in MuSK+MG patients at 9 months (p=0.046) and correlated with a more sustained clinical improvement. We did not find any significant changes in IgG4 that could explain the different outcome observed between these two groups.
Collapse
Affiliation(s)
- Isabel Illa
- Department of Neurology, Neuromuscular Unit, Hospital Santa Creu i Sant Pau, Universitat Autònoma Barcelona, Barcelona, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- Anisur Rahman
- Centre for Rheumatology Research, Division of Medicine, University College London, London, United Kingdom
| | | |
Collapse
|
30
|
Sutter JA, Kwan-Morley J, Dunham J, Du YZ, Kamoun M, Albert D, Eisenberg RA, Luning Prak ET. A longitudinal analysis of SLE patients treated with rituximab (anti-CD20): factors associated with B lymphocyte recovery. Clin Immunol 2008; 126:282-90. [PMID: 18226586 DOI: 10.1016/j.clim.2007.11.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 11/07/2007] [Accepted: 11/13/2007] [Indexed: 10/22/2022]
Abstract
Identifying factors associated with B lymphocyte depletion and recovery may aid the development of individualized treatment regimens, optimizing therapy for patients with autoimmune disease. In this study, 12 patients with active SLE were monitored at baseline and monthly following treatment with rituximab. The number and phenotype of peripheral blood B lymphocytes, T lymphocytes and natural killer cells were correlated with the extent and longevity of B lymphocyte depletion. This analysis generated three candidate biomarkers for lymphocyte monitoring in patients with autoimmune disease who are treated with rituximab: circulating transitional B cells, the kappa:lambda ratio and natural killer cells. Further refinement of these potential biomarkers may lead to a better understanding of the role of B cells in disease pathogenesis and a more rational use of B cell depletion therapies.
Collapse
Affiliation(s)
- Jennifer A Sutter
- Department of Pathology and Laboratory Medicine, School of Medicine, University of Pennsylvania, 405B Stellar Chance Labs, 422 Curie Boulevard, Philadelphia, PA 19104, USA
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Lee SJ, Kavanaugh AF. Monoclonal antibodies and fusion proteins. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10095-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
32
|
Affiliation(s)
- Stephen M Jackson
- Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma 73104, USA
| | | | | | | |
Collapse
|
33
|
Stuiver I, von Herrath M. At long last: clinically significant immunomodulatory therapies. Expert Rev Clin Immunol 2007; 3:667-70. [PMID: 20477016 DOI: 10.1586/1744666x.3.5.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
34
|
Selamet U, Kovaliv YB, Savage CO, Harper L. ANCA-associated vasculitis: new options beyond steroids and cytotoxic drugs. Expert Opin Investig Drugs 2007; 16:689-703. [PMID: 17461741 DOI: 10.1517/13543784.16.5.689] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Small vessel vasculitic syndromes--Wegener's granulomatosis, microscopic polyangiitis and renal limited vasculitis (which are associated with circulating antineutrophil cytoplasmic autoantibodies)--are an important cause of renal failure. Present immunosuppressive regimens that are based on cyclophosphamide have significantly increased survival rates. However, these treatments are toxic, increase the risk of infection and do not cure disease. Therefore, newer approaches are required. Understanding disease pathogenesis has allowed rational use for newer therapies such as rituximab, which depletes B cells. Unfortunately, blockade of promising targets such as TNF-alpha, which was thought to be a pivotal cytokine in inflammation, has not shown benefit in a randomised controlled trial. Better understanding of the pathogenesis of the disease is the key to the development of novel targeted therapies, which are urgently required to improve patient prognosis. Gene therapy with targeted delivery of specific proteins is an exciting future prospect.
Collapse
Affiliation(s)
- Umut Selamet
- University of Birmingham, Division of Immunity and Infection, The Medical School, Edgbaston, Birmingham, B15 2TT, UK
| | | | | | | |
Collapse
|
35
|
Affiliation(s)
- Susan J Lee
- Division of Rheumatology, Allergy, and Immunology, The University of California, San Diego, USA.
| | | |
Collapse
|
36
|
Bussel JB, Giulino L, Lee S, Patel VL, Sandborg C, Stiehm ER. Update on therapeutic monoclonal antibodies. Curr Probl Pediatr Adolesc Health Care 2007; 37:118-35. [PMID: 17434008 DOI: 10.1016/j.cppeds.2007.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Monoclonal antibodies are among the most important class of drugs introduced into the therapeutic armamentarium since the introduction of antimicrobials in the 1930s. The first therapeutic monoclonal antibody, the anti T-cell monoclonal antibody OKT4, was licensed in 1986. Since then, 18 additional antibodies have been licensed in the US, with many more in the pipeline. Before 1986, many monoclonal antibodies were available for laboratory studies, notably to identify specific cells in the blood and tissues. This is best illustrated by the cluster designation (CD) system for antigens present on hematopoietic cells, now numbering over 200.
