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Shah K, Leandro M, Cragg M, Kollert F, Schuler F, Klein C, Reddy V. Disrupting B and T-cell collaboration in autoimmune disease: T-cell engagers versus CAR T-cell therapy? Clin Exp Immunol 2024; 217:15-30. [PMID: 38642912 PMCID: PMC11188544 DOI: 10.1093/cei/uxae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/07/2024] [Accepted: 04/18/2024] [Indexed: 04/22/2024] Open
Abstract
B and T cells collaborate to drive autoimmune disease (AID). Historically, B- and T-cell (B-T cell) co-interaction was targeted through different pathways such as alemtuzumab, abatacept, and dapirolizumab with variable impact on B-cell depletion (BCD), whereas the majority of patients with AID including rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, and organ transplantation benefit from targeted BCD with anti-CD20 monoclonal antibodies such as rituximab, ocrelizumab, or ofatumumab. Refractory AID is a significant problem for patients with incomplete BCD with a greater frequency of IgD-CD27+ switched memory B cells, CD19+CD20- B cells, and plasma cells that are not directly targeted by anti-CD20 antibodies, whereas most lymphoid tissue plasma cells express CD19. Furthermore, B-T-cell collaboration is predominant in lymphoid tissues and at sites of inflammation such as the joint and kidney, where BCD may be inefficient, due to limited access to key effector cells. In the treatment of cancer, chimeric antigen receptor (CAR) T-cell therapy and T-cell engagers (TCE) that recruit T cells to induce B-cell cytotoxicity have delivered promising results for anti-CD19 CAR T-cell therapies, the CD19 TCE blinatumomab and CD20 TCE such as mosunetuzumab, glofitamab, or epcoritamab. Limited evidence suggests that anti-CD19 CAR T-cell therapy may be effective in managing refractory AID whereas we await evaluation of TCE for use in non-oncological indications. Therefore, here, we discuss the potential mechanistic advantages of novel therapies that rely on T cells as effector cells to disrupt B-T-cell collaboration toward overcoming rituximab-resistant AID.
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Affiliation(s)
| | - Maria Leandro
- Centre for Rheumatology, UCLH, London,UK
- Department of Rheumatology, University College London Hospital, London, UK
| | - Mark Cragg
- University of Southampton Faculty of Medicine, Antibody and Vaccine Group, Centre for Cancer Immunology, University of Southampton, Southampton, UK
| | - Florian Kollert
- Roche Innovation Center Basel, Early Development Immunology, Infectious Diseases & Ophthalmology, Basel, Switzerland
| | - Franz Schuler
- Roche Innovation Center Basel, Roche Pharma Research and Early Development, Schlieren, Switzerland
| | - Christian Klein
- Roche Innovation Center Zurich, Cancer Immunotherapy Discovery, Oncology Discovery & Translational Area, Schlieren, Switzerland
| | - Venkat Reddy
- Centre for Rheumatology, UCLH, London,UK
- Department of Rheumatology, University College London Hospital, London, UK
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Schett G, Nagy G, Krönke G, Mielenz D. B-cell depletion in autoimmune diseases. Ann Rheum Dis 2024:ard-2024-225727. [PMID: 38777374 DOI: 10.1136/ard-2024-225727] [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: 02/26/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Abstract
B cells have a pivotal function in the pathogenesis of autoimmune diseases, such as rheumatoid arthritis, multiple sclerosis and systemic lupus erythematosus. In autoimmune disease, B cells orchestrate antigen presentation, cytokine production and autoantibody production, the latter via their differentiation into antibody-secreting plasmablasts and plasma cells. This article addresses the current therapeutic strategies to deplete B cells in order to ameliorate or potentially even cure autoimmune disease. It addresses the main target antigens in the B-cell lineage that are used for therapeutic approaches. Furthermore, it summarises the current evidence for successful treatment of autoimmune disease with monoclonal antibodies targeting B cells and the limitations and challenges of these approaches. Finally, the concept of deep B-cell depletion and immunological reset by chimeric antigen receptor T cells is discussed, as well as the lessons from this approach for better understanding the role of B cells in autoimmune disease.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - György Nagy
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
| | - Gerhard Krönke
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Rheumatology, Charite, Berlin, Germany
| | - Dirk Mielenz
- Division of Molecular Immunology, Department of Internal Medicine 3, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
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3
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Zisa D, Zhang-Sun J, Christos PJ, Kirou KA. Sustained depression of B cell counts in lupus nephritis after treatment with rituximab and/or belimumab is associated with fewer disease flares. Lupus 2024:9612033241260283. [PMID: 38860319 DOI: 10.1177/09612033241260283] [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: 06/12/2024]
Abstract
OBJECTIVE To study the risk of lupus nephritis flare (LNF) or severe lupus flare (SLF) as a function of B cell count kinetics in lupus nephritis (LN) patients after they achieve at least a partial renal response (PRR) with induction treatment that includes rituximab (RTX) and/or belimumab (BLM). METHODS We performed a retrospective analysis of a cohort of 19 patients with severe LN that received a B cell agent (BCA), RTX and/or BLM, as part of an initial treatment regimen for an LN flare and had subsequent CD19+ B cell measurements in peripheral blood. We then characterized the follow-up periods, after B cell depressions occurred and PRR were achieved, by the corresponding trajectories of B cell counts (BCC). Time periods with sustained low BCC were type 1 (T1) episodes, while those with repletion of BCC>100 cells/μL were called type 2 (T2) episodes. Time periods with rapid BCC repletion, defined as >50 cells/μL in ≤6 months, were called T2b episodes. Corresponding C3, C4, and anti-dsDNA levels were recorded for each episode. The time from PRR until an event, either a LNF or SLF, or to censoring, either at the end of the study period or the end of available patient follow-up, was assessed for each episode type. Kaplan-Meier survival analysis was used to compare time to flare between T1 and T2 episodes. RESULTS There were 26 episodes of B cell depression. Seventeen (65%) were T1 and 9 (35%) were T2. Compared to T1 episodes, T2 episodes were 9.0 times more likely to result in flare over the follow-up period (hazard ratio (HR) = 9.0, 95% CI for HR = 2.2-36.7); this risk was even larger for T2b vs T1 episodes. Median BCC was 14 cells/μL in T1 and 160 cells/μL in T2 episodes. Both C3 and C4 levels significantly increased over the duration of the episode in T1 episodes only. CONCLUSION Sustained low BCC was associated with prolonged serologic and clinical response, whereas repletion, and particularly rapid repletion, of B cells after treatment with BCA was associated with subsequent disease flare.
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Affiliation(s)
- Diane Zisa
- Columbia University Irving Medical Center, New York, NY, USA
| | | | | | - Kyriakos A Kirou
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
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4
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Hartinger JM, Šíma M, Hrušková Z, Pilková A, Krátký V, Ryšavá R, Jančová E, Bobek D, Douša J, Francová I, Tesař V, Slanař O. A novel dosing approach for rituximab in glomerular diseases based on a population pharmacokinetic analysis. Biomed Pharmacother 2024; 175:116655. [PMID: 38678967 DOI: 10.1016/j.biopha.2024.116655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/01/2024] Open
Abstract
OBJECTIVES Rituximab is being increasingly prescribed for the treatment of autoimmune glomerular diseases. While it is highly effective for some diseases, the response is less predictable for others, which may be due to differing requirements in terms of the dosing according to the disease type and variations concerning exposure to the drug. METHODS We compiled novel rituximab dosing schedules according to pharmacokinetic analysis of data gathered from rituximab treated patients in a tertiary referral nephrology centre between May 2020 and June 2023. The population-pharmacokinetic analysis was based on the rituximab dosing, the patients' characteristics, rituximab levels and anti-rituximab antibodies. RESULTS The analysis, which was based on data from 185 patients, clearly highlighted differing rituximab dosing requirements for patients with ANCA associated vasculitis and minimal change disease compared to those with membranous nephropathy, focal-segmental glomerulosclerosis and lupus nephritis. This corresponded to the good treatment response of the first two diseases and the unreliable efficacy for the others. The model predicts the rituximab pharmacokinetics with high degree of accuracy when body weight, proteinuria, type of glomerulonephritis, treatment length and anti-rituximab antibodies formation are used as covariates. We proposed a dosing schedule with shortened dosing intervals for difficult-to-treat diagnoses with high proteinuria. CONCLUSION In order to ensure reliable and comparable exposure of rituximab with respect to the full range of glomerular diseases, the dosing schedule should be adjusted for membranous nephropathy, focal-segmental glomerulosclerosis and lupus nephritis. This is largely, but not solely, due to the enhanced level of unselective proteinuria in these diseases.
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Affiliation(s)
- Jan Miroslav Hartinger
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
| | - Martin Šíma
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zdenka Hrušková
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Alena Pilková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vojtěch Krátký
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Romana Ryšavá
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Jančová
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Daniel Bobek
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jiří Douša
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ivana Francová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
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Johnson NM, Koumpouras F. Chimeric antigen receptors: "CARs" in the fast lane for rheumatology. Curr Opin Rheumatol 2024; 36:176-183. [PMID: 38517338 DOI: 10.1097/bor.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
PURPOSE OF REVIEW Recent advances in hematology-oncology have pioneered cell-mediated elimination of pathologic B-cell populations employing chimeric antigen receptor (CAR) T cells. In this review, we discuss recent adoption of CAR-T treatment for severe refractory autoimmune disease. We highlight unique aspects of the autoimmune model and review current clinical data regarding treatment of rheumatologic disease. RECENT FINDINGS To date, several CAR-Ts are FDA approved for Multiple Myeloma and B-cell malignancies and have demonstrated extraordinary clinical responses in refractory disease. Realizing the central role of B-cells in certain autoimmune diseases, CAR-T is now being explored for achieving drug-free remission induction, and potentially cure, of several rheumatologic diseases. The largest experience to date in the field of autoimmunity, building off the University Hospital Erlangen groups' earlier success treating a single patient with CD19-CAR in severe refractory SLE, Mackensen et al. enrolled five patients in a compassionate use program. Following autologous CD19-CAR T infusion, they demonstrated drug-free clinical and laboratory remission for at least 12 months in all five patients, with reconstitution of B cells expressing a naïve phenotype. SUMMARY CAR-T treatment has shown striking drug-free responses in severe lupus and other autoimmune diseases, creating a need for further exploration and development.
