1
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 79] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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2
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Emmi G, Bettiol A, Gelain E, Bajema IM, Berti A, Burns S, Cid MC, Cohen Tervaert JW, Cottin V, Durante E, Holle JU, Mahr AD, Del Pero MM, Marvisi C, Mills J, Moiseev S, Moosig F, Mukhtyar C, Neumann T, Olivotto I, Salvarani C, Seeliger B, Sinico RA, Taillé C, Terrier B, Venhoff N, Bertsias G, Guillevin L, Jayne DRW, Vaglio A. Evidence-Based Guideline for the diagnosis and management of eosinophilic granulomatosis with polyangiitis. Nat Rev Rheumatol 2023; 19:378-393. [PMID: 37161084 DOI: 10.1038/s41584-023-00958-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 05/11/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, characterized by asthma, eosinophilia and granulomatous or vasculitic involvement of several organs. The diagnosis and management of EGPA are often challenging and require an integrated, multidisciplinary approach. Current practice relies on recommendations and guidelines addressing the management of ANCA-associated vasculitis and not specifically developed for EGPA. Here, we present evidence-based, cross-discipline guidelines for the diagnosis and management of EGPA that reflect the substantial advances that have been made in the past few years in understanding the pathogenesis, clinical subphenotypes and differential diagnosis of the disease, as well as the availability of new treatment options. Developed by a panel of European experts on the basis of literature reviews and, where appropriate, expert opinion, the 16 statements and five overarching principles cover the diagnosis and staging, treatment, outcome and follow-up of EGPA. These recommendations are primarily intended to be used by healthcare professionals, pharmaceutical industries and drug regulatory authorities, to guide clinical practice and decision-making in EGPA. These guidelines are not intended to limit access to medications by healthcare agencies, nor to impose a fixed order on medication use.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Gelain
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ingeborg M Bajema
- Department of Pathology, Groningen University Medical Center, Groningen, the Netherlands
| | - Alvise Berti
- Rheumatology, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy
| | - Stella Burns
- Vasculitis and Lupus Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- University of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Jan W Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, University of Lyon, IVPC, INRAE, ERN-LUNG, Lyon, France
| | - Eugenia Durante
- APACS, Associazione Pazienti con Sindrome di Churg Strauss, Arosio, Italy
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster/Kiel, Germany
| | - Alfred D Mahr
- Department of Rheumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marcos Martinez Del Pero
- Vasculitis and Lupus Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- ENT Department, West Suffolk Hospital, Bury St Edmunds, UK
| | - Chiara Marvisi
- Rheumatology Unit, Università di Modena e Reggio Emilia, Modena, Italy
| | | | - Sergey Moiseev
- Tareev Clinic of Internal Disease, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster/Kiel, Germany
| | - Chetan Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Thomas Neumann
- Department of Rheumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Iacopo Olivotto
- Meyer Children Hospital and Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research, Hannover Medical School, Hannover, Germany
| | - Renato A Sinico
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Renal Unit, ASST-Monza, Monza, Italy
| | - Camille Taillé
- Reference center for rare respiratory diseases, Bichat Hospital, AP-HP-Nord, University Paris Cité, Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Nils Venhoff
- Clinic for Rheumatology and Clinical Immunology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Crete, Greece
- Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP, University of Paris, Paris, France
| | - David R W Jayne
- University of Cambridge, Box 118, Addenbrooke's Hospital, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
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3
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Holle JU, Moosig F. [Eosinophilia: hypereosinophilic syndrome vs. eosinophilic granulomatosis with polyangiitis]. Z Rheumatol 2023; 82:307-320. [PMID: 37099180 DOI: 10.1007/s00393-023-01345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 04/27/2023]
Abstract
Hypereosinophilic syndrome (HES) is defined as a peripheral eosinophil count of > 1500/μl (assessed twice at an interval of ≥ 2 weeks) and an eosinophil-induced organ damage. Idiopathic HES is differentiated from primary (clonal or neoplastic) HES and secondary (reactive) HES, depending on the etiology. Eosinophilic granulomatosis with polyangiitis (EGPA) is categorized as a secondary form of HES and is characterized by hypereosinophilia and vasculitis of small to medium-sized vessels and can be associated with an antineutrophil cytoplasmic antibody (ANCA). The treatment of HES is dependent on the etiology. Clonal HES is treated according to the respective genetic aberration, e.g. with tyrosine kinase inhibitors or chemotherapy and allogenic stem cell transplantation. Secondary forms should be treated according to the underlying cause (e.g. parasitic infection). The treatment of EGPA is carried out with immunosuppressants depending on the disease stage and disease activity. Conventional drugs, such as glucocorticoids (GC), cyclophosphamide (CYC) and methotrexate (MTX) or biologics, such as the monoclonal anti-IL5 antibody mepolizumab are commonly used. Mepolizumab is also a good option for the treatment of idiopathic HES.
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Affiliation(s)
- Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a-7, 24345, Neumünster, Deutschland.
- Rheumazentrum Schleswig-Holstein Mitte, Sophienblatt 13-17, 24113, Kiel, Deutschland.
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a-7, 24345, Neumünster, Deutschland
- Rheumazentrum Schleswig-Holstein Mitte, Sophienblatt 13-17, 24113, Kiel, Deutschland
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4
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Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rheumatic diseases characterized by small-to-medium vessel vasculitis. Three different entities can be distinguished: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). While lung and renal involvement are typical manifestations of both GPA and MPA, EGPA usually shows paranasal sinus and lung involvement as well as a history of bronchial asthma. Furthermore, EGPA is frequently associated with cardiac disease and peripheral neuropathy. Cyclophosphamide or rituximab, combined with glucocorticoids, are used to induce remission of severe disease. Maintenance therapy options include rituximab as the first-line treatment, as well as methotrexate or azathioprine plus low-dose glucocorticoids.
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Affiliation(s)
- Marco L. Krasselt
- Medizinische Klinik III – Endokrinologie, Nephrologie und Rheumatologie, Bereich Rheumatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103 Leipzig, Deutschland
| | - Julia U. Holle
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a–7, 24534 Neumünster, Deutschland
- Rheumazentrum Schleswig-Holstein Mitte, Sophienblatt 13–17, 24103 Kiel, Deutschland
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5
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Leipe J, Holle JU, Weseloh C, Pfeil A, Krüger K. German Society of Rheumatology recommendations for management of glucocorticoid-induced osteoporosis. Z Rheumatol 2021; 80:49-63. [PMID: 34705070 DOI: 10.1007/s00393-021-01025-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use. OBJECTIVE To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment. METHODS A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process. RESULTS Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment. CONCLUSION This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.
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Affiliation(s)
- Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany. .,Division of Rheumatology and Clinical Immunology, Medizinische Klinik and Poliklinik IV, University of Munich, Munich, Germany.
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Christiane Weseloh
- German Society of Rheumatology (Deutsche Gesellschaft für Rheumatologie, DGRh), Berlin, Germany
| | - Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, Munich, Germany
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6
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Moosig F, Holle JU. [ANCA-associated vasculitis]. Dtsch Med Wochenschr 2021; 146:1287-1290. [PMID: 34553355 DOI: 10.1055/a-1308-5732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
GPA/MPA INDUCTION OF REMISSION As demonstrated in the ADVOCATE-trial avacopan allows for a substantial reduction of glucocorticoid (GC) use during induction of remission. A future role of avacopan in the treatment of GPA and MPA is likely. Likewise, the PEXIVAS-trial showed that GC reduction of up to 60 % compared to standard dose was equal effective. The same trial proved no benefit of plasma exchange in addition to standard induction of remission. Plasma exchange therefore is now mostly obsolete. GPA/MPA MAINTENANCE Rituximab is well established as maintenance therapy in AAV. The optimal duration however is still unknown. The MAINRITSAN 3 study indicates that prolonged use of more than 2 years is beneficial. EGPA: In line with earlier clinical evidence a GWAS including 534 EGPA patients indicated at last 2 distinct subgroups. The conception of a predominantly "vasculitis" and a more "eosinophilic" phenotype is supported by this genetic evidence and most likely will lead to more differentiated therapies. With the IL5-antibody mepolizumab a first principle targeting the eosinophilic component of EGPA is now available and proved to be clinically beneficial.