Collapse
Affiliation(s)
- James B Bussel
- Department of Pediatrics, Cornell University School of Medicine, New York, NY, USA
| | | | | | | | | | | |
Collapse
|
37
|
Schmidt E, Seitz CS, Benoit S, Bröcker EB, Goebeler M. Rituximab in autoimmune bullous diseases: mixed responses and adverse effects. Br J Dermatol 2007; 156:352-6. [PMID: 17223877 DOI: 10.1111/j.1365-2133.2006.07646.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intolerably high doses of systemic corticosteroids and additional immunosuppressants may be required to control disease activity in autoimmune bullous skin diseases. New therapeutic options are needed for such patients. OBJECTIVES To determine the efficacy and adverse effects of adjuvant rituximab. METHODS Seven patients with refractory autoimmune blistering diseases (pemphigus vulgaris, PV, n = 4; bullous pemphigoid, BP, n = 2; mucous membrane pemphigoid, MMP, n = 1) were treated four times with rituximab at an individual dose of 375 mg m(-2) at weekly intervals. RESULTS All lesions cleared in three patients (two PV, one BP), while they were reduced by more than 50% in three others (two PV, one BP). The concomitant immunosuppressive medication was reduced in five patients (four PV, one BP). The patient with MMP developed bilateral blindness while nasopharyngeal lesions resolved. Three patients (two BP, one PV) experienced severe adverse events including fatal pneumonia. CONCLUSIONS Adjuvant B-cell depletion by rituximab is effective in otherwise therapy-resistant bullous autoimmune disorders but may be associated with substantial adverse effects including fatal outcomes.
Collapse
Affiliation(s)
- E Schmidt
- Department of Dermatology, University of Würzburg, Josef-Schneider-Strasse 2, D-97080 Würzburg,
| | | | | | | | | |
Collapse
|
38
|
Williams DL. Fighting tooth and CLAW for more monoclonal antibodies against canine leucocyte antigens. Vet J 2007; 173:18-9. [PMID: 16246602 DOI: 10.1016/j.tvjl.2005.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
39
|
Abstract
Immunoglobulins (Igs) or antibodies (Abs) are the principal operators of the adaptive humoral immune response. For optimum functional activity they acquire an optimized structure for antigen (Ag) recognition, precipitation, agglutination, phagocytosis (IgG1/3 and IgA), cytotoxicity (IgG1/3), transport through mucosa (IgA and IgM) and placenta (IgG1/3), complement activation (IgG1/3 and IgM) and release of inflammatory mediators (IgE). A diversity with potentially up to 10(15) different Ab specificities is generated during Ag-independent B cell development in the bone marrow by combinatorial V-D-J joining, creation of junctional diversity, and combinatorial association of L and H chains. Furthermore,Ab variety is created during Ag-dependent B cell maturation in peripheral lymphatic tissues by isotype class switching and somatic hypermutation. Two types of enzymes play a key role in Ab diverseness, i. e., the products of recombination-activating genes RAG1 and RAG2 and the affinity induced deaminase (AID). The prevailing adult-type B2 cells provide the basis for the acquired humoral immune response characterized by Ab production,Ag processing and presentation, immunological memory and tolerance along with the generation of the anti-idiotype network,whereas the fetal-type B1 cells may play a role in innate immunity and autoimmunity. Impairment of B cell immunity includes immunodeficiency (agammaglobulinemia), malignant transformation (leukemia, lymphoma, plasmocytoma) and immune dysregulation (allergy, autoimmunity). The diagnostic relevance of Abs comprises classical serology (immunoprecipitation, agglutination, complement binding, RIA, ELISA), immunocytochemistry and immunohistochemistry, immunofluorescence (microscopic and flow cytometric), cytotoxicity tests, immunoblots, immunospot assays and immunoabsorption (affinity chromatography). Therapeutic application of Abs (passive immunization) is directed against infections, intoxications, solid tumors, leukemias and lymphomas, graft rejection and graft-versus-host reaction, hemolytic anemia, and autoimmune diseases. The generation of genetically engineered monoclonal Abs (mAbs) has revolutionized the diagnostic and therapeutic potential of Abs in almost all disciplines of modern medicine.
