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Fussner LA, Flores-Suárez LF, Cartin-Ceba R, Specks U, Cox PG, Jayne DRW, Merkel PA, Walsh M. Alveolar Hemorrhage in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results of an International Randomized Controlled Trial (PEXIVAS). Am J Respir Crit Care Med 2024; 209:1141-1151. [PMID: 38346237 DOI: 10.1164/rccm.202308-1426oc] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/12/2024] [Indexed: 05/02/2024] Open
Abstract
Rationale: Diffuse alveolar hemorrhage (DAH) is a life-threatening manifestation of antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The PEXIVAS (Plasma Exchange and Glucocorticoids in Severe Antineutrophil Cytoplasmic Antibody-Associated Vasculitis) (NCT00987389) trial was the largest in AAV and the first to enroll participants with DAH requiring mechanical ventilation. Objectives: Evaluate characteristics, treatment effects, and outcomes for patients with AAV with and without DAH. Methods: PEXIVAS randomized 704 participants to plasma exchange (PLEX) or no-PLEX and reduced or standard-dose glucocorticoids (GC). DAH status was defined at enrollment as no-DAH, nonsevere, or severe (room air oxygen saturation of ⩽ 85% as measured by pulse oximetry, or use of mechanical ventilation). Measurements and Main Results: At enrollment, 191 (27.1%) participants had DAH (61 severe, including 29 ventilated) and were younger, more frequently relapsing, PR3 (proteinase 3)-ANCA positive, and had lower serum creatinine but were more frequently dialyzed than participants without DAH (n = 513; 72.9%). Among those with DAH, 8/95 (8.4%) receiving PLEX died within 1 year versus 15/96 (15.6%) with no-PLEX (hazard ratio, 0.52; confidence interval [CI], 0.21-1.24), whereas 13/96 (13.5%) receiving reduced GC died versus 10/95 (10.5%) with standard GC (hazard ratio, 1.33; CI, 0.57-3.13). When ventilated, ventilator-free days were similar with PLEX versus no-PLEX (medians, 25; interquartile range [IQR], 22-26 vs. 22-27) and fewer with reduced GC (median, 23; IQR, 20-25) versus standard GC (median, 26; IQR, 25-28). Treatment effects on mortality did not vary by presence or severity of DAH. Overall, 23/191 (12.0%) with DAH died within 1 year versus 34/513 (6.6%) without DAH. End-stage kidney disease and serious infections did not differ by DAH status or treatments. Conclusions: Patients with AAV and DAH differ from those without DAH in multiple ways. Further data are required to confirm or refute a benefit of PLEX or GC dosing on mortality. Original clinical trial registered with www.clinicaltrials.gov (NCT00987389).
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Affiliation(s)
- Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Luis Felipe Flores-Suárez
- La Clínica de Vasculitis Sistémicas Primarias, Instituto Nacional de Enfermedades Respiratorias, Tlalpan, Ciudad de México, Mexico
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, and
- Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Walsh
- Division of Nephrology, Department of Medicine
- Department of Health Research Methods, Evidence, and Impact, and
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Falde SD, Fussner LA, Tazelaar HD, O'Brien EK, Lamprecht P, Konig MF, Specks U. Proteinase 3-specific antineutrophil cytoplasmic antibody-associated vasculitis. Lancet Rheumatol 2024; 6:e314-e327. [PMID: 38574742 DOI: 10.1016/s2665-9913(24)00035-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/13/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024]
Abstract
Proteinase 3 (PR3)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is one of two major ANCA-associated vasculitis variants and is pathogenically linked to granulomatosis with polyangiitis (GPA). GPA is characterised by necrotising granulomatous inflammation that preferentially affects the respiratory tract. The small vessel vasculitis features of GPA are shared with microscopic polyangiitis. Necrotising granulomatous inflammation of GPA can lead to PR3-ANCA and small vessel vasculitis via activation of neutrophils and monocytes. B cells are central to the pathogenesis of PR3-ANCA-associated vasculitis. They are targeted successfully by remission induction and maintenance therapy with rituximab. Relapses of PR3-ANCA-associated vasculitis and toxicities associated with current standard therapy contribute substantially to remaining mortality and damage-associated morbidity. More effective and less toxic treatments are sought to address this unmet need. Advances with cellular and novel antigen-specific immunotherapies hold promise for application in autoimmune disease, including PR3-ANCA-associated vasculitis. This Series paper describes the inter-related histopathological and clinical features, pathophysiology, as well as current and future targeted treatments for PR3-ANCA-associated vasculitis.
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Affiliation(s)
- Samuel D Falde
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, Ohio State University, Columbus, OH, USA
| | - Henry D Tazelaar
- Department of Anatomic Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maximilian F Konig
- Division of Rheumatology, Department of Medicine & Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA.
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Cohen SP, Wodarcyk AJ, Wong A, Patterson KC, Lyons MI, Barnes A, Strickland A, Pan X, Almaani S, Meara AS, Crouser ED, Wewers MD, Fussner LA. Impact of concurrent glomerulonephritis on outcomes of diffuse alveolar haemorrhage in antineutrophil cytoplasmic antibody-associated vasculitis. Clin Exp Rheumatol 2024; 42:811-815. [PMID: 37976113 DOI: 10.55563/clinexprheumatol/s9su9e] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/11/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) commonly presents with diffuse alveolar haemorrhage (DAH) and/or glomerulonephritis. Patients who present with DAH but without kidney involvement have been understudied. METHODS Patients with DAH diagnosed by bronchoscopy and attributed to AAV over 8.5 years were retrospectively identified through electronic medical records and bronchoscopy reporting software. Patients with end-stage kidney disease (ESKD) or prior kidney transplant were excluded. Characteristics, treatments, and outcomes were abstracted. RESULTS 30 patients were identified with DAH secondary to AAV. Five with ESKD or prior kidney transplant, and one with concomitant anti-glomerular basement membrane disease, were excluded, leaving 24 patients for analysis. At the time of qualifying bronchoscopy, six patients had no apparent kidney involvement by AAV, while eight of 18 with kidney involvement required dialysis. Of the eight patients dialysed during the initial hospitalisation, four were declared to have ESKD and three died in the subsequent year (one of whom did both). None of the 16 patients without initial dialysis requirement developed kidney involvement requiring dialysis in the subsequent year, though three of the six without initial evidence of kidney involvement by AAV ultimately developed it. No patient without initial kidney involvement died during follow-up. CONCLUSIONS In our cohort, patients with DAH due to AAV without initial kidney involvement did not develop kidney involvement requiring dialysis or die during the follow-up period, though half of patients without initial evidence of kidney involvement subsequently developed it. Larger studies are warranted to better characterise this population and guide medical management.
