1
|
Sciascia S, Foddai SG, Arbrile M, Radin M, Cecchi I, Barinotti A, Fenoglio R, Roccatello D. Assessing the steroid-sparing effect of biological agents in randomized controlled trials for lupus: a scoping review. Immunol Res 2024:10.1007/s12026-024-09463-y. [PMID: 38459403 DOI: 10.1007/s12026-024-09463-y] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/04/2024] [Indexed: 03/10/2024]
Abstract
Prompt disease control of flares in patients with systemic lupus erythematosus (SLE) is a priority in treatment strategy planning. However, the long-term dosage-related collateral effects of glucocorticoids (GCs) have pushed researchers towards the identification and utilization of novel biological agents that could both induce and maintain low disease activity and remission, especially in the context of lupus nephritis (LN). This scoping review aims at assessing the current evidence of the potential steroid-sparing effect of biologic therapies by reviewing phase II and phase III randomized, placebo-controlled trials involving SLE/LN patients. A scoping review of the literature was carried out in accordance with PRISMA-ScR recommendations. Risk of bias was assessed through the utilization of the Cochrane Collaboration's tool for randomized controlled trials (RCTs). Eight RCTs met the inclusion criteria and were included in this analysis (treatment drug, 7 belimumab; 1 anifrolumab). Four studies showed a definite steroid-sparing effect (treatment drug, 3 belimumab; 1 anifrolumab), while in the remaining four RCTs, the steroid-sparing effect was not observed. When focusing on phase III trials, the overall quality of the studies resulted fair or good considering the risk of bias. However, a degree of heterogeneity of steroid regimen protocol (considering initial dosage, tapering and rescue treatment allowance) was observed. While a growing body of evidence is supporting the safety and efficacy of biological treatment in SLE, the evidence on their steroid-sparing effect remains scattered. Future research needs to pursue the identification of precise SLE clusters of patients who would benefit most from a specific treatment protocol with a definite steroid-sparing effect.
Collapse
Affiliation(s)
- Savino Sciascia
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| | - Silvia Grazietta Foddai
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy.
| | - Marta Arbrile
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| | - Massimo Radin
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| | - Alice Barinotti
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence On Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10124, Turin, Italy
| |
Collapse
|
2
|
Saglia C, Bracciamà V, Trotta L, Mioli F, Faini AC, Brach Del Prever GM, Kalantari S, Luca M, Romeo CM, Scolari C, Peruzzi L, Calvo PL, Mussa A, Fenoglio R, Roccatello D, Alberti C, Carli D, Amoroso A, Deaglio S, Vaisitti T. Relevance of next generation sequencing (NGS) data re-analysis in the diagnosis of monogenic diseases leading to organ failure. BMC Med Genomics 2023; 16:303. [PMID: 38012624 PMCID: PMC10680258 DOI: 10.1186/s12920-023-01747-w] [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: 09/20/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND In 2018, our center started a program to offer genetic diagnosis to patients with kidney and liver monogenic rare conditions, potentially eligible for organ transplantation. We exploited a clinical exome sequencing approach, followed by analyses of in silico gene panels tailored to clinical suspicions, obtaining detection rates in line with what reported in literature. However, a percentage of patients remains without a definitive genetic diagnosis. This work aims to evaluate the utility of NGS data re-analysis for those patients with an inconclusive or negative genetic test at the time of first analysis considering that (i) the advance of alignment and variant calling processes progressively improve the detection rate, limiting false positives and false negatives; (ii) gene panels are periodically updated and (iii) variant annotation may change over time. METHODS 114 patients, recruited between 2018 and 2020, with an inconclusive or negative NGS report at the time of first analysis, were included in the study. Re-alignment and variant calling of previously generated sequencing raw data were performed using the GenomSys Variant Analyzer software. RESULTS 21 previously not reported potentially causative variants were identified in 20 patients. In most cases (n = 19), causal variants were retrieved out of the re-classification from likely benign to variants of unknown significance (VUS). In one case, the variant was included because of inclusion in the analysis of a newly disease-associated gene, not present in the original gene panel, and in another one due to the improved data alignment process. Whenever possible, variants were validated with Sanger sequencing and family segregation studies. As of now, 16 out of 20 patients have been analyzed and variants confirmed in 8 patients. Specifically, in two pediatric patients, causative variants were de novo mutations while in the others, the variant was present also in other affected relatives. In the remaining patients, variants were present also in non-affected parents, raising questions on their re-classification. CONCLUSIONS Overall, these data indicate that periodic and systematic re-analysis of negative or inconclusive NGS data reports can lead to new variant identification or reclassification in a small but significant proportion of cases, with benefits for patients' management.