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Affiliation(s)
- Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster
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7
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Leipe J, Holle JU, Weseloh C, Pfeil A, Krüger K. [German Society of Rheumatology Recommendations for the management of glucocorticoid-induced Osteoporosis. German version]. Z Rheumatol 2021; 80:670-687. [PMID: 34357436 DOI: 10.1007/s00393-021-01028-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use. OBJECTIVE To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment. METHODS A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process. RESULTS Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment. CONCLUSION This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.
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Affiliation(s)
- Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätskrankenhaus Mannheim, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland. .,Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik IV, Ludwig-Maximilians-Universität München, München, Deutschland.
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | | | - Alexander Pfeil
- Klinik für Innere Medizin III, Funktionsbereich Rheumatologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, München, Deutschland
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8
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Schirmer JH, Aries PM, Balzer K, Berlit P, Bley TA, Buttgereit F, Czihal M, Dechant C, Dejaco C, Garske U, Henes J, Holle JU, Holl-Ulrich K, Lamprecht P, Nölle B, Moosig F, Rech J, Scheuermann K, Schmalzing M, Schmidt WA, Schneider M, Schulze-Koops H, Venhoff N, Villiger PM, Witte T, Zänker M, Hellmich B. [S2k guidelines (executive summary): management of large-vessel vasculitis]. Z Rheumatol 2021; 79:937-942. [PMID: 33156418 DOI: 10.1007/s00393-020-00894-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J H Schirmer
- Klinik für Innere Medizin I, Sektion Rheumatologie, Exzellenzzentrum Entzündungsmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - P M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - K Balzer
- Abteilung für Gefäß- und Endovaskulärchirurgie, St. Marien Hospital, GFO Kliniken Bonn, Bonn, Deutschland
| | - P Berlit
- Deutsche Gesellschaft für Neurologie, Berlin, Deutschland
| | - T A Bley
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - F Buttgereit
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie (CCM), Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - M Czihal
- Sektion Angiologie - Gefäßzentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Deutschland
| | - C Dechant
- Sektion Rheumatologie und klinische Immunologie, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Deutschland
| | - C Dejaco
- Klinische Abteilung für Rheumatologie und Immunologie, Medizinische Universität Graz, Landesweiter Dienst für Rheumatologie, Südtiroler Sanitätsbetrieb, Graz, Österreich
| | - U Garske
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Deutschland
| | - J Henes
- Medizinische Klinik II, Rheumatologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - J U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - K Holl-Ulrich
- Pathologie - Hamburg, Labor Lademannbogen MVZ, Hamburg, Deutschland
| | - P Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - B Nölle
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - F Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - J Rech
- Medizinische Klinik 3, Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - K Scheuermann
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Deutschland
| | - M Schmalzing
- Medizinische Klinik II, Rheumatologie/Klinische Immunologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - W A Schmidt
- Rheumatologie und klinische Immunologie, Immanuel Krankenhaus Berlin-Buch, Berlin, Deutschland
| | - M Schneider
- Poliklinik und Funktionsbereich für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - H Schulze-Koops
- Sektion Rheumatologie und klinische Immunologie, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Deutschland
| | - N Venhoff
- Klinik für Rheumatologie und klinische Immunologie, Vaskulitis-Zentrum Freiburg, Department Innere Medizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - P M Villiger
- Universitätsklinik für Rheumatologie, Immunologie und Allergologie, Inselspital, Bern, Schweiz
| | - T Witte
- Klinik für Immunologie und Rheumatologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - M Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - B Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik, Eugenstr. 3, 73230, Kirchheim unter Teck, Deutschland.
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9
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Lyons PA, Peters JE, Alberici F, Liley J, Coulson RMR, Astle W, Baldini C, Bonatti F, Cid MC, Elding H, Emmi G, Epplen J, Guillevin L, Jayne DRW, Jiang T, Gunnarsson I, Lamprecht P, Leslie S, Little MA, Martorana D, Moosig F, Neumann T, Ohlsson S, Quickert S, Ramirez GA, Rewerska B, Schett G, Sinico RA, Szczeklik W, Tesar V, Vukcevic D, Terrier B, Watts RA, Vaglio A, Holle JU, Wallace C, Smith KGC. Genome-wide association study of eosinophilic granulomatosis with polyangiitis reveals genomic loci stratified by ANCA status. Nat Commun 2019; 10:5120. [PMID: 31719529 PMCID: PMC6851141 DOI: 10.1038/s41467-019-12515-9] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 07/01/2019] [Indexed: 02/02/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare inflammatory disease of unknown cause. 30% of patients have anti-neutrophil cytoplasmic antibodies (ANCA) specific for myeloperoxidase (MPO). Here, we describe a genome-wide association study in 676 EGPA cases and 6809 controls, that identifies 4 EGPA-associated loci through conventional case-control analysis, and 4 additional associations through a conditional false discovery rate approach. Many variants are also associated with asthma and six are associated with eosinophil count in the general population. Through Mendelian randomisation, we show that a primary tendency to eosinophilia contributes to EGPA susceptibility. Stratification by ANCA reveals that EGPA comprises two genetically and clinically distinct syndromes. MPO+ ANCA EGPA is an eosinophilic autoimmune disease sharing certain clinical features and an HLA-DQ association with MPO+ ANCA-associated vasculitis, while ANCA-negative EGPA may instead have a mucosal/barrier dysfunction origin. Four candidate genes are targets of therapies in development, supporting their exploration in EGPA.
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Affiliation(s)
- Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre University of Cambridge, Cambridge, CB2 0AW, UK
| | - James E Peters
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK
- Health Data Research UK, Cambridge, UK
| | - Federico Alberici
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Nephrology and Immunopathology Unit-ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milan, Italy
- Dipartimento di Scienze della Salute, University of Milano, Milano, Italy
| | - James Liley
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Medical Research Council Biostatistics Unit, Cambridge Institute of Public Health, Cambridge Biomedical Campus, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | - Richard M R Coulson
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - William Astle
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK
- Medical Research Council Biostatistics Unit, Cambridge Institute of Public Health, Cambridge Biomedical Campus, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
- NHS Blood and Transplant, Long Road, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Francesco Bonatti
- Unit of Molecular Genetics, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CRB-CELLEX, Barcelona, Spain
| | - Heather Elding
- The National Institute for Health Research Blood and Transplant Unit in Donor Health and Genomics at the University of Cambridge, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK
- Department of Human Genetics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1HH, UK
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Jörg Epplen
- Human Genetics, Ruhr University Bochum, Bochum, Germany
| | - Loïc Guillevin
- Service de Médecine Interne, Hôpital Cochin, 75679, Paris Cedex 14, France
| | - David R W Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Tao Jiang
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, 23562, Lübeck, Germany
| | - Stephen Leslie
- Schools of Mathematics and Statistics, and BioSciences, and Melbourne Integrative Genomics, University of Melbourne, Parkville, VIC, 3010, Australia
- Data Science, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Tallaght Hospital, Dublin, Ireland
| | - Davide Martorana
- Unit of Molecular Genetics, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Thomas Neumann
- Department of Internal Medicine 3, Jena University Hospital, Jena, Germany
- Department of Rheumatology, Immunology and Rehabilitation, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Sophie Ohlsson
- Department of Nephrology, Division of Clinical Sciences, Lund University, Lund, Sweden
| | - Stefanie Quickert
- Department of Internal Medicine 3, Jena University Hospital, Jena, Germany
- Department of Internal Medicine 4 (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Giuseppe A Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Università Vita Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | - Renato A Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca (School of Medicine and Surgery), via Cadore, 48, 20900, Monza, Italy
| | | | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Damjan Vukcevic
- Schools of Mathematics and Statistics, and BioSciences, and Melbourne Integrative Genomics, University of Melbourne, Parkville, VIC, 3010, Australia
- Data Science, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, 75679, Paris Cedex 14, France
| | - Richard A Watts
- Department of Rheumatology, Ipswich Hospital, Heath Road, Ipswich, Suffolk, IP4 5PD, UK
- Norwich Medical School, University of East Anglia, Norwich, NR7 4TJ, UK
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, and Meyer Children's Hospital, Firenze, Italy
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Chris Wallace
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre University of Cambridge, Cambridge, CB2 0AW, UK
- Medical Research Council Biostatistics Unit, Cambridge Institute of Public Health, Cambridge Biomedical Campus, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre University of Cambridge, Cambridge, CB2 0AW, UK.