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Affiliation(s)
- Sarah P Cohen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Andrew J Wodarcyk
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Alexander Wong
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kevin C Patterson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Matthew I Lyons
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Alexis Barnes
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Alan Strickland
- Bronchoscopy and Pulmonary Function Lab, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Xueliang Pan
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Salem Almaani
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Alexa S Meara
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mark D Wewers
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA.
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Mikacenic C, Fussner LA, Simpson AJ, Singer BD, Files DC. Reply: Research Bronchoscopy Standards and the Need for Noninvasive Sampling of the Failing Lungs. Ann Am Thorac Soc 2024; 21:184-185. [PMID: 37776284 PMCID: PMC10867905 DOI: 10.1513/annalsats.202309-811le] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 09/29/2023] [Indexed: 10/02/2023] Open
Affiliation(s)
| | | | - A. John Simpson
- Newcastle UniversityNewcastle upon Tyne, United Kingdom
- Newcastle upon Tyne Hospitals National Health Service Foundation TrustNewcastle upon Tyne, United Kingdom
| | | | - D. Clark Files
- Wake Forest School of MedicineWinston-Salem, North Carolina
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Almaani S, Song H, Suthanthira M, Toy C, Fussner LA, Meara A, Nagaraja H, Cuthbertson D, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Warrington KJ, Monach PA, Merkel PA, Rovin B, Birmingham D. Urine and Plasma Complement Ba Levels During Disease Flares in Patients With Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis. Kidney Int Rep 2023; 8:2421-2427. [PMID: 38025219 PMCID: PMC10658281 DOI: 10.1016/j.ekir.2023.08.017] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Although the alternative complement pathway has been implicated in the pathogenesis of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV), the specific nature of its involvement is unclear. This study measured levels of urine and plasma complement fragment Ba at multiple time points in a group of patients with AAV. Methods The complement fragment Ba was measured by enzyme-linked immunosorbent assay in serial urine and plasma samples from 21 patients with AAV who developed a renal flare, 19 who developed a nonrenal flare, and 20 in long-term remission. Urine Ba levels were corrected for urine creatinine concentration. Changes in Ba levels were modeled using mixed linear-effect models. A logistic regression model was fit to predict a renal flare using Ba levels at the time of flare versus the nonrenal flare and long-term remission groups. Results Data from 60 patients with AAV were used for this analysis; 53% were male, 93% were White, and 74% had antiproteinase3-ANCA. Urine Ba levels increased at renal flare (P < 0.001) but remained stable during a nonrenal flare or long-term remission. Plasma Ba levels were stable over time in all groups. Urine Ba levels predicted a renal flare with an area under the curve of 0.76 (P < 0.001), with a cutoff of 12.53 ng/mg urine creatinine yielding a sensitivity of 76.2% and a specificity of 68.4%. Conclusion Urine Ba levels, but not plasma Ba levels, are increased at the time of a renal flare in AAV, suggesting intrarenal complement activation and highlighting the potential use of this biomarker for surveillance of active renal vasculitis.
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Affiliation(s)
- Salem Almaani
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Huijuan Song
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Meshora Suthanthira
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher Toy
- Department of Soil and Crop Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Lynn A. Fussner
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexa Meara
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Haikady Nagaraja
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, Florida, USA
| | - Nader A. Khalidi
- Division of Rheumatology, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | | | | | - Carol A. McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Larry W. Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, Colorado, USA
| | - Christian Pagnoux
- Division of Rheumatology, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Ulrich Specks
- Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Antoine G. Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth J. Warrington
- Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul A. Monach
- Veteran’s Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Peter A. Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brad Rovin
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Birmingham
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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6
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Moura MC, Thompson GE, Nelson DR, Fussner LA, Hummel AM, Jenne DE, Emerling D, Fervenza FC, Kallenberg CGM, Langford CA, McCune WJ, Merkel PA, Monach PA, Seo P, Spiera RF, St. Clair EW, Ytterberg SR, Stone JH, Robinson WH, Specks U. Activation of a Latent Epitope Causing Differential Binding of Antineutrophil Cytoplasmic Antibodies to Proteinase 3. Arthritis Rheumatol 2023; 75:748-759. [PMID: 36515151 PMCID: PMC10191989 DOI: 10.1002/art.42418] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/17/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Proteinase 3 (PR3) is the major antigen for antineutrophil cytoplasmic antibodies (ANCAs) in the systemic autoimmune vasculitis, granulomatosis with polyangiitis (GPA). PR3-targeting ANCAs (PR3-ANCAs) recognize different epitopes on PR3. This study was undertaken to study the effect of mutations on PR3 antigenicity. METHODS The recombinant PR3 variants, iPR3 (clinically used to detect PR3-ANCAs) and iHm5 (containing 3 point mutations in epitopes 1 and 5 generated for epitope mapping studies) immunoassays and serum samples from patients enrolled in ANCA-associated vasculitis (AAV) trials were used to screen for differential PR3-ANCA binding. A patient-derived monoclonal ANCA 518 (moANCA518) that selectively binds to iHm5 within the mutation-free epitope 3 and is distant from the point mutations of iHm5 was used as a gauge for remote epitope activation. Selective binding was determined using inhibition experiments. RESULTS Rather than reduced binding of PR3-ANCAs to iHm5, we found substantially increased binding of the majority of PR3-ANCAs to iHm5 compared to iPR3. This differential binding of PR3-ANCA to iHm5 is similar to the selective moANCA518 binding to iHm5. Binding of iPR3 to monoclonal antibody MCPR3-2 also induced recognition by moANCA518. CONCLUSION The preferential binding of PR3-ANCAs from patients, such as the selective binding of moANCA518 to iHm5, is conferred by increased antigenicity of epitope 3 on iHm5. This can also be induced on iPR3 when captured by monoclonal antibody MCPR2. This previously unrecognized characteristic of PR3-ANCA interactions with its target antigen has implications for studying antibody-mediated autoimmune diseases, understanding variable performance characteristics of immunoassays, and design of potential novel treatment approaches.