Collapse
Affiliation(s)
- Claudia Saglia
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valeria Bracciamà
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Fiorenza Mioli
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Angelo Corso Faini
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giulia Margherita Brach Del Prever
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Silvia Kalantari
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maria Luca
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Carmelo Maria Romeo
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Caterina Scolari
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Licia Peruzzi
- Pediatric Nephrology Dialysis and Transplantation Unit, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Alessandro Mussa
- Pediatric Clinical Genetics, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- Nephrology and Dialysis Unit, Center of Research on Immunopathology and Rare Diseases, CMID, San Giovanni Bosco Hospital, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, Center of Research on Immunopathology and Rare Diseases, CMID, San Giovanni Bosco Hospital, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | | | - Diana Carli
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Silvia Deaglio
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Tiziana Vaisitti
- Immunogenetics and Transplant Biology Service, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy.
- Department of Medical Sciences, University of Turin, Turin, Italy.
| |
Collapse
|
3
|
Roccatello D, Careddu A, Ferro M, Naretto C, Quattrocchio G, Fenoglio R, Sciascia S. The steroid-sparing effects of a mycophenolate mofetil-based regimen in the management of immunoglobulin A nephropathy in patients with histologically active lesions: A comparison with a control cohort receiving conventional therapy. J Nephrol 2023; 36:2223-2231. [PMID: 37306917 PMCID: PMC10638182 DOI: 10.1007/s40620-023-01636-6] [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] [Accepted: 04/02/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION While the use of different immunosuppressants has been investigated in immunoglobulin A nephropathy, further investigation is needed to assess the effect of a regimen of mycophenolate mofetil combined with a short course of glucocorticosteroids in the subset of patients with histologically active features. We compared the efficacy and safety of a combined regimen of mycophenolate mofetil and glucocorticosteroids to a conventional regimen of glucocorticosteroids alone in patients with immunoglobulin A nephropathy who have active lesions and major urinary abnormalities. METHODS This retrospective study involved 30 immunoglobulin A nephropathy patients with active histological lesions, 15 of whom were treated with both mycophenolate mofetil 2 g/day for 6 months and 3 pulses of 15 mg/kg methylprednisolone, followed by a short tapering schedule of oral prednisone. The control group was made up of the remaining 15 clinically- and histologically-matched patients treated with glucocorticosteroids alone according to a validated schedule, i.e., 1 g of methylprednisolone given intravenously for 3 consecutive days, followed by oral prednisone 0.5 mg/kg every other day for 6 months. At diagnosis, all patients had urinary protein excretion > 1 g/24 h and microscopic hematuria. RESULTS At the end of the first year of follow-up (30 patients) and after 5 years (17 patients), there were no differences between the two groups in terms of urinary abnormalities and functional parameters. Both regimens achieved a statistically significant decrease in 24-h urinary protein excretion (p < 0.001) and a reduction of microscopic hematuria. However, the mycophenolate mofetil-based regimen allowed a cumulative sparing dose of 6 g of glucocorticosteroids. CONCLUSION In this single center study on immunoglobulin A nephropathy patients with active lesions and major urinary abnormalities and at increased risk of glucocorticosteroid-related complications, a mycophenolate mofetil-based regimen demonstrated similar outcomes in terms of complete response and relapse (at 1 and 5 years) compared to a conventional glucocorticosteroid-based protocol, while achieving a consistent reduction of glucocorticosteroid cumulative dose.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy.
