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Clardy SL, Smith TL. Therapeutic Approach to Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1226-1258. [PMID: 39088294 DOI: 10.1212/con.0000000000001463] [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: 08/03/2024]
Abstract
OBJECTIVE Autoimmune neurologic disorders encompass a broad category of diseases characterized by immune system attack of the central, peripheral, or autonomic nervous systems. This article provides information on both acute and maintenance immunotherapy used to treat autoimmune neurologic disorders as well as a review of symptomatic management and special considerations when caring for patients with these diseases. LATEST DEVELOPMENTS Over the past 20 years, more than 50 antibodies have been identified and associated with autoimmune neurologic disorders. Although advances in diagnostic testing have allowed for more rapid diagnosis, the therapeutic approach to these disorders has largely continued to rely on expert opinion, case series, and case reports. With US Food and Drug Administration (FDA) approval of biologic agents to treat neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis as well as ongoing clinical trials for the treatment of autoimmune encephalitis, the landscape of immunotherapy options continues to expand. Consideration of the unique pathogenesis of individual autoimmune neurologic disorders as well as the mechanism of action of the diverse range of treatment options can help guide treatment decisions today while evidence from clinical trials informs new therapeutics in the future. ESSENTIAL POINTS Recognizing patients who have a clinical history and examination findings concerning for autoimmune neurologic disorders and conducting a thorough and directed imaging and laboratory evaluation aimed at ruling out mimics, identifying specific autoimmune syndromes, and screening for factors that may have an impact on immunotherapy choices early in the clinical course are essential to providing optimal care for these patients. Providers must consider immunotherapy, symptomatic treatment, and a multidisciplinary approach that addresses each patient's unique needs when treating patients with autoimmune neurologic disorders.
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Piemonti L, Vettor L, Contro E. A Case Report of Metastatic Gastric Cancer Treated with Pembrolizumab during Pregnancy. Fetal Diagn Ther 2024; 51:493-499. [PMID: 38934141 PMCID: PMC11446398 DOI: 10.1159/000540000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Immune checkpoint inhibitors are extensively used in present-day clinical practice for treating many types of cancers at different stages. To date, there are scarce data on the use of immunotherapy in pregnancy. Immune-related adverse events are a typical consequence of this therapy miming autoimmune diseases. CASE PRESENTATION A 35-year-old woman (G1P0) diagnosed with gastric carcinoma underwent neoadjuvant chemotherapy followed by surgery. During follow-up, axillary metastasis was discovered, radiotherapy failed, and consequently immunotherapy was started. Concurrently, pregnancy ensued. Despite potential risks, the patient opted to continue immunotherapy and the pregnancy. At 31 weeks, fetal bowel dilation was noted. Subsequently, the fetus also developed fetal growth restriction. A cesarean section was performed at 35 weeks. The newborn required repeated bowel resections for necrotizing enterocolitis, necessitating extensive medical intervention. The mother continues pembrolizumab treatment with a positive response. CONCLUSION To the best of our knowledge, this might constitute a possible case of a fetal immune-related adverse event after immunotherapy in utero exposure.
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Affiliation(s)
- Linda Piemonti
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,
| | - Laura Vettor
- Department of Women's and Children's Health Gynecologic and Obstetrics Clinic, University of Padua, Padua, Italy
| | - Elena Contro
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Florez N, Kaufman RA, Yáñez-Sarmiento A, Abioye O, Kiel LR. When the unimaginable happens: Lung cancer diagnosis during pregnancy. Cancer 2024; 130:1905-1909. [PMID: 38285618 DOI: 10.1002/cncr.35227] [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] [Indexed: 01/31/2024]
Abstract
The increasing incidence of lung cancer diagnosis during pregnancy has brought new challenges and opportunities to expand the knowledge gap in this protected patient population. Here, available data and top recommendations for the practicing oncologist are discussed.
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Affiliation(s)
- Narjust Florez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rebekah A Kaufman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Oyepeju Abioye
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lauren R Kiel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Khedr L, Ekram M. Azathioprine Associated with Intrahepatic Cholestasis in a Patient with Twin Pregnancy after a Second Kidney Transplant. Eur J Case Rep Intern Med 2024; 11:004385. [PMID: 38584904 PMCID: PMC10997401 DOI: 10.12890/2024_004385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Most pregnancies in women after a kidney transplant result in a live birth, but kidney functions should be stable for one year before conception. For immunosuppression modification occurring before pregnancy, azathioprine is used because it is considered safe for major congenital malformations during pregnancy. However, there may be an association between exposure to azathioprine during pregnancy and the onset of an unusual, early and severe form of intrahepatic cholestasis. Case description A young patient with a twin pregnancy after a second kidney transplant experienced intrahepatic cholestasis. There was a wide range of differential diagnosis. A battery of tests was requested including autoimmune markers, virology, and imaging. The conclusion that azathioprine was contributing to intrahepatic cholestasis with pregnancy was reached after exclusion of all other differentials. Conclusions Complications of pregnancy after a kidney transplant include hypertension, pre-eclampsia, deterioration of graft function up to rejection, but also unusual side effects of immunosuppression medication. LEARNING POINTS A twin pregnancy after a second kidney transplant is rare.In addition to bone marrow suppression and elevation of liver enzymes, azathioprine can contribute to intrahepatic cholestasis of pregnancy.Complications of pregnancy after kidney transplant include hypertension, pre-eclampsia, deterioration of graft function up to rejection, but also unusual side effects of immunosuppression medication.
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Affiliation(s)
- Lamis Khedr
- Nephrology Department, Ain Shams University, Cairo, Egypt
| | - Mohamed Ekram
- Internal Medicine Department, New Giza University, Cairo, Egypt
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Drie T, Alsamman MI, Tarcha R, Haidar G, Kudsi M. Successful pregnancy after cyclophosphamide therapy for systemic lupus erythematosus: a case report. Ann Med Surg (Lond) 2024; 86:1156-1160. [PMID: 38333243 PMCID: PMC10849339 DOI: 10.1097/ms9.0000000000001641] [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: 10/31/2023] [Accepted: 12/10/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction and importance The use of cyclophosphamide in women of childbearing age with severe systemic lupus erythematosus is normally indicated. However, cyclophosphamide is generally avoided during pregnancy due to the risk of teratogenicity, especially since its effect on fetal survival is poorly understood. This is a case report of a lupus patient exposed to cyclophosphamide during pregnancy. Case presentation A 35-year-old woman with a history of lupus presented to our outpatient clinic in the 12th week of pregnancy for her sixth routine cyclophosphamide bolus. The fetal echocardiogram result with the gynecology consultation was normal with the recommendation for a medical termination of pregnancy, which has been refused by the patient. Shared decision-making with the patient included a discussion of the maternal risks of continuation of pregnancy in the setting of worsening systemic function and the fetal risks of definitive treatment with cyclophosphamide for a lupus flare and the patient decided to proceed with the pregnancy. Treatment with immunosuppressants, including azathioprine was initiated replacing cyclophosphamide with close monitoring of her and the fetus every month. Clinical discussion The first trimester of pregnancy seems to be particularly susceptible to fetal malformations, although CPA effects on fetuses in later stages of pregnancy are also reported occasionally. Nonetheless, its repercussions on fetal survival remain poorly comprehended. Conclusion In conclusion, exposing pregnancy to cyclophosphamide could end with pregnancy loss. Based on our experience, the survival of the fetus is strongly in doubt when cyclophosphamide is required to treat lupus in the mother. However, in rare cases, it could be without complications.
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Affiliation(s)
- Tasneem Drie
- Rheumatology Department, Faculty of Medicine, Damascus University
| | | | - Raghad Tarcha
- Rheumatology Department, Faculty of Medicine, Damascus University
| | - Ghina Haidar
- Rheumatology Department, Faculty of Medicine, Damascus University
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Rose M, Ritter D, Gupta N, Tolusso L, Horn P, Wakefield E, Glass J. Healthcare provider recognition of pregnancy related risks and management considerations in patients with tuberous sclerosis complex. Orphanet J Rare Dis 2024; 19:4. [PMID: 38166979 PMCID: PMC10763101 DOI: 10.1186/s13023-023-03015-7] [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: 09/20/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Patients with tuberous sclerosis complex (TSC) face an increased risk of maternal health complications and worsening disease manifestations during pregnancy. There are no established consensus guidelines that address the management of pregnancy in patients with TSC and healthcare providers rely on their individual experiences and preferences to derive treatment decisions. We sought to obtain provider opinion of pregnancy related maternal complications in patients with TSC, and the common evaluation and management strategies used to address these issues. METHODS We conducted a cross-sectional survey of healthcare providers with diverse areas of expertise related to the multisystem nature of involvement in TSC. Descriptive analyses were used to analyze our three primary variables: (1) provider recognition of maternal risks/complications; (2) provider recommendations before and during pregnancy; and (3) provider/clinic protocols. RESULTS We received responses from 87 providers from 11 countries, with 40.7% (n = 35) seeing > 30 TSC patients yearly. The majority of providers (n = 70, 88.6%) deemed that a patient with TSC needed expert care beyond the standard of care for a typical pregnancy, with over 25% of providers reporting that they have seen lymphangioleiomyomatosis (LAM) exacerbation, seizures, and preterm labor in pregnant patients with TSC. Providers who managed patients treated with mTOR inhibitors (mTORi) also agreed that mTORi use should be stopped prior to pregnancy (n = 45, 68.2%) but there was uncertainty about when to stop the mTORi (one month 28.9%, two months 11.1%, three months 42.2%, and 6-12 months 2.2%). Additionally, there were mixed opinions on restarting mTORi in response to disease progression during pregnancy. When asked about provider or clinic specific protocols, 71.6% (n = 53) of providers stated that they do not have a clear protocol for management decisions for patients with TSC before or during pregnancy. CONCLUSION Healthcare providers recognize that patients with TSC are at an increased risk for maternal health complications during pregnancy. However, there are wide inter-individual variances in practice, especially pertaining to decisions regarding mTORi use. There is a critical need to better understand the implications of pregnancy for patients with TSC, and to draft consensus recommendations to guide management decisions.