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Affiliation(s)
- Marta Casal Moura
- Mayo Clinic and Foundation, Rochester, MN, USA
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | | | - Lynn A. Fussner
- Mayo Clinic and Foundation, Rochester, MN, USA
- Ohio State University, Columbus, OH, USA
| | | | - Dieter E. Jenne
- Max-Planck-Institute for Biological Intelligence, 82152 Martinsried, Germany
| | | | | | | | | | | | | | - Paul A. Monach
- VA Boston Healthcare System, Rheumatology, Boston, MA, USA
| | - Philip Seo
- Johns Hopkins University, Baltimore, MD, USA
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Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, Dickson RP, Almonor F, Luo F, Madan K, Morales-Nebreda L, Mould KJ, Simpson AJ, Singer BD, Stapleton RD, Wendt CH, Files DC. Research Bronchoscopies in Critically Ill Research Participants: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:621-631. [PMID: 37125997 PMCID: PMC10174130 DOI: 10.1513/annalsats.202302-106st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Bronchoscopy for research purposes is a valuable tool to understand lung-specific biology in human participants. Despite published reports and active research protocols using this procedure in critically ill patients, no recent document encapsulates the important safety considerations and downstream applications of this procedure in this setting. The objectives were to identify safe practices for patient selection and protection of hospital staff, provide recommendations for sample procurement to standardize studies, and give guidance on sample preparation for novel research technologies. Seventeen international experts in the management of critically ill patients, bronchoscopy in clinical and research settings, and experience in patient-oriented clinical or translational research convened for a workshop. Review of relevant literature, expert presentations, and discussion generated the findings presented herein. The committee concludes that research bronchoscopy with bronchoalveolar lavage in critically ill patients on mechanical ventilation is valuable and safe in appropriately selected patients. This report includes recommendations on standardization of this procedure and prioritizes the reporting of sample management to produce more reproducible results between laboratories. This document serves as a resource to the community of researchers who endeavor to include bronchoscopy as part of their research protocols and highlights key considerations for the inclusion and safety of research participants.
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8
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Matthews CEP, Fussner LA, Yaeger M, Aloor JJ, Reece SW, Kilburg-Basnyat BJ, Varikuti S, Luo B, Inks M, Sergin S, Schmidt CA, Neufer PD, Pennington ER, Fisher-Wellman KH, Chowdhury SM, Fessler MB, Fenton JI, Anderson EJ, Shaikh SR, Gowdy KM. The prohibitin complex regulates macrophage fatty acid composition, plasma membrane packing, and lipid raft-mediated inflammatory signaling. Prostaglandins Leukot Essent Fatty Acids 2023; 190:102540. [PMID: 36706677 PMCID: PMC9992117 DOI: 10.1016/j.plefa.2023.102540] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/28/2022] [Accepted: 01/15/2023] [Indexed: 01/20/2023]
Abstract
Prohibitins (PHB1 and PHB2) are ubiquitously expressed proteins which play critical roles in multiple biological processes, and together form the ring-like PHB complex found in phospholipid-rich cellular compartments including lipid rafts. Recent studies have implicated PHB1 as a mediator of fatty acid transport as well as a membrane scaffold mediating B lymphocyte and mast cell signal transduction. However, the specific role of PHBs in the macrophage have not been characterized, including their role in fatty acid uptake and lipid raft-mediated inflammatory signaling. We hypothesized that the PHB complex regulates macrophage inflammatory signaling through the formation of lipid rafts. To evaluate our hypothesis, RAW 264.7 macrophages were transduced with shRNA against PHB1, PHB2, or scrambled control (Scr), and then stimulated with lipopolysaccharide (LPS) or tumor necrosis factor-alpha (TNF-α), which activate lipid raft-dependent receptor signaling (CD14/TLR4 and TNFR1, respectively). PHB1 knockdown was lethal, whereas PHB2 knockdown (PHB2kd), which also resulted in decreased PHB1 expression, led to attenuated nuclear factor-kappa-B (NF-κB) activation and subsequent cytokine and chemokine production. PHB2kd macrophages also had decreased cell surface TNFR1, CD14, TLR4, and lipid raft marker ganglioside GM1 at baseline and post-stimuli. Post-LPS, PHB2kd macrophages did not increase the concentration of cellular saturated, monounsaturated, and polyunsaturated fatty acids. This was accompanied by decreased lipid raft formation and modified plasma membrane molecular packing, further supporting the PHB complex's importance in lipid raft formation. Taken together, these data suggest a critical role for PHBs in regulating macrophage inflammatory signaling via maintenance of fatty acid composition and lipid raft structure. SUMMARY: Prohibitins are proteins found in phospholipid-rich cellular compartments, including lipid rafts, that play important roles in signaling, transcription, and multiple other cell functions. Macrophages are key cells in the innate immune response and the presence of membrane lipid rafts is integral to signal transduction, but the role of prohibitins in macrophage lipid rafts and associated signaling is unknown. To address this question, prohibitin knockdown macrophages were generated and responses to lipopolysaccharide and tumor necrosis factor-alpha, which act through lipid raft-dependent receptors, were analyzed. Prohibitin knockdown macrophages had significantly decreased cytokine and chemokine production, transcription factor activation, receptor expression, lipid raft assembly and membrane packing, and altered fatty acid remodeling. These data indicate a novel role for prohibitins in macrophage inflammatory signaling through regulation of fatty acid composition and lipid raft formation.
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Affiliation(s)
- Christine E Psaltis Matthews
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Michael Yaeger
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Jim J Aloor
- Diabetes and Obesity Institute, Department of Physiology, East Carolina University, Greenville, NC, United States
| | - Sky W Reece
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Brita J Kilburg-Basnyat
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Sanjay Varikuti
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Bin Luo
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Morgan Inks
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Selin Sergin
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
| | - Cameron A Schmidt
- Diabetes and Obesity Institute, Department of Physiology, East Carolina University, Greenville, NC, United States
| | - P Darrell Neufer
- Diabetes and Obesity Institute, Department of Physiology, East Carolina University, Greenville, NC, United States
| | - Edward Ross Pennington
- Department of Nutrition, Gillings School of Global Public Health and School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Kelsey H Fisher-Wellman
- Diabetes and Obesity Institute, Department of Physiology, East Carolina University, Greenville, NC, United States
| | - Saiful M Chowdhury
- Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, TX, United States
| | - Michael B Fessler
- Immunity, Inflammation and Disease Laboratory, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, NC, United States
| | - Jenifer I Fenton
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
| | - Ethan J Anderson
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, FOE Diabetes Research Center, University of Iowa, Iowa City, IA, United States
| | - Saame Raza Shaikh
- Department of Nutrition, Gillings School of Global Public Health and School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Kymberly M Gowdy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States.