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Affiliation(s)
- Nathan M Johnson
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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6
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Wenderfer SE, Cooper JC. Do we really need cyclophosphamide for lupus nephritis? Pediatr Nephrol 2024:10.1007/s00467-024-06367-9. [PMID: 38607424 DOI: 10.1007/s00467-024-06367-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
A 14-year-old patient presents with hematuria and proteinuria. Clinical evaluation reveals a positive anti-nuclear antibody titer, positive anti-double stranded DNA antibody and hypocomplementemia. Systemic lupus erythematosus (SLE) is diagnosed based on the 2019 EULAR/ACR (European League Against Rheumatism/American College of Rheumatology) classification criteria (Aringer et al. Arthritis Rheumatol 71:1400-1412, 2019). A kidney biopsy is performed that confirms the presence of immune complex glomerulonephritis, ISN-RPS (International Society of Nephrology/Renal Pathology Society) class IV (Bajema et al. Kidney Int 93:789-796, 2018). According to the latest clinical practice guidelines (Rovin et al. Kidney Int 100:753-779, 2021; Fanouriakis et al. Ann Rheum Dis 83:15-29, 2023), there are alternatives to treating this patient with cyclophosphamide. But what if this patient also presented with oliguria and volume overload requiring intensive care and dialysis? What if this patient also presented with altered mental status and seizures, and was diagnosed with neuropsychiatric lupus? What if this patient was also diagnosed with a pulmonary hemorrhage and respiratory failure? The clinical practice guidelines do not address these scenarios that are not uncommon in patients with SLE. Moreover, in some countries worldwide, patients do not have the privilege of access to biologics or more expensive alternatives. The purpose of this review is to evaluate the contemporary options for initial treatment of nephritis in patients with SLE.
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Affiliation(s)
- Scott E Wenderfer
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada.
- Pediatric Nephrology, BC Children's Hospital, Vancouver, BC, Canada.
| | - Jennifer C Cooper
- Department of Pediatrics, University of Colorado, Denver, CO, USA
- Pediatric Rheumatology, Children's Hospital Colorado, Aurora, CO, USA
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7
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Rodziewicz M, Mendoza-Pinto C, Dyball S, Munguía-Realpozo P, Parker B, Bruce IN. Predictors and prognostic factors influencing outcomes of anti-CD20 monoclonal antibodies in systemic lupus erythematosus: A systematic review update. Semin Arthritis Rheum 2024; 65:152346. [PMID: 38185077 DOI: 10.1016/j.semarthrit.2023.152346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/09/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Anti-C20 monoclonal antibodies (MAb), such as rituximab, are commonly used for the treatment of patients with severe or refractory systemic lupus erythematosus (SLE) but clinical outcomes are highly variable. We aimed to provide an update of a systematic review of predictive and prognostic factors of anti-CD20 MAb treatment in SLE. METHODS A systematic literature search was undertaken to identify predictive and prognostic factors of clinical response following treatment with anti-CD20 therapies in SLE patients. Studies examining rituximab published prior to 2015 were excluded. Risk of bias was assessed for randomized controlled trials (RCTs) using the Cochrane Collaboration (RoB2) tool for RCTs and the Quality In Prognosis Studies Tool (QUIPS) for cohort studies. A narrative synthesis of the evidence was undertaken and quality of evidence (QoE) was assessed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS From 850 studies identified, 17 studies met the inclusion criteria. A further 8 studies were identified and included through search updates. There were two post-hoc analyses of RCTs of rituximab, one RCT of ocrelizumab and one of obinutuzumab; and 16 cohort studies examining rituximab treatment. The overall QoE was low or very low. There was wide heterogeneity in definitions of clinical disease activity and outcome measures, non-standardized laboratory cut-offs, failure to account for confounders and multiple subgroup analyses of differing outcomes. B cell depletion as well as novel biomarkers, such as S100 proteins, FCGR genotype, anti-vimentin and anti-drug antibodies showed some evidence of prognostic value but QoE was limited due to moderate to high risk of bias, early phase of investigation and imprecision of results. CONCLUSION There has been no validation of previously identified prognostic factors to guide outcome in anti-CD20 treated lupus patients. Hypothesis-driven studies of several novel markers however, demonstrate prognostic value and require replication and validation to support their use in routine clinical practice. PROSPERO REGISTRATION NUMBER CRD42020220339.
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Affiliation(s)
- Mia Rodziewicz
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK.
| | - Claudia Mendoza-Pinto
- High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Rheumatology and Immunology, School of Medicine, Autonomous University of Puebla, Mexico
| | - Sarah Dyball
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK
| | - Pamela Munguía-Realpozo
- High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Rheumatology and Immunology, School of Medicine, Autonomous University of Puebla, Mexico
| | - Ben Parker
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK; Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University Hospitals Foundation Trust, Manchester Academic Health Science Centre Manchester, UK
| | - Ian N Bruce
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre Manchester, Oxford Rd, Manchester M13 9PL, UK; Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University Hospitals Foundation Trust, Manchester Academic Health Science Centre Manchester, UK
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8
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Salehi T, Krishnan A, Al Jurdi A, So P, Lerma E, Wiegley N. Rituximab Resistance in Glomerular Diseases: A GlomCon Mini Review. Kidney Med 2024; 6:100791. [PMID: 38495600 PMCID: PMC10943057 DOI: 10.1016/j.xkme.2024.100791] [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] [Indexed: 03/19/2024] Open
Abstract
Resistance to rituximab B-cell depletion therapy is a clinically pertinent adverse sequela that can have significant implications for the treatment of immune-mediated glomerular diseases. The true incidence of rituximab resistance remains unknown; however, it is an increasingly recognized treatment complication. Resistance typically presents with suboptimal treatment response, rapid B-cell reconstitution, and a relapsing disease course. Although the diverse mechanisms resulting in rituximab resistance are ongoing topics of research, both primary and secondary mechanisms have been identified as key catalysts. The emergence of human antichimeric antibodies (HACAs) is a major cause of secondary resistance to rituximab therapy and typically appears following repeated drug exposure. Frequently, HACAs develop in the setting of underlying autoimmune disease and contribute to poor B-cell depletion, reduced rituximab therapeutic efficacy, and enhanced drug clearance. The clinical challenge of rituximab resistance necessitates heightened awareness among clinicians. Screening for HACAs should be considered in individuals with poor clinical response to rituximab, more rapid B-cell reconstitution, and relapsing disease. Detection of HACAs may guide treatment alterations, including addition of further immunosuppressive therapy and transitioning to a humanized B-cell depleting monoclonal antibody.
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Affiliation(s)
- Tania Salehi
- Central Northern Adelaide Renal and Transplantation Service, Adelaide, Australia
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Anoushka Krishnan
- Department of Renal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Paolo So
- Private Practice, Manila, Philippines
| | - Edgar Lerma
- University of Illinois at Chicago, Chicago, Illinois
- Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Nasim Wiegley
- University of California Davis School of Medicine, Sacramento, California
| | - GlomCon Editorial Team
- Central Northern Adelaide Renal and Transplantation Service, Adelaide, Australia
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
- Department of Renal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Massachusetts General Hospital, Boston, Massachusetts
- Private Practice, Manila, Philippines
- University of Illinois at Chicago, Chicago, Illinois
- Advocate Christ Medical Center, Oak Lawn, Illinois
- University of California Davis School of Medicine, Sacramento, California
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Markmann JF, Burrell BE, Bromberg JS, Hartono C, Kaufman DB, Possselt AM, Naji A, Bridges ND, Breeden C, Kanaparthi S, Pardo J, Kopetskie H, Mason K, Lim N, Chandran S. Immunosuppression withdrawal in living-donor renal transplant recipients following induction with antithymocyte globulin and rituximab: Results of a prospective clinical trial. Am J Transplant 2024:S1600-6135(24)00202-8. [PMID: 38467375 DOI: 10.1016/j.ajt.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/19/2024] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Abstract
Durable tolerance in kidney transplant recipients remains an important but elusive goal. We hypothesized that adding B cell depletion to T cell depletion would generate an immune milieu postreconstitution dominated by immature transitional B cells, favoring tolerance. The Immune Tolerance Network ITN039ST Research Study of ATG and Rituximab in Renal Transplantation was a prospective multicenter pilot study of live donor kidney transplant recipients who received induction with rabbit antithymocyte globulin and rituximab and initiated immunosuppression (IS) withdrawal (ISW) at 26 weeks. The primary endpoint was freedom from rejection at 52 weeks post-ISW. Six of the 10 subjects successfully completed ISW. Of these 6 subjects, 4 restarted immunosuppressive medications due to acute rejection or recurrent disease, 1 remains IS-free for over 9 years, and 1 was lost to follow-up after being IS-free for 42 weeks. There were no cases of patient or graft loss. CD19+ B cell frequencies returned to predepletion levels by 26 weeks posttransplant; immunoglobulin D+CD27--naïve B cells predominated. In contrast, memory cells dominated the repopulation of the T cell compartment. A regimen of combined B and T cell depletion did not generate the tolerogenic B cell profile observed in preclinical studies and did not lead to durable tolerance in the majority of kidney transplant recipients.
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Affiliation(s)
- James F Markmann
- Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Bryna E Burrell
- Biomarker Discovery Group, Immune Tolerance Network, Bethesda, Maryland, USA
| | - Jonathan S Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Choli Hartono
- Rogosin Institute, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, USA
| | - Dixon B Kaufman
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Andrew M Possselt
- Department of Surgery, University of California-San Francisco Medical Center, San Francisco, California, USA
| | - Ali Naji
- Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - Nancy D Bridges
- Division of Allergy, Immunology and Transplantation, The National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Cynthia Breeden
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Sai Kanaparthi
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Jorge Pardo
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | | | | | - Noha Lim
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Sindhu Chandran
- Immune Tolerance Network, Clinical Trials Group at the University of California- San Francisco, San Francisco, California, USA.
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10
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Appalaneni R, Achanta N, Mohan C. Chimeric antigen receptor T-cell therapy in rheumatology: B-cell depletion 2.0. Curr Opin Rheumatol 2024; 36:126-133. [PMID: 38099466 DOI: 10.1097/bor.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
PURPOSE OF REVIEW Chimeric antigen receptor T-cell therapy (CAR-T) has revolutionized cancer treatment by harnessing the immune system's power to target malignancies. CD19, a B-cell surface antigen, a key target for CAR-T cell therapy in hematological malignancies, displayed remarkable clinical responses. Recently, there has been a growing interest in exploring the application of CD19 CAR-T cell therapy beyond oncology. The rationale for investigating CD19 CAR-T cells in Rheumatology stems from their ability to selectively target B cells, which play a central pathogenic role through autoantibody-dependent and independent mechanisms. RECENT FINDINGS Preclinical and five completed clinical studies have shown remarkable efficacy and safety in diseases such as systemic lupus erythematosus, antisynthetase syndrome, and systemic sclerosis. It is thus not surprising that 17 active clinical trials exploring CAR-T cells in Rheumatology are in progress. SUMMARY Although CAR-T therapy holds great promise in Rheumatology, many challenges loom. Whether this new way to deplete B-cells is superior to conventional antibody-based B-cell depletion in rheumatic diseases will be closely watched in the coming years.