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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11
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Holle JU, Moosig F. Update Therapie der ANCA-assoziierten Vaskulitiden. AKTUEL RHEUMATOL 2019. [DOI: 10.1055/a-0958-1958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
ZusammenfassungDieser Artikel gibt eine Übersicht über die aktuellen deutschen und europäischen Therapieempfehlungen zu den ANCA-assoziierten Vaskulitiden (AAV) sowie ein Update zu seither publizierten wichtigen Therapiestudien. Nach den deutschen und europäischen Empfehlungen erfolgt die Remissionsinduktion bei GPA/MPA mit organbedrohender Erkrankung mit Glucocorticoiden und Cycloposphamid oder Rituximab, bei nicht organbedrohender Erkrankung mit Glucocorticoiden und Methotrexat (MTX) oder Mycophenolat-Mofetil (MMF). Die kürzlich publizierte MYCYC-Studie unterstützt die Empfehlungen; sie zeigte eine Nicht-Unterlegenheit gegenüber i. v. Cyclosphamid bei GPA/MPA-Patienten mit nicht-organbedrohender und organbedrohender Erkrankung auf. Die remissionserhaltende Therapie soll mit niedrig-dosierten Glucocorticoiden sowie Azathioprin, MTX und Rituximab durchgeführt werden. Rituximab wurde Ende 2018 auf der Basis der MAINRITSAN-Studie als remissionserhaltende Therapie zugelassen und ist damit nun die formal einzige zur Remissionserhaltung zugelassene Therapie. Mehrere Studien zur untersuchten zudem die kurze Anwendung von Glucocorticoiden (z. B. durch additive Therapie mit Avacopan) in der Remissionsinduktion und das komplette Ausschleichen von Glucocorticoiden in der Remissionserhaltung. Die ersten Ergebnisse hierzu sind vielversprechend; Langzeitdaten stehen allerdings aus. Für die sehr viel seltenere EGPA liegen insgesamt deutlich weniger Studiendaten vor. Die Therapie wird jedoch im Wesentlichen nach den gleichen Prinzipien wie bei den anderen AAV durchgeführt. Neuerdings steht, in Deutschland für diese Indikation aber noch nicht zugelassen, eine Biologikatherapie mit dem Anti-IL-5-Antikörper Mepolizumab zur Verfügung.
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Affiliation(s)
- Julia U. Holle
- Rheumatologie, Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Frank Moosig
- Rheumatologie, Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
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12
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Holle JU, Moosig F. Drei Jahre Terminservicestelle: hohe Rate an Fehlzuweisungen und No-show-Patienten – Eine retrospektive Auswertung des Rheumazentrum Schleswig-Holstein Mitte. Z Rheumatol 2019; 78:832-838. [DOI: 10.1007/s00393-019-0656-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Wong L, Mescia F, Alberici F, Ball MJ, Baslund B, Brenchley P, Bruchfeld A, Cid MC, Tervaert JWC, Coulson RMR, Farahi N, Feighery C, Gross WL, Guillevin L, Gunnarsson I, Harper L, Holle JU, Hruskova Z, Jayne DRW, Lamprecht P, Leslie S, Little MA, Martorana D, Neumann T, Ohlsson S, Peh CA, Pusey CD, Quickert S, Ramirez GA, Rees AJ, Rewerska B, Salama AD, Sanders JSF, Savage CO, Segelmark M, Solans R, Stegeman CA, Szczeklik W, Terrier B, Tesar V, Watts RA, Wieczorek S, Wilde B, Zwerina J, Vaglio A, Lyons PA, Smith KG. 185. GENETIC EVIDENCE OF EOSINOPHIL NUMBER UNDERPINNING PR3-AAV AND PLAUSIBLE HOST GENETIC PREDISPOSITION TO MICROBIAL DRIVERS OF DISEASE. Rheumatology (Oxford) 2019. [DOI: 10.1093/rheumatology/kez060.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Limy Wong
- University of Cambridge, Cambridge, United Kingdom
| | | | - Federico Alberici
- University of Cambridge, Cambridge, United Kingdom
- ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milan, Italy
| | - Miriam J Ball
- Clinical Institute of Pathology, Medical University of Vienna, Austria
| | - Bo Baslund
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Maria C Cid
- Hospital Clinic, University of Barcelona, Spain
| | | | | | - Neda Farahi
- University of Cambridge, Cambridge, United Kingdom
| | - Conleth Feighery
- Trinity College Dublin and St. James's Hospital, Dublin, Ireland
| | - Wolfgang L Gross
- University Hospital Schleswig-Holstein, Luebeck, Germany
- Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Loic Guillevin
- Hospital Cochin, Université Paris Descartes, Paris, France
| | | | - Lorraine Harper
- University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Julia U Holle
- University Hospital Schleswig-Holstein, Luebeck, Germany
- Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Zdenka Hruskova
- Charles University in Prague and General University Hospital, Prague, Czech Republic
| | | | | | - Stephen Leslie
- University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | | | | | | | - Chen Au Peh
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | | | - Giuseppe A Ramirez
- Università Vita Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrew J Rees
- Clinical Institute of Pathology, Medical University of Vienna, Austria
| | | | - Alan D Salama
- Imperial College London, London, United Kingdom
- University College London Centre for Nephrology, Royal Free Hospital, London, United Kingdom
| | | | | | | | | | - Coen A Stegeman
- University of Groningen, University Medical Center Groningen, Netherlands
| | | | | | - Vladimir Tesar
- Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Richard A Watts
- Ipswich Hospital NHS Trust Ipswich, Suffolk, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | | | - Benjamin Wilde
- Maastricht University Medical Centre, Maastricht, Neitherlands
| | - Jochen Zwerina
- University of Erlangen-Nuremberg, Erlangen-Nuremberg, Germany
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of Wiener Gebietskrankenkasse and Allgemeine Unfallversicherungsanstalt Trauma Centre Meidling, Hanusch Hospital, Vienna, Austria
| | | | - Paul A Lyons
- University of Cambridge, Cambridge, United Kingdom
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Lange C, Csernok E, Moosig F, Holle JU. Immune stimulatory effects of neutrophil extracellular traps in granulomatosis with polyangiitis. Clin Exp Rheumatol 2017; 35 Suppl 103:33-39. [PMID: 28281454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 01/16/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES The aim of this study was to analyse the role of netting neutrophils in the pathogenesis of granulomatosis with polyangiitis (GPA), especially their interplay with peripheral blood mononuclear cells (PBMCs). METHODS The amount of cell-free DNA (cfDNA) was determined in sera from GPA patients (pairs active/inactive state of disease, n=18) and from healthy controls (HCs, n=10). Furthermore, we performed in vitro incubation experiments using PBMCs and NETs from patients and HCs for accessing the effect of NETs on PBMC behaviour. We determined proliferation of T- and B-cells (CSFE assay), B-cell maturation (CD38 staining and flow cytometry), production of IgG (ELISpot, ELISA), and secretion of the cytokines IFN-γ, IL-4, IL-10, IL-17A (ELISA). RESULTS We detected a significant increase in serum cfDNA levels of GPA patients compared to HCs. The concentration of cfDNA was associated with disease activity. NETs of patients and HCs induced proliferation of CD4+ T- cells and CD19+ B-cells and maturation of B-cells. Furthermore, we detected an increase in IL-17A secretion after stimulating PBMCs with NETs. A significant difference between PBMCs from GPA patients and HCs was not detectable. CONCLUSIONS NETs activate PBMCs of HCs and GPA patients. Our findings give supportive evidence that NETosis plays a role in the pathogenesis of GPA.