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Collister D, Farrar M, Farrar L, Brown P, Booth M, Firth T, Mahr A, Zeng L, Little MA, Mustafa RA, Fussner LA, Meara A, Guyatt G, Jayne D, Merkel PA, Walsh M. Plasma Exchange for ANCA-Associated Vasculitis: An International Survey of Patient Preferences. Kidney Med 2022; 5:100595. [PMID: 36686273 PMCID: PMC9851885 DOI: 10.1016/j.xkme.2022.100595] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Rationale & Objective We sought to elicit patient preferences regarding the use of plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and its tradeoffs of risk of kidney failure and risk of serious infection. Study Design Patient survey. Setting & Participants The online survey was circulated to adults with AAV via kidney and vasculitis networks in Canada, the United Kingdom, and the United States. Outcomes Respondents reviewed the estimated 1-year risks of kidney failure and serious infection in AAV with and without plasma exchange across 5 serum creatinine categories (150, 250, 350, 450, and 600 μmol/L). For each scenario, participants indicated whether or not they would choose plasma exchange. Analytical Approach Responses were assessed with multilevel multivariable logistic regression models to identify predictors of respondent choice regarding treatment with plasma exchange. Results The 470 respondents from the 13 countries (United States 61.7%, United Kingdom 20.0%, Canada 13.8%, and other countries 4.5%) had a mean age of 58.6 (SD 14.3) years, 70.2% women. Respondents were more likely to choose plasma exchange in scenarios at high risk of kidney failure and serious infection (creatinine level of 350 or 450 μmol/L) compared with lower risk scenarios or the highest risk scenario. However, 145 (30.9%) chose plasma exchange across all scenarios, whereas 80 (17.0%) declined plasma exchange across all scenarios. Respondents from the United Kingdom (OR, 2.61; 95% CI, 1.09-6.22) who received previous dialysis (OR, 2.70; 95% CI, 1.12-6.52) or received previous plasma exchange (OR, 5.62; 95% CI, 2.72-11.61) were more likely to choose plasma exchange, whereas older respondents (OR, 0.98; 95% CI, 0.96-0.99 per 1 year increase) were less likely. Limitations Unclear generalizability to non-English-speaking, older, and less health literate adults, possible responder bias, survivor bias, lack of individualized risk assessments for kidney failure, and serious infection. Conclusions Patients with AAV do not express a consistent choice for plasma exchange, which highlights the need for shared decision making.
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Affiliation(s)
- David Collister
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada,Population Health Research Institute, Hamilton, Ontario, Canada,Address for Correspondence: David Collister, MD, PhD, University of Alberta, 11-113H Clinical Sciences Bldg, 11350 83 Ave Edmonton, AB, Canada, T6G2P4.
| | | | | | - Paul Brown
- Vasculitis Patient-Powered Research Network, Kansas City, MO
| | - Michelle Booth
- Vasculitis Patient-Powered Research Network, Kansas City, MO
| | | | - Alfred Mahr
- Clinic for Rheumatology, Kantonnspital St Gallen, St Gallen, Switzerland
| | - Linan Zeng
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mark A. Little
- Trinity Health Kidney Centre, Tallaght University Hospital, Dublin, Ireland
| | - Reem A. Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Health System, Kansas City, KS
| | - Lynn A. Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Alexa Meara
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David Jayne
- Department of Medicine, University of Cambridge, United Kingdom
| | - Peter A. Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA,Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Michael Walsh
- Population Health Research Institute, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada,Department of Medicine, Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
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10
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Zeng L, Walsh M, Guyatt GH, Siemieniuk RAC, Collister D, Booth M, Brown P, Farrar L, Farrar M, Firth T, Fussner LA, Kilian K, Little MA, Mavrakanas TA, Mustafa RA, Piram M, Stamp LK, Xiao Y, Lytvyn L, Agoritsas T, Vandvik PO, Mahr A. Plasma exchange and glucocorticoid dosing for patients with ANCA-associated vasculitis: a clinical practice guideline. BMJ 2022; 376:e064597. [PMID: 35217581 DOI: 10.1136/bmj-2021-064597] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CLINICAL QUESTIONS What is the role of plasma exchange and what is the optimal dose of glucocorticoids in the first 6 months of therapy of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV)? This guideline was triggered by the publication of a new randomised controlled trial. CURRENT PRACTICE Existing guideline recommendations vary regarding the use of plasma exchange in AAV and lack explicit recommendations regarding the tapering regimen of glucocorticoids during induction therapy. RECOMMENDATIONS The guideline panel makes a weak recommendation against plasma exchange in patients with low or low-moderate risk of developing end stage kidney disease (ESKD), and a weak recommendation in favour of plasma exchange in patients with moderate-high or high risk of developing ESKD. For patients with pulmonary haemorrhage without renal involvement, the panel suggests not using plasma exchange (weak recommendation). The panel made a strong recommendation in favour of a reduced dose rather than standard dose regimen of glucocorticoids, which involves a more rapid taper rate and lower cumulative dose during the first six months of therapy. HOW THIS GUIDELINE WAS CREATED A guideline panel including patients, a care giver, clinicians, content experts, and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. The recommendations are based on two linked systematic reviews. The panel took an individual patient perspective in the development of recommendations. THE EVIDENCE The systematic review of plasma exchange identified nine randomised controlled trials (RCTs) that enrolled 1060 patients with AAV. Plasma exchange probably has little or no effect on mortality or disease relapse (moderate and low certainty). Plasma exchange probably reduces the one year risk of ESKD (approximately 0.1% reduction in those with low risk, 2.1% reduction in those with low-moderate risk, 4.6% reduction in those with moderate-high risk, and 16.0% reduction in those with high risk or requiring dialysis) but increases the risk of serious infections (approximately 2.7% increase in those with low risk, 4.9% increase in those with low-moderate risk, 8.5% increase in those with moderate-high risk, to 13.5% in high risk group) at 1 year (moderate to high certainty). The guideline panel agreed that most patients with low or low-moderate risk of developing ESKD would consider the harms to outweigh the benefits, while most of those with moderate-high or high risk would consider the benefits to outweigh the harms. For patients with pulmonary haemorrhage without kidney involvement, based on indirect evidence, plasma exchange may have little or no effect on death (very low certainty) but may have an important increase in serious infections at 1 year (approximately 6.8% increase, low certainty). The systematic review of different dose regimens of glucocorticoids identified two RCTs at low risk of bias with 704 and 140 patients respectively. A reduced dose regimen of glucocorticoid probably reduces the risk of serious infections by approximately 5.9% to 12.8% and probably does not increase the risk of ESKD at the follow-up of 6 months to longer than 1 year (moderate certainty for both outcomes). UNDERSTANDING THE RECOMMENDATION The recommendations were made with the understanding that patients would place a high value on reduction in ESKD and less value on avoiding serious infections. The panel concluded that most (50-90%) of fully informed patients with AAV and with low or low-moderate risk of developing ESKD with or without pulmonary haemorrhage would decline plasma exchange, whereas most patients with moderate-high or high risk or requiring dialysis with or without pulmonary haemorrhage would choose to receive plasma exchange. The panel also inferred that the majority of fully informed patients with pulmonary haemorrhage without kidney involvement would decline plasma exchange and that all or almost all (≥90%) fully informed patients with AAV would choose a reduced dose regimen of glucocorticoids during the first 6 months of therapy.