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Affiliation(s)
- Rohith Appalaneni
- Department Biomedical Engineering, University of Houston, Houston, Texas, USA
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11
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Rovin BH, Furie RA, Ross Terres JA, Giang S, Schindler T, Turchetta A, Garg JP, Pendergraft WF, Malvar A. Kidney Outcomes and Preservation of Kidney Function With Obinutuzumab in Patients With Lupus Nephritis: A Post Hoc Analysis of the NOBILITY Trial. Arthritis Rheumatol 2024; 76:247-254. [PMID: 37947366 DOI: 10.1002/art.42734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To determine whether adding obinutuzumab to standard-of-care lupus nephritis (LN) therapy could improve the likelihood of long-term preservation of kidney function and do so with less glucocorticoids. METHODS Post hoc analyses of the phase II NOBILITY trial were performed. Time to unfavorable kidney outcome (a composite of treatment failure, doubling of serum creatinine, or death), LN flare, first 30% and 40% declines in estimated glomerular filtration rate (eGFR) from baseline, and chronic eGFR slope during the trial were compared between patients with active LN who were randomized to take obinutuzumab (n = 63) or placebo (n = 62) in combination with mycophenolate mofetil and glucocorticoids. The number of patients who achieved complete renal response (CRR) on 7.5 mg or less per day of prednisone was also determined. RESULTS Obinutuzumab reduced the risk of developing the composite kidney outcome by 60%, LN flare by 57%, and first eGFR decline of 30% or 40% by 80% and 91%, respectively. Patients receiving obinutuzumab had a significantly slower decline in eGFR than patients receiving placebo, with an annualized eGFR slope advantage of 4.1 ml/min/1.73 m2 /year (95% confidence interval 0.14-8.08). Overall, 38% of patients receiving obinutuzumab compared with 16% of patients receiving placebo achieved CRR at week 76 while receiving 7.5 mg or less per day of prednisone (P < 0.01); at week 104, the difference did not achieve significance (38% vs 22%; P = 0.06). CONCLUSION Post hoc analyses of NOBILITY demonstrated that compared with standard-of-care therapy, obinutuzumab treatment resulted in superior preservation of kidney function and prevention of LN flares. More patients achieved CRR at week 76 with less glucocorticoid use in the obinutuzumab group.
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Affiliation(s)
- Brad H Rovin
- The Ohio State University Wexner Medical Center, Columbus
| | | | | | | | | | | | - Jay P Garg
- Genentech, Inc, South San Francisco, California
| | | | - Ana Malvar
- Hospital Fernandez, Buenos Aires, Argentina
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12
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Aryanian Z, Balighi K, Emadi SN, Hatami P. Rituximab as a maintenance treatment in patients with pemphigus vulgaris: When is the right time for discontinuation? J Cosmet Dermatol 2024; 23:406-408. [PMID: 37916650 DOI: 10.1111/jocd.16030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Naser Emadi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Hatami
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Xu JW, Wang MY, Mao Y, Hu ZY, Miao XL, Jiang F, Zhou GP. Inhibition of STAT3 alleviates LPS-induced apoptosis and inflammation in renal tubular epithelial cells by transcriptionally down-regulating TASL. Eur J Med Res 2024; 29:34. [PMID: 38184662 PMCID: PMC10770942 DOI: 10.1186/s40001-023-01610-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 12/21/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a common autoimmune disease that impacts various organs. Lupus nephritis (LN) significantly contributes to death in children with SLE. Toll-like receptor (TLR) adaptor interacting with SLC15A4 on the lysosome (TASL) acts as an innate immune adaptor for TLR and is implicated in the pathogenesis of SLE. A transcription factor known as signal transducer and activator of transcription 3 (STAT3), which is known to be linked to autoimmune diseases, is also involved in the development of SLE. METHODS Bioinformatics and real-time quantitative PCR (qRT-PCR) was used to detect the expression of STAT3 and TASL in peripheral blood of SLE patients and their correlation. Bioinformatics analysis, qRT-PCR, luciferase assay and chromatin immunoprecipitation (ChIP) were used to verify the regulation of transcription factor STAT3 on TASL. The expression levels of STAT3, TASL and apoptosis-related genes in LPS-induced HK2 cells were detected by qRT-PCR and Western blot. TUNEL staining were used to detect the apoptosis of HK2 cells after LPS stimulation. ELISA and qRT-PCR were used to detect the levels of inflammatory cytokines in the cell culture supernatant. TASL knockdown in HK2 cells was used to detect the changes in apoptosis-related genes and inflammatory factors. The expression level of TASL in LPS-stimulated HK2 cells and its effect on cell apoptosis and inflammatory factors were observed by knocking down and overexpressing STAT3, respectively. It was also verified in a rescue experiment. RESULTS The expressions of STAT3 and TASL were higher in SLE than in healthy children, and the expression of STAT3 was positively correlated with TASL. Transcription factor STAT3 can directly and positively regulate the expression of TASL through the promoter region binding site. The expression of STAT3, TASL and inflammatory cytokines was elevated, and the change of apoptosis was up-regulated in LPS-stimulated HK2 cells. Inhibition of STAT3 alleviates LPS-stimulated apoptosis and inflammatory response in HK2 cells through transcriptional regulation of TASL. CONCLUSIONS These findings provide new insights into the transcriptional regulation of TASL and provide new evidence of a direct regulatory relationship between signaling nodes in the lupus signaling network.
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Affiliation(s)
- Jin-Wen Xu
- Department of Pediatrics, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
- Department of Pediatric Nephrology, Wuxi Children's Hospital Affiliated to Jiangnan University, Wuxi, China
| | - Ming-Yan Wang
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yan Mao
- Department of Pediatrics, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zheng-Yun Hu
- Department of Pediatrics, Songjiang Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (Preparatory Stage), Shanghai, China
| | - Xiao-Lin Miao
- Department of Pediatrics, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Jiang
- Department of Neonatology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
| | - Guo-Ping Zhou
- Department of Pediatrics, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China.
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Jia X, Lu Y, Zheng X, Tang R, Chen W. Targeted therapies for lupus nephritis: Current perspectives and future directions. Chin Med J (Engl) 2024; 137:34-43. [PMID: 38057972 PMCID: PMC10766263 DOI: 10.1097/cm9.0000000000002959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 12/08/2023] Open
Abstract
ABSTRACT Lupus nephritis (LN), a severe manifestation of systemic lupus erythematosus, poses a substantial risk of progression to end-stage renal disease, with increased mortality. Conventional therapy for LN relies on broad-spectrum immunosuppressants such as glucocorticoids, mycophenolate mofetil, and calcineurin inhibitors. Although therapeutic regimens have evolved over the years, they have inherent limitations, including non-specific targeting, substantial adverse effects, high relapse rates, and prolonged maintenance and remission courses. These drawbacks underscore the need for targeted therapeutic strategies for LN. Recent advancements in our understanding of LN pathogenesis have led to the identification of novel therapeutic targets and the emergence of biological agents and small-molecule inhibitors with improved specificity and reduced toxicity. This review provides an overview of the current evidence on targeted therapies for LN, elucidates the biological mechanisms of responses and failure, highlights the challenges ahead, and outlines strategies for subsequent clinical trials and integrated immunomodulatory approaches.
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Affiliation(s)
- Xiuzhi Jia
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University), and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong 510080, China
| | - Yuewen Lu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University), and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong 510080, China
| | - Xunhua Zheng
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University), and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong 510080, China
| | - Ruihan Tang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University), and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong 510080, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University), and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong 510080, China
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Al Jurdi A, El Mouhayyar C, Efe O, Jeyabalan A, Riella LV. Nephrotic-range proteinuria: a potential risk factor for failure of tixagevimab-cilgavimab prophylaxis. J Nephrol 2024; 37:141-147. [PMID: 37658973 DOI: 10.1007/s40620-023-01750-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/28/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Pre-exposure prophylaxis with tixagevimab-cilgavimab has been shown to reduce the incidence of SARS-CoV-2 infection in immunocompromised individuals. Individuals with nephrotic-range proteinuria can lose immunoglobulins such as tixagevimab-cilgavimab in the urine and, therefore, may derive less benefit from tixagevimab-cilgavimab. There are no published studies evaluating the association of nephrotic-range proteinuria with failure of tixagevimab-cilgavimab prophylaxis. METHODS We conducted a retrospective observational cohort study of all individuals at our center who received tixagevimab-cilgavimab while they had nephrotic-range proteinuria. Each individual in the nephrotic group was matched 1:3 with controls who were matched for B cell depletion therapy in addition to the total dose and date of first tixagevimab-cilgavimab administration. The primary outcome was the development of breakthrough SARS-CoV-2 infection after receiving tixagevimab-cilgavimab. RESULTS Sixteen patients received tixagevimab-cilgavimab between January 1st, 2022, and June 30th, 2022, at a time when they had nephrotic-range proteinuria. Proteinuria levels and serum creatinine levels were higher while serum albumin levels were lower in the nephrotic group compared to the control group. At a median follow-up of 251 days, 38% of individuals in the nephrotic group had developed breakthrough SARS-CoV-2 infections, compared to only 13% in the control group at a median follow-up of 238 days. Nephrotic-range proteinuria was associated with a higher incidence of breakthrough infection (log-rank P = 0.04). CONCLUSIONS Nephrotic-range proteinuria may increase the risk of failure of tixagevimab-cilgavimab pre-exposure prophylaxis. Prospective studies to validate these findings and to evaluate the optimal dosing strategy of antibody-based prophylaxis in this group of patients are needed.
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Affiliation(s)
- Ayman Al Jurdi
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Orhan Efe
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Anushya Jeyabalan
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Leonardo V Riella
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Schett G, Mackensen A, Mougiakakos D. CAR T-cell therapy in autoimmune diseases. Lancet 2023; 402:2034-2044. [PMID: 37748491 DOI: 10.1016/s0140-6736(23)01126-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/12/2023] [Accepted: 05/25/2023] [Indexed: 09/27/2023]
Abstract
Despite the tremendous progress in the clinical management of autoimmune diseases, many patients do not respond to the currently used treatments. Autoreactive B cells play a key role in the pathogenesis of autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis. B-cell-depleting monoclonal antibodies, such as rituximab, have poor therapeutic efficacy in autoimmune diseases, mainly due to the persistence of autoreactive B cells in lymphatic organs and inflamed tissues. The adoptive transfer of T cells engineered to target tumour cells via chimeric antigen receptors (CARs) has emerged as an effective treatment modality in B-cell malignancies. In the last 2 years treatment with autologous CAR T cells directed against the CD19 antigen has been introduced in therapy of autoimmune disease. CD19 CAR T cells induced a rapid and sustained depletion of circulating B cells, as well as in a complete clinical and serological remission of refractory systemic lupus erythematosus and dermatomyositis. In this paper, we discuss the evolving strategies for targeting autoreactive B cells via CAR T cells, which might be used for targeted therapy in autoimmune diseases.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich Alexander Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany; Deutsches Zentrum Immuntherapie, Friedrich Alexander Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.