| | - Andrea Careddu
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Michela Ferro
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Giacomo Quattrocchio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| |
Collapse
|
4
|
Roccatello D, La Manna G, Fenoglio R. [Onconefrologia: una sfida]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007820] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Gaetano La Manna
- UOC Nephrology, Dialysis and Transplantation, Policlinico di Sant'Orsola, Bologna, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
5
|
Fenoglio R, Cortazzi S, Guarino A, Longo R, Caniggia I, Sciascia S, Roccatello D. [Management of the Oncological Patient with Chronic Renal Failure]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007824] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Cancer is a leading cause of death in people with chronic kidney disease (CKD). The incidence of CKD in patients with cancer is higher than in the non-cancer population. Across various populations, CKD is associated with an elevated risk of cancer incidence and cancer death compared with people without CKD, although the risks are cancer site-specific. The potential mechanisms for the increased risk of cancer observed in CKD, include patient factors, disease, and treatment factors. CKD has also a major impact on the treatment of cancer patients. The kidney is the primary route of elimination of many anticancer drugs. Dosing of anticancer agents according to kidney function is essential to avoid undertreatment and toxicity. Because of the systemic exclusion of patients with severe kidney dysfunction from clinical cancer trials, data are lacking to guide dosing of anticancer drugs in patients with chronic kidney disease. As a consequence, many therapies are denied to CKD patients due to their possible toxicities. An orchestrated effort by all stakeholders is required to fill the knowledge gap and improve the outcome of cancer patients with kidney dysfunction.
Collapse
Affiliation(s)
- Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Simone Cortazzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Annalisa Guarino
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Roberta Longo
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Ilaria Caniggia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
6
|
Fenoglio R, Cortazzi S, Marchisio M, Rabajoli G, Terzolo E, Sciascia S, Roccatello D. [Renal Side Effects of Novel Molecular Targeted Oncologic Agents]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007829] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
The introduction of innovative therapies has changed the scenario of complications. The delay in the recognition of kidney adverse effects is partly due to the timing of the development of the kidney damage which occurs later than the observation period of registration studies, and partly to the exclusion of patients with known kidney impairment from registration trials. Renal disease has a significant impact on the management of cancer patients and often leads to discontinuation of therapy. Histological evaluations of kidney disorders induced by targeted/immunotherapy are very limited. Renal biopsy is critical for the management of renal toxicities and should be especially encouraged for patients showing adverse renal effects to novel cancer agents. We recently examined the histological features of patients treated with new cancer agents who underwent renal biopsy for new onset renal failure and/or urinary abnormalities. The cohort included 42 patients. The most frequently administered therapies were immunotherapy (54.8%) and anti-angiogenic treatments (45.2%). The most common adverse effect was tubular interstitial nephritis in the first group and thrombotic microangiopathy in the second one. Based on histological findings, definitive discontinuation of treatment could be restricted to a very limited number of patients. All of them had anti-VEGF-related TMA. Treatment discontinuation was unneeded in patients treated with ICIs. In patients treated with multidrug therapy, the histological findings made it possible to identify the weight of drug-related specific injury. Based on this data, renal biopsy should be considered in every cancer patient who develops urinary abnormalities or shows a worsening of renal function during treatment with immunotherapy or targeted therapy.
Collapse
Affiliation(s)
- Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Simone Cortazzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Martina Marchisio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Gianluca Rabajoli
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Edoardo Terzolo
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
7
|
De Simone E, Fenoglio R, Cortazzi S, Careddu A, Geraci G, Bugliosi F, Sciascia S, Roccatello D. [Management of Cast Nephropathy]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007838] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Myeloma cast nephropathy is the most common cause of acute kidney injury in patients affected by multiple myeloma. The mainstay of management of cast nephropathy is the clone-based therapy by reducing production and thereby precipitation of light chains. Adjuvant therapy consists of inducing high urine volume flow and alkalinisation, where possible. Extracorporeal removal of light chains is still debated and the advantages of these procedures are not established. The use of safe and low expensive membranes may encourage their use and address their utility.