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Affiliation(s)
- Christina Lange
- Christian Albrecht University of Kiel, Institute of Anatomy, Kiel, Germany.
| | - Elena Csernok
- Klinikum Bad Bramstedt, Rheumatology and Immunology, Bad Bramstedt, Germany
| | - Frank Moosig
- Klinikum Bad Bramstedt, Rheumatology and Immunology, Bad Bramstedt; and Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Julia U Holle
- Klinikum Bad Bramstedt, Rheumatology and Immunology, Bad Bramstedt; and Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
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15
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Burkel M, Arndt F, Schirmer JH, Moosig F, Holle JU. Serum immunoglobulin G4 in giant cell arteritis and polymyalgia rheumatica. Clin Exp Rheumatol 2017; 35 Suppl 103:94-97. [PMID: 27974093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To date, no specific serum marker for giant cell arteritis and polymyalgia rheumatica has been established in routine practice. Therefore, the aim of this study was to examine whether immunoglobulin G4 serum concentrations could be a potential biomarker for the differentiation of both diseases. METHODS Serum immunoglobulin G4 (IgG4) concentrations were measured in patients with giant cell arteritis (n=41) and polymyalgia rheumatica (n=27) by an in-house enzyme-linked immunosorbent assay. In the subgroup of untreated patients with disease activity (polymyalgia rheumatica n=27, giant cell arteritis n=19) additional parameters of T-helper 2 cell inflammatory responses were analysed. RESULTS IgG4-values above the prior determined cut-off value of 1400 μg/ml in giant cell arteritis were rare and also significantly less frequent in giant cell arteritis than in polymyalgia rheumatica patients (7.3% vs. 44.4%; p<0.001). The relative risk that patients with clinical features of PMR, presenting without elevated IgG4 levels, have simultaneously GCA was 5.8 compared to those patients with elevated IgG4 levels. In untreated patients absolute counts of eosinophilic leukocytes were lower in giant cell arteritis than in polymyalgia rheumatica (p=0.002) and the cytokines interleukin-4 (p=0.013) and interleukin-10 (p=0.033) were less frequently detectable in giant cell arteritis than in polymyalgia rheumatica. CONCLUSIONS In giant cell arteritis serum levels of IgG4 usually are within the normal range. In polymyalgia rheumatica however, increased IgG4 serum levels are frequently found. Normal IgG4 serum levels in polymyalgia rheumatica may have predictive value in identifying patients with additional, clinically non-apparent giant cell arteritis.
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Affiliation(s)
- Mara Burkel
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt, Germany.
| | - Fabian Arndt
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Jan-Henrik Schirmer
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt; and Department of Internal Medicine I, University Hospital Schleswig-Holstein, Campus Kiel and Christian-Albrechts-University of Kiel, Germany
| | - Frank Moosig
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt; and Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Julia U Holle
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt; and Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
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16
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Schirmer JH, Wright MN, Herrmann K, Laudien M, Nölle B, Reinhold-Keller E, Bremer JP, Moosig F, Holle JU. Myeloperoxidase-Antineutrophil Cytoplasmic Antibody (ANCA)-Positive Granulomatosis With Polyangiitis (Wegener's) Is a Clinically Distinct Subset of ANCA-Associated Vasculitis: A Retrospective Analysis of 315 Patients From a German Vasculitis Referral Cent. Arthritis Rheumatol 2016; 68:2953-2963. [DOI: 10.1002/art.39786] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 06/07/2016] [Indexed: 11/08/2022]
Affiliation(s)
| | - Marvin N. Wright
- Department of Medical Biometry and Statistics, University of Lübeck, University Hospital Schleswig-Holstein; Lübeck Germany
| | | | - Martin Laudien
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Schleswig-Holstein and Christian-Albrechts-University of Kiel; Kiel Germany
| | - Bernhard Nölle
- Department of Ophthalmology, University Hospital Schleswig-Holstein, Campus Kiel and Christian-Albrechts-University of Kiel; Kiel Germany
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17
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Moosig F, Schirmer JH, Lamprecht P, Holle JU. [Clinical spectrum of IgG4-related diseases and the connection to rheumatology]. Z Rheumatol 2016; 75:675-80. [PMID: 27418057 DOI: 10.1007/s00393-016-0138-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Rheumatologist should be familiar with the concept of IgG4-related disease (IgG4-RD). Due to the clinical spectrum IgG4-RD can fall directly within the scope of rheumatology and are often diagnosed primarily by rheumatologists. Furthermore, IgG4RD are relevant differential diagnoses for many other rheumatic conditions. Finally, there are an increasing amount of data suggesting an important role of immunological processes observed in IgG4-RD for other rheumatic diseases.
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Affiliation(s)
- F Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a-7, 24534, Neumünster, Deutschland.
| | - J H Schirmer
- 1. Medizinische Universitätsklinik der Christian-Albrechts-Universität zu Kiel, Schittenhelmstr., 24105, Kiel, Deutschland
| | - P Lamprecht
- Klinik für Rheumatologie, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - J U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a-7, 24534, Neumünster, Deutschland
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18
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Yates M, Watts RA, Bajema IM, Cid MC, Crestani B, Hauser T, Hellmich B, Holle JU, Laudien M, Little MA, Luqmani RA, Mahr A, Merkel PA, Mills J, Mooney J, Segelmark M, Tesar V, Westman K, Vaglio A, Yalçındağ N, Jayne DR, Mukhtyar C. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016; 75:1583-94. [PMID: 27338776 DOI: 10.1136/annrheumdis-2016-209133] [Citation(s) in RCA: 718] [Impact Index Per Article: 89.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/27/2016] [Indexed: 12/13/2022]
Abstract
In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.
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Affiliation(s)
- M Yates
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK Norwich Medical School, University of East Anglia, Norwich, UK
| | - R A Watts
- Norwich Medical School, University of East Anglia, Norwich, UK Department of Rheumatology, Ipswich Hospital NHS Trust, Ipswich, Suffolk, UK
| | - I M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - B Crestani
- Assistance Publique-Hôpitaux de Paris, Department of Pulmonology, Bichat-Claude Bernard University Hospital, Paris, France
| | - T Hauser
- Immunologie-Zentrum Zürich, Zürich, Switzerland
| | - B Hellmich
- Vaskulits-Zentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Kreiskliniken Esslingen, Kirchheim-Teck, Germany
| | - J U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - M Laudien
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel, Kiel, Germany
| | - M A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - R A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, Université Paris 7 René Diderot, Paris, France
| | - P A Merkel
- Division of Rheumatology and the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Mills
- Vasculitis UK, West Bank House, Winster, Matlock, UK
| | - J Mooney
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - M Segelmark
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Department of Nephrology, Linköping University, Linköping, Sweden
| | - V Tesar
- Department of Nephrology, 1st School of Medicine, Charles University, Prague, Czech Republic
| | - K Westman
- Department of Nephrology, Lund University, Skåne University Hospital, Lund and Malmö, Sweden
| | - A Vaglio
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - N Yalçındağ
- Department of Ophthalmology, School of Medicine, Ankara University, Ankara, Turkey
| | - D R Jayne
- Lupus and Vasculitis Unit, Addenbrooke's Hospital, Cambridge, UK
| | - C Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
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Herrmann K, Schinke S, Csernok E, Moosig F, Holle JU. Diagnostic Value of Procalcitonin in ANCA-Associated Vasculitis (AAV) to Differentiate Between Disease Activity, Infection and Drug Hypersensitivity. Open Rheumatol J 2015; 9:71-6. [PMID: 26535070 PMCID: PMC4627387 DOI: 10.2174/1874312901409010071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/16/2015] [Accepted: 07/23/2015] [Indexed: 11/22/2022] Open
Abstract
Objective: Procalcitonin (PCT) is considered to be a specific marker for severe bacterial infections and sepsis. Elevated PCT levels have been reported in active autoimmune diseases without infection. The aim of this study was to assess the diagnostic value of PCT serum levels in ANCA-associated vasculitis (AAV) patients with respect to infection, disease activity and drug fever using a high sensitive PCT detection method. Methods: In 53 AAV patients with elevated C-reactive protein (CRP) PCT was determined by the Thermo Scientific BRAHMS PCT sensitive KRYPTOR assay. Patients underwent standardized diagnostic procedures for evaluation of disease activity and infection. Results: 53 patients with AAV and elevated CRP (7.7±6.9 mg/dl, PCT 0.34±1.02 ng/ml) were assessed, 10 had infection with elevated CRP levels of 11.2±10.2 mg/dl and PCT levels of 1.06±2.07 ng/dl. 43 patients had no evidence of infection, 36 of them were presented with AAV with normal or only slightly positive PCT levels in active disease (n=36) (PCT 0.06±0.06 ng/ml). 7 patients had increased PCT levels due to azathioprine hypersensitivity (0.76±1.01 ng/ml). For discrimination between infection and vasculitis activity PCT was more useful than CRP with the best cut-off at 0.1 ng/ml (sensitivity 60%, specificity 92%). Conclusion: In contrast to previous studies using semiquantitative PCT assays, the KRYPTOR performs better with respect to discrimination of infection from active AAV. In all patients assessed with active AAV (and without infection) PCT levels remained below the PCT reference limit (0.5 ng/ml) for infections. Drug hypersensitivity seems to be an important differential diagnosis in the setting of elevated CRP and PCT in patients who receive azathioprine.