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Affiliation(s)
- Meredith Rose
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
- Medical Genetics Clinic, Mary Bridge Children's/MultiCare Health System, Tacoma, USA.
| | - David Ritter
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, USA
- Medical Service, Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Leandra Tolusso
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- Cincinnati Children's Fetal Care Center, Cincinnati, USA
| | - Paul Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, USA
| | - Emily Wakefield
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jennifer Glass
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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Ongun H, Celik K, Arayici S, Dogan NU, Mendilcioglu I, Ozkan O, Ozkan O. Miracles of science: Birth after uterus transplantation. J Obstet Gynaecol Res 2024; 50:5-14. [PMID: 37922953 DOI: 10.1111/jog.15825] [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: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
AIM The concept of regaining childbearing ability via uterus transplantation (UTx) motivates many infertile women to pursue giving birth to their own children. This article provides insight into maternal and neonatal outcomes of the procedure globally and facilitates quality of care in related medical fields. METHODS The authors searched ISI Web of Science, MEDLINE, non-PubMed-indexed journals, and common search engines to identify peer-review publications and unpublished sources in scientific reference databases. RESULTS The feasibility of the procedure has been proven with 46 healthy children in 88 procedures so far. Success relies upon dedicated teamwork involving transplantation surgery, obstetrics and reproductive medicine, neonatology, pediatrics, psychology, and bioethics. However, challenges exist owing to donor, recipient, and fetus. Fetal growth in genetically foreign uterine allograft with altered feto-maternal interface and vascular anatomy, immunosuppressive exposure, lack of graft innervation leading to "unable-to-feel" uterine contractions and conception via assisted reproductive technology create notable risks during pregnancy. Significant portion of women are complicated by at least one or more obstetric problems. Preeclampsia, gestational hypertension and diabetes mellitus, elevated kidney indices, and preterm delivery are common complications. CONCLUSIONS UTx has short- and long-term satisfying outcome. Advancements in the post-transplant management would undoubtedly lead this experimental procedure into mainstream clinical practice in the near future. However, both women and children of UTx need special consideration due to prematurity-related neonatal problems and the long-term effects of transplant pregnancy. Notable health risks for the recipient and fetus should be discussed with potential candidates for UTx.
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Affiliation(s)
- Hakan Ongun
- Department of Pediatrics, Division of Neonatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Kiymet Celik
- Department of Pediatrics, Division of Neonatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Sema Arayici
- Department of Pediatrics, Division of Neonatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Nasuh Utku Dogan
- Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Inanc Mendilcioglu
- Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Ozlenen Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Omer Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey
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Ashok A, Russell L, Dey M, Kouranloo K. Incidence, clinical features, management and outcomes of ANCA-associated vasculitis in pregnancy- a systematic literature review. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2023; 40:e2023040. [PMID: 38126499 DOI: 10.36141/svdld.v40i4.15094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIM Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare multi-system conditions, usually presenting in older age groups. However, younger individuals are also affected. The average increase of childbearing age and lack of studies in pregnancy necessitates this comprehensive review of data to guide the management of AAV in pregnancy. This systematic review (SR) aimed to summarise the incidence, clinical features, management and maternal and foetal outcomes in female patients with AAV. METHODS The protocol was registered on PROSPERO (CRD42023437482). Articles published in Medline, Embase and Cochrane Databases from 1946 until June 2023 were included. Single case reports, reviews and conference abstracts were excluded. Articles meeting inclusion criteria were examined by two authors. Data on demographics, treatment, clinical features, flares during pregnancy and maternal and foetal outcomes were extracted. RESULTS Eight studies were included, detailing 82 pregnancies in 64 women. The most common drugs used for remission induction pre-conception were cyclophosphamide, rituximab, prednisolone and azathioprine. Serious maternal complications in pregnancy included progressive tracheal/subglottic stenosis (n=5), renal disease (n=2), preeclampsia (n=10) and miscarriages (n=5). Foetal anomalies were rare (n=5). The mean birth weight was 3.37kgs and mean gestation age was 38.26 weeks. No maternal deaths or vasculitis in newborns were reported. Conclusions: Patients can have positive maternal and foetal outcomes following strong induction therapy, vigorous monitoring and prompt treatment of flares during pregnancy. Serious complications and flares are not associated with worse outcomes for newborns.
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Affiliation(s)
| | - Laura Russell
- British Medical Association Library, BMA House London.
| | - Mrinalini Dey
- Department of Rheumatology, Queen Elizabeth Hospital London; University if Liverpool, Institute of Life Courses and Medical Sciences .
| | - Koushan Kouranloo
- University of Liverpool, School of Medicine; Liverpool University NHS Foundation Trust .
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Hung YH, Liu HY, Chang R, Huang JY, Wu CD, Yen MS, Hung YM, Wei JCC, Wang PYP. Association between parental autoimmune disease and childhood atopic dermatitis varied by sex: a nationwide case-control study. Arch Dermatol Res 2023; 315:2011-2021. [PMID: 36892596 DOI: 10.1007/s00403-023-02582-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 03/10/2023]
Abstract
Atopic dermatitis (AD) is a common inflammatory skin disorder induced by dysfunction of immune suppression sharing similar pathogenesis to autoimmune diseases. To explore the association between autoimmune diseases and AD in children, we linked the birth data from National Birth Registry with National Health Insurance Research Database. There were 1,174,941 children obtained from 2006 to 2012 birth cohort. A total of 312,329 children diagnosed with AD before 5 years old were compared to 862,612 children without AD in the control group. Conditional logistic regression was utilized to calculate adjusted odds ratio (OR) and Bonferroni-corrected confidence interval (CI) for overall significance level of 0.05. In 2006-2012 birth cohort, the prevalence rate of AD was 26.6% (95% CI 26.5, 26.7) before 5 years of age. Having parental autoimmune disease (including rheumatoid arthritis, systemic lupus erythematosus, Sjogren's syndrome, ankylosing spondylitis, and psoriasis) was associated with a significant higher risk of children AD development. The other associated factors were maternal obstetric complications (including gestational diabetes mellitus and cervical incompetence), parental systemic diseases (including anemia, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, hyperthyroidism, and obstructive sleep apnea), and parental allergic disease (including asthma and AD). The subgroup analysis showed similar results between children's sexes. Moreover, maternal autoimmune disease had higher impact on the risk of developing AD in the child compared with paternal autoimmune disease. In conclusion, parental autoimmune diseases were found to be related to their children's AD before 5 years old.
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Affiliation(s)
- Yu-Hsuan Hung
- School of Medicine, Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hsin-Yu Liu
- School of Medicine, Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University, Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Rd., South District, Taichung City, 40201, Taiwan
| | - Cheng-Dong Wu
- School of Medicine, Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Man-Syuan Yen
- School of Medicine, Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yao-Min Hung
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital Taitung Branch, No.1000, Gengsheng Rd, Taitung City, 95050, Taiwan.
- College of Science and Engineering, National Taitung University, Taitung, Taiwan.
- College of Health and Nursing, Meiho University, Pingtung, Taiwan.
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Rd., South District, Taichung City, 40201, Taiwan.