Collapse
Affiliation(s)
- Emanuele De Simone
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Simone Cortazzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Andrea Careddu
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Giovanni Geraci
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Federico Bugliosi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
8
|
Roccatello D, Cortazzi S, Bertinetto F, La Rosa A, Nescis L, Sciascia S, Fenoglio R. [Cancer and the Kidney: A Deadly Embrace]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007822] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
A deadly embrace occurs between cancer and chronic kidney disease. The estimation of kidney function in cancer patients is of utmost interest due to its direct impact on chemotherapy dosing, selection, and eligibility for chemotherapeutics. Overestimating kidney function (determined as estimated glomerular filtration rate -eGFR) can lead to overdosing and drug toxicity, while underestimating kidney function can prevent patients from receiving novel therapies. Notably, the current measures of eGFR are not validated in transplanted patients yet. The field of onconephrology ranges from nephrotoxicity of existing and novel therapeutics, paraproteinemias, and cancer-associated electrolyte imbalance, fluid and acid-base disturbances, the effects of the destruction of cancer cells, and acute and/or chronic kidney injuries. Recently, the therapeutic armamentarium has been enriched with new agents that interfere with specific proteins involved in oncogenesis. These are the so-called target therapies, which although acquired as "targeted" therapies do not have absolute specificity and selectivity and tend to inhibit multiple targets, often involving the kidney. Renal biopsy may be critical in managing these adverse effects. Moreover, primary hematological and oncological disorders can have significant kidney implications in the form of glomerular or nonglomerular diseases presenting with proteinuria, hematuria, hypertension, and kidney function decline, specifically including cast nephropathy or systemic light chain amyloidosis, and paraneoplastic glomerulopathies that occur as a result of occult malignancy, such as Membranous Nephropathy and Minimal Change disease.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Simone Cortazzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Francesca Bertinetto
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Alessandra La Rosa
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Lorenzo Nescis
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
9
|
Pozzato M, Fenoglio R, Caruso N, Ceruti C, Amore G, Sciascia S, Roccatello D. [Renal Replacement Therapy in Cancer Patients with AKI]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007827] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Acute renal failure (AKI) is a high-prevalence complication in patients with cancer. The risk of AKI after cancer diagnosis is 18% in the first year, 27% in the fifth year, and 40% of critically ill patients with cancer require renal replacement therapy. The causes of AKI may be pre-renal due to hemodynamic problems, related to the cancer, metabolic complications, and drug or surgical treatment. One must preventively protect renal function by hydration, use of non-nephrotoxic drugs, correction of anemia, prevention of contrast agent-induced AKI (CI-AKI), and adjustment of cancer therapy in patients with CKD. It is essential to check basal renal function, creatinine trend, electrolytes, urinalysis and proteinuria, perform imaging, renal biopsy if necessary. The evaluation of patients should be multidisciplinary and timely including the initiation of renal replacement treatment (RRT). There are different modalities of replacement treatment depending on the clinical picture of the patient with AKI and cancer: intermittent hemodialysis (IHD), intermittent prolonged replacement therapy (PIRRT), and continuous replacement therapy (CRRT). The concept of dose administered, as opposed to prescribed dose, as well as the anticoagulation of extracorporeal circuits, which must be regional with citrate (RCA) as the first choice in the management of CRRT, turns out to be fundamental in order to achieve optimal circuit anticoagulation, with reduction of coagulation episodes and downtime, while maintaining the patient's coagulation status. The onco-nephrologic multidisciplinary approach is crucial to reduce the mortality rate, which is still high in this category of patients.