| | - Andreas Mackensen
- Deutsches Zentrum Immuntherapie, Friedrich Alexander Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany; Department of Internal Medicine 5-Hematology and Clinical Oncology, Friedrich Alexander Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Dimitrios Mougiakakos
- Department of Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany; Health Campus Immunology, Infectiology and Inflammation (GCI(3)), Medical Center, Otto-von-Guericke University, Magdeburg, Germany
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Welte T, Westermann L, Kappes J, Schramm MA, Bemtgen X, Staudacher DL, Hug MJ, Venhoff N, Arnold F. Identification of Covariates Modulating B-Cell Repopulation Kinetics in Subjects Receiving Rituximab Treatment. Arthritis Rheumatol 2023; 75:2045-2053. [PMID: 37276446 DOI: 10.1002/art.42625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/15/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE B-cell depletion using the anti-CD20 monoclonal antibody rituximab is a cornerstone in the therapeutic concept of multiple autoimmune diseases. B-cell depletion is associated with a higher risk for severe infections, and the time span of B-cell repopulation differs greatly between individuals. Data on factors influencing B-cell repopulation kinetics are limited. This study aims to identify patient-specific and therapy-associated covariates that modulate B-cell repopulation. METHODS This single-center retrospective observational study presents data of 839 subjects receiving 2,017 courses of rituximab for autoimmune diseases. Assessed covariates are patient-specific factors (sex, age, kidney function, and underlying disease) and co-immunosuppression with common agents (azathioprine, cyclosporine A, cyclophosphamide, hydroxychloroquine, methotrexate, mycophenolate mofetil, tacrolimus, and corticosteroids). The primary end point is the time to B-cell repopulation (≥5/μl). The secondary end point is the time to B-cell reconstitution (≥50/μl). Multivariate time-to-event analysis and logistic regression models were applied to estimate the influence of covariates. RESULTS Age over 60 years (hazard ratio [HR] 0.71 for repopulation, P = 0.008), impaired kidney function (HR 0.72, P = 0.001), antineutrophil cytoplasmic antibody-associated vasculitis (HR 0.61, P < 0.001), solid organ transplantation (HR 0.4, P < 0.001), and co-immunosuppression with corticosteroids (HR 0.64, P < 0.001) or azathioprine (HR 0.49, P < 0.001) were associated with impaired B-cell repopulation and reconstitution. Effects of corticosteroids (P = 0.043) and azathioprine (P = 0.025) were dose dependent. CONCLUSION Prolonged rituximab dosing intervals may be effective to achieve B-cell depletion and reduce risk of infection in advanced age or patients with impaired kidney function. Co-medication with corticosteroids or azathioprine prolongs B-cell recovery, which may increase therapeutic effects but also the rate of adverse events.
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Affiliation(s)
- Thomas Welte
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Westermann
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Kappes
- Department of Pneumology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Markus A Schramm
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, and Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, and Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin J Hug
- Pharmacy, Medical Center, University of Freiburg, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frederic Arnold
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, and Institute for Microbiology and Hygiene, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Pennesi M, Benvenuto S. Lupus Nephritis in Children: Novel Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1841. [PMID: 37893559 PMCID: PMC10607957 DOI: 10.3390/medicina59101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
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Roccatello D, Fenoglio R, Caniggia I, Kamgaing J, Naretto C, Cecchi I, Rubini E, Rossi D, De Simone E, Del Vecchio G, Cozzi M, Sciascia S. Daratumumab monotherapy for refractory lupus nephritis. Nat Med 2023; 29:2041-2047. [PMID: 37563241 PMCID: PMC10427415 DOI: 10.1038/s41591-023-02479-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023]
Abstract
Treatment-refractory lupus nephritis (LN) has a high risk of a poor outcome and is often life-threatening. Here we report a case series of six patients (one male and five females) with a median age of 41.3 years (range, 20-61 years) with refractory LN who received renal biopsies and were subsequently treated with intravenous daratumumab, an anti-CD38 monoclonal antibody (weekly for 8 weeks, followed by eight biweekly infusions and up to eight monthly infusions). One patient did not show any improvement after 6 months of therapy, and daratumumab was discontinued. In five patients, the mean disease activity, as assessed by the Systemic Lupus Erythematosus Disease Activity 2000 index, decreased from 10.8 before treatment to 3.6 at 12 months after treatment. Mean proteinuria (5.6 g per 24 h to 0.8 g per 24 h) and mean serum creatinine (2.3 mg dl-1 to 1.5 mg dl-1) also decreased after 12 months. Improvement of clinical symptoms was accompanied by seroconversion of anti-double-stranded DNA antibodies; decreases in median interferon-gamma levels, B cell maturation antigen and soluble CD163 levels; and increases in C4 and interleukin-10 levels. These data suggest that daratumumab monotherapy warrants further exploration as a potential treatment for refractory LN.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy.
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Ilaria Caniggia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Joelle Kamgaing
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Elena Rubini
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Emanuele De Simone
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Martina Cozzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
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Odler B, Pollheimer MJ, Kronbichler A, Säemann MD, Windpessl M, Gauckler P, Rudnicki M, Zitt E, Neumann I, Lhotta K, Eller K. [Diagnostic and therapy of lupus nephritis - 2023]. Wien Klin Wochenschr 2023; 135:675-687. [PMID: 37728652 PMCID: PMC10511585 DOI: 10.1007/s00508-023-02263-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
The manuscript summarizes the consensus of the Austrian Society of Nephrology on the diagnosis and therapy of lupusnephritis, which is built on existing studies and literature. We discuss in detail the immunosuppressive treatment in proliferative forms of lupusnephritis (III and IV ± V) and in pure lupusnephritis V with nephrotic-range proteinuria. Furthermore, the supportive medication in lupusnephritis is summarized in the consensus. The figures were designed to provide the reader a guidance through the therapeutical approach in lupusnephritis for the daily practice.
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Affiliation(s)
- Balazs Odler
- Abteilung für Nephrologie, Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | | | - Andreas Kronbichler
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Philipp Gauckler
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Michael Rudnicki
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Emanuel Zitt
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Kathrin Eller
- Abteilung für Nephrologie, Innere Medizin, Medizinische Universität Graz, Graz, Österreich.
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21
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Beck LH, Ayoub I, Caster D, Choi MJ, Cobb J, Geetha D, Rheault MN, Wadhwani S, Yau T, Whittier WL. KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases. Am J Kidney Dis 2023; 82:121-175. [PMID: 37341661 DOI: 10.1053/j.ajkd.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 06/22/2023]
Abstract
The KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases represents the first update to this set of recommendations since the initial set of KDIGO guideline recommendations was published in 2012. The pace of growth in our molecular understanding of glomerular disease has quickened and a number of newer immunosuppressive and targeted therapies have been introduced since the original set of guideline recommendations, making such an update necessary. Despite these updates, many areas of controversy remain. In addition, further updates since the publication of KDIGO 2021 have occurred which this guideline does not encompass. With this commentary, the KDOQI work group has generated a chapter-by-chapter companion opinion article that provides commentary specific to the implementation of the KDIGO 2021 guideline in the United States.
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Affiliation(s)
- Laurence H Beck
- Division of Nephrology, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Isabelle Ayoub
- Department of Medicine, Division of Nephrology, Wexner Medical, The Ohio State University, Columbus, Ohio
| | - Dawn Caster
- Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky
| | | | - Jason Cobb
- Division of Renal Medicine, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Shikha Wadhwani
- Division of Nephrology and Hypertension, Northwestern University, Chicago, Illinois
| | - Timothy Yau
- Division of Nephrology, Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri
| | - William L Whittier
- Division of Nephrology, Rush University Medical Center, Chicago, Illinois
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22
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Thakare SB, So PN, Rodriguez S, Hassanein M, Lerma E, Wiegley N. Novel Therapeutics for Management of Lupus Nephritis: What Is Next? Kidney Med 2023; 5:100688. [PMID: 37533564 PMCID: PMC10393586 DOI: 10.1016/j.xkme.2023.100688] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
Lupus nephritis is a severe, organ-threatening manifestation of systemic lupus erythematosus. The current standard of care in the treatment of lupus nephritis is limited to broad-spectrum immunosuppressants, which have significant concerns of short- and long-term toxicity. With traditional approaches, kidney survival and patient outcomes have remained suboptimal. Robust research in the therapeutics of lupus nephritis has resulted in development of many novel drugs targeting specific inflammatory response pathways. Some newer agents have shown a definitive signal of benefit when added to standard of care. With the advent of precision medicine in nephrology, lupus nephritis treatment may undergo a shift toward incorporating approaches using these newer drugs and individualizing care of our patients. This review highlights major advances in management of lupus nephritis over the last 25 years and explores the ongoing trials of emerging therapies in lupus nephritis.
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Affiliation(s)
| | | | - Sonia Rodriguez
- Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Mohamed Hassanein
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Nasim Wiegley
- University of California Davis School of Medicine, Sacramento, CA
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23
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Katarzyna PB, Wiktor S, Ewa D, Piotr L. Current treatment of systemic lupus erythematosus: a clinician's perspective. Rheumatol Int 2023:10.1007/s00296-023-05306-5. [PMID: 37171669 DOI: 10.1007/s00296-023-05306-5] [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: 12/13/2022] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Its variable course makes it difficult to standardize patient treatment. This article aims at a literature review on available drugs for treating SLE and on drugs that have shown therapeutic effects in this disease. The PubMed/MEDLINE electronic search engine was used to identify relevant studies. This review presents the current therapeutic options, new biological therapies, and combination therapies of biologics with standard immunosuppressive and immunomodulating drugs. We have also underlined the importance to implement the treat-to-target strategy aimed at reducing or discontinuing therapy with glucocorticosteroids (GCs). The awareness of the benefits and risks of using GCs helps in refining their dosage and thereby obtaining a better safety profile. The advent of biological targeted therapies, and more recently, low-molecular-weight compounds such as kinase inhibitors, initiated numerous clinical trials in SLE patients and led to the approval of two biological drugs, belimumab, and anifrolumab, for SLE treatment. Progress in the treatment of SLE was reflected in the 2019 and 2021 recommendations of the European Alliance of Associations for Rheumatology (EULAR). However, a mass of recent clinical research data requires continuous consolidation to optimize patient outcomes.
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Affiliation(s)
- Pawlak-Buś Katarzyna
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland.
| | - Schmidt Wiktor
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
- Doctoral School, Poznań University of Medical Sciences, Poznań, Poland
| | - Dudziec Ewa
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Leszczyński Piotr
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
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24
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Kaneko M, Jackson SW. Recent advances in immunotherapies for lupus nephritis. Pediatr Nephrol 2023; 38:1001-1012. [PMID: 35778517 PMCID: PMC10219838 DOI: 10.1007/s00467-022-05670-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/03/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022]
Abstract
Childhood-onset systemic lupus erythematosus (SLE) is characterized by increased rates of kidney involvement, termed lupus nephritis. Despite the significant morbidity and mortality associated with this disease, lupus nephritis trials have been plagued by repeated failures to meet clinical endpoints. However, improvements in trial design and the development of targeted approaches have begun to yield promising results, including two new FDA-approved lupus nephritis treatments since 2020. These include belimumab, a monoclonal antibody targeting the B cell survival cytokine BAFF (B cell activating factor), and voclosporin, a cyclosporin analog with improved pharmacokinetic characteristics. In this review, we will summarize the data supporting regulatory approval for these agents in lupus nephritis and highlight ongoing clinical trials targeting the diverse immunologic drivers of renal inflammation in SLE. While pediatric patients remain underrepresented in lupus clinical trials, given the increased severity of childhood-onset SLE and need for long-term protection from kidney damage, we anticipate the need for off-label use of these targeted therapies in the pediatric population. Future studies are needed to define optimal patient selection, drug combinations, and treatment duration in pediatric lupus nephritis.