Collapse
Affiliation(s)
- Eilhard Mix
- University of Rostock, Dept. of Neurology, Gehlsheimer Str. 20, 18147, Rostock, Germany.
| | | | | |
Collapse
|
40
|
Bryce AH, Dispenzieri A, Kyle RA, Lacy MQ, Rajkumar SV, Inwards DJ, Yasenchak CA, Kumar SK, Gertz MA. Response to Rituximab in Patients with Type II Cryoglobulinemia. ACTA ACUST UNITED AC 2006; 7:140-4. [PMID: 17026826 DOI: 10.3816/clm.2006.n.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Type II cryoglobulinemia (CG) is a heterogeneous, generally indolent disorder caused by a monoclonal antibody with activity against polyclonal antibodies and is commonly associated with hepatitis C, lymphoproliferative disorders (LPDs), or autoimmune diseases. It can lead to substantial morbidity, including renal failure, cutaneous ulcers, or neuropathy. Medical records were reviewed for 8 patients with previously treated symptomatic CG who were part of a prospectively held dysproteinemia database. Patients subsequently received 14 total courses of rituximab treatment (standard infusion, 375 mg/m2 for 4 or 8 doses) between February 1999 and March 2005. One patient had essential CG, and 1 had Gaucher disease with hypersplenism. Six patients had an LPD, and 4 of them had concomitant disorders (2 with hepatitis C and 2 with Sjogren syndrome). Treatment indications included purpura, LPD, cutaneous ulcers, and renal failure. Clinical improvement was evaluated by improved cryocrit, total complement, C4, and rheumatoid factor. Six patients had some clinical improvement. Cutaneous manifestations were the most responsive; renal disease and lymphoma were more refractory. Laboratory values showed improvement after 7 of 12 available treatment courses. No adverse reactions were noted. Overall, rituximab appears to be a safe and effective therapy.
Collapse
Affiliation(s)
- Alan H Bryce
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
El Tal AK, Posner MR, Spigelman Z, Ahmed AR. Rituximab: A monoclonal antibody to CD20 used in the treatment of pemphigus vulgaris. J Am Acad Dermatol 2006; 55:449-59. [PMID: 16908351 DOI: 10.1016/j.jaad.2006.05.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Revised: 05/03/2006] [Accepted: 05/05/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Rituximab is an anti-CD20 chimeric antibody that selectively targets B lymphocytes. Recently, it has been reported to be beneficial in treating pemphigus vulgaris. OBJECTIVE Our aim was to review the English-language literature on the treatment of pemphigus vulgaris (PV) with rituximab and to determine its efficacy and influence on clinical outcome(s). MATERIAL AND METHODS A retrospective review of the literature on the use of rituximab in the treatment of PV was conducted. Seventeen patients in 10 reports were described and their data were reviewed. RESULTS The majority of patients received one course of rituximab along with conventional immunosuppressive therapy as concomitant therapy; 88% of the patients demonstrated improvement. More than half of the patients were followed up for more than 6 months after rituximab treatment; they appeared to be clinically disease free, but were still receiving conventional immunosuppressive therapy. Side effects in most patients were transient and infusion related. Serious infections occurred in 4 patients. One patient died. LIMITATIONS The sample size of this study is small; there is no uniformity of data collection or measurement of key and critical indices, and follow-up was limited. CONCLUSION Rituximab may be a promising agent in treatment of PV.
Collapse
Affiliation(s)
- Abdul Kader El Tal
- Department of Medicine, New England Baptist Hospital, Harvard School of Dental Medicine, Boston, Massachusetts 02120, USA
| | | | | | | |
Collapse
|
42
|
Abstract
The ability of antibodies to recognize specific antigenic targets and trigger responses from the immune system has made them attractive candidates as therapeutic agents. Monoclonal and recombinant technology have made possible the development of a new class of therapeutic and diagnostic agents that combine the exquisite specificity of antibodies with biologic compatibility and protracted half-lives. This technology is just beginning to be explored and considerable evolution may be expected in the next few decades.
Collapse
|
43
|
Browning JL. B cells move to centre stage: novel opportunities for autoimmune disease treatment. Nat Rev Drug Discov 2006; 5:564-76. [PMID: 16816838 DOI: 10.1038/nrd2085] [Citation(s) in RCA: 205] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The B-cell arm of the immune system has long been appreciated for its crucial role in pathogen resistance, but in the study of many autoimmune diseases, T cells have dominated the limelight for decades. However, the development of the B-cell-depleting antibody rituximab as a lymphoma therapy has provided a tool to probe the contribution made by B cells in several immune disorders. Recently, the success of B-cell depletion with rituximab in the treatment of rheumatoid arthritis has stimulated investigation of its effects in several other immune disorders, and considerable interest in the potential of drugs that can modulate B-cell function for the treatment of such diseases in general. This article discusses the role of B cells in a range of autoimmune disorders, including rheumatoid arthritis and systemic lupus erythematosus, and analyses approaches to therapeutic B-cell manipulation.