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Affiliation(s)
- Linan Zeng
- Pharmacy department/Evidence-based pharmacy centre, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michael Walsh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David Collister
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | | | | | | | | | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Karin Kilian
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mark A Little
- Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
- Irish Centre for Vascular Biology, Tallaght University Hospital, Dublin, Ireland
| | - Thomas A Mavrakanas
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas, USA
| | - Maryam Piram
- CHU Sainte Justine Research Center, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
- CEREMAIA, Centre d'épidémiologie et de santé des populations (CESP), University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Lisa K Stamp
- University of Otago Christchurch, Christchurch, New Zealand
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- West China School of Nursing/Department of Nursing, West China Hospital, Sichuan University, China
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Hospital Trust, Oslo, Norway
| | - Alfred Mahr
- Rheumatology Clinic, Department of Internal Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
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11
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Specks U, Fussner LA, Cartin-Ceba R, Casal Moura M, Zand L, Fervenza FC. Plasma exchange for the management of ANCA-associated vasculitis: the con position. Nephrol Dial Transplant 2021; 36:231-236. [PMID: 33374017 DOI: 10.1093/ndt/gfaa312] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023] Open
Abstract
Advances in the diagnosis and treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis have led to continued improvement in survival and prognosis over the course of the last 4 decades. Nevertheless, the most acute and severe disease manifestations, including severe kidney disease and alveolar hemorrhage, continue to be associated with increased early mortality from disease activity or treatment complications as well as risk for the development of end-stage kidney disease (ESKD), which in turn directly affects the overall prognosis of ANCA-associated vasculitis. Plasma exchange (PLEX) has long been proposed and used for these most severe disease manifestations under the assumption that its effects are swift and supported by our understanding of the pathogenic role of ANCA. Yet convincing evidence of a beneficial effect of PLEX in ANCA-associated vasculitis has been lacking, as early studies and small trials have generated conflicting results. The controversy regarding PLEX has been accentuated recently as the largest randomized controlled trial ever conducted in ANCA-associated vasculitis, the Plasma Exchange and Glucocorticoids in Severe ANCA-associated Vasculitis trial, which was specifically designed to evaluate the efficacy of PLEX in patients with severe renal disease or alveolar hemorrhage, failed to show a difference in the combined primary outcome measure of death or ESKD in patients who received PLEX versus those who did not. In light of these disappointing results, we herein review the currently available data on PLEX for ANCA-associated vasculitis and explain why we believe that these data no longer support the use of PLEX in ANCA-associated vasculitis.
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Affiliation(s)
- Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary and Critical Care Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Department of Critical Care, Mayo Clinic, Scottsdale, AZ, USA
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ladan Zand
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, USA
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12
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Almaani S, Fussner LA, Brodsky S, Meara AS, Jayne D. ANCA-Associated Vasculitis: An Update. J Clin Med 2021; 10:jcm10071446. [PMID: 33916214 PMCID: PMC8037363 DOI: 10.3390/jcm10071446] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/28/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) represents a group of small vessel vasculitides characterized by granulomatous and neutrophilic tissue inflammation, often associated with the production of antibodies that target neutrophil antigens. The two major antigens targeted by ANCAs are leukocyte proteinase 3 (PR3) and myeloperoxidase (MPO). AAV can be classified into 3 categories based on patterns of clinical involvement: namely, granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic GPA (EGPA). Clinically, AAV involves many organ systems including the lungs, kidneys, skin, and nervous system. The prognosis of AAV has improved dramatically due to advances in the understanding of its pathogenesis and treatment modalities. This review will highlight some of the recent updates in our understanding of the pathogenesis, clinical manifestations, and treatment options in patients with AAV focusing on kidney involvement.