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Affiliation(s)
- Machi Kaneko
- Division of Pediatric Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Shaun W Jackson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA.
- Seattle Childrens Research Institute, 1900 Ninth Avenue, M/S JMB-6, WA, 98101, Seattle, USA.
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25
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Accapezzato D, Caccavale R, Paroli MP, Gioia C, Nguyen BL, Spadea L, Paroli M. Advances in the Pathogenesis and Treatment of Systemic Lupus Erythematosus. Int J Mol Sci 2023; 24:ijms24076578. [PMID: 37047548 PMCID: PMC10095030 DOI: 10.3390/ijms24076578] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a genetically predisposed, female-predominant disease, characterized by multiple organ damage, that in its most severe forms can be life-threatening. The pathogenesis of SLE is complex and involves cells of both innate and adaptive immunity. The distinguishing feature of SLE is the production of autoantibodies, with the formation of immune complexes that precipitate at the vascular level, causing organ damage. Although progress in understanding the pathogenesis of SLE has been slower than in other rheumatic diseases, new knowledge has recently led to the development of effective targeted therapies, that hold out hope for personalized therapy. However, the new drugs available to date are still an adjunct to conventional therapy, which is known to be toxic in the short and long term. The purpose of this review is to summarize recent advances in understanding the pathogenesis of the disease and discuss the results obtained from the use of new targeted drugs, with a look at future therapies that may be used in the absence of the current standard of care or may even cure this serious systemic autoimmune disease.
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Affiliation(s)
- Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Rosalba Caccavale
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Maria Pia Paroli
- Eye Clinic, Department of Sense Organs, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Bich Lien Nguyen
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Luca Spadea
- Post Graduate School of Public Health, University of Siena, 53100 Siena, Italy
| | - Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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26
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Roccatello D, Sciascia S, Rossi D, Fenoglio R. Refractory Systemic Lupus Erythematosus: Identification and Pharmacological Management. Drugs 2023; 83:117-134. [PMID: 36729344 DOI: 10.1007/s40265-022-01824-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 02/03/2023]
Abstract
Systemic lupus erythematosus (SLE) is characterized by an aberrant immune response, leading to an extremely heterogeneous clinical presentation, potentially affecting different systems and organs. Despite the fact that SLE mortality has greatly decreased since the introduction of steroids, some forms of refractory/severe SLE still have the potential to result in permanent organ damage as well as increased mortality and morbidity. Furthermore, SLE patients with multiple comorbidities may face a clinical conundrum and have a bad prognosis. An improved prognosis for severe refractory SLE depends on prompt and appropriate treatment. Due to the scarcity of solid data from a well-characterized group of patients with refractory/severe SLE coming from randomized controlled studies, this review aims to shed light on this with real-world evidence from clinical research performed at our Unit, the University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID) (Turin, Italy). In order to determine the key clinical and prognostic features, and therapeutic approaches for severe and/or refractory SLE, our experience will be described together with existing literature, primarily focused on dermatological, neuropsychiatric, and renal symptoms.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
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27
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Krustev E, Clarke AE, Barber MRW. B cell depletion and inhibition in systemic lupus erythematosus. Expert Rev Clin Immunol 2023; 19:55-70. [PMID: 36342225 DOI: 10.1080/1744666x.2023.2145281] [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
INTRODUCTION Systemic lupus erythematosus (SLE) is characterized by autoantibody expression and aberrant autoreactive B cells contribute to disease progression; therefore, B cell inhibition has been an attractive target for novel therapies. However, after more than two decades of research and over 40 randomized clinical trials, only one such therapy, belimumab, has been approved for use in SLE. AREAS COVERED In this review, we discuss the evidence for B cell-targeted therapies in SLE and lupus nephritis. Belimumab has been successful in several large clinical trials and is approved in several countries for use in SLE and lupus nephritis. Despite a lack of supporting phase III evidence, rituximab is used off-label in SLE. Several other B cell-targeted therapies have failed to meet their end points in late-stage clinical trials. Successful phase II trials have recently been reported for obinutuzumab and telitacicept with larger confirmatory trials currently underway. EXPERT OPINION Refinements in pharmaceutical mechanisms of action, trial design, and patient selection have resulted in recent preliminary successes, offering renewed optimism for B-cell targeted therapeutics in SLE management.
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Affiliation(s)
- Eugene Krustev
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ann E Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Megan R W Barber
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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28
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Mariette X, Barone F, Baldini C, Bootsma H, Clark KL, De Vita S, Gardner DH, Henderson RB, Herdman M, Lerang K, Mistry P, Punwaney R, Seror R, Stone J, van Daele PL, van Maurik A, Wisniacki N, Roth DA, Tak PP. A randomized, phase II study of sequential belimumab and rituximab in primary Sjögren's syndrome. JCI Insight 2022; 7:163030. [PMID: 36477362 PMCID: PMC9746921 DOI: 10.1172/jci.insight.163030] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDPrimary Sjögren's syndrome (pSS) is characterized by B cell hyperactivity and elevated B-lymphocyte stimulator (BLyS). Anti-BLyS treatment (e.g., belimumab) increases peripheral memory B cells; decreases naive, activated, and plasma B cell subsets; and increases stringency on B cell selection during reconstitution. Anti-CD20 therapeutics (e.g., rituximab) bind and deplete CD20-expressing B cells in circulation but are less effective in depleting tissue-resident CD20+ B cells. Combined, these 2 mechanisms may achieve synergistic effects.METHODSThis 68-week, phase II, double-blind study (GSK study 201842) randomized 86 adult patients with active pSS to 1 of 4 arms: placebo, s.c. belimumab, i.v. rituximab, or sequential belimumab + rituximab.RESULTSOverall, 60 patients completed treatment and follow-up until week 68. The incidence of adverse events (AEs) and drug-related AEs was similar across groups. Infections/infestations were the most common AEs, and no serious infections of special interest occurred. Near-complete depletion of minor salivary gland CD20+ B cells and a greater and more sustained depletion of peripheral CD19+ B cells were observed with belimumab + rituximab versus monotherapies. With belimumab + rituximab, reconstitution of peripheral B cells occurred, but it was delayed compared with rituximab. At week 68, mean (± standard error) total EULAR Sjögren's syndrome disease activity index scores decreased from 11.0 (1.17) at baseline to 5.0 (1.27) for belimumab + rituximab and 10.4 (1.36) to 8.6 (1.57) for placebo.CONCLUSIONThe safety profile of belimumab + rituximab in pSS was consistent with the monotherapies. Belimumab + rituximab induced enhanced salivary gland B cell depletion relative to the monotherapies, potentially leading to improved clinical outcomes.TRIAL REGISTRATIONClinicalTrials.gov NCT02631538.FUNDINGFunding was provided by GSK.
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Affiliation(s)
- Xavier Mariette
- Department of Rheumatology, Université Paris-Saclay, Hôpital Bicêtre, Assistance Publique — Hôpitaux de Paris, INSERM UMR1184, Le Kremlin Bicêtre, Paris, France
| | - Francesca Barone
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Chiara Baldini
- Centro Farmacologia Clinica AOUP, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Salvatore De Vita
- Rheumatology Clinic, Department of Medical Area, Azienda Ospedaliera Universitaria di Udine, Udine, Italy
| | - David H. Gardner
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Robert B. Henderson
- Clinical Pharmacology and Experimental Medicine, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Michael Herdman
- Clinical Pharmacology and Experimental Medicine, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Karoline Lerang
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
| | - Prafull Mistry
- R&D Biostatistics, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Raj Punwaney
- Pharmaceutical Research and Development, GSK, Collegeville, Pennsylvania, USA
| | - Raphaele Seror
- Department of Rheumatology, Université Paris-Saclay, Hôpital Bicêtre, Assistance Publique — Hôpitaux de Paris, INSERM UMR1184, Le Kremlin Bicêtre, Paris, France
| | - John Stone
- R&D, GSK, Stevenage, Hertfordshire, United Kingdom
| | - Paul L.A. van Daele
- Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - André van Maurik
- Clinical Pharmacology and Experimental Medicine, GSK, Stevenage, Hertfordshire, United Kingdom
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29
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Robinson JI, Md Yusof MY, Davies V, Wild D, Morgan M, Taylor JC, El-Sherbiny Y, Morris DL, Liu L, Rawstron AC, Buch MH, Plant D, Cordell HJ, Isaacs JD, Bruce IN, Emery P, Barton A, Vyse TJ, Barrett JH, Vital EM, Morgan AW. Comprehensive genetic and functional analyses of Fc gamma receptors influence on response to rituximab therapy for autoimmunity. EBioMedicine 2022; 86:104343. [PMID: 36371989 PMCID: PMC9663864 DOI: 10.1016/j.ebiom.2022.104343] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Rituximab is widely used to treat autoimmunity but clinical response varies. Efficacy is determined by the efficiency of B-cell depletion, which may depend on various Fc gamma receptor (FcγR)-dependent mechanisms. Study of FcγR is challenging due to the complexity of the FCGR genetic locus. We sought to assess the effect of FCGR variants on clinical response, B-cell depletion and NK-cell-mediated killing in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). METHODS A longitudinal cohort study was conducted in 835 patients [RA = 573; SLE = 262]. Clinical outcome measures were two-component disease activity score in 28-joints (2C-DAS28CRP) for RA and British Isles Lupus Assessment Group (BILAG)-2004 major clinical response (MCR) for SLE at 6 months. B-cells were evaluated by highly-sensitive flow cytometry. Single nucleotide polymorphism and copy number variation for genes encoding five FcγRs were measured using multiplex ligation-dependent probe amplification. Ex vivo studies assessed NK-cell antibody-dependent cellular cytotoxicity (ADCC) and FcγR expression. FINDINGS In RA, carriage of FCGR3A-158V and increased FCGR3A-158V copies were associated with greater 2C-DAS28CRP response (adjusted for baseline 2C-DAS28CRP). In SLE, MCR was associated with increased FCGR3A-158V, OR 1.64 (95% CI 1.12-2.41) and FCGR2C-ORF OR 1.93 (95% CI 1.09-3.40) copies. 236/413 (57%) patients with B-cell data achieved complete depletion. Homozygosity for FCGR3A-158V and increased FCGR3A-158V copies were associated with complete depletion in combined analyses. FCGR3A genotype was associated with rituximab-induced ADCC, and increased NK-cell FcγRIIIa expression was associated with improved clinical response and depletion in vivo. Furthermore, disease status and concomitant therapies impacted both NK-cell FcγRIIIa expression and ADCC. INTERPRETATION FcγRIIIa is the major low affinity FcγR associated with rituximab response. Increased copies of the FCGR3A-158V allele (higher affinity for IgG1), influences clinical and biological responses to rituximab in autoimmunity. Enhancing FcγR-effector functions could improve the next generation of CD20-depleting therapies and genotyping may stratify patients for optimal treatment protocols. FUNDING Medical Research Council, National Institute for Health and Care Research, Versus Arthritis.