Collapse
Affiliation(s)
- Marco Pozzato
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Nunziante Caruso
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Cecilia Ceruti
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Giorgio Amore
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
10
|
De Simone E, Sciascia S, Fenoglio R, Oddone V, Barreca A, Roccatello D. Antiphospholipid Syndrome and Kidney Involvement. Kidney Blood Press Res 2023; 48:666-677. [PMID: 37734329 DOI: 10.1159/000529229] [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] [Received: 05/13/2022] [Accepted: 01/07/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the development of autoantibodies and the impairment of the coagulation system. Knowledge about this syndrome is increasing over time, but kidney involvement, especially APS nephropathy, still represents a challenge for physicians. SUMMARY A "two hit" model has been hypothesized to explain APS pathophysiology, and the role played by some factors, such as the complement system, is becoming more and more clear. From a clinical point of view, along with thrombosis in any site and/or obstetric morbidities, that are the hallmarks of APS, a constellation of several other clinical symptoms is related to APS. These symptoms alone are not sufficient to fulfill Sydney criteria for APS and this could potentially lead to omitting some diagnoses. The mainstay of management of APS is antithrombotic therapy, but there are expectations for new drugs that regulate the immune system. APS could affect the kidneys in many ways and among them, APS nephropathy is an intriguing entity that has been overlooked in recent years. Novel studies on APS nephropathy are lacking. KEY MESSAGES In this review, we discuss what we currently know about APS and its relationship with the kidney, with an eye toward the future perspectives. Multicenter studies on APS nephropathy are necessary in order to develop targeted therapies.
Collapse
Affiliation(s)
- Emanuele De Simone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy,
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Valentina Oddone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| |
Collapse
|
11
|
Sciascia S, Rilat MLA, Fenoglio R, Foddai SG, Radin M, Cecchi I, Cinnirella G, Crosasso P, Guidetti MG, Barinotti A, Baldovino S, Menegatti E, Roccatello D. Safety and efficacy of pre-exposure prophylaxis with tixagevimab/cilgavimab (Evusheld) in patients with glomerular diseases who received rituximab. Clin Kidney J 2023; 16:1465-1468. [PMID: 37664578 PMCID: PMC10469100 DOI: 10.1093/ckj/sfad111] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Indexed: 09/05/2023] Open
Abstract
Background Patients on B-cell-depleting agents may have a suboptimal response to vaccination, placing them at a higher risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or suffering from a more severe prognosis. Indeed, available data on pre-exposure prophylaxis with tixagevimab/cilgavimab (Evusheld) in subjects with glomerular diseases (GDs) who received rituximab are limited. Methods We conducted a prospective study analysing the safety and efficacy of tixagevimab/cilgavimab for pre-exposure prophylaxis in patients with GDs who received rituximab in the previous 12 months. The rates of symptomatic infections and hospitalizations were compared with those for patients with GD treated with rituximab who refused to receive tixagevimab/cilgavimab. Results Tixagevimab/cilgavimab was administered to 22 patients (12 females, mean age 58.4 ± 19.6 years) with GD diagnoses including membranous nephropathy, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis and focal segmental glomerulosclerosis. No patient treated with tixagevimab/cilgavimab experienced symptomatic infection with SARS-CoV-2 during the follow-up (mean observation time of follow-up was 112 ± 23 days), while 11 of 28 controls (39.3%) reported a symptomatic infection (P = .0001), requiring hospitalization in 2 cases. Reported adverse events were mild, namely self-limiting headache [4], discomfort at the injection site [3], flu-like symptoms/myalgia [3] and fever [1]. No serious adverse events (e.g. cardiac events, anaphylaxis) were reported. Conclusion Pre-exposure prophylaxis with tixagevimab/cilgavimab seems safe and lowered the risk of symptomatic SARS-CoV-2 infection by ≈40% in vaccinated subjects with GD who received anti-CD20 therapy. Possible applications in the subset of patients who need immunosuppressive therapy, especially with rituximab, in a pandemic setting might be envisaged.