- Divison of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan.
| | - Paul Yung-Pou Wang
- Division of Nephrology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, CA, 91706, USA
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Lv Y, Zhou Y, Hu R, Liang Y, Lian Y, Wang J, Wei Y, Zhang Y, Qiao Y, He T. Association between hypoproteinaemia with massive proteinuria and small for gestational age in pre-eclampsia: a single-centre, retrospective cohort study using propensity score matching. BMJ Open 2023; 13:e071835. [PMID: 37463811 PMCID: PMC10357757 DOI: 10.1136/bmjopen-2023-071835] [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] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To investigate the association between hypoproteinaemia with massive proteinuria and the incidence of small for gestational age in pre-eclampsia. DESIGN Retrospective cohort study using propensity score matching. SETTING Northwest Women's and Children's Hospital in Shaanxi Province, China, using data from January 2016 to December 2021. PARTICIPANTS Patients diagnosed with pre-eclampsia were grouped into the massive proteinuria group if the maximum proteinuria was >3.5 g/day and the minimum serum albumin was <30 g/L; otherwise, they were placed in the control group. OUTCOME MEASURES The primary outcome was the incidence of small for gestational age infants. Secondary outcomes included fetal death, admission to the neonatal intensive care unit, a 5 min APGAR score <7, severe small for gestational age, fetal growth restriction, birth weight, premature birth, and maternal outcomes such as eclampsia, encephalopathy, placental abruption, haemolysis, elevated liver enzymes and low platelet syndrome, heart failure and retinal detachment. RESULTS In total, 468 patients (234 from each group) were included, and the groups were well matched. The incidences of small for gestational age (33.76% vs 20.51%, OR 1.646, 95% CI 1.208 to 2.243, p=0.001), severe small for gestational age (14.70% vs 7.69%, OR 1.833, 95% CI 1.063 to 3.162, p=0.026), fetal growth restriction (23.93% vs 16.24%, OR 1.474, 95% CI 1.018 to 2.133, p=0.038), and the numbers of infants admitted to the neonatal intensive care unit (67.52% vs 58.55%, OR 1.153, 95% CI 1.003 to 1.326, p=0.044) were significantly higher in patients with hypoproteinaemia and massive proteinuria than in the control group. In addition, the median birth weight was significantly lower in the massive proteinuria group. There were no significant differences in maternal outcomes except for renal parameters, which were worse in the massive proteinuria group. CONCLUSION Hypoproteinaemia with massive proteinuria was associated with fetal growth and a higher incidence of small for gestational age infants in pre-eclampsia.
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Affiliation(s)
- Yanxiang Lv
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Ying Zhou
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Rui Hu
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yan Liang
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yanan Lian
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Jun Wang
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yang Wei
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yanmei Zhang
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yuan Qiao
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Tongqiang He
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
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Xie J, Gu A, He H, Zhao Q, Yu Y, Chen J, Cheng Z, Zhou P, Zhou Q, Jin M. Autoimmune thyroid disease disrupts immune homeostasis in the endometrium of unexplained infertility women-a single-cell RNA transcriptome study during the implantation window. Front Endocrinol (Lausanne) 2023; 14:1185147. [PMID: 37501789 PMCID: PMC10368980 DOI: 10.3389/fendo.2023.1185147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/23/2023] [Indexed: 07/29/2023] Open
Abstract
Objective Autoimmune thyroid disease (AITD) is known to be associated with unexplained infertility in women. Although the presence of antithyroid antibodies have been speculated to be a marker of an immune imbalance that might lead to implantation failure, its underlying mechanism influencing the endometrial receptivity remains to be elucidated. In this study, we used single-cell RNA sequencing (scRNA-seq) to dissect immune microenvironment in endometrium of AITD patients during window of implantation (WOI). Methods We collected CD45+ immune cell populations of endometrium samples of unexplained infertile women with AITD (n=3), as well as samples of AITD- controls (n=3). The cells were then processed with 10X Genomics Chromium for further analysis. Results We characterized 28 distinct immune cell subtypes totally, and uncovered differences in the composition and gene expression patterns between AITD patients and controls. The proportions of T CD4+, cNK, ILC3, T CD8+ GZMK+, T CD8+ Cytotoxic and ILC3 CD3E - cells were increased, and CD366+ uNK1 was decreased in AITD+ patients. And the abnormal expression of GNLY and chemokines was observed in AITD patients. In addition, uNK and T CD8+ Cytotoxic cells showed lower cytotoxicity but activation of immune response. Genes enriched in cell adhesion of ILC3 and Tregs were downregulated, while the number of ILC3 and Tregs were increased. Conclusion Immune imbalance exists in endometrium during WOI, which may impact embryo implantation.
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Affiliation(s)
- Jilai Xie
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
| | - Aiyuan Gu
- Ministry of Education (MOE) Laboratory of Biosystems Homeostasis & Protection and Zhejiang Provincial Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Huangyi He
- Ministry of Education (MOE) Laboratory of Biosystems Homeostasis & Protection and Zhejiang Provincial Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Qiaohang Zhao
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
| | - Ya Yu
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
| | - Jian Chen
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
| | - Zhangliang Cheng
- Ministry of Education (MOE) Laboratory of Biosystems Homeostasis & Protection and Zhejiang Provincial Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Ping Zhou
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
| | - Qi Zhou
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
- Ministry of Education (MOE) Laboratory of Biosystems Homeostasis & Protection and Zhejiang Provincial Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
- Department of Neuroscience and Developmental Biology, University of Vienna, Vienna, Austria
| | - Min Jin
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Department of Reproductive Medicine, Hangzhou, China
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Disis ML, Adams SF, Bajpai J, Butler MO, Curiel T, Dodt SA, Doherty L, Emens LA, Friedman CF, Gatti-Mays M, Geller MA, Jazaeri A, John VS, Kurnit KC, Liao JB, Mahdi H, Mills A, Zsiros E, Odunsi K. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of gynecologic cancer. J Immunother Cancer 2023; 11:e006624. [PMID: 37295818 PMCID: PMC10277149 DOI: 10.1136/jitc-2022-006624] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/12/2023] Open
Abstract
Advanced gynecologic cancers have historically lacked effective treatment options. Recently, immune checkpoint inhibitors (ICIs) have been approved by the US Food and Drug Administration for the treatment of cervical cancer and endometrial cancer, offering durable responses for some patients. In addition, many immunotherapy strategies are under investigation for the treatment of earlier stages of disease or in other gynecologic cancers, such as ovarian cancer and rare gynecologic tumors. While the integration of ICIs into the standard of care has improved outcomes for patients, their use requires a nuanced understanding of biomarker testing, treatment selection, patient selection, response evaluation and surveillance, and patient quality of life considerations, among other topics. To address this need for guidance, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline. The Expert Panel drew on the published literature as well as their own clinical experience to develop evidence- and consensus-based recommendations to provide guidance to cancer care professionals treating patients with gynecologic cancer.
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Affiliation(s)
- Mary L Disis
- Cancer Vaccine Institute, University of Washington, Seattle, Washington, USA
| | - Sarah F Adams
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | - Jyoti Bajpai
- Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Marcus O Butler
- Department of Medical Oncology and Hematology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Tyler Curiel
- Dartmouth-Hitchcock's Norris Cotton Cancer Center, Dartmouth Medical School, Hanover, New Hampshire, USA
| | | | - Laura Doherty
- Program in Women's Oncology, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Leisha A Emens
- Department of Medicine, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Claire F Friedman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Margaret Gatti-Mays
- Pelotonia Institute for Immuno-Oncology, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Melissa A Geller
- Department of Obstetrics, Gynecology & Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amir Jazaeri
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Veena S John
- Department of Medical Oncology & Hematology, Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Katherine C Kurnit
- University of Chicago Medicine Comprehensive Cancer Center, University of Chicago, Chicago, Illinois, USA
| | - John B Liao
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Haider Mahdi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anne Mills
- Department of Pathology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Emese Zsiros
- Department of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Kunle Odunsi
- The University of Chicago Medicine Comprehensive Cancer Center, Chicago, Illinois, USA
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13
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Wilk A, Szypulska-Koziarska D, Oszutowska-Mazurek D, Baraniskin A, Kabat-Koperska J, Mazurek P, Wiszniewska B. Prenatal Exposition to Different Immunosuppressive Protocols Results in Vacuolar Degeneration of Hepatocytes. BIOLOGY 2023; 12:biology12050654. [PMID: 37237468 DOI: 10.3390/biology12050654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Abstract
Immunosuppressive drugs are essential for transplant recipients, since they prolong proper function of graft; however, they affect the morphology and function of organs, including liver. One commonly observed alteration in hepatocytes is vacuolar degeneration. Numerous medications are contraindicated in pregnancy and breastfeeding, mostly due to a lack of data concerning their advert effects. The aim of the current study was to compare the effects of prenatal exposition to different protocols of immunosuppressants on vacuolar degeneration in the hepatocytes of livers of rats. Thirty-two livers of rats with usage of digital analysis of the images were examined. Area, perimeter, axis length, eccentricity and circularity regarding vacuolar degeneration were analysed. The most prominent vacuolar degeneration in hepatocytes in the aspects of presence, area and perimeter was observed in rats exposed to tacrolimus, mycophenolate mofetil and glucocorticoids, and cyclosporine A, everolimus with glucocorticoids.This is the first study that demonstrates the results of the influence of multidrug immnunosuppression distributed in utero on the hepatic tissue of offspring.