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Affiliation(s)
- K Herrmann
- Division of Rheumatology, Department of Medicine III, University Medical Center Carl Gustav Carus at the TU Dresden, Dresden, Germany ; Department of Rheumatology, Klinikum Bad Bramstedt, Germany
| | - S Schinke
- Department of Rheumatology, Klinikum Bad Bramstedt, Germany
| | - E Csernok
- Department of Rheumatology, Klinikum Bad Bramstedt, Germany
| | - F Moosig
- Department of Rheumatology, Klinikum Bad Bramstedt, Germany
| | - J U Holle
- Department of Rheumatology, Klinikum Bad Bramstedt, Germany
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Schirmer JH, Wright MN, Vonthein R, Herrmann K, Nölle B, Both M, Henes FO, Arlt A, Gross WL, Schinke S, Reinhold-Keller E, Moosig F, Holle JU. Clinical presentation and long-term outcome of 144 patients with microscopic polyangiitis in a monocentric German cohort. Rheumatology (Oxford) 2015; 55:71-9. [PMID: 26297628 DOI: 10.1093/rheumatology/kev286] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To evaluate the clinical presentation and long-term outcome of a vasculitis centre cohort of patients with microscopic polyangiitis (MPA) with respect to organ manifestations, treatment, chronic damage and mortality. METHODS We performed a retrospective chart review at our vasculitis referral centre. MPA patients admitted between 1991 and 2013 classified by a modified European Medicines Agency algorithm were diagnosed and treated according to a standardized interdisciplinary approach. RESULTS Comprehensive data from standardized interdisciplinary workups was available for 144 patients (median follow-up 72 months). The overall standardized mortality ratio was 1.40 (95% CI 0.91, 2.07; P = 0.13). We observed a higher mortality [hazard ratio (HR) 4.04 (95% CI 1.21, 13.45), P = 0.02] in 17 patients with MPA-associated fibrosing interstitial lung disease (ILD) and 56 patients with peripheral nervous system involvement [HR 5.26 (95% CI 1.10, 25.14), P = 0.04] at disease onset. One hundred and fifteen patients (79.9%) responded to the initial treatment. Sixty-one (42.3%) achieved complete remission and 54 (37.5%) achieved partial remission. Twenty (13.9%) showed a refractory disease course. CONCLUSION MPA patients at our tertiary rheumatology referral centre seemed to have a less severe phenotype resulting in a less severe disease course and better outcome than reported in other cohorts. Fibrosing ILD was significantly associated with mortality in this cohort.
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Affiliation(s)
- Jan H Schirmer
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt,
| | - Marvin N Wright
- Department of Medical Biometry and Statistics, University of Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck
| | - Reinhard Vonthein
- Department of Medical Biometry and Statistics, University of Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Center for Clinical Trials Lübeck, University of Lübeck, Lübeck
| | - Kristine Herrmann
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | | | - Marcus Both
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel
| | - Frank O Henes
- Clinic and Policlinic for Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andreas Arlt
- Department of Medical and Neurological Rehabilitation, Klinikum Bad Bramstedt, Bad Bramstedt and
| | - Wolfgang L Gross
- University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Susanne Schinke
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | - Eva Reinhold-Keller
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | - Frank Moosig
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | - Julia U Holle
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
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Schirmer JH, Thorns C, Moosig F, Holle JU. Treatment failure by canakinumab in a patient with progressive multisystemic Erdheim–Chester disease refractory to anakinra: successful use of vemurafenib: Fig. 1. Rheumatology (Oxford) 2015; 54:1932-4. [DOI: 10.1093/rheumatology/kev237] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Moosig F, Holle JU. Of evidence and uncertainties. Rheumatology (Oxford) 2014; 53:2129-30. [DOI: 10.1093/rheumatology/keu009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Wieczorek S, Holle JU, Cohen Tervaert JW, Harper L, Moosig F, Gross WL, Epplen JT. The SEM6A6 locus is not associated with granulomatosis with polyangiitis or other forms of antineutrophil cytoplasmic antibody-associated vasculitides in Europeans: comment on the article by Xie et al. Arthritis Rheumatol 2014; 66:1400-1. [PMID: 24470065 DOI: 10.1002/art.38367] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Holle JU, Gross WL. [Genetic risk factors for vasculitis]. Internist (Berl) 2013; 55:128-34. [PMID: 24217527 DOI: 10.1007/s00108-013-3305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Among the vasculitides, genome-wide association studies (GWAS) have so far been performed for Behçet's disease, Kawasaki disease, granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). These studies delivered valuable information with respect to the pathogenesis and therapeutic targets: Apart from HLA-B51 and HLA-A26, distinct polymorphisms in cytokine (IL-10) or cytokine receptor (IL-12R/IL-23R) genes, transcription factors (STAT4) and genes encoding for proteins involved in antigen presentation (ERAP-1) have been identified as risk factors for Behçet's disease. The results of two GWAS performed for antineutrophil cytoplasmic antibody (ANCA) associated vasculitis GPA and MPA in Europe and the USA confirmed that the HLA-DP locus is the most relevant risk factor for GPA. Furthermore, the European GWAS confirmed SERPINA-1, a deficiency allele of the α-1-antitrypsin gene, as a genetic risk factor in GPA and identified a polymorphism in the proteinase 3 gene (PR3), one of the target antigens of ANCA, as a risk factor for GPA and PR3-ANCA-associated vasculitis.
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Affiliation(s)
- J U Holle
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland,
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Chand S, Holle JU, Hilhorst M, Simmonds MJ, Smith S, Kamesh L, Hewins P, McKnight AJ, Maxwell AP, Cohen Tervaert JW, Wieczorek S, Harper L, Borrows R. Caveolin-1 single nucleotide polymorphism in antineutrophil cytoplasmic antibody associated vasculitis. PLoS One 2013; 8:e69022. [PMID: 23894397 PMCID: PMC3716813 DOI: 10.1371/journal.pone.0069022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/03/2013] [Indexed: 01/29/2023] Open
Abstract
Objective Immunosuppression is cornerstone treatment of antineutrophil cytoplasmic antibody associated vasculitis (AAV) but is later complicated by infection, cancer, cardiovascular and chronic kidney disease. Caveolin-1 is an essential structural protein for small cell membrane invaginations known as caveolae. Its functional role has been associated with these complications. For the first time, caveolin-1 (CAV1) gene variation is studied in AAV. Methods CAV1 single nucleotide polymorphism rs4730751 was analysed in genomic DNA from 187 white patients with AAV from Birmingham, United Kingdom. The primary outcome measure was the composite endpoint of time to all-cause mortality or renal replacement therapy. Secondary endpoints included time to all-cause mortality, death from sepsis or vascular disease, cancer and renal replacement therapy. Validation of results was sought from 589 white AAV patients, from two European cohorts. Results The primary outcome occurred in 41.7% of Birmingham patients. In a multivariate model, non-CC genotype variation at the studied single nucleotide polymorphism was associated with increased risk from: the primary outcome measure [HR 1.86; 95% CI: 1.14-3.04; p=0.013], all-cause mortality [HR:1.83; 95% CI: 1.02-3.27; p=0.042], death from infection [HR:3.71; 95% CI: 1.28-10.77; p=0.016], death from vascular disease [HR:3.13; 95% CI: 1.07-9.10; p=0.037], and cancer [HR:5.55; 95% CI: 1.59-19.31; p=0.007]. In the validation cohort, the primary outcome rate was far lower (10.4%); no association between genotype and the studied endpoints was evident. Conclusions The presence of a CC genotype in Birmingham is associated with protection from adverse outcomes of immunosuppression treated AAV. Lack of replication in the European cohort may have resulted from low clinical event rates. These findings are worthy of further study in larger cohorts.
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Affiliation(s)
- Sourabh Chand
- Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom.