Collapse
Affiliation(s)
- Jeffrey L Browning
- Department of Immunobiology, Biogen Idec, 12 Cambridge Center, Cambridge, Massachusetts 02445, USA.
| |
Collapse
|
44
|
Ruggenenti P, Chiurchiu C, Abbate M, Perna A, Cravedi P, Bontempelli M, Remuzzi G. Rituximab for Idiopathic Membranous Nephropathy: Who Can Benefit? Clin J Am Soc Nephrol 2006; 1:738-48. [PMID: 17699281 DOI: 10.2215/cjn.01080905] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rituximab effectively reduces proteinuria in patients with idiopathic membranous nephropathy (IMN), but response to treatment may vary from patient to patient. The association between baseline clinical, laboratory, and histology covariates and proteinuria reduction was evaluated retrospectively by multiple linear regression analysis at 3 mo after rituximab therapy in 14 patients with IMN with proteinuria > 3.5 g/24 h while on angiotensin-converting enzyme inhibition for at least 6 mo and no previous remissions. The association strength was expressed by standardized beta coefficients (SbetaC). Glomerular (SbetaC = 0.48, P = 0.049) and tubulointerstitial (TI) scores (SbetaC = 0.61, P = 0.003) predicted the outcome. Among glomerular and TI score components, tubular atrophy (SbetaC = 0.59, P = 0.003) and interstitial fibrosis (SbetaC = 0.60, P = 0.001) were significantly associated with 3-mo proteinuria. Urinary protein excretion decreased from 9.1 +/- 4.0 to 4.6 +/- 3.5 g/24 h (P < 0.001) in eight patients with TI score 1.7 but did not change in six with a score > or = 1.7. Nine additional patients with IMN then were allocated prospectively to rituximab treatment on the basis of a TI score < 1.7. Three-month proteinuria decreased in all patients from 8.9 +/- 5.3 to 4.9 +/- 3.9 g/24 h (P < 0.001) and serum albumin increased from 2.2 +/- 0.6 to 2.8 +/- 0.5 mg/dl (P < 0.01). Changes in serum albumin and cholesterol were inversely correlated (P < 0.02, r = -0.44). Rituximab achieved CD20 and CD19 depletion in all patients. In patients with IMN and nephrotic proteinuria despite angiotensin-converting enzyme inhibition therapy, renal biopsy findings may help in predicting response to rituximab and defining selection criteria for randomized trials that aim to assess the risk/benefit profile of B cell target therapy as compared with aspecific immunosuppressants and/or conservative therapy alone.
Collapse
Affiliation(s)
- Piero Ruggenenti
- Clinical Research Center for Rare Diseases Aldo & Cele Daccò, Mario Negri Institute for Pharmacological Research, Via Gavazzeni, 11, 24125 Bergamo, Italy.
| | | | | | | | | | | | | |
Collapse
|
45
|
Fabbri A, Gozzetti A, Lazzi S, Lenoci M, D'Amuri A, Leoncini L, Lauria F. Activity of Rituximab Monotherapy in Refractory Splenic Marginal Zone Lymphoma Complicated with Autoimmune Hemolytic Anemia. ACTA ACUST UNITED AC 2006; 6:496-9. [PMID: 16796783 DOI: 10.3816/clm.2006.n.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe the case of a 61-year-old patient with refractory splenic marginal zone lymphoma and secondary autoimmune hemolytic anemia, both successfully treated with rituximab. This case demonstrates that rituximab monotherapy might also be a valid therapeutic approach in marginal zone lymphoma and autoimmune hemolytic anemia after failure of first-line treatment. Maintenance therapy, although expensive, could be useful to improve event-free survival in patients with unfavorable clinical behavior.