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Affiliation(s)
- Aleksandra Wilk
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | | | | | - Alexander Baraniskin
- Department of Hematology, Oncology and Palliative Care, Evangelisches Krankenhaus Hamm, 59063 Hamm, Germany
| | - Joanna Kabat-Koperska
- Department of Nephrology, Transplantology and Internal Diseases, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Przemyslaw Mazurek
- Department of Signal Processing and Multimedia Engineering, West Pomeranian University of Technology in Szczecin, 71-126 Szczecin, Poland
| | - Barbara Wiszniewska
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland
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14
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Sherard C, Bisbee C, Konsek H, Kang L, Turek JW, Rajab TK. Partial Heart Transplantation in Adult Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:126-131. [PMID: 36872577 DOI: 10.1177/15569845231156921] [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: 03/07/2023]
Abstract
Many young adults require heart valve replacements. Current options for valve replacement in adults include mechanical valves, bioprosthetic valves, or the Ross procedure. Of these, mechanical and bioprosthetic valves are the most common options, although mechanical valve usage predominates in younger adults due to durability, while bioprosthetic valve usage predominates in older adults. Partial heart transplantation is a new method of valvular replacement that can deliver durable and self-repairing valves and allow adult patients freedom from anticoagulation therapy. This procedure involves transplantation of donor heart valves only, permitting expanded utilization of donor hearts as compared with orthotopic heart transplantation. In this review, we discuss the potential benefits of this procedure in adults who elect against the anticoagulation regimen required of mechanical valve replacements, although it has not yet been clinically established. Partial heart transplantation is a promising new therapy for the treatment of pediatric valvular dysfunction. This is a novel technique in the adult population with potential utility for valve replacement in young patients for whom anticoagulation therapy is problematic, such as women who wish to become pregnant, patients with bleeding disorders, and patients with active lifestyles.
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Affiliation(s)
- Curry Sherard
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Cora Bisbee
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Haley Konsek
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Taufiek K Rajab
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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15
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FSRH Guideline (March 2023) Intrauterine contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:1-142. [PMID: 37188461 DOI: 10.1136/bmjsrh-2023-iuc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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16
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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17
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Wilson NK, Schulz P, Wall A, Parrott M, Testa G, Johannesson L, Sam T. Immunosuppression in Uterus Transplantation: Experience From the Dallas Uterus Transplant Study. Transplantation 2023; 107:729-736. [PMID: 36445981 DOI: 10.1097/tp.0000000000004437] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Uterus transplantation is a temporary transplant allowing women with absolute uterine factor infertility to experience pregnancy and childbirth. The degree of immunosuppression (IS) required to prevent rejection while minimizing toxicity to the recipient and fetus remains an area of investigation. METHODS In this article, we describe immunosuppressive therapy, rejection episodes, infections, and adverse events in 14 uterus transplant recipients. Induction consisted of antithymocyte globulin and methylprednisolone. Ten recipients (71%) received no steroids postoperatively, and 4 (29%) had steroids tapered off at 42 d. All received oral tacrolimus, either immediate release (n = 2, 14%) or extended release (n = 12, 86%). Mycophenolate was used in 4 cases (29%), de novo azathioprine in 9 (64%), and de novo everolimus in 1 (7%). RESULTS Sixteen clinically silent, treatment-responsive rejection episodes occurred in 10 recipients. Five recipients (36%) experienced acute kidney injury. In 3 recipients, IS was discontinued due to renal dysfunction. Eleven infection episodes were noted in 7 recipients. No babies had congenital abnormalities. CONCLUSIONS Our experience demonstrates that safe IS regimens can be used for uterus transplant recipients before and during pregnancy.
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Affiliation(s)
- Nicole K Wilson
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
| | - Philipp Schulz
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Anji Wall
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Megan Parrott
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Liza Johannesson
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
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18
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Moroni G, Calatroni M, Donato B, Ponticelli C. Kidney Biopsy in Pregnant Women with Glomerular Diseases: Focus on Lupus Nephritis. J Clin Med 2023; 12:jcm12051834. [PMID: 36902621 PMCID: PMC10003332 DOI: 10.3390/jcm12051834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Despite significant improvements of renal and obstetrical management, pregnancies in women with glomerular diseases and with lupus nephritis continue to be associated with increased complications both for the mother and the fetus as compared to those of pregnancies in healthy women. To reduce the risk of these complications, planning pregnancy in a phase of stable remission of the underlining disease is necessary. A kidney biopsy is an important event in any phase of pregnancy. A kidney biopsy can be of help during counselling before pregnancy in cases of incomplete remission of the renal manifestations. In these situations, histological data may differentiate active lesions that require the reinforcement of therapy from chronic irreversible lesions that may increase the risk of complications. In pregnant women, a kidney biopsy can identify new-onset systemic lupus erythematous (SLE) and necrotizing or primitive glomerular diseases and distinguish them from other, more common complications. Increasing proteinuria, hypertension, and the deterioration of kidney function during pregnancy may be either due to a reactivation of the underlying disease or to pre-eclampsia. The results of the kidney biopsy suggest the need to initiate an appropriate treatment, allowing the progression of the pregnancy and the fetal viability or the anticipation of delivery. Data from the literature suggest avoiding a kidney biopsy beyond 28 weeks of gestation to minimize the risks associated with the procedure vs. the risk of preterm delivery. In case of the persistence of renal manifestations after delivery in women with a diagnosis of pre-eclampsia, a renal kidney assessment allows the final diagnosis and guides the therapy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-345-872-1910
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Beatriz Donato
- Nephrology Department, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
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19
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Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
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20
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York JR, Testa G, Gunby RT, Putman JM, McKenna GJ, Koon EC, Bayer J, Zhang L, Gregg AR, Johannesson L. Neonatal Outcomes after Uterus Transplantation: Dallas Uterus Transplant Study. Am J Perinatol 2023; 40:42-50. [PMID: 33878776 DOI: 10.1055/s-0041-1727212] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Limited data are available on the outcome of infants born after uterus transplantation. Our aim was to describe the hospital course and laboratory findings in the first 2 months of life of the 12 infants born in the Dallas UtErus Transplant Study (DUETS). STUDY DESIGN Based on the trial protocol, information about infants was collected in a prospective fashion, including infant demographics, hospital course, and laboratory values. RESULTS Twelve infants were delivered, all by cesarean section, from 11 mothers who had undergone uterus transplantation (one mother had two pregnancies and delivered two babies). All pregnancies were singleton. The mothers received immunosuppressive therapy, and one had a rejection episode that was detected during pregnancy. The rejection episode resolved after steroid treatment. The infants had a median gestational age of 366/7 weeks (range: 306/7-380/7 weeks) and median birth weight of 2,920 g (range: 1,770-3,470 g). The lowest Apgar's score at 5 minutes was 8. All infants were appropriate size for gestational age. Two infants presented with bandemia but negative blood cultures. At 2 months of age, all infants achieved the developmental and behavioral milestones outlined by the American Academy of Pediatrics. CONCLUSION The 12 infants born from mothers with uterus transplants had a neonatal course that reflected the gestational age at delivery. No baby was born with an identified malformation or organ dysfunction. Longer follow-up and a larger number of infants are needed to confirm these observations. KEY POINTS · Normal fetal development after uterus transplantation.. · No baby was born with malformations or showed any organ dysfunction.. · At 2 months, all infants achieved appropriate developmental and behavioral milestones..
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Affiliation(s)
- Jackie R York
- Department of Neonatology, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Robert T Gunby
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - J Michael Putman
- Fertility Center of Dallas, Baylor University Medical Center, Dallas, Texas
| | - Gregory J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Eric C Koon
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Johanna Bayer
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Lilly Zhang
- Fertility Center of Dallas, Baylor University Medical Center, Dallas, Texas
| | - Anthony R Gregg
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas.,Department of Obstetrics and Gynecology, PRISMA Health-University of South Carolina School of Medicine, Columbia, South Carolina
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas.,Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
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21
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Schulz P, Testa G, York JR, Johannesson L. Children after Uterus Transplantation: 2‐Year Outcomes from the Dallas UtErus Transplant Study (DUETS). BJOG 2022; 129:2117-2124. [DOI: 10.1111/1471-0528.17270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Philipp Schulz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center Dallas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center Dallas
| | - Jackie R. York
- Department of Neonatology Baylor University Medical Center Dallas
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center Dallas
- Department of Obstetrics and Gynecology Baylor University Medical Center Dallas
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22
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Chung YY, Heneghan MA. Autoimmune hepatitis in pregnancy: Pearls and pitfalls. Hepatology 2022; 76:502-517. [PMID: 35182079 DOI: 10.1002/hep.32410] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 12/13/2022]
Abstract
Autoimmune hepatitis (AIH) in pregnancy has many unique considerations. Evidence provided from single center studies with patient level data and nationwide population studies provide valuable insight into this complex situation. Because a planned pregnancy is a safer pregnancy, preconception counseling is a crucial opportunity to optimize care and risk stratify women with AIH. Women with chronic liver disease who receive preconception advice and counseling are more likely to achieve stable liver disease at conception and undergo appropriate variceal surveillance. Loss of biochemical response in pregnancy is associated with adverse outcomes in unstable disease. New onset AIH in pregnancy should be managed with classical treatment regimens. The continued use of immunosuppression in pregnancy, with the exception of mycophenolate mofetil, has not shown to adversely affect the rates of stillbirth or congenital malformation. Previously adopted immunosuppression withdrawal paradigms in pregnancy should no longer be considered advantageous, because remission loss postdelivery is likely (12%-86%). Population studies, report improved outcomes with preterm birth rates falling from 20% to 9%-13% in AIH pregnancies over a 20-year period. Newer data have also demonstrated an increased risk of gestational diabetes and hypertensive complications in AIH pregnancy, which has implications for management and preeclampsia prevention with aspirin use. This review aims to provide the framework to guide and manage pregnancy in AIH outlining pearls and pitfalls to ensure optimal outcomes for mother, baby and to reduce variation in practice.