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Affiliation(s)
- Salem Almaani
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA
- Correspondence:
| | - Lynn A. Fussner
- Division of Pulmonary and Critical Care Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA;
| | - Sergey Brodsky
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA;
| | - Alexa S. Meara
- Division of Rheumatology, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA;
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridg CB2 0QQ, UK;
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13
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Thompson GE, Fussner LA, Hummel AM, Schroeder DR, Silva F, Snyder MR, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Specks U. Clinical Utility of Serial Measurements of Antineutrophil Cytoplasmic Antibodies Targeting Proteinase 3 in ANCA-Associated Vasculitis. Front Immunol 2020; 11:2053. [PMID: 33013868 PMCID: PMC7495134 DOI: 10.3389/fimmu.2020.02053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/01/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The utility of ANCA testing as an indicator of disease activity in ANCA-associated vasculitis (AAV) remains controversial. This study aimed to determine the association of ANCA testing by various methods and subsequent remission and examine the utility of a widely used automated addressable laser-bead immunoassay (ALBIA) to predict disease relapses. Methods: Data from the Rituximab vs. Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial were used. ANCA testing was performed by direct ELISA, capture ELISA, and ALBIA. Cox proportional hazards regression models were used to evaluate the association of PR3-ANCA level and subsequent remission or relapse. The ALBIA results are routinely reported as >8 when the value is high. For this study, samples were further titrated. A decrease and increase in PR3-ANCA were defined as a halving or doubling in value, respectively. Results: A decrease in ANCA by ALBIA at 2 months was associated with shorter time to sustained remission (HR 4.52, p = 0.035). A decrease in ANCA by direct ELISA at 4 months was associated with decreased time to sustained remission (HR 1.77, p = 0.050). There were no other associations between ANCA decreases or negativity and time to remission. An increase in PR3-ANCA by ALBIA was found in 78 of 93 subjects (84%). Eleven (14%) had a PR3-ANCA value which required titration for detection of an increase. An increase of ANCA by ALBIA was associated with severe relapse across various subgroups. Conclusions: A decrease in ANCA by ALBIA at 2 months and by direct ELISA at 4 months may be predictive of subsequent remission. These results should be confirmed in a separate cohort with similarly protocolized sample and clinical data collection. A routinely used automated ALBIA for PR3-ANCA measurement is comparable to direct ELISA in predicting relapse in PR3-AAV. Without titration, 14% of the increases detected by ALBIA would have been missed. Titration is recommended when this assay is used for disease monitoring. The association of an increase in PR3-ANCA with the risk of subsequent relapse remains complex and is affected by disease phenotype and remission induction agent.
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Affiliation(s)
- Gwen E Thompson
- Essentia Health, Division of Pulmonary and Critical Care, Fargo, ND, United States.,Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Amber M Hummel
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Darrell R Schroeder
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Francisco Silva
- Department of Rheumatology, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Melissa R Snyder
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Carol A Langford
- Cleveland Clinic, Division of Rheumatology, Cleveland, OH, United States
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, United States
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| | - Robert F Spiera
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, United States
| | | | - John H Stone
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, United States
| | - Ulrich Specks
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
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14
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Holsen MR, Wardlow LC, Bazan JA, Fussner LA, Coe KE, Elefritz JL. Clinical outcomes following treatment of Enterobacter species pneumonia with piperacillin/tazobactam compared to cefepime or ertapenem. Int J Antimicrob Agents 2019; 54:824-828. [PMID: 31319191 DOI: 10.1016/j.ijantimicag.2019.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 10/09/2018] [Revised: 07/07/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Enterobacter spp. are a common cause of nosocomial pneumonia and treatment can be complicated by AmpC resistance. Carbapenems are the treatment of choice; however, alternatives are needed. Cefepime has been shown to be non-inferior to carbapenems. There are limited data to support the use of piperacillin/tazobactam. The objective of this study was to determine if piperacillin/tazobactam is non-inferior to cefepime or ertapenem for Enterobacter pneumonia treatment. OBJECTIVES To compare the rate of clinical cure in patients with Enterobacter pneumonia receiving definitive treatment with piperacillin/tazobactam, cefepime, or ertapenem. Secondary outcomes included hospital mortality, infection-related length of stay, duration of mechanical ventilation, recurrent pneumonia, and resistance. METHODS Retrospective, single-center study. RESULTS Of 114 patients included, 59 received definitive treatment with piperacillin/tazobactam and 55 received cefepime or ertapenem. There was no difference in the proportion of patients who achieved clinical cure in the piperacillin/tazobactam group compared to the cefepime or ertapenem group (76.3% vs. 87.3%, P = 0.13). Treatment group was not associated with clinical cure when controlling for confounders in multivariable logistic regression (adjusted odds ratio [OR] 0.59, 95% confidence interval [CI] 0.15-2.37). The rate of recurrent pneumonia was 11.4% in the piperacillin/tazobactam group and 6.7% in the cefepime or ertapenem group (P = 0.48). Other secondary outcomes did not differ between the groups. CONCLUSIONS In this retrospective study of patients with Enterobacter pneumonia, clinical cure with piperacillin/tazobactam was comparable to that with cefepime or ertapenem; however, a prospective trial with a larger population is needed to determine if definitive treatment with piperacillin/tazobactam is non-inferior to definitive treatment with cefepime or ertapenem.
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Affiliation(s)
- Maya R Holsen
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 West 10(th) Avenue, Columbus, Ohio 43210, United States of America
| | - Lynn C Wardlow
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 West 10(th) Avenue, Columbus, Ohio 43210, United States of America
| | - Jose A Bazan
- Division of Infectious Diseases, The Ohio State University College of Medicine, 370 West 9(th) Avenue, Columbus, OH 43210, United States of America
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, 370 West 9(th) Avenue, Columbus, OH 43210, United States of America
| | - Kelci E Coe
- Division of Infectious Diseases, The Ohio State University College of Medicine, 370 West 9(th) Avenue, Columbus, OH 43210, United States of America
| | - Jessica L Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 West 10(th) Avenue, Columbus, Ohio 43210, United States of America.
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15
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Fussner LA, Karlstedt E, Hodge DO, Fine NM, Kalra S, Carmona EM, Utz JP, Isaac DL, Cooper LT. Management and outcomes of cardiac sarcoidosis: a 20-year experience in two tertiary care centres. Eur J Heart Fail 2018; 20:1713-1720. [PMID: 30378224 DOI: 10.1002/ejhf.1319] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/21/2018] [Accepted: 08/27/2018] [Indexed: 11/09/2022] Open
Abstract
AIMS Cardiac sarcoidosis (CS) often presents with ventricular arrhythmias, heart block, and cardiomyopathy. The prognosis of CS with contemporary management is uncertain. We estimated the impact of baseline and treatment variables on left ventricular ejection fraction (LVEF), ventricular assist device placement, heart transplant, and death. METHODS AND RESULTS We identified patients with CS seen from 1994-2014 at two large academic medical centres. All met the 2014 Heart Rhythm Society expert consensus criteria for diagnosis. From the 574 patients identified, 91 met inclusion criteria. Twenty-two (24.2%) were diagnosed by endomyocardial biopsy. Cardiomyopathy was the primary presentation in 47 patients (51.6%). Within 90 days of diagnosis, 41 patients (45.0%) received prednisone alone, 29 (31.9%) received alternative immunosuppression with or without prednisone, and 21 (23.1%) received no immunosuppression. During follow-up, 31 of 47 cardiomyopathy patients experienced improvement in LVEF, while 23 experienced decline in LVEF or clinical exacerbation, and 15 of 22 patients presenting with ventricular arrhythmia had recurrence. These results did not differ by treatment group. During a median follow-up of 44 months for our cohort, 14 patients reached the composite endpoint of ventricular assist device placement, heart transplant, or death. Survival without the composite outcome did not differ by treatment group, but was worse among patients presenting with cardiomyopathy (log-rank = 0.005). CONCLUSION In a large series of CS subjects, rates of ventricular arrhythmia and heart failure events remain high with no treatment regimen clearly associated with better outcome. Patients with cardiomyopathy at diagnosis were more likely to reach the composite endpoint.