Collapse
MESH Headings
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/pathology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/therapeutic use
- Biopsy
- Bone Marrow/pathology
- Humans
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/pathology
- Male
- Middle Aged
- Prednisone/therapeutic use
- Rituximab
- Splenectomy
- Treatment Outcome
Collapse
Affiliation(s)
- Alberto Fabbri
- Division of Hematology and Transplants, Policlinico S. Maria alle Scotte, and University of Siena, Italy.
| | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
The term vasculitis refers to a pathologic condition defined by inflammatory cell infiltration and destruction of blood vessels. Systemic vasculitis is classified as primary (eg, polyarteritis nodosa, Churg-Strauss syndrome) or secondary, the latter associated with connective tissue disorders, infections, medications, and rarely, as a paraneoplastic phenomenon. Neuropathy is a common complication of systemic vasculitis and is related to ischemic nerve fiber damage with axon loss. Peripheral neuropathy may be the sole manifestation of vasculitis, a condition termed nonsystemic vasculitic neuropathy (NSVN). Treatment of vasculitic neuropathy requires long-term immunosuppressive therapies with potential side effects. The diagnosis of vasculitis should be established by tissue (preferably nerve) biopsy. High-dose prednisone is the standard platform therapy for patients with systemic and NSVN; for those with systemic vasculitis, at least 3 to 12 months of treatment with cyclophosphamide (monthly intravenous pulse or daily oral therapy) is also necessary to sustain remission and allow successful prednisone tapering. The use of cyclophosphamide in patients with NSVN is controversial, but recent retrospective data suggest that those treated with prednisone and cyclophosphamide from the outset fare better than those initially treated only with prednisone. If prednisone is administered as monotherapy, cyclophosphamide should be added after several months if there is no improvement or relapse occurs with tapering of prednisone. Intravenous pulse and daily oral cyclophosphamide probably offer similar efficacy, although the risk of complications is greater with oral therapy. Azathioprine can be safely substituted for cyclophosphamide after 3 months without an increased relapse rate. Azathioprine, methotrexate, intravenous immune globulin, mycophenolate mofetil, plasma exchange, and rituximab can be offered to patients who are intolerant or have a contraindication to cyclophosphamide. However, efficacy is unproven for any of these therapies. Interferon-alpha, sometimes combined with plasma exchange, is used to treat vasculitis associated with hepatitis B infection. Some patients also may improve with corticosteroids. The classification of diabetic lumbosacral radiculoplexus neuropathy as a vasculitic disorder remains controversial. However, there is compelling pathological evidence that this condition represents a T-cell-mediated microvasculitis. Some patients treated with intravenous corticosteroids may have greater recovery and improved pain control.
Collapse
Affiliation(s)
- Kenneth C Gorson
- Neuromuscular Service, Department of Neurology, St. Elizabeth's Medical Center, Tufts University School of Medicine, 736 Cambridge Street, Boston, MA 02135, USA.
| |
Collapse
|
47
|
|
48
|
Eisenberg R, Looney RJ. The therapeutic potential of anti-CD20 "what do B-cells do?". Clin Immunol 2005; 117:207-13. [PMID: 16169773 DOI: 10.1016/j.clim.2005.08.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 08/17/2005] [Indexed: 12/16/2022]
Abstract
B-cells play a major role in the immunopathogenesis of autoimmune diseases. Not only do they produce autoantibodies, but they regulate other cell types, secrete cytokines, and present antigens. They are thus potential targets for therapeutic intervention. CD20 is a B-cell specific cell surface molecule of uncertain function. An anti-CD20 chimeric mAb (rituximab) has been FDA approved for treatment of B-cell lymphomas since 1997. Rituximab also depletes normal B-cells by several mechanisms, including ADCC. Over the past seven years, it has shown promise in a number of autoimmune diseases in phase I trials and anecdotal reports. Efficacy in rheumatoid arthritis has already been demonstrated in randomized control trials (RCTs), and RCTs in SLE, inflammatory myositis, and ANCA associated vasculitis are under way. Safety does not appear to be a major problem, but continued vigilance is warranted. The increased use of rituximab, other anti-CD20 agents, and other B-cell targeting therapies holds great promise for substantial clinical benefits, as well as providing special opportunities to understand better disease pathogenesis.
Collapse
Affiliation(s)
- Robert Eisenberg
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA 19104, USA. raemd@mail. med.upenn.edu
| | | |
Collapse
|
49
|
Park SJ, Han CW. The Long Term Remission Effect of Rituximab in Two Patients with Autoimmune-associated Cytopenias that were Refractory to Standard Treatments. THE KOREAN JOURNAL OF HEMATOLOGY 2005. [DOI: 10.5045/kjh.2005.40.2.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Soo-Jeong Park
- Division of Hemato-Oncology, Department of Internal Medicine, Our Lady of Mercy Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chi-Wha Han
- Division of Hemato-Oncology, Department of Internal Medicine, Our Lady of Mercy Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| |
Collapse
|