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Affiliation(s)
- Y Y Chung
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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23
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Pregnancy outcomes in women with pemphigus exposed to rituximab before or during pregnancy. Int J Womens Dermatol 2022; 8:e038. [PMID: 35837335 PMCID: PMC9276145 DOI: 10.1097/jw9.0000000000000038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/14/2022] [Indexed: 01/03/2023] Open
Abstract
Rituximab (RTX) is an effective treatment for pemphigus; however, the drug labeling recommends not to use RTX within 1 year before conception.
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24
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Latifah SY, Gopalsamy B, Abdul Rahim R, Manaf Ali A, Haji Lajis N. Ultrastructural and Morphological Effects in T-Lymphoblastic Leukemia CEM-SS Cells Following Treatment with Nordamnacanthal and Damnacanthal from Roots of Morinda elliptica. Molecules 2022; 27:molecules27134136. [PMID: 35807381 PMCID: PMC9268620 DOI: 10.3390/molecules27134136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/28/2022] [Accepted: 06/13/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Morinda elliptica (family Rubiaceae), locally known as ‘mengkudu kecil’, has been used by the Malays for medicinal purposes. Anthraquinones isolated from the roots of Morinda elliptica, namely nordamnacanthal and damnacanthal, have been widely reported to exhibit anticancer and antioxidant properties in various cancer models in vitro and in vivo. Aim: This study analyzed the morphological and ultrastructural effects of damnacanthal and nordamnacanthal on T-lymphoblastic leukemia CEM-SS cells. Method: Light microscopy, Giemsa staining, Wright’s staining, scanning electron microscopy, and transmission electron microscopy were carried out to determine apoptosis, necrosis, and ultrastructural changes that occurred within the cells. Results: The outcomes showed that these compounds induced cell death by apoptosis and necrosis, specifically at higher doses of 10 and 30 μg/mL. Condensation and fragmentation of the nuclear chromatin, which further separated into small, membrane-bound vesicles known as apoptotic bodies, were observed in the nuclei and cytoplasm. The plasma membranes and cytoskeletons also showed marked morphological changes upon treatment with damnacanthal and nordamnacanthal, indicating apoptosis. Conclusion: Therefore, we report that damnacanthal and nordamnacanthal exhibit anticancer properties by inducing apoptosis and necrosis in CEM-SS cells, and they have potential as a drug for the treatment of T-lymphoblastic leukemia.
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Affiliation(s)
- Saiful Yazan Latifah
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia;
- Correspondence: ; Tel.: +603-89472308
| | - Banulata Gopalsamy
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia;
| | - Raha Abdul Rahim
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia;
| | - Abdul Manaf Ali
- Faculty of Bioresources and Food Industry, Universiti Sultan Zainal Abidin (UniSZA), Kuala Terengganu 20300, Malaysia;
| | - Nordin Haji Lajis
- Laboratory of Natural Products, Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Malaysia;
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25
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The Most Promising Biomarkers of Allogeneic Kidney Transplant Rejection. J Immunol Res 2022; 2022:6572338. [PMID: 35669103 PMCID: PMC9167141 DOI: 10.1155/2022/6572338] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/30/2022] [Indexed: 12/13/2022] Open
Abstract
Clinical transplantology is a constantly evolving field of medicine. Kidney transplantation has become standard clinical practice, and it has a significant impact on reducing mortality and improving the quality of life of patients. Allogenic transplantation induces an immune response, which may lead to the rejection of the transplanted organ. The gold standard for evaluating rejection of the transplanted kidney by the recipient's organism is a biopsy of this organ. However, due to the high invasiveness of this procedure, alternative diagnostic methods are being sought. Therefore, the biomarkers may play an essential predictive role in transplant rejection. A review of the most promising biomarkers for early diagnosis and prognosis prediction of allogenic kidney transplant rejection summarizes novel data on neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), C-X-C motif chemokine 10 (CXCL-10), cystatin C (CysC), osteopontin (OPN), and clusterin (CLU) and analyses the dynamics of changes of the biomarkers mentioned above in kidney diseases and the mechanism of rejection of the transplanted kidney.
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26
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Akiyama S, Hamdeh S, Murakami N, Cotter TG, Suzuki H, Tsuchiya K. Pregnancy and neonatal outcomes in women receiving calcineurin inhibitors: A systematic review and meta-analysis. Br J Clin Pharmacol 2022; 88:3950-3961. [PMID: 35593302 DOI: 10.1111/bcp.15414] [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] [Received: 02/04/2022] [Revised: 04/24/2022] [Accepted: 05/12/2022] [Indexed: 12/04/2022] Open
Abstract
AIM Calcineurin inhibitors (CNIs) are often used for solid organ transplantation recipients or patients with immune-mediated diseases. This systematic review and meta-analysis aims to understand how CNIs affect pregnancy and neonatal outcomes. METHODS Electronic databases were searched for observational studies assessing pregnancy and neonatal outcomes in CNI-treated patients. The pooled rate of each outcome was determined. Meta-regression was conducted to identify contributing factors to the outcomes. RESULTS We analyzed 98 studies with a total of 5,355 pregnancies in 4,450 CNI-treated patients. The pooled rates of live birth and spontaneous abortion were 82.1% (95% CI 76.7%-86.4%) and 11.7% (95% CI 8.7%-15.5%), respectively. The rates of preterm delivery (33.2%, 95% CI 29.2%-37.5%), low birth weight (35.8%, 95% CI 27.7%-44.8%), and preeclampsia (13.5%, 95% CI 9.4%-19.2%) were 3-4 times higher than the rates of general population. Nearly half of the CNI-treated patients required C-section (43.5%, 95% CI 36.9%-50.3%). The rates of stillbirth, neonatal, and maternal death were 4.2% (95% CI 2.8%-6.2%), 2.9% (95% CI 1.8%-4.8%), and 2.3% (95% CI 1.3%-4.1%), respectively. Meta-regression showed preeclampsia was significantly associated with the risks of preterm delivery and low birth weight. Older maternal age, pre-pregnancy hypertension, and cyclosporine use increased the risk of preeclampsia. CONCLUSION Given the higher mortalities in CNI-treated patients and their children than the general averages, their pregnancy is considered high risk. The risks of preterm delivery and low birth weight were primarily attributed to preeclampsia. Since pre-pregnancy hypertension increased its risk, an appropriate preconception blood pressure management may improve their outcomes.
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Affiliation(s)
- Shintaro Akiyama
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Shadi Hamdeh
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Motility, University of Kansas, KS, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| | - Hideo Suzuki
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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27
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Tokariev A, Oberlander VC, Videman M, Vanhatalo S. Cortical Cross-Frequency Coupling Is Affected by in utero Exposure to Antidepressant Medication. Front Neurosci 2022; 16:803708. [PMID: 35310093 PMCID: PMC8927083 DOI: 10.3389/fnins.2022.803708] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/27/2022] [Indexed: 11/24/2022] Open
Abstract
Up to five percent of human infants are exposed to maternal antidepressant medication by serotonin reuptake inhibitors (SRI) during pregnancy, yet the SRI effects on infants’ early neurodevelopment are not fully understood. Here, we studied how maternal SRI medication affects cortical frequency-specific and cross-frequency interactions estimated, respectively, by phase-phase correlations (PPC) and phase-amplitude coupling (PAC) in electroencephalographic (EEG) recordings. We examined the cortical activity in infants after fetal exposure to SRIs relative to a control group of infants without medical history of any kind. Our findings show that the sleep-related dynamics of PPC networks are selectively affected by in utero SRI exposure, however, those alterations do not correlate to later neurocognitive development as tested by neuropsychological evaluation at two years of age. In turn, phase-amplitude coupling was found to be suppressed in SRI infants across multiple distributed cortical regions and these effects were linked to their neurocognitive outcomes. Our results are compatible with the overall notion that in utero drug exposures may cause subtle, yet measurable changes in the brain structure and function. Our present findings are based on the measures of local and inter-areal neuronal interactions in the cortex which can be readily used across species, as well as between different scales of inspection: from the whole animals to in vitro preparations. Therefore, this work opens a framework to explore the cellular and molecular mechanisms underlying neurodevelopmental SRI effects at all translational levels.