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Affiliation(s)
- Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erin Karlstedt
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Nowell M Fine
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay Kalra
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eva M Carmona
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - James P Utz
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Debra L Isaac
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Leslie T Cooper
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
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16
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Fussner LA, Hummel AM, Schroeder DR, Silva F, Cartin-Ceba R, Snyder MR, Hoffman GS, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, William St Clair E, Tchao NK, Stone JH, Specks U. Factors Determining the Clinical Utility of Serial Measurements of Antineutrophil Cytoplasmic Antibodies Targeting Proteinase 3. Arthritis Rheumatol 2017; 68:1700-10. [PMID: 26882078 DOI: 10.1002/art.39637] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Relapse following remission is common in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), particularly with ANCAs directed at proteinase 3 (PR3). This study was undertaken to evaluate the association of an increase in PR3-ANCA level with subsequent relapse. METHODS Data from the Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial were used. Starting from the time of achieving complete remission, serial measurements by direct and capture enzyme-linked immunosorbent assays (ELISAs) were analyzed in 93 patients with PR3-ANCA, using Cox proportional hazards regression. RESULTS An increase in PR3-ANCA level was identified in 58 of 93 subjects (62.4%) by direct ELISA and in 59 of 93 (63.4%) by capture ELISA. Relapses occurred in 55 of 93 subjects (59.1%), with 25 and 21 occurring within 1 year after an increase by direct ELISA and capture ELISA, respectively. An increase by direct ELISA was associated with subsequent severe relapses (hazard ratio [HR] 4.57; P < 0.001), particularly in patients presenting with renal involvement (HR 7.94; P < 0.001) and alveolar hemorrhage (HR 24.19; P < 0.001). Both assays identified increased risk for severe relapse in the rituximab group (HR 5.80; P = 0.002 for direct ELISA and HR 4.54; P = 0.007 for capture ELISA) but not the cyclophosphamide/azathioprine group (P = 0.103 and P = 0.197, respectively). CONCLUSION The association of an increase in PR3-ANCA level with the risk of subsequent relapse is partially affected by the PR3-ANCA detection methodology, disease phenotype, and remission induction treatment. An increase in PR3-ANCA level during complete remission conveys an increased risk of relapse, particularly severe relapse, among patients with renal involvement or alveolar hemorrhage and those treated with rituximab. Serial measurements of PR3-ANCA may be informative in this subset of patients, but the risk of relapse must be weighed carefully against the risks associated with therapy.
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Affiliation(s)
- Lynn A Fussner
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | - Amber M Hummel
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | - Darrell R Schroeder
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | | | - Rodrigo Cartin-Ceba
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | - Melissa R Snyder
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | | | | | | | | | - Paul A Monach
- Boston University, Boston University Medical Center, and VA Boston Healthcare System, Boston, Massachusetts
| | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ulrich Specks
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
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Affiliation(s)
- Michael H Bourne
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Lynn A Fussner
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Eva M Carmona
- Advisor to Residents and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Fussner LA, Iyer VN, Cartin-Ceba R, Lin G, Watt KD, Krowka MJ. Intrapulmonary vascular dilatations are common in portopulmonary hypertension and may be associated with decreased survival. Liver Transpl 2015; 21:1355-64. [PMID: 26077312 DOI: 10.1002/lt.24198] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/01/2015] [Accepted: 06/11/2015] [Indexed: 12/17/2022]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are pulmonary vascular complications of portal hypertension with divergent clinicopathologic features and management. The presence of intrapulmonary vascular dilatations (IPVDs), detected by agitated saline contrast-enhanced transthoracic echocardiography (cTTE), is an essential feature of HPS but is not typically characteristic of POPH. Although IPVDs have been reported rarely in POPH, the prevalence and significance of this finding have not been systematically studied. We conducted a retrospective chart review of 80 consecutive patients diagnosed with POPH from January 1, 2002 to June 30, 2014 with documentation of cTTE findings, pulmonary hemodynamics, oxygenation, and survival. A total of 34 of the 80 patients (42%) underwent cTTE during initial diagnosis of POPH. IPVDs were detected in 20/34 patients (59%); intracardiac shunting was detected in 9/34 patients (26%; 4 also had IPVDs); and 9 patients (26%) had negative cTTE with no evidence of IPVD or intracardiac shunting. Patients with IPVD had decreased survival as compared to those without IPVD (P = 0.003), a trend that persisted after exclusion of liver transplant recipients (P = 0.07). The IPVD group had a trend toward higher Model for End-Stage Liver Disease score with and without incorporating sodium (MELD or MELD-Na; P = 0.05 for both). The right ventricular index of myocardial performance (RIMP) was lower in the IPVD group (median, 0.4 versus 0.6; P = 0.006). Patients with moderate or large IPVDs (n = 6) had worse oxygenation parameters (partial pressure of arterial oxygen, diffusing capacity of the lung for carbon monoxide, and alveolar-arterial oxygen gradient) as compared to the rest of the cohort. Unexpectedly, IPVDs were frequently documented in POPH and associated with decreased survival. To further understand this observation, we recommend screening for IVPD in all patients with POPH.