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Husmann CA, Holle JU, Moosig F, Mueller S, Wilde B, Cohen Tervaert JW, Harper L, Assmann G, Gross WL, Epplen JT, Wieczorek S. Genetics of toll like receptor 9 in ANCA associated vasculitides. Ann Rheum Dis 2013; 73:890-6. [PMID: 23592712 DOI: 10.1136/annrheumdis-2012-202803] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To investigate the contribution of genetic polymorphisms of toll like receptor (TLR) 9 and related genes on the susceptibility and clinical manifestation of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitides (AAV). METHODS Four single nucleotide polymorphisms (SNPs) in TLR9 were genotyped in 863 German AAV cases and 1344 healthy controls. Significant results were replicated in a cohort of 426 Dutch and British AAV cases. 11 polymorphisms in TLR9 related genes were studied concomitantly. RESULTS A strong association of TLR9 genotypes and haplotypes with granulomatosis with polyangiitis was observed as well as a contrariwise association with microscopic polyangiitis. The association was confirmed when cases were compared according to ANCA status rather than to clinical entity. This was partly replicated in the second cohort leading to a striking overall difference in TLR9 allele/haplotype frequencies between proteinase 3 (PR3) ANCA+ and myeloperoxidase (MPO) ANCA+ cases (p=0.00000398, pc=0.000016, OR 1.68 (95% CI 1.35 to 2.1) for rs352140; p=0.000011, pc=0.000044, OR 1.64 (95% CI 1.31 to 2.04) for a 3-SNP haplotype). No significant association or epistatic effect was detected for TLR9 related genes: interleukin 6, interleukin 23 receptor, myeloid differentiation primary response 88, TNF receptor-associated factor 6, interleukin-1 receptor-associated kinase 4, discs large homolog 5 and nucleotide-binding oligomerisation domain containing 2. CONCLUSIONS We provide further evidence that PR3-ANCA+ AAV differs genetically from MPO-ANCA+ AAV. TLR9 signalling may be involved in disease pathology, favouring models of infectious agents triggering AAV development.
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Affiliation(s)
- C A Husmann
- Department of Human Genetics, Ruhr University, , Bochum, Germany
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Holle JU, Windmöller M, Lange C, Gross WL, Herlyn K, Csernok E. Toll-like receptor TLR2 and TLR9 ligation triggers neutrophil activation in granulomatosis with polyangiitis. Rheumatology (Oxford) 2013; 52:1183-9. [PMID: 23407387 DOI: 10.1093/rheumatology/kes415] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The aim of the study was to characterize the expression of TLR2, TLR4 and TLR9 in PMNs of patients with granulomatosis with polyangiitis (GPA) and to elucidate the role of these receptors in GPA with respect to neutrophil activation. METHODS The expression of TLR2, TLR4 and TLR9 was determined on ex vivo PMNs in whole blood samples of GPA patients (n = 35) and healthy controls (HCs) (n = 24). Isolated PMNs were stimulated in vitro with TLR agonists and assessed for degranulation, membrane proteinase 3 (mPR3) expression, soluble l-selectin shedding and cytokine production (IL-8) in five GPA patients and five HCs. The priming effects of TLR2 and TLR9 ligation were assessed by measurement of serine protease activity after stimulation with PR3-ANCA. RESULTS There were no significant differences in the ex vivo expression of TLRs on PMNs in HCs and GPA patients. Stimulation of TLR4 and TLR9 induced MPO release, stimulation with TLR2, TLR4 and TLR9 ligands elicited IL-8 production and stimulation of TLR2 and TLR9 led to an upregulation in mPR3 expression on PMNs with no significant differences between GPA and HC after 1 or 24 h stimulation. Priming of PMNs with TLR2 and TLR9 ligands induced degranulation after subsequent stimulation with PR3-ANCA, which was comparable to priming with TNF-α. CONCLUSION Expression of TLR2, TLR4 and TLR9 in PMNs and the TLR-induced activation of PMNs was comparable in GPA and HC. mPR3 upregulation by TLR2 and TLR9 stimulation and the priming effect of TLR ligands on PMNs may have a potential implication for triggering disease activity during infection in GPA.
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Affiliation(s)
- Julia U Holle
- Department of Rheumatology and Immunology, University Hospital Schleswig-Holstein, Campus Luebeck and Klinikum Bad Bramstedt, Oskar-Alexander-Straße 26, 24576 Bad Bramstedt, Germany.
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Holle JU, Voigt C, Both M, Holl-Ulrich K, Nölle B, Laudien M, Moosig F, Gross WL. Orbital masses in granulomatosis with polyangiitis are associated with a refractory course and a high burden of local damage. Rheumatology (Oxford) 2013; 52:875-82. [DOI: 10.1093/rheumatology/kes382] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Holle JU. [First genomewide association study of ANCA-associated vasculitis]. Z Rheumatol 2012; 72:187-8. [PMID: 23247869 DOI: 10.1007/s00393-012-1087-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J U Holle
- Poliklinik für Rheumatologie, Klinik für Rheumatologie und Immunologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck & Klinikum Bad Bramstedt, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
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Moosig F, Reinhold-Keller E, Holl-Ulrich K, Feller AC, Bley T, Holle JU, Zwerina J, Lamprecht P, Dalhoff K, Venhoff N, Thiel J, Peter HH, Laudien M, Quetz J, Ambrosch P, Both M, Heller M. [How I treat …]. Z Rheumatol 2012; 71:775-84. [PMID: 23138555 DOI: 10.1007/s00393-012-0988-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- F Moosig
- Klinikum Bad Bramstedt GmbH, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Bad Bramstedt, Deutschland.
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Abstract
Granulomatosis with polyangitis (GPA, Wegener's granulomatosis) is characterized by a granulomatous inflammation of the respiratory tract and a necrotizing ANCA-associated small to medium-size vessel vasculitis with a predilection for the lungs (pulmonary capillaritis) and kidneys (necrotizing glomerulonephritis). The disease evolves stage-wise and typically starts as inflammation of the respiratory tract followed by development of systemic vasculitis manifestations. Today, treatment is evidence-based and adapted according to activity and disease stage which has resulted in a significant improvement in long-term outcome. Early mortality during the first year of treatment poses one of the main problems and is a result of infections under immunosuppressive treatment. Furthermore, treatment of refractory disease activity which is often represented by granulomatous manifestations is still a challenge and may result in significant organ damage if not treated successfully.
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Affiliation(s)
- J U Holle
- UKSH, Campus Lübeck, Poliklinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander Str. 26, 24576, Bad Bramstedt, Deutschland.
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Lyons PA, Rayner TF, Trivedi S, Holle JU, Watts RA, Jayne DRW, Baslund B, Brenchley P, Bruchfeld A, Chaudhry AN, Cohen Tervaert JW, Deloukas P, Feighery C, Gross WL, Guillevin L, Gunnarsson I, Harper L, Hrušková Z, Little MA, Martorana D, Neumann T, Ohlsson S, Padmanabhan S, Pusey CD, Salama AD, Sanders JSF, Savage CO, Segelmark M, Stegeman CA, Tesař V, Vaglio A, Wieczorek S, Wilde B, Zwerina J, Rees AJ, Clayton DG, Smith KGC. Genetically distinct subsets within ANCA-associated vasculitis. N Engl J Med 2012; 367:214-23. [PMID: 22808956 PMCID: PMC3773907 DOI: 10.1056/nejmoa1108735] [Citation(s) in RCA: 632] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a severe condition encompassing two major syndromes: granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis) and microscopic polyangiitis. Its cause is unknown, and there is debate about whether it is a single disease entity and what role ANCA plays in its pathogenesis. We investigated its genetic basis. METHODS A genomewide association study was performed in a discovery cohort of 1233 U.K. patients with ANCA-associated vasculitis and 5884 controls and was replicated in 1454 Northern European case patients and 1666 controls. Quality control, population stratification, and statistical analyses were performed according to standard criteria. RESULTS We found both major-histocompatibility-complex (MHC) and non-MHC associations with ANCA-associated vasculitis and also that granulomatosis with polyangiitis and microscopic polyangiitis were genetically distinct. The strongest genetic associations were with the antigenic specificity of ANCA, not with the clinical syndrome. Anti-proteinase 3 ANCA was associated with HLA-DP and the genes encoding α(1)-antitrypsin (SERPINA1) and proteinase 3 (PRTN3) (P=6.2×10(-89), P=5.6×10(-12,) and P=2.6×10(-7), respectively). Anti-myeloperoxidase ANCA was associated with HLA-DQ (P=2.1×10(-8)). CONCLUSIONS This study confirms that the pathogenesis of ANCA-associated vasculitis has a genetic component, shows genetic distinctions between granulomatosis with polyangiitis and microscopic polyangiitis that are associated with ANCA specificity, and suggests that the response against the autoantigen proteinase 3 is a central pathogenic feature of proteinase 3 ANCA-associated vasculitis. These data provide preliminary support for the concept that proteinase 3 ANCA-associated vasculitis and myeloperoxidase ANCA-associated vasculitis are distinct autoimmune syndromes. (Funded by the British Heart Foundation and others.).