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Affiliation(s)
- James I Robinson
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Md Yuzaiful Md Yusof
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Vinny Davies
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; School of Mathematics and Statistics, University of Glasgow, UK
| | - Dawn Wild
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Michael Morgan
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; Cancer Research UK Cambridge Institute, University of Cambridge, UK
| | - John C Taylor
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Yasser El-Sherbiny
- Department of Biosciences, School of Science and Technology, Nottingham Trent University, UK; Department of Clinical Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - David L Morris
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Lu Liu
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Andy C Rawstron
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals NHS Trust, UK
| | - Maya H Buch
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | - Darren Plant
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | | | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University and Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Ian N Bruce
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | - Paul Emery
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; NIHR Leeds Medtech and In vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, UK
| | - Anne Barton
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester and NIHR Manchester BRC, Manchester University NHS Foundation Trust, UK
| | - Timothy J Vyse
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Jennifer H Barrett
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Edward M Vital
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Ann W Morgan
- School of Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK; NIHR Leeds Medtech and In vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, UK.
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van Schaik M, Arends EJ, Soonawala D, van Ommen E, de Leeuw K, Limper M, van Paassen P, Huizinga TWJ, Toes REM, van Kooten C, Rotmans JI, Rabelink TJ, Teng YKO. Efficacy of belimumab combined with rituximab in severe systemic lupus erythematosus: study protocol for the phase 3, multicenter, randomized, open-label Synbiose 2 trial. Trials 2022; 23:939. [DOI: 10.1186/s13063-022-06874-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/22/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Belimumab, an anti-B-cell activating factor antibody, is approved for the treatment of auto-antibody positive systemic lupus erythematosus with a high degree of disease activity. Anti-CD20 B cell depletion with rituximab is used in refractory SLE as well, although with variable responses. We hypothesized that incomplete B cell depletion, related to a surge in BAFF levels following rituximab treatment, can cause ongoing disease activity and flares. The Synbiose 1 study primarily focused on immunological effects and shows the preliminary clinical benefit of combined rituximab and belimumab in SLE. The Synbiose 2 study will evaluate the clinical efficacy of combining belimumab with rituximab in patients with severe SLE, allowing the tapering of prednisolone and mycophenolate.
Methods
Synbiose 2 is a phase 3, multicenter, randomized, controlled, open-label 2-year clinical trial. Seventy adults with severe SLE including lupus nephritis will be randomized 1:1 to receive either standard of care consisting of prednisolone and mycophenolate as induction and maintenance treatment, or belimumab and rituximab combined with standard of care as induction treatment, followed by prednisolone and belimumab as maintenance treatment. The primary objective is to assess whether combined B cell therapy will lead to a reduction of treatment failure. Secondary endpoints are complete and partial clinical and renal response and the improvement of SLE-specific autoimmune phenomena. Safety endpoints include the incidence of adverse events, with a special interest in infections.
Discussion
The Synbiose 2 trial is the first multicenter phase 3 clinical trial investigating combined B cell targeted therapy in SLE, including lupus nephritis. The outcome of this study will provide further evidence for the clinical efficacy of this new treatment strategy in severe SLE.
Trial registration
ClinicalTrials.gov NCT03747159. Registered on 20 November 2018.
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Hartinger JM, Kratky V, Hruskova Z, Slanar O, Tesar V. Implications of rituximab pharmacokinetic and pharmacodynamic alterations in various immune-mediated glomerulopathies and potential anti-CD20 therapy alternatives. Front Immunol 2022; 13:1024068. [PMID: 36420256 PMCID: PMC9676507 DOI: 10.3389/fimmu.2022.1024068] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
Abstract
The specific B-cell depleting anti-CD20 monoclonal antibody rituximab (RTX) is effective in terms of the treatment of various immune-mediated glomerulopathies. The administration of RTX has been shown to be reliable and highly effective particularly in patients with ANCA-associated vasculitis, which is manifested predominantly with non-nephrotic proteinuria. Stable long-term B-cell depletion is usually readily attained in such patients using standard dosing regimens. However, in patients with nephrotic syndrome and non-selective proteinuria, the RTX pharmacokinetics is altered profoundly and RTX does not maintain high enough levels for a sufficiently long period, which may render RTX treatment ineffective. Since complement-derived cytotoxicity is one of the important modes of action of RTX, hypocomplementemia, frequently associated with systemic lupus erythematodes, may act to hamper the efficacy of RTX in the treatment of patients with lupus nephritis. This review provides a description of RTX pharmacokinetics and pharmacodynamics in several selected glomerulopathies, as well as the impact of proteinuria, anti-drug antibodies and other clinical variables on the clearance and volume of distribution of RTX. The impact of plasmapheresis and peritoneal dialysis on the clearance of RTX is also discussed in the paper. A review is provided of the potential association between pharmacokinetic and pharmacodynamic alterations in various kidney-affecting glomerular diseases, the sustainability of B-cell depletion and the clinical efficacy of RTX, with proposals for potential dosing implications. The role of therapeutic drug monitoring in treatment tailoring is also discussed, and various previously tested RTX dosing schedules are compared in terms of their clinical and laboratory treatment responses. Since alternative anti-CD20 molecules may prove effective in RTX unresponsive patients, their pharmacokinetics, pharmacodynamics and current role in the treatment of glomerulopathies are also mentioned.
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Affiliation(s)
- Jan Miroslav Hartinger
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
- *Correspondence: Jan Miroslav Hartinger,
| | - Vojtech Kratky
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Ondrej Slanar
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
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Burger C, Créon A, Karras A. Time for new therapeutic options in lupus nephritis. Joint Bone Spine 2022; 89:105451. [PMID: 35944598 DOI: 10.1016/j.jbspin.2022.105451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Carole Burger
- Nephrology Department, Hôpital Européen Georges-Pompidou, Paris, France; Université Paris Cité, Paris, France
| | - Antoine Créon
- Nephrology Department, Hôpital Européen Georges-Pompidou, Paris, France
| | - Alexandre Karras
- Nephrology Department, Hôpital Européen Georges-Pompidou, Paris, France; Université Paris Cité, Paris, France.
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Alzayer H, Sebastian KK, O’Shaughnessy MM. Rituximab Dosing in Glomerular Diseases: A Scoping Review. Can J Kidney Health Dis 2022; 9:20543581221129959. [PMID: 36275037 PMCID: PMC9583230 DOI: 10.1177/20543581221129959] [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: 06/03/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose of Review Rituximab is increasingly prescribed for glomerular diseases. However, the recently published Kidney Disease Improving Global Outcomes (KDIGO) 2021 Clinical Practice Guideline for the Management of Glomerular Diseases lacks details on recommended dosing regimens for most individual glomerular diseases. We performed this scoping review summarizing the evidence for rituximab dosing in glomerular disease. Sources of Information PubMed database. Methods The PubMed search methodology was developed with a medical librarian and performed by the first, with review by a second, author. Randomized controlled trials (RCTs) and prospective cohort studies (PCSs) examining rituximab efficacy and/or safety in antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV), membranous nephropathy (MN), lupus nephritis (LN), or podocytopathies (minimal change disease or focal segmental glomerulosclerosis [FSGS]) were included. Fifty-three studies (14 RCTs and 39 PCSs) were included. Key Findings We identified 16 different rituximab dosing regimens studied as induction therapy for one or more of the 5 glomerular diseases of interest. The most frequently studied rituximab induction regimens were 1000 mg as 2 doses 2 weeks apart (17 studies, 32%) and 4 doses of 375 mg/m2/week (18 studies, 33.9%). Twenty-six studies (49%) examined rituximab as monotherapy or in conjunction with corticosteroids alone, while the remaining studies examined rituximab as part of combination immunosuppression. Adapting treatment to achieve B-cell depletion, with frequent evaluation of disease-specific biomarkers, might prove the optimal approach to achieving and maintaining remission. Rituximab might also enable steroid minimization or avoidance. Limitations Restriction of the search to a single database and to studies published in the English language, and with an accompanying abstract, could have led to selection bias. While the search was limited to prospective observational studies and RCTs, no formal assessment of study quality was performed.
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Affiliation(s)
- Husam Alzayer
- Department of Nephrology, Ministry of
Health, Arar, Saudi Arabia,Royal College of Surgeons in Ireland,
Dublin, Ireland,Husam Alzayer, Department of Nephrology,
Ministry of Health, Arar, Northern Boarders, 73241, Saudi Arabia.
;
| | - Kuruvilla K. Sebastian
- Department of Renal Medicine, Cork
University Hospital, Ireland,Department of Medicine, National
University of Ireland Galway, Ireland
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Roberts JE, Berbert L, Chang J, Son MBF. Association of Race and Ethnicity With Medication Use for Pediatric Lupus in the Childhood Arthritis and Rheumatology Research Alliance Registry. ACR Open Rheumatol 2022; 4:954-963. [DOI: 10.1002/acr2.11494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/06/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jordan E. Roberts
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Laura Berbert
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Joyce Chang
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
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35
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Yu C, Li P, Dang X, Zhang X, Mao Y, Chen X. Lupus nephritis: new progress in diagnosis and treatment. J Autoimmun 2022; 132:102871. [PMID: 35999111 DOI: 10.1016/j.jaut.2022.102871] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic multifactorial autoimmune disease that affects many organs, including the kidney. Lupus nephritis (LN) is a common manifestation characterized by heterogeneous clinical and histopathological findings, and often associates with poor prognosis. The diagnosis and treatment of LN is challenging, depending largely on renal biopsy, and there is no reliable non-invasive LN biomarker. Up to now, the complete remission rate of LN is only 20%∼30% after receiving six months of standard treatment, which is far from satisfactory. Moreover, adverse reactions to immunosuppressants, especially glucocorticoids, further compromise the prognosis of LN. Biological reagents targetting autoimmune responses and inflammatory pathways, bring hope to the treatment of intractable lupus. The European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) and KDIGO (Kidney Disease: Improving Global Outcomes) have been working on and launched the recommendations for the management of LN. In this review, we update our knowledge in the pathogenesis, diagnosis, and management of LN and prospect for the future potential targets in the management of LN.
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Affiliation(s)
- Chen Yu
- Department of Nephrology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ping Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing 100853, China
| | - Xin Dang
- Department of Nephrology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xuan Zhang
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yonghui Mao
- Department of Nephrology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing 100853, China.