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Affiliation(s)
- Anton Tokariev
- Department of Clinical Neurophysiology, BABA Center, New Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Neuroscience Center, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- *Correspondence: Anton Tokariev,
| | - Victoria C. Oberlander
- Department of Clinical Neurophysiology, BABA Center, New Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Computer Science, Aalto University, Espoo, Finland
| | - Mari Videman
- Department of Clinical Neurophysiology, BABA Center, New Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Pediatric Neurology, New Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology, BABA Center, New Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Neuroscience Center, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Physiology, University of Helsinki, Helsinki, Finland
- Sampsa Vanhatalo,
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28
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Akhtar NH, Khosravi-Hafshejani T, Akhtar D, Dhadwal G, Kanani A. The use of dupilumab in severe atopic dermatitis during pregnancy: a case report. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:9. [PMID: 35115035 PMCID: PMC8815205 DOI: 10.1186/s13223-022-00650-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 01/12/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Atopic dermatitis is a common chronic skin disease that can occur in pregnancy. Current treatments include topical and systemic glucocorticoids and cyclosporine. Presently, the only biologic approved for atopic dermatitis is dupilumab with limited data available regarding its safety profile in pregnancy. CASE PRESENTATION We report a case of severe atopic dermatitis treated safely with dupilumab with no adverse maternal or fetal outcomes and resolution of atopic dermatitis postpartum in the absence of maintenance dupilumab therapy. CONCLUSION Here we demonstrate the safe use of dupilumab in pregnancy. Further research is needed to elucidate the role of dupilumab in the management of atopic dermatitis during pregnancy.
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Affiliation(s)
| | | | - Daud Akhtar
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Gurbir Dhadwal
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada
| | - Amin Kanani
- Department of Medicine, Division of Allergy and Immunology, University of British Columbia, Vancouver, Canada
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29
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Verschuuren JJGM, Palace J, Murai H, Tannemaat MR, Kaminski HJ, Bril V. Advances and ongoing research in the treatment of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:189-202. [DOI: 10.1016/s1474-4422(21)00463-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/16/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
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30
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Immunotherapy for cancer treatment during pregnancy. Lancet Oncol 2021; 22:e550-e561. [PMID: 34856152 DOI: 10.1016/s1470-2045(21)00525-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 12/14/2022]
Abstract
Immunotherapy has greatly improved outcomes for subgroups of patients with cancer. As indications keep expanding, there is an unmet need to gain a better understanding of the effect of these therapies on pregnancy and fertility. During pregnancy, substantial adaptations occur in the maternal immune system to maintain protection against pathogens while avoiding detrimental reactions to the semi-allogeneic fetus. The pathways involved in the establishment of this fetomaternal tolerance can be hijacked by cancers. Immunotherapies that target these inhibitory pathways, or that directly interact with the regulatory immune cells involved in tolerance mechanisms, might therefore result in complications during pregnancy. Similarly, by activating the patient's immune system with immunotherapy, a broad range of immune-related adverse events can occur that could negatively affect the fetus or impede a future desired pregnancy. This Review summarises preclinical and clinical data related to the use of immunotherapy during pregnancy, including all approved immune checkpoint inhibitors, recombinant cytokines, cell therapies, vaccines, and immunomodulatory drugs.
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31
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Dashti-Khavidaki S, Saidi R, Lu H. Current status of glucocorticoid usage in solid organ transplantation. World J Transplant 2021; 11:443-465. [PMID: 34868896 PMCID: PMC8603633 DOI: 10.5500/wjt.v11.i11.443] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids (GCs) have been the mainstay of immunosuppressive therapy in solid organ transplantation (SOT) for decades, due to their potent effects on innate immunity and tissue protective effects. However, some SOT centers are reluctant to administer GCs long-term because of the various related side effects. This review summarizes the advantages and disadvantages of GCs in SOT. PubMed and Scopus databases were searched from 2011 to April 2021 using search syntaxes covering “transplantation” and “glucocorticoids”. GCs are used in transplant recipients, transplant donors, and organ perfusate solution to improve transplant outcomes. In SOT recipients, GCs are administered as induction and maintenance immunosuppressive therapy. GCs are also the cornerstone to treat acute antibody- and T-cell-mediated rejections. Addition of GCs to organ perfusate solution and pretreatment of transplant donors with GCs are recommended by some guidelines and protocols, to reduce ischemia-reperfusion injury peri-transplant. GCs with low bioavailability and high potency for GC receptors, such as budesonide, nanoparticle-mediated targeted delivery of GCs to specific organs, and combination use of dexamethasone with inducers of immune-regulatory cells, are new methods of GC application in SOT patients to reduce side effects or induce immune-tolerance instead of immunosuppression. Various side effects involving different non-targeted organs/tissues, such as bone, cardiovascular, neuromuscular, skin and gastrointestinal tract, have been noted for GCs. There are also potential drug-drug interactions for GCs in SOT patients.
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Affiliation(s)
- Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 14155, Iran
| | - Reza Saidi
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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32
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Feyaerts D, Gillard J, van Cranenbroek B, Rigodanzo Marins L, Baghdady MMS, Comitini G, Lely AT, van Hamersvelt HW, van der Heijden OWH, Joosten I, van der Molen RG. Maternal, Decidual, and Neonatal Lymphocyte Composition Is Affected in Pregnant Kidney Transplant Recipients. Front Immunol 2021; 12:735564. [PMID: 34777345 PMCID: PMC8585145 DOI: 10.3389/fimmu.2021.735564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Pregnancy after renal transplantation is associated with an increased risk of complications. While a delicately balanced uterine immune system is essential for a successful pregnancy, little is known about the uterine immune environment of pregnant kidney transplant recipients. Moreover, children born to kidney transplant recipients are exposed in utero to immunosuppressive drugs, with possible consequences for neonatal outcomes. Here, we defined the effects of kidney transplantation on the immune cell composition during pregnancy with a cohort of kidney transplant recipients as well as healthy controls with uncomplicated pregnancies. Maternal immune cells from peripheral blood were collected during pregnancy as well as from decidua and cord blood obtained after delivery. Multiparameter flow cytometry was used to identify and characterize populations of cells. While systemic immune cell frequencies were altered in kidney transplant patients, immune cell dynamics over the course of pregnancy were largely similar to healthy women. In the decidua of women with a kidney transplant, we observed a decreased frequency of HLA-DR+ Treg, particularly in those treated with tacrolimus versus those that were treated with azathioprine next to tacrolimus, or with azathioprine alone. In addition, both the innate and adaptive neonatal immune system of children born to kidney transplant recipients was significantly altered compared to neonates born from uncomplicated pregnancies. Overall, our findings indicate a significant and distinct impact on the maternal systemic, uterine, and neonatal immune cell composition in pregnant kidney transplant recipients, which could have important consequences for the incidence of pregnancy complications, treatment decisions, and the offspring's health.
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Affiliation(s)
- Dorien Feyaerts
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joshua Gillard
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Section Pediatric Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bram van Cranenbroek
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lina Rigodanzo Marins
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Gynecology and Obstetrics, Hospital de Clinicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Mariam M S Baghdady
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gaia Comitini
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Irma Joosten
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Renate G van der Molen
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
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33
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Emens LA, Adams S, Cimino-Mathews A, Disis ML, Gatti-Mays ME, Ho AY, Kalinsky K, McArthur HL, Mittendorf EA, Nanda R, Page DB, Rugo HS, Rubin KM, Soliman H, Spears PA, Tolaney SM, Litton JK. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of breast cancer. J Immunother Cancer 2021; 9:e002597. [PMID: 34389617 PMCID: PMC8365813 DOI: 10.1136/jitc-2021-002597] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 12/17/2022] Open
Abstract
Breast cancer has historically been a disease for which immunotherapy was largely unavailable. Recently, the use of immune checkpoint inhibitors (ICIs) in combination with chemotherapy for the treatment of advanced/metastatic triple-negative breast cancer (TNBC) has demonstrated efficacy, including longer progression-free survival and increased overall survival in subsets of patients. Based on clinical benefit in randomized trials, ICIs in combination with chemotherapy for the treatment of some patients with advanced/metastatic TNBC have been approved by the United States (US) Food and Drug Administration (FDA), expanding options for patients. Ongoing questions remain, however, about the optimal chemotherapy backbone for immunotherapy, appropriate biomarker-based selection of patients for treatment, the optimal strategy for immunotherapy treatment in earlier stage disease, and potential use in histological subtypes other than TNBC. To provide guidance to the oncology community on these and other important concerns, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline (CPG). The expert panel drew upon the published literature as well as their clinical experience to develop recommendations for healthcare professionals on these important aspects of immunotherapeutic treatment for breast cancer, including diagnostic testing, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence-based and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with breast cancer.