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Affiliation(s)
- Paul A Lyons
- Cambridge Institute for Medical Research, and Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Holle JU, Herrmann K, Gross WL, Csernok E. Comparative analysis of different commercial ELISA systems for the detection of anti-neutrophil cytoplasm antibodies in ANCA-associated vasculitides. Clin Exp Rheumatol 2012; 30:S66-S69. [PMID: 22512915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 03/02/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To assess the diagnostic performance of 11 commercial PR3- and MPO-ANCA ELISA systems (direct, capture and high sensitive [hs] ELISA). METHODS Sera from 90 patients with AAV (GPA, MPA and CSS) and 20 disease controls (SLE; RA) and healthy individuals were tested for the presence of ANCA by IFT and by different ELISAs for the presence of PR3-and MPO-ANCA, respectively. Furthermore, the binding capacity of the IUIS-CDC reference sera for PR3-/MPO-ANCA in different commercial assays was analysed. RESULTS Commercial ELISA kits for PR3-ANCA differed moderately in their sensitivity (from 45% to 62.5%). The highest sensitivity for PR3-ANCA was obtained with hs ELISA (kit A) and capture ELISA (kit N). Testing for MPO-ANCA the highest sensitivity (85%) was obtained with direct ELISA (kit D and I). Specificity was high in all kits. Only three PR3-ANCA commercial kits and three MPO-ANCA kits produced binding at the expected value for the IUIS-CDC reference sera (100 U/ml). In all of the kits, serial dilutions of the reference sera did not yield linearity. CONCLUSIONS Second (capture) and third (high sensitivity) generation PR3-ANCA ELISA kits are superior to conventional ELISAs. Direct and capture MPO-ANCA ELISAs showed a good overall performance in all kits. Most of the kits have not been standardised to allow their results to be compared.
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Affiliation(s)
- Julia U Holle
- University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Dept. of Rheumatology and Immunology, Germany.
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Holle JU, Dubrau C, Herlyn K, Heller M, Ambrosch P, Noelle B, Reinhold-Keller E, Gross WL. Rituximab for refractory granulomatosis with polyangiitis (Wegener's granulomatosis): comparison of efficacy in granulomatous versus vasculitic manifestations. Ann Rheum Dis 2011; 71:327-33. [PMID: 22021864 DOI: 10.1136/ard.2011.153601] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE First, to investigate the overall efficacy and safety of rituximab (RTX) in refractory granulomatosis with polyangiitis (GPA) in a tertiary referral centre. Second, to compare the efficacy of RTX in granulomatous and vasculitic manifestations in GPA. PATIENTS AND METHODS This study comprised a retrospective, standardised data collection from all patients who received RTX for refractory Wegener's granulomatosis from 2002 to 2010. Patients were assessed by a standardised interdisciplinary diagnostic procedure (including ear, nose and throat and ophthalmology assessment, MRI, immunodiagnostics, B-cell levels and Birmingham Vasculitis Activity Score) and were treated by standardised therapeutic regimens according to available evidence. RESULTS 59 patients received 75 cycles of RTX. 9.3% achieved complete remission. A response was documented in 61.3% (improvement in 52%, unchanged disease activity in 9.3%), 26.7% had refractory disease. Birmingham Vasculitis Activity Score, disease extent index, erythrocyte sedimentation rate, C-reactive protein and prednisolone demand decreased significantly. All patients achieved B-cell depletion. Granulomatous manifestations such as orbital granuloma and pachymeningitis were more frequently refractory to RTX than vasculitis or other granulomatous manifestations. Thus, for example, complete remission/improvement was found in 89.2% of patients with renal disease and in only 44.4% of those with orbital masses (p=0.003). The relapse rate was 44.4% after a median period of 13.5 months. Adverse events occurred in 29%, pneumonia in 15% and death in 3%. CONCLUSION The overall response rate of refractory GPA to RTX was high (61.3% complete remission or improvement). Response rates of vasculitic manifestations were excellent; failure of response/progress was mostly due to granulomatous manifestations, especially orbital masses. Relapse rates were high (40%) despite maintenance treatment.
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Affiliation(s)
- Julia U Holle
- Department of Rheumatology and Clinical Immunology, Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Bad Bramstedt, Germany.
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Morris H, Morgan MD, Wood AM, Smith SW, Ekeowa UI, Herrmann K, Holle JU, Guillevin L, Lomas DA, Perez J, Pusey CD, Salama AD, Stockley R, Wieczorek S, McKnight AJ, Maxwell AP, Miranda E, Williams J, Savage CO, Harper L. ANCA-associated vasculitis is linked to carriage of the Z allele of α₁ antitrypsin and its polymers. Ann Rheum Dis 2011; 70:1851-6. [PMID: 21821620 DOI: 10.1136/ard.2011.153569] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Small studies have linked α1 antitrypsin (α1AT) deficiency to patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV). OBJECTIVE To test the validity and the mechanism of this association between α1AT and AAV. METHODS The distribution of α1AT deficiency alleles Z and S was compared between 856 White Europeans with AAV and 1505 geographic and ethnically matched healthy controls. Genotyping was performed by allelic discrimination assay. RESULTS were compared between cases and controls using χ(2) tests. The serum and renal biopsies for α1AT polymers were compared using the polymer-specific 2C1 antibody. The role of α1AT polymers in promoting inflammation was investigated by examining their ability to prime neutrophils for ANCA activation as assessed by CD62L shedding, superoxide production and myeloperoxidase degranulation. Results The Z but not the S allele was over-represented in the patients compared with controls (HR=2.25, 95% CI 1.60 to 3.19). Higher concentrations of polymers of α1AT were detected in serum from patients carrying the Z allele than in those not carrying the Z allele (median (IQR) 1.40 (0.91-3.32) mg/dl vs 0.17 (0.06-0.28) mg/dl, p<0.001); polymers of α1AT were also seen in the renal biopsy of a patient with vasculitic glomerulonephritis. Polymers of α1AT primed neutrophils with CD62L shedding and increased superoxide production following ANCA activation. Carriage of the Z allele was not associated with disease severity, survival or relapse. CONCLUSIONS The Z but not the S deficiency allele is associated with AAV. Polymers of α1AT are present in the serum and glomeruli of at least some patients with the Z allele, which may promote inflammation through priming of neutrophils.
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Affiliation(s)
- H Morris
- School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Abstract
Pulmonary involvement is a common complication of vasculitides, especially small vessel vasculitides. This review provides an overview of vasculitic manifestations of the lung as well as of other organs involved in vasculitides. Furthermore, it provides the diagnostic procedures required to asses a patient with vasculitic lung involvement and gives an overview of current treatment strategies.
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Affiliation(s)
- Julia U Holle
- Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Germany
| | - Frank Moosig
- Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Germany
| | - Klaus Dalhoff
- Department of Pulmology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Wolfgang L Gross
- Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Germany
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Abstract
Genetic association studies have been of great value in the past by contributing to the understanding of pathophysiological mechanisms of chronic inflammatory and autoimmune diseases. Many genetic risk factors have been identified which confer susceptibility for one or several (autoimmune) disease(s). Using a candidate-gene approach, the first genetic risk factors and polymorphisms of vasculitides have been identified. Due to the rarity of autoimmune vasculitides often only small sample numbers have been generated and analysed, leading to inconsistent results. Furthermore, differences in ethnic background may complicate analysis. Only few of the detected risk factors have been reliably replicated in larger cohorts, such as the association of the PTPN22*620W allele with WG and MPA, the deficiency allele Pi*Z of the alpha1 antitrypsin gene and the HLA-DPB*04041 allele with WG and the HLA-DRB3/DRB4 with CSS. Genome-wide association studies (GWAS) offer the advantage of screening the whole genome for risk factors rather than relying on disease models postulated by the investigator; however, they require even larger sample sizes. Initial results from GWA studies are available for Behçet's disease and Kawasaki syndrome, which identified new genetic associations but require replication, especially since some of the identified risk factors could not be linked to pathophysiological pathways to date.