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Sciascia S, Parodis I, Karim MY. Editorial: Clinical, Molecular and Adverse Responses to B-Cell Therapies in Autoimmune Disease. Front Immunol 2022; 13:962088. [PMID: 35874715 PMCID: PMC9298074 DOI: 10.3389/fimmu.2022.962088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/21/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mohammed Yousuf Karim
- Department of Pathology, Sidra Medicine, Doha, Qatar
- *Correspondence: Mohammed Yousuf Karim,
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Reddy VR, Pepper RJ, Shah K, Cambridge G, Henderson SR, Klein C, Kell L, Taylor SJ, Isenberg DA, Cragg MS, Leandro MJ. Disparity in peripheral and renal B-cell depletion with rituximab in systemic lupus erythematosus: an opportunity for obinutuzumab? Rheumatology (Oxford) 2022; 61:2894-2904. [PMID: 34788412 PMCID: PMC9258539 DOI: 10.1093/rheumatology/keab827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/05/2021] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To investigate key factors that may contribute to the variability of rituximab-mediated peripheral and renal B cell depletion (BCD) in SLE. METHODS We analysed: (i) CD19+ B cell counts in patients with SLE before and 1, 2, 3 and 6 months after treatment with rituximab, comparing them with RA patients; (ii) the presence of B cells in renal biopsies after rituximab therapy; (iii) whether the duration of BCD correlated with patient demographics and B cell expression of CD20 and FcγRIIb; and (iv) the effect of B cell activation factor (BAFF) on the efficiency of rituximab and obinutuzumab at inducing BCD in whole blood assays, in vitro. RESULTS In SLE (n = 71), the duration of BCD was shorter compared with RA (n = 27). B cells were detectable in renal biopsy samples (n = 6) after treatment with rituximab in all patients with poor response while peripheral blood B cells remained low or undetectable in the same patients. There were no significant relationships between peripheral BCD and patient age, disease duration, serum C3 levels or the level of expression of B cell surface proteins CD20 and FcγRIIb. Obinutuzumab was more efficient than rituximab at inducing BCD in whole blood assays, regardless of excess BAFF. CONCLUSIONS BCD in SLE is less efficient than in RA. Renal B cell presence following rituximab treatment was associated with poor outcomes. No significant relationships between any measured B cell related, clinical or laboratory parameters and the efficiency of BCD by rituximab was found. Obinutuzumab was superior to rituximab at inducing BCD.
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Affiliation(s)
- Venkat R Reddy
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
| | - Ruth J Pepper
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Department of Renal Medicine (formerly Centre for Nephrology), Royal Free Hospital, London, UK
| | - Kavina Shah
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
| | - Geraldine Cambridge
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
| | - Scott R Henderson
- Department of Renal Medicine (formerly Centre for Nephrology), Royal Free Hospital, London, UK
| | - Christian Klein
- Cancer Immunotherapy Discovery, Oncology Discovery & Translational AreaRoche Pharma Research & Early Development, Roche Innovation Center, Zurich, Switzerland
| | - Loren Kell
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
| | - Samuel J Taylor
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
| | - Mark S Cragg
- Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Maria J Leandro
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London
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Alternative CAR Therapies: Recent Approaches in Engineering Chimeric Antigen Receptor Immune Cells to Combat Cancer. Biomedicines 2022; 10:biomedicines10071493. [PMID: 35884798 PMCID: PMC9313317 DOI: 10.3390/biomedicines10071493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 02/08/2023] Open
Abstract
For nearly three decades, chimeric antigen receptors (CARs) have captivated the interest of researchers seeking to find novel immunotherapies to treat cancer. CARs were first designed to work with T cells, and the first CAR T cell therapy was approved to treat B cell lymphoma in 2017. Recent advancements in CAR technology have led to the development of modified CARs, including multi-specific CARs and logic gated CARs. Other immune cell types, including natural killer (NK) cells and macrophages, have also been engineered to express CARs to treat cancer. Additionally, CAR technology has been adapted in novel approaches to treating autoimmune disease and other conditions and diseases. In this article, we review these recent advancements in alternative CAR therapies and design, as well as their mechanisms of action, challenges in application, and potential future directions.
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Obrișcă B, Vornicu A, Procop A, Herlea V, Terinte-Balcan G, Gherghiceanu M, Ismail G. A Histology-Guided Approach to the Management of Patients with Lupus Nephritis: Are We There Yet? Biomedicines 2022; 10:biomedicines10061409. [PMID: 35740431 PMCID: PMC9220241 DOI: 10.3390/biomedicines10061409] [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: 05/20/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Renal involvement is a frequent complication of systemic lupus erythematosus (SLE). It occurs in up to two-thirds of patients, often early during the disease course, and is the most important predictor of the morbidity and mortality of SLE patients. Despite tremendous improvements in the approach of the lupus nephritis (LN) therapy, including the recent approval of two new disease-modifying therapies, up to 50% of patients do not obtain a renal response and up to 25% will eventually progress to end-stage renal disease (ESRD) within 10 years of diagnosis. Given the lack of correlation between clinical features and histological lesions, there is an increasing need for a histology-guided approach to the management of patients with LN. Apart from the initial diagnosis of type and severity of renal injury in SLE, the concept of a repeat kidney biopsy (either in a for-cause or a per-protocol scenario) has begun to gain increasing popularity in the nephrology community. Herein, we will provide a comprehensive overview of the most important areas of utility of the kidney biopsy in patients with LN.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandru Procop
- Department of Pathology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.P.); (V.H.)
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.P.); (V.H.)
| | - George Terinte-Balcan
- Ultrastructural Pathology, “Victor Babes” National Institute of Pathology, 050097 Bucharest, Romania; (G.T.-B.); (M.G.)
| | - Mihaela Gherghiceanu
- Ultrastructural Pathology, “Victor Babes” National Institute of Pathology, 050097 Bucharest, Romania; (G.T.-B.); (M.G.)
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
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Wu TH, Liao HT, Li TH, Tsai HC, Lin NC, Chen CY, Tsai SF, Huang TH, Tsai CY, Yu CL. High-Throughput Sequencing of Complementarity Determining Region 3 in the Heavy Chain of B-Cell Receptor in Renal Transplant Recipients: A Preliminary Report. J Clin Med 2022; 11:jcm11112980. [PMID: 35683373 PMCID: PMC9181060 DOI: 10.3390/jcm11112980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/01/2022] [Accepted: 05/23/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Graft failure resulting from rejection or any other adverse event usually originates from an aberrant and/or exaggerated immune response and is often catastrophic in renal transplantation. So, it is essential to monitor patients’ immune status for detecting a rejection/graft failure early on. Methods: We monitored the sequence change of complementary determining region 3 (CDR3) in B-cell receptor (BCR) immunoglobulin heavy-chain (IGH) immune repertoire (iR) in 14 renal transplant patients using next-generation sequencing (NGS), correlating its diversity to various clinical events occurring after transplantation. BCR-IGH-CDR3 in peripheral blood mononuclear cells was sequenced along the post-transplantation course by NGS using the iRweb server. Results: Datasets covering VDJ regions of BCR-IGH-CDR3 indicated clonal diversity (D50) variations along the post-transplant course. Furthermore, principal component analysis showed the clustering of these sequence variations. A total of 544 shared sequences were identified before transplantation. D50 remained low in three patients receiving rituximab. Among them, one’s D50 resumed after 3 m, indicating graft tolerance. The D50 rapidly increased after grafting and decreased thereafter in four patients without rejection, decreased in two patients with T-cell-mediated rejection (TCMR) and exhibited a sharp down-sliding after 3 m in two patients receiving donations after cardiac death (DCD). In another two patients with TCMR, D50 was low just before individual episodes, but either became persistently low or returned to a plateau, depending on the failure or success of the immunosuppressive treatments. Shared CDR3 clonal expansions correlated to D50 changes. Agglomerative hierarchical clustering showed a commonly shared CDR3 sequence and at least two different clusters in five patients. Conclusions: Clonal diversity in BCR-IGH-CDR3 varied depending on clinical courses of 14 renal transplant patients, including B-cell suppression therapy, TCMR, DCD, and graft tolerance. Adverse events on renal graft failure might lead to different clustering of BCR iR. However, these preliminary data need further verification in further studies for the possible applications of iR changes as genetic expression biomarkers or laboratory parameters to detect renal graft failure/rejection earlier.
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Affiliation(s)
- Tsai-Hung Wu
- Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Hsien-Tzung Liao
- Division of Allergy, Immunology & Rheumatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (H.-T.L.); (H.-C.T.)
| | - Tzu-Hao Li
- Division of Immunology & Rheumatology, Shin Kong Wu Ho Su Memorial Hospital, Taipei 11101, Taiwan;
| | - Hung-Cheng Tsai
- Division of Allergy, Immunology & Rheumatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (H.-T.L.); (H.-C.T.)
| | - Niang-Cheng Lin
- Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (N.-C.L.); (C.-Y.C.)
| | - Cheng-Yen Chen
- Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (N.-C.L.); (C.-Y.C.)
| | - Shih-Feng Tsai
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan 35053, Taiwan;
| | - Tzu-Hao Huang
- Department of Urology, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Chang-Youh Tsai
- Division of Allergy, Immunology & Rheumatology, Fu Jen Catholic University Hospital, New Taipei City 24352, Taiwan
- Correspondence: or (C.-Y.T.); (C.-L.Y.)
| | - Chia-Li Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Correspondence: or (C.-Y.T.); (C.-L.Y.)
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Abstract
Despite improvements in patient and renal death rates following the introduction of potent immunosuppressive drugs in earlier decades, a sizeable fraction of patients with lupus nephritis is burdened with suboptimal or delayed responses, relapses, chronic use of glucocorticoids and accrual of renal (chronic renal insufficiency) and extra-renal organ damage. The recently approved combinatory treatments comprising belimumab or voclosporin added to conventional agents, especially mycophenolate, hold promise for further improving disease outcomes and enabling a faster steroid tapering, thus being relevant to the treat-to-target context. However, it remains uncertain whether these dual regimens should become the first-line choice for all patients or instead be prioritized to certain subgroups. In the present article, we summarize the existing lupus nephritis management recommendations, followed by a critical appraisal of the randomized trials of belimumab and voclosporin, as well as the available data on obinutuzumab and other novel compounds under development. We conclude that pending the identification of accurate clinical, histological, or translational predictors for guiding personalized decisions, it is of utmost importance that lupus nephritis patients are monitored closely with appropriate treatment adjustments aiming at a prompt, deep response to ensure long-term preservation of kidney function.
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Effect of Rituximab on 24-Hour Urine Protein and Albumin or Renal Function in Patients with Glomerulonephritis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6412740. [PMID: 35463670 PMCID: PMC9020919 DOI: 10.1155/2022/6412740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/19/2022] [Indexed: 11/18/2022]
Abstract
This study aimed to investigate the correlation between the urine protein/creatinine ratio (PCR) and 24 h urine total protein quantity (24hUTP) in morning and random urine and its prediction equation. Rituximab (RTX), a monoclonal antibody that acts on the B cell epitope CD20, has been used in the renal field since 2005 and has become a hot topic in the clinical treatment of many glomerulonephritis diseases. Apart from focusing on the safety and efficacy of RTX in clinical treatment, some scholars are still working on the mechanism of its action in the treatment of renal diseases, trying to find its specific targets in renal tissues. Results. There was no significant difference between morning urine PCR, random urine PCR, and 24hUTP (P=0.81); there was a significant positive correlation between morning urine PCR and 24hUTP (r = 0.90, P < 0.01) and between random urine PCR and 24hUTP (r = 0.95, P < 0.01), and the correlation between random urine PCR and 24hUTP was higher than that between morning urine PCR and 24hUTP. The results of the ROC curve analysis showed that the correlation between morning urine PCR, random urine PCR, and 24hUTP was higher than that between morning urine PCR and 24hUTP in different groups. The optimal threshold values for random urine PCR to predict 2.4hUTP were 0.56 g/g (sensitivity 93.5%; specificity 75.4%), 1.11 g/g (sensitivity 98.3%; specificity 92.4%), and 3.43 g/g (sensitivity 87.9%; specificity 89.9%), respectively. The equations for predicting 24hUTP by morning urine PCR and random urine PCR were as follows: (1) 24hUTP(g) = 0.793 + 0.793 × morning urine PCR + 0.124 × total cholesterol − 0.177 × Alb (coefficient of determination R2 = 0.87); (2) 24hUTP(g) = 0.369 + 0.856 × random urine PCR + 0.132 × total cholesterol − 0.092 × Alb (coefficient of determination R2 = 0.92); the prediction equation of random urine was more accurate than that of morning urine. The correlation was not affected by gender, age, 24 h urine volume, etiology, eGFR, Alb, or total cholesterol level, and the correlation between random urine PCR and 24hUTP was higher than that of morning urine PCR. CR prediction equation was used instead of the 24hUTP test.