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Affiliation(s)
- Leisha A Emens
- Department of Medicine, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sylvia Adams
- Perlmutter Cancer Center, New York University Langone, New York, New York, USA
| | - Ashley Cimino-Mathews
- Department of Pathology and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary L Disis
- Cancer Vaccine Institute, University of Washington, Seattle, Washington, USA
| | - Margaret E Gatti-Mays
- Pelotonia Institute for Immuno-Oncology, Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin Kalinsky
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | | | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Breast Oncology Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Rita Nanda
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medicine Comprehensive Cancer Center, Chicago, Illinois, USA
| | - David B Page
- Earle A Chiles Research Institute, Portland, Oregon, USA
| | - Hope S Rugo
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Krista M Rubin
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Hatem Soliman
- Department of Breast Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer K Litton
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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34
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Drug Exposure in Newborns: Effect of Selected Drugs Prescribed to Mothers During Pregnancy and Lactation. Ther Drug Monit 2021; 42:255-263. [PMID: 32068668 DOI: 10.1097/ftd.0000000000000747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The number of newborns exposed to therapeutic drugs during pregnancy is growing because of the increased use of drugs during pregnancy. In recent years, advances in our understanding of drug placental transfer have augmented the likelihood of a healthy baby in mothers with chronic diseases needing drug therapy. Globally, for example, more than 1.4 million pregnancies in 2015 have been burdened with antiretroviral drugs due to an increasing number of HIV-positive women treated with these drugs, particularly in low- and middle-income countries. In most cases, the fetus is exposed to much higher drug doses in utero than the newborn nursed by the mother. Drug transfer through the placenta takes place by passive diffusion, active transport, or facilitated transport, and drug concentrations in the fetal circulation may be comparable to that in the mother's blood concentration. The excretion of drugs into breastmilk predominantly occurs by passive diffusion, allowing only the non-protein-bound fraction of the blood drug concentration to penetrate. Drug agencies in the United States and Europe highly recommend performing clinical trials in pregnant or breastfeeding women. However, only a few drugs have reported statistically sound data in these patient groups. Most available results concerning pregnancy are obtained from observational studies after birth, assessing outcomes in the newborn or by measuring drug concentrations in the mother and umbilical cord blood. In the case of the lactation period, some studies have evaluated drug concentrations in breastmilk and blood of the mother and/or infant. In this review, exposure to antiretrovirals, immunosuppressants used after solid organ transplantation, and antiepileptics during pregnancy and lactation has been discussed in detail.
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Abstract
During pregnancy, there are several physiological changes during each trimester that can affect the absorption, distribution, metabolism, and elimination of drugs. Although there is a potential need to understand the pharmacokinetics and pharmacodynamics of drugs in pregnant patients, therapeutic drug monitoring is not well established for various drug classes due to ethical and safety concerns regarding the neonate. Potential risks from in utero drug exposure to the fetus may impact growth and development and may cause malformations or teratogenesis. The clinician must consider the benefits of drug treatment for the pregnant mother versus the risk to the fetus, before prescribing medications during pregnancy. The objective of this review is to aid clinicians, pharmacists, and laboratorians in understanding the pharmacokinetic and pharmacodynamic changes during pregnancy, to provide drug class recommendations for monitoring therapy throughout pregnancy via therapeutic drug monitoring, and to highlight the recent directives of governing agencies on maternal and fetal health.
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Lobo Y, Lee RC, Spelman L. Atopic Dermatitis Treated Safely with Dupilumab during Pregnancy: A Case Report and Review of the Literature. Case Rep Dermatol 2021; 13:248-256. [PMID: 34177514 PMCID: PMC8215998 DOI: 10.1159/000515246] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/15/2021] [Indexed: 11/27/2022] Open
Abstract
Dupilumab is currently the only biologic treatment approved for moderate-to-severe atopic dermatitis. Though limited, available clinical data describing dupilumab use in pregnancy have not identified a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Systemic treatment in pregnant women with atopic dermatitis is currently restricted to corticosteroids, cyclosporine A, and azathioprine. Atopic dermatitis often has a deleterious course in pregnancy which can cause substantial distress and significantly impact on global health and quality of life. We report a case of severe atopic dermatitis treated safely with dupilumab during pregnancy with no adverse maternal or fetal outcomes observed. Our case highlights that dupilumab use in pregnancy has its place but should always be preceded by careful assessment of the risks and benefits. Clinicians are encouraged to enroll their patients in relevant pregnancy registry studies to monitor outcomes in women exposed to dupilumab during pregnancy and lactation.
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Affiliation(s)
- Yolanka Lobo
- Veracity Clinical Research, Brisbane, Queensland, Australia.,Gabba Dermatology, Brisbane, Queensland, Australia
| | - Ruby C Lee
- Veracity Clinical Research, Brisbane, Queensland, Australia.,Gabba Dermatology, Brisbane, Queensland, Australia
| | - Lynda Spelman
- Veracity Clinical Research, Brisbane, Queensland, Australia.,Gabba Dermatology, Brisbane, Queensland, Australia
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Cooper N, Bird R, Chinthammitr Y, George B, Stentoft J, Tomiyama Y, Zaja F, Hokland P. How I treat immune thrombocytopenia - a global view. Br J Haematol 2021; 193:1076-1086. [PMID: 33570179 DOI: 10.1111/bjh.17324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Nichola Cooper
- Department of Haematology. Division of Immunology and Inflammation, Imperial College London, London, UK
| | - Robert Bird
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Yingyong Chinthammitr
- Department of Medicine, Division of Hematology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, India
| | - Jesper Stentoft
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Peter Hokland
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Siligato R, Gembillo G, Cernaro V, Torre F, Salvo A, Granese R, Santoro D. Maternal and Fetal Outcomes of Pregnancy in Nephrotic Syndrome Due to Primary Glomerulonephritis. Front Med (Lausanne) 2020; 7:563094. [PMID: 33363180 PMCID: PMC7758435 DOI: 10.3389/fmed.2020.563094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease (CKD) affects 3% of pregnancies, impacting on maternal and fetal outcomes, and at the same time, a recurrent question in nephrology regards gestation impact on kidney function. Observational studies stated that CKD stage, pre-existent hypertension, and proteinuria are the main predictors of possible complications, such as maternal CKD progression, maternal or fetal death, prematurity, small for gestational age (SGA) newborn, or admission to the neonatal intensive care unit. In this regard, given the prominence of proteinuria among other risk factors, we focused on primary nephrotic syndrome in pregnancy, which accounts for 0.028% of cases, and its impact on materno-fetal outcomes and kidney survival. Data extracted from literature are scattered because of the small cohorts investigated in each trial. However, they showed different outcomes for each glomerular disease, with membranous nephropathy (MN) having a better maternal and fetal prognosis than focal and segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), or minimal change disease (MCD). Nephrotic syndrome does not have to discourage women to undertake a pregnancy, but the correct management may include a specific evaluation of risk factors and follow-up for adverse materno-fetal events and/or maternal kidney disease progression.
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Affiliation(s)
- Rossella Siligato
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Guido Gembillo
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina, Italy
| | - Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Torre
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonino Salvo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberta Granese
- Unit of Gynecology, Department of Human Pathology of Adult and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Agrawal H, Doan H, Pham B, Khosla A, Babu M, McCluskey P, Nguyen QD, Sangwan V, Reddy S, Sawhney S, Tyagi M. Systemic immunosuppressive therapies for uveitis in developing countries. Indian J Ophthalmol 2020; 68:1852-1862. [PMID: 32823402 PMCID: PMC7690522 DOI: 10.4103/ijo.ijo_1548_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
There are multiple approaches to inhibit inflammatory molecules and pathways in noninfectious uveitis. The cornerstone of local and systemic anti-inflammatory treatment is corticosteroid therapy. Corticosteroids remain the most potent and efficacious drugs for treating intraocular inflammation. However, their long-term use is limited by their medium- and long-term side effects, which are a major concern. The approach taken to limit corticosteroid side effects is to introduce steroid-sparing agents that suppress the inflammatory pathways and immune response differently than corticosteroids. There are several classes of such drugs that are affordable, effective, and generally well-tolerated. Relatively recently, an increasing range of biologic agents has become available to treat intraocular inflammation. However, the relatively expensive cost of these therapies limits their use in the developing world. This systemic review aimst to discuss the use of corticosteroids and different immunosuppressive regimens in the management of various uveitides.