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Affiliation(s)
- J U Holle
- Poliklinik für Rheumatologie, Vaskulitiszentrum, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Klinik für Rheumatologie und Klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland.
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Holle JU, Gross WL, Latza U, Nölle B, Ambrosch P, Heller M, Fertmann R, Reinhold-Keller E. Improved outcome in 445 patients with Wegener's granulomatosis in a German vasculitis center over four decades. ACTA ACUST UNITED AC 2010; 63:257-66. [PMID: 20862686 DOI: 10.1002/art.27763] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Julia U Holle
- University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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Fröhlich K, Holle JU, Aries PM, Gross WL, Moosig F. Successful use of bortezomib in a patient with systemic lupus erythematosus and multiple myeloma. Ann Rheum Dis 2010; 70:1344-5. [PMID: 21173019 DOI: 10.1136/ard.2010.133256] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Holle JU, Bley T, Gross WL. [Classification and therapy of vasculitis according to recommendations of the European League Against Rheumatism (EULAR)]. Radiologe 2010; 50:846-54. [PMID: 20717646 DOI: 10.1007/s00117-010-2000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Vasculitis is still being classified according the criteria of the American College of Rheumatology and the Chapel Hill Consensus Conference Definitions. Diagnostic criteria are currently being established. The classification criteria are based on the size of the inflamed blood vessel (e.g. large vessel vasculitis with inflammation of the aorta and its branches), clinical symptoms and findings (such as cephalalgia in giant cell arteritis) and histological findings. In recent years a definition of disease stages and activity has been established and a number of controlled trials have been carried out in order to provide evidence-based stage and activity adapted therapy regimens. Recommendations for the management of vasculitis have been published in 2009 by EULAR (European League Against Rheumatism). This article gives a review of the classification of vasculitis and summarizes the current European guidelines on management.
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Affiliation(s)
- J U Holle
- Klinik für Rheumatologie und Klinische Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland.
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Abstract
Churg-Strauss syndrome is a rare small-vessel vasculitis that is associated with asthma, granulomatous inflammation, peripheral/tissue eosinophilia and a positive antineutrophil cytoplasmic antibody status (in approximately 40% of patients). The disease can be organ- and life-threatening, either due to tissue eosinophil infiltration such as myocarditis or due to vasculitis manifestations, for example glomerulonephritis. Furthermore, life-threatening disease can also occur due to the side effects of immunosuppression, for example, infection. A thorough diagnostic work-up should be performed in order to identify all organs involved and to rule out other disorders with similar features, such as hypereosinophilic syndrome. Therapeutic management is conducted according to disease stage and activity. Glucocorticoids remain the mainstay of therapy; however, further immunosuppressants (e.g., cyclophosphamide for life-threatening disease) are usually required. Future promising therapy options target cytokines involved in the disease process, such as IL-5.
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Affiliation(s)
- Julia U Holle
- University Hospital Schleswig-Holstein, Campus Luebeck, Dept of Rheumatology and Klinikum Bad Bramstedt, Dept of Rheumatology and Immunology, Oskar-Alexander-Strasse 26, 24576 Bad, Bramstedt, Germany.
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Wibisono D, Csernok E, Lamprecht P, Holle JU, Gross WL, Moosig F. Serum HMGB1 levels are increased in active Wegener's granulomatosis and differentiate between active forms of ANCA-associated vasculitis. Ann Rheum Dis 2010; 69:1888-9. [PMID: 20542962 DOI: 10.1136/ard.2009.119172] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Holle JU, Gross WL, Holl-Ulrich K, Ambrosch P, Noelle B, Both M, Csernok E, Moosig F, Schinke S, Reinhold-Keller E. Prospective long-term follow-up of patients with localised Wegener's granulomatosis: does it occur as persistent disease stage? Ann Rheum Dis 2010; 69:1934-9. [PMID: 20511614 DOI: 10.1136/ard.2010.130203] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectiveTo identify patients with localised Wegener's granulomatosis (locWG) to assess whether it occurs as a long-term disease stage or phenotype and to characterise its outcome.MethodsPatients in a ‘localised stage’ with histological criteria compatible with WG and a follow-up period of ≥1 year were included. They were prospectively followed at the Vasculitis Center Schleswig-Holstein from 1989 to 2009 and the clinical manifestations, antineutrophil cytoplasmic autoantibodies (ANCA) status and damage were evaluated. Immunosuppression was adapted to disease activity and severity in a step-up regimen.ResultsOf 1024 patients with suspected WG, 99 were clinically diagnosed with locWG and 50 fulfilled the inclusion criteria (72% women, median age 43 years, 46% ANCA-positive). The median follow-up was 48 months. All achieved a response to treatment, 34% achieved complete remission, 1–4 relapses occurred in 46%, 5 (10%) had generalised disease (median 6 years after onset). ANCA status was not associated with relapse (p=0.98), transition to generalised disease (p=0.51) or refractory manifestations (p=0.60). 47% required cyclophosphamide for localised manifestations, 36% of them for pulmonary masses and 24% for orbital masses. 66% developed organ damage, mostly due to bony destruction or space obturation (28% saddle nose, 24% septal perforation, 10% orbital wall destruction). There were two deaths that were not related to WG.ConclusionThere is evidence that locWG is a long-term disease stage or phenotype (5% of all patients with WG), 46% of whom are ANCA-positive. LocWG is characterised by destructive and/or space-consuming lesions associated with high relapse rates (46%) and local damage.
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Affiliation(s)
- Julia U Holle
- Department of Rheumatology and Clinical Immunology, Vasculitis Center, University Hospital Schleswig-Holstein, Germany.
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Wieczorek S, Holle JU, Bremer JP, Wibisono D, Moosig F, Fricke H, Assmann G, Harper L, Arning L, Gross WL, Epplen JT. Contrasting association of a non-synonymous leptin receptor gene polymorphism with Wegener’s granulomatosis and Churg–Strauss syndrome. Rheumatology (Oxford) 2010; 49:907-14. [PMID: 20185531 DOI: 10.1093/rheumatology/kep420] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Holle JU, Csernok E, Fredenhagen G, Backes M, Bremer JP, Gross WL. Clinical evaluation of hsPR3-ANCA ELISA for detection of antineutrophil cytoplasmatic antibodies directed against proteinase 3. Ann Rheum Dis 2010; 69:468-9. [DOI: 10.1136/ard.2009.109868] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wieczorek S, Holle JU, Müller S, Fricke H, Gross WL, Epplen JT. A functionally relevant IRF5 haplotype is associated with reduced risk to Wegener's granulomatosis. J Mol Med (Berl) 2010; 88:413-21. [PMID: 20049410 DOI: 10.1007/s00109-009-0580-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 12/11/2009] [Accepted: 12/15/2009] [Indexed: 01/06/2023]
Abstract
Wegener's granulomatosis (WG), characterized by systemic vasculitis and granulomatous inflammation, is a rare chronic rheumatic condition potentially sharing some etiopathological principles with other autoimmune disorders, e.g., rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Several large association studies have identified genetic risk factors for RA and SLE. Thereof, we have evaluated the relevance of the most promising ones in WG. 22 single nucleotide polymorphisms (SNPs) within or in the vicinity of CCL21, CD40, CDK6, IL21, IL2RB, IRF5, KIF5A, KLF12, MMEL1, PRKCQ, STAT4, TNFAIP3, and TRAF1/C5 have been genotyped in >600 German WG cases and >800 matched controls. While most polymorphisms did not show suspicious effects on WG susceptibility, SNPs representing TNFAIP3 (rs6922466, p = 0.032, odds ratio (OR) 0.83, 95% confidence interval (CI) 0.7--0.98) and CDK6 (rs42041, p = 0.0201, OR 1.21, 95% CI 1.03-1.43) revealed nominally significant differences in allele distribution. The strongest association was detected for a functionally relevant four SNP haplotype of IRF5, which comprised a protective effect (p = 0.0000897, p (corrected) = 0.0012, OR 0.73, 95% CI 0.62-0.85) similar to those previously seen in RA and SLE. Thus, we suggest that WG, SLE, and RA share some, but not many, genetic risk factors, which supports models of partly overlapping etiopathological mechanisms in these disorders.
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Affiliation(s)
- Stefan Wieczorek
- Department of Human Genetics, Ruhr University, MA5/39, 44780, Bochum, Germany.
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