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43
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Noone DG, Silverman ED. Treatment of Childhood-onset Proliferative Lupus Nephritis in the 21st Century: A Call to Catch Up With the Evidence. J Rheumatol Suppl 2022; 49:552-554. [PMID: 35365579 DOI: 10.3899/jrheum.220196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Proliferative lupus nephritis (PLN) is associated with significant morbidity, mortality, and kidney failure, especially in childhood-onset PLN (cPLN). Therefore, it is important to treat it promptly and aggressively, while being cognizant of the risk-benefit ratio and side effects of therapies.
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Affiliation(s)
- Damien G Noone
- D. Noone, MB BCh BAO, MSc, Division of Nephrology, The Hospital for Sick Children, and Associate Professor, Department of Paediatrics, University of Toronto; E.D. Silverman, MD, FRCPC, Division of Rheumatology, The Hospital for Sick Children, Senior Associate Scientist, Physiology & Experimental Medicine Program, SickKids Research Institute, and Professor of Paediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. E.D. Silverman, The Hospital for Sick Children, Division of Rheumatology, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Earl D Silverman
- D. Noone, MB BCh BAO, MSc, Division of Nephrology, The Hospital for Sick Children, and Associate Professor, Department of Paediatrics, University of Toronto; E.D. Silverman, MD, FRCPC, Division of Rheumatology, The Hospital for Sick Children, Senior Associate Scientist, Physiology & Experimental Medicine Program, SickKids Research Institute, and Professor of Paediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. E.D. Silverman, The Hospital for Sick Children, Division of Rheumatology, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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BLISS-LN trial revisited: function matters. Kidney Int 2022; 101:224-226. [DOI: 10.1016/j.kint.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/22/2022]
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Aghajanian H, Rurik JG, Epstein JA. CAR-based therapies: opportunities for immuno-medicine beyond cancer. Nat Metab 2022; 4:163-169. [PMID: 35228742 PMCID: PMC9947862 DOI: 10.1038/s42255-022-00537-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/20/2022] [Indexed: 02/01/2023]
Abstract
One of the most exciting new therapies for cancer involves the use of autologous T cells that are engineered to recognize and destroy cancerous cells. Patients with previously untreatable B cell leukaemias and lymphomas have been cured, and efforts are underway to extend this success to other tumours. Here, we discuss recent studies and emerging research aimed to extend this approach beyond oncology in areas such as cardiometabolic disorders, autoimmunity, fibrosis and senescence. We also summarize new technologies that may help to reduce the cost and increase access to related forms of immunotherapy.
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Affiliation(s)
- Haig Aghajanian
- Department of Cell and Developmental Biology, Penn Cardiovascular Institute, and Institute for Regenerative Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Joel G. Rurik
- Department of Cell and Developmental Biology, Penn Cardiovascular Institute, and Institute for Regenerative Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan A. Epstein
- Department of Cell and Developmental Biology, Penn Cardiovascular Institute, and Institute for Regenerative Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Radic M, Neeli I, Marion T. Prospects for CAR T cell immunotherapy in autoimmune diseases: clues from Lupus. Expert Opin Biol Ther 2022; 22:499-507. [PMID: 35089116 DOI: 10.1080/14712598.2022.2026921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Medicine stands at the threshold of a new era heralded by the vast potential of cell engineering. Like advances made possible by genetic engineering, current prospects for purposeful control of cell functions through cell engineering may bring breakthroughs in the treatment of previously intractable diseases. AREAS COVERED Engineering of cytotoxic T cells for expression of chimeric antigen receptors (CARs) instructs them to attack and destroy malignant cells and thus provides an exciting new approach in oncology. A decade of practical experience and first-in-human trials encourage the search for new and broader uses of CAR technology, including in autoimmune diseases. EXPERT OPINION Systemic lupus erythematosus is an example of a broader category of autoimmune diseases, for which cell engineering will provide a powerful new therapeutic approach. This article describes different types of CAR T cell strategies that will provide new treatment options for patients with autoimmune diseases and replace conventional therapies.
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Affiliation(s)
- Marko Radic
- Department of Microbiology, Immunology and Biochemistry, University of Tennessee Health Science Center, Memphis, TN (USA)
| | - Indira Neeli
- Department of Microbiology, Immunology and Biochemistry, University of Tennessee Health Science Center, Memphis, TN (USA)
| | - Tony Marion
- Department of Microbiology, Immunology and Biochemistry, University of Tennessee Health Science Center, Memphis, TN (USA)
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Kostopoulou M, Fanouriakis A, Bertsias G, Boumpas DT. Treatment of lupus: more options after a long wait. Ann Rheum Dis 2022; 81:753-756. [PMID: 35027404 DOI: 10.1136/annrheumdis-2021-221817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Myrto Kostopoulou
- "Attikon" University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Antonis Fanouriakis
- "Attikon" University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece.,First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - George Bertsias
- Rheumatology, University of Crete School of Medicine, Iraklio, Crete, Greece.,Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Dimitrios T Boumpas
- "Attikon" University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece .,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Attica, Greece
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48
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Skácelová M. What is new in the treatment of Systemic Lupus Erythematosus? VNITRNI LEKARSTVI 2022; 68:273-278. [PMID: 36283816 DOI: 10.36290/vnl.2022.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Systemic lupus erythematosus treatment is targeted to achieve remission or low disease activity and protection from disease flares. A number of immunosupresive drugs in combination with glucocorticoids are used for this purpose and there is an increased possibility of the use of biologic treatment, especially of belimumab. Calcineurin inhibitor voclosporin is a novelty in lupus nephritis treatment. Another novelty is anifrolumab, a biologic drug which inhibits the activity of type I interferons. An integral part of care is the prevention of late disease complications, especially cardiovascular risk management.
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Choi SJ, Ahn SM, Oh JS, Hong S, Lee CK, Yoo B, Kim YG. Initial Preserved Renal Function as a Predictor of Favorable Renal Response to Rituximab in Refractory or Relapsing Lupus Nephritis: A Single-center Cohort Study in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:22-32. [PMID: 37476702 PMCID: PMC10324915 DOI: 10.4078/jrd.2022.29.1.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Previous studies investigating the beneficial effect of rituximab on lupus nephritis (LN) reported controversial results There have been few reports of renal response to rituximab according to renal function We investigated the efficacy of rituximab in refractory/relapsing LN and the role of renal function as a predictor of renal response. METHODS From 2016 to 2019, we retrospectively reviewed 22 patients with refractory/relapsing LN receiving rituximab Renal responses (complete and partial) at 6 and 12 months were compared between normal (glomerular filtration rate [GFR]≥90 mL/min/173 m2, n=11) and decreased (GFR<90 mL/min/173 m2, n=11) GFR groups Multivariate Cox regression analysis was used to assess predictors of renal response. RESULTS At baseline, the decreased GFR group had a higher urine proteinuria to creatinine ratio (p=0008) and proportion of refractory LN (p=0010) and previous cyclophosphamide therapy (p=0035) than the normal GFR group The overall renal response rate was 455% (10 patients) at 6 months and 545% (12 patients) at 12 months Renal response rates were higher in the normal GFR group (818% and 909% at 6 and 12 months, respectively) than in the decreased GFR group (91% and 182% at 6 and 12 months, respectively; p<0001) Normal GFR and anti-La were associated with renal response to rituximab, with hazard ratios of 9256 (p=0008) and 5478 (p=0041), respectively. CONCLUSION Rituximab is an effective therapy for refractory/relapsing LN, particularly in patients with preserved renal function.
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Affiliation(s)
- Su Jin Choi
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Rheumatology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Simon JR, Pereira MFB, Marques HH, Elias AM, Sakita NK, Ferreira JCOA, Precioso AR, Grisi SJFE, Ferrer APS, Bain V, Silva CA, Campos LMA. Seroconversion in asymptomatic COVID-19 pediatric patients with rheumatic diseases of one tertiary referral hospital. Clinics (Sao Paulo) 2022; 77:100110. [PMID: 36179528 PMCID: PMC9464576 DOI: 10.1016/j.clinsp.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/12/2022] [Accepted: 08/29/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To evaluate seroconverted asymptomatic COVID-19 in pediatric Autoimmune Rheumatic Diseases (ARDs) patients and to identify the risk factors related to contagion. METHODS A cross-sectional study was conducted in March 2021, before vaccination of children and adolescents in Brazil, including 77 pediatric ARDs patients, followed at a tertiary hospital and 45 healthy controls, all of them without a previous diagnosis of COVID-19. Data was obtained by a questionnaire with demographic data, symptoms compatible with COVID-19 over the previous year, and contact with people with confirmed COVID-19. Patient's medical records were reviewed to access data regarding disease and current medications. A qualitative immunochromatographic SARS-CoV-2 test was performed on all participants. RESULTS Patients and controls were similar in terms of female gender (70.1% vs. 57.8%, p = 0.173), age (14 vs. 13 years, p = 0.269) and SARS-CoV-2 positive serology (22% vs. 15.5%, p = 0.481). 80.5% of rheumatic patients were in use of immunosuppressive drugs: 27.3% of them used corticosteroids (33.3% in high doses), and 7.8% on immunobiologicals. No statistical differences were found between positive (n = 17) and negative serology (n = 60) patients regarding demographic/socioeconomic data, contact with people with confirmed COVID-19, use and number of immunosuppressive drugs, use and dose of corticosteroids, use of hydroxychloroquine and immunobiological drugs (p > 0.05). CONCLUSIONS Pediatric rheumatic disease patients were infected at the same rate as healthy ones. Neither the underlying pathology nor its immunosuppressive treatment seemed to interfere with contagion risk.
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Affiliation(s)
- Juliana R Simon
- Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Maria F B Pereira
- Pediatric Infectology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Heloisa H Marques
- Pediatric Infectology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Adriana M Elias
- Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Neusa K Sakita
- Clinical Research Center, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Juliana C O A Ferreira
- Clinical Research Center, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Alexander Roberto Precioso
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil; Division of Clinical Trials and Pharmacovigilance, Instituto Butantan, São Paulo, SP, Brazil
| | - Sandra J F E Grisi
- Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Ana Paula S Ferrer
- Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Vera Bain
- Pediatric Infectology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Rheumatology Division, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Lúcia M A Campos
- Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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