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Affiliation(s)
| | - Hien Doan
- Byers Eye Institute, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | - Mudit Tyagi
- L V Prasad Eye Institute, Hyderabad, Telangana, India
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Wang W, Sung N, Gilman-Sachs A, Kwak-Kim J. T Helper (Th) Cell Profiles in Pregnancy and Recurrent Pregnancy Losses: Th1/Th2/Th9/Th17/Th22/Tfh Cells. Front Immunol 2020; 11:2025. [PMID: 32973809 PMCID: PMC7461801 DOI: 10.3389/fimmu.2020.02025] [Citation(s) in RCA: 199] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022] Open
Abstract
During pregnancy, various immune effectors and molecules participating in the immune-microenvironment establish specific maternal tolerance toward the semi-allogeneic fetus. Activated maternal immune effectors by the trophoblast antigens, such as T helper (Th), T cytotoxic (Tc), T regulatory (Treg), and B cells, are involved in the regulation of adaptive immunity. Recognition of active signal through the T cell receptors stimulate the differentiation of naive CD3+CD4+ T cells into specific T cell subsets, such as Th1, Th2, Th9, Th17, Th22, and follicular Th cells (Tfh). Each of these subsets has a significant and distinct role in human pregnancy. Th1 immunity, characterized by immune-inflammatory responses, becomes dominant during the peri-implantation period, and the “controlled” Th1 immunity benefits the invading trophoblasts rather than harm. Quickly after the placental implantation, the early inflammatory Th1 immunity is shifted to the Th2 anti-inflammatory immune responses. The predominant Th2 immunity, which overrules the Th1 immunity at the placental implantation site, protects a fetus by balancing Th1 immunity and accommodate fetal and placental development. Moreover, Treg and Th9 cells regulate local inflammatory immune responses, potentially detrimental to the fetus. Th17 cells induce protective immunity against extracellular microbes during pregnancy. However, excessive Th17 immunity may induce uncontrolled neutrophil infiltration at the maternal-fetal interface. Other Th cell subsets such as Tfh cells, also contribute to pregnancy by setting up favorable humoral immunity during pregnancy. However, dysregulation of Th cell immunity during pregnancy may result in obstetrical complications, such as recurrent pregnancy losses (RPL) and preeclampsia (PE). With this review, we intend to deliver a comprehensive overview of CD4+ Th cell subsets, including Th1, Th2, Th9, Th17, Th22, and Tfh cells, in human pregnancy by reviewing their roles in normal and pathological pregnancies.
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Affiliation(s)
- Wenjuan Wang
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Department of Clinical Sciences, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Reproductive Medicine Center, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Nayoung Sung
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Department of Clinical Sciences, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Alice Gilman-Sachs
- Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Clinical Immunology Laboratory, Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Joanne Kwak-Kim
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Department of Clinical Sciences, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
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Mian M, Dunlap R, Simpson E. Dupilumab for the treatment of severe atopic dermatitis in a pregnant patient: A case report. JAAD Case Rep 2020; 6:1051-1052. [PMID: 32995444 PMCID: PMC7509357 DOI: 10.1016/j.jdcr.2020.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
| | - Rachel Dunlap
- Oregon Health & Science University, Portland, Oregon
| | - Eric Simpson
- Oregon Health & Science University, Portland, Oregon
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Abstract
PURPOSE OF REVIEW To provide an update about the impact of infections in autoimmune rheumatic diseases (ARDs), from the analysis of the role of infections in pregnant women without ARDs, to the identification of maternal-fetal infections and their role in the maternal-fetal outcome of women with ARDs. RECENT FINDINGS Recent studies indicate that patients with ARDs and pregnancy are also susceptible to presenting infections of varying degrees, including serious infections, which contribute to the morbidity and mortality observed in pregnancy and postpartum of these patients.Any type of infectious agent will interact with a hormonal, immunological and metabolic environments modified by ARD, treatments, and by the changes inherent in pregnancy. Therefore, infections in the pregnancy of patients with ARDs should be considered as a risk factor for an unfavorable maternal-fetal outcome. SUMMARY The recognition of infections in the pregnancy of ARDs as a risk factor is the first step to prevent, identify, and treat them in a timely manner, and thus contribute to the favorable course of pregnancy in these patients. Patients with ARDs and major organ involvement, use of high doses of steroids, immunosuppressant and biological therapies, adolescence, and obesity are populations susceptible to developing infections.
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Sivaprasadan S, Mathew JS, Surendran S, Padma UD. Pregnancy After Liver Transplantation: Outcomes From a Single-Center Experience. J Clin Exp Hepatol 2020; 10:329-333. [PMID: 32655236 PMCID: PMC7335724 DOI: 10.1016/j.jceh.2019.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES Although much has been learnt regarding pregnancy after liver transplantation, data from India are scant. Hence, we evaluated the maternal and fetal outcomes of pregnancies after liver transplantation at our center. METHODS We conducted a retrospective review of all patients who underwent liver transplantation and later conceived at our center between 2006 and 2019. RESULTS Of the 750 liver transplantations performed at our center, 129 were female and 62 of them were in the childbearing age group (15-44 years). A total of seven conceptions occurred in seven patients during the study period. All the pregnancies occurred spontaneously. The median age of the patients at the time of liver transplantation and conception was 25 years (range, 24-33 years) and 29 years (range, 26-36 years), respectively. The median interval between transplantation and conception was 40 months (range, 7-48 months). All patients were on tacrolimus monotherapy. None of the patients had rejection during pregnancy despite a low median tacrolimus trough level of 2.7 ng/mL. Live birth (five cesarean and one normal) occurred in six of seven pregnancies at a median gestation age of 37.5 weeks. Mean birth weight was 3055.8 g (range, 2470-3635 g). Antenatal rubella infection and grade III intrauterine growth restriction resulting in still birth at 29 weeks occurred in one patient. The median postnatal follow-up was 25 months (range, 2-81 months). All babies and mothers were healthy. CONCLUSIONS Pregnancy after liver transplantation has a favorable outcome with a multidisciplinary team approach. There is a physiological reduction of tacrolimus trough levels during pregnancy for which dose augmentation is not usually required.
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Affiliation(s)
- Saraswathy Sivaprasadan
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
| | - Johns S. Mathew
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
| | - Sudhindran Surendran
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
| | - Uma D. Padma
- Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
- Address for correspondence: Dr. Uma Devi P, Associate Professor and Head, Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India.
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Ormaechea MS, Hassan M, Onghanseng N, Park JH, Mahajan S, Al-Kirwi KY, Uludag G, Halim MS, Schlaen A, Sepah YJ, Do DV, Nguyen QD. Safety of systemic therapy for noninfectious uveitis. Expert Opin Drug Saf 2019; 18:1219-1235. [PMID: 31801415 DOI: 10.1080/14740338.2019.1692810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: The treatment strategies for noninfectious uveitis (NIU) aim to achieve disease remission, prevention of recurrences, and preserving vision, while minimizing the side effects associated with the therapies used.Areas covered: The index review aims to provide a detailed overview of the adverse events and safety parameters associated with the systemic therapies for the management of the NIU.Expert opinion: Despite being the cornerstone of management of acute cases of NIU, long-term corticosteroid use is associated with multi-system side effects, requiring the use of steroid-sparing agents. Adalimumab was recently approved by the FDA for the management of NIU based on the results of VISUAL studies. Similarly, newer drugs targeting various aspects of the inflammatory cascade are being developed. However, until we completely understand the molecular pathways of the inflammatory diseases, the therapeutic profile of these newer agents needs to be broad enough to suppress inflammatory cascade and narrow enough to spare normal cellular processes. Another strategy that has shown some potential in decreasing the systemic side effects is to provide local drug delivery. Therefore, the future of management of NIU is very bright with many novel therapeutic agents and strategies of drug delivery on the horizon.
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Affiliation(s)
- Maria Soledad Ormaechea
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina.,Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Jung Hyun Park
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Khalid Yusuf Al-Kirwi
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, Imamein Khadhimein Medical City University Hospital, Baghdad, Iraq
| | - Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Ariel Schlaen
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Kojima M, Nakayama T, Tsutani K, Igarashi A, Kojima T, Suzuki S, Miyasaka N, Yamanaka H. Epidemiological characteristics of rheumatoid arthritis in Japan: Prevalence estimates using a nationwide population-based questionnaire survey. Mod Rheumatol 2019; 30:941-947. [DOI: 10.1080/14397595.2019.1682776] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Masayo Kojima
- Department of Frailty Research, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
- Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kiichiro Tsutani
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Ataru Igarashi
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Sadao Suzuki
- Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuyuki Miyasaka
- Department of Medicine and Rheumatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hisashi Yamanaka
- Department of Rheumatology, Sanno Medical Center, Tokyo, Japan
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
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COUTO CA, TERRABUIO DRB, CANÇADO ELR, PORTA G, LEVY C, SILVA AEB, BITTENCOURT PL, CARVALHO FILHO RJD, CHAVES DM, MIURA IK, CODES L, FARIA LC, EVANGELISTA AS, FARIAS AQ, GONÇALVES LL, HARRIZ M, LOPES EPDA, LUZ GO, OLIVEIRA PMC, OLIVEIRA EMG, SCHIAVON JLN, SEVÁ-PEREIRA T. UPDATE OF THE BRAZILIAN SOCIETY OF HEPATOLOGY RECOMMENDATIONS FOR DIAGNOSIS AND MANAGEMENT OF AUTOIMMUNE DISEASES OF THE LIVER. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:232-241. [PMID: 31460591 DOI: 10.1590/s0004-2803.201900000-43] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 02/08/2023]
Abstract
ABSTRACT New data concerning the management of autoimmune liver diseases have emerged since the last single-topic meeting sponsored by the Brazilian Society of Hepatology to draw recommendations about the diagnosis and treatment of autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), overlap syndromes of AIH, PBC and PSC and specific complications and topics concerning AIH and cholestatic liver diseases. This manuscript updates those previous recommendations according to the best evidence available in the literature up to now. The same panel of experts that took part in the first consensus document reviewed all recommendations, which were subsequently scrutinized by all members of the Brazilian Society of Hepatology using a web-based approach. The new recommendations are presented herein.
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