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Affiliation(s)
| | - Vivek N Iyer
- Divisions of Pulmonary and Critical Care Medicine
| | | | - Grace Lin
- Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Kymberly D Watt
- Divisions of Gastroenterology and Hepatology, Mayo Clinic Transplant Center, Rochester, Minnesota
| | - Michael J Krowka
- Divisions of Pulmonary and Critical Care Medicine.,Divisions of Gastroenterology and Hepatology, Mayo Clinic Transplant Center, Rochester, Minnesota
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Fussner LA, Heimbach JK, Fan C, Dierkhising R, Coss E, Leise MD, Watt KD. Cardiovascular disease after liver transplantation: When, What, and Who Is at Risk. Liver Transpl 2015; 21:889-96. [PMID: 25880971 DOI: 10.1002/lt.24137] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/09/2015] [Accepted: 03/22/2015] [Indexed: 12/11/2022]
Abstract
The evolution of metabolic and cardiovascular disease (CVD) complications after liver transplantation (LT) is poorly characterized. We aim to illustrate the prevalence of obesity and metabolic syndrome (MS), define the cumulative incidence of CVD, and characterize risk factors associated with these comorbidities after LT. A retrospective review of 455 consecutive LT recipients from 1999 to 2004 with an 8- to 12-year follow-up was performed. Obesity increased from 23.8% (4 months) to 40.8% (3 years) after LT. Increase in body mass index predicted MS at 1 year after LT (odds ratio, 1.1; P < 0.001, per point). CVD developed in 10.6%, 20.7%, and 30.3% of recipients within 1, 5, and 8 years, respectively. Age, diabetes, hypertension, glomerular filtration rate < 60 mL/minute, prior CVD, ejection fraction < 60%, left ventricular hypertrophy, and serum troponin (TN) > 0.07 ng/mL were associated with CVD on univariate analysis. Age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01-1.06; P = 0.019), diabetes (HR, 1.78; 95% CI, 1.09-2.92; P = 0.022), prior history of CVD (HR, 2.46; 95% CI, 1.45-4.16; P < 0.001), and serum TN > 0.07 ng/mL (HR, 1.98; 95% CI, 1.23-3.18; P = 0.005) were independently associated with CVD in the long term. Smoking history (ever), sex, hyperlipidemia, and serum ferritin levels were not predictive of CVD. Tacrolimus use versus noncalcineurin-based immunosuppression (HR, 0.26; 95% CI, 0.14-0.49; P < 0.001) was associated with reduced risk of CVD but not versus cyclosporine (HR, 0.67; 95% CI, 0.30-1.49; P = 0.322). CVD is common after LT. Independent of MS, more data are needed to identify nonconventional risk factors and biomarkers like serum TN. Curbing weight gain in the early months after transplant may impact MS and subsequent CVD in the long term.
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Affiliation(s)
- Lynn A Fussner
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN
| | | | - Chun Fan
- Division of Biomedical Statistics and Informatics, Transplant Center, Mayo Clinic, Rochester, MN
| | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Transplant Center, Mayo Clinic, Rochester, MN
| | - Elizabeth Coss
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN
| | - Michael D Leise
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN.,Gastroenterology and Hepatology, Transplant Center, Mayo Clinic, Rochester, MN
| | - Kymberly D Watt
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN.,Gastroenterology and Hepatology, Transplant Center, Mayo Clinic, Rochester, MN
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Fussner LA, Charlton MR, Heimbach JK, Fan C, Dierkhising R, Coss E, Watt KD. The impact of gender and NASH on chronic kidney disease before and after liver transplantation. Liver Int 2014; 34:1259-66. [PMID: 24262002 DOI: 10.1111/liv.12381] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Chronic kidney disease (CKD) after liver transplant (LT) is associated with increased long-term mortality. The impact of gender on CKD before and after LT is unknown. To further define risk factors and analyse gender differences in the incidence and progression of CKD after liver transplant. METHODS Four hundred and fifty-five consecutive adult primary solitary LT recipients were included. Iothalamate clearance tests performed over time were analysed. RESULTS Mean age was 51.4 ± 10.4 years with 63% males. A percentage of 29.1% of females and 21.1% of males had a GFR<60 ml/min/1.73 m(2) and 10.2% of females and 5.9% of males had GFR<30 ml/min/1.73 m(2) prior to transplant. At 1 year, 52.6% of recipients tested (69.6% females, 43.0% males) had GFR<60 ml/min/1.73 m(2) and 7.3% (11.6% females, 4.9% males) had GFR<30 ml/min/1.73 m(2) . Pre-LT GFR<60 ml/min/1.73 m(2) [OR 3.28, (1.76-6.10), P ≤ 0.001], female gender (OR 2.96, (1.72-5.10), P < 0.001) and age [OR 1.09, (1.05-1.12), P < 0.001] were independently predictive of stage ≥3 CKD at 1 year post-LT. Female gender [OR 2.52, (1.25-4.71), P = 0.004], age [OR 1.05, (1.02-1.08), P = 0.003] and NASH [OR 2.95, (1.06-8.21), P = 0.039] were independently predictive of ≥stage 3 CKD at 5 years post-LT. Pre-LT diabetes was associated with stage 4 CKD at 5 years [OR 2.91, (1.33-6.36), P = 0.008] post-LT. CONCLUSIONS In addition to age and pre-LT CKD, female gender and NASH are independent predictors of ≥stage 3 CKD post-LT. Gender-based approaches to optimize modifiable risk factors are needed to improved post-transplant renal function.
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Affiliation(s)
- Lynn A Fussner
- Department of Internal Medicine, Mayo Clinic Transplant Center, Rochester, MN, USA
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Fussner LA, Midthun DE. Characteristics and management strategies for the incidental pulmonary nodule. Lung Cancer Manag 2014. [DOI: 10.2217/lmt.14.9] [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: 11/21/2022] Open
Abstract
SUMMARY: Pulmonary nodules are frequent, unanticipated findings on imaging studies obtained for other purposes across all areas of medical practice. As nodule detection raises concern for malignancy, evaluation and follow-up of an incidental nodule is imperative. Clinicians are charged with counseling patients and directing further evaluation amid uncertainty and anxiety. The goals of follow-up and management are to identify malignant lesions at an early stage, while avoiding unnecessary procedures and potential harm to patients with benign nodules. In this review, we aim to outline the clinical and radiographic characteristics that can aid in likelihood stratification, to identify gaps in our current knowledge, and to present a logical approach to nodule management, based on the available evidence.
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Affiliation(s)
- Lynn A Fussner
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - David E Midthun
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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22
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Affiliation(s)
- Lynn A Fussner
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN 55905, USA
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