Collapse
Affiliation(s)
- Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Maria Letizia Antonietta Rilat
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Silvia Grazietta Foddai
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | | | - Paola Crosasso
- Pharmacy Department, S. Giovanni Bosco Hospital, Turin, Italy
| | - Maria Gabriella Guidetti
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Alice Barinotti
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Simone Baldovino
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Elisa Menegatti
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Turin, Italy
| |
Collapse
|
12
|
Roccatello D, Fenoglio R, Caniggia I, Kamgaing J, Naretto C, Cecchi I, Rubini E, Rossi D, De Simone E, Del Vecchio G, Cozzi M, Sciascia S. Daratumumab monotherapy for refractory lupus nephritis. Nat Med 2023; 29:2041-2047. [PMID: 37563241 PMCID: PMC10427415 DOI: 10.1038/s41591-023-02479-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 01/12/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023]
Abstract
Treatment-refractory lupus nephritis (LN) has a high risk of a poor outcome and is often life-threatening. Here we report a case series of six patients (one male and five females) with a median age of 41.3 years (range, 20-61 years) with refractory LN who received renal biopsies and were subsequently treated with intravenous daratumumab, an anti-CD38 monoclonal antibody (weekly for 8 weeks, followed by eight biweekly infusions and up to eight monthly infusions). One patient did not show any improvement after 6 months of therapy, and daratumumab was discontinued. In five patients, the mean disease activity, as assessed by the Systemic Lupus Erythematosus Disease Activity 2000 index, decreased from 10.8 before treatment to 3.6 at 12 months after treatment. Mean proteinuria (5.6 g per 24 h to 0.8 g per 24 h) and mean serum creatinine (2.3 mg dl-1 to 1.5 mg dl-1) also decreased after 12 months. Improvement of clinical symptoms was accompanied by seroconversion of anti-double-stranded DNA antibodies; decreases in median interferon-gamma levels, B cell maturation antigen and soluble CD163 levels; and increases in C4 and interleukin-10 levels. These data suggest that daratumumab monotherapy warrants further exploration as a potential treatment for refractory LN.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy.
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Ilaria Caniggia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Joelle Kamgaing
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Elena Rubini
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Emanuele De Simone
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Martina Cozzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
13
|
Roccatello D, Baffa A, Naretto C, Barreca A, Cravero R, Roscini E, Sciascia S, Fenoglio R. Focal segmental glomerular sclerosis can be effectively treated using an intensive B-cell depletion therapy. Clin Kidney J 2023; 16:1258-1264. [PMID: 37529640 PMCID: PMC10387391 DOI: 10.1093/ckj/sfac207] [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] [Received: 06/02/2022] [Indexed: 08/03/2023] Open
Abstract
Background Focal segmental glomerular sclerosis (FSGS) is a histologic lesion rather than a specific disease entity and represents a cluster of different conditions affecting both children and adults that includes primary, secondary and genetically mediated forms. These forms can be distinguished by electron microscopy and genetic assessment and show different responsiveness to steroids and immunosuppressants. Despite some promising effects of rituximab in nephrotic syndrome in children, the results in adults with FSGS are disappointing. Our group previously explored the effectiveness of rituximab in eight adult patients with unselected forms of FSGS and achieved a consistent reduction in proteinuria in one case. Following this experience, we developed an alternative therapeutic option intended to enhance the potential of rituximab with the support of other synergic drugs. We herein report the results of this therapeutic protocol (six administrations of rituximab plus two of intravenous cyclophosphamide plus glucocorticoids) in seven prospectively enrolled patients with extensive podocyte effacement and recurrent relapses or steroid dependence. Results Patients had a median baseline serum creatinine level of 2.2 mg/dl (range 1-4.7) that decreased to 1.1 mg/dl (range 0.9-2.2) and 1.1 mg/dl (range 0.75-2.21) after 3 and 6 months, respectively, and remained unchanged at 12 months. Three of five patients with renal failure turned to normal function while the other two patients maintained a stable impairment after 18 and 52 months. The median proteinuria decreased from 6.1 g/24 h to 3.5, 3.5 and 1.9 g/24 h at 3, 6 and 12 months, respectively. Specifically, five of seven patients had a partial response at 12 months and became non-nephrotic. One of them had a complete response at 18 months and was still in complete remission at the last follow-up visit at 36 months. Proteinuria persisted unchanged in two of seven patients with a genetic-related disease. No serious late adverse events were observed. Conclusions Our results show that intensive B-cell depletion therapy is able to reverse the nephrotic syndrome of steroid-dependent or frequently relapsing adult patients with putatively idiopathic FSGS (i.e. with extensive podocyte effacement).
Collapse
Affiliation(s)
| | - Alessandra Baffa
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnet and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, 10154 Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnet and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, 10154 Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | - Raffaella Cravero
- Unit of Nephrology and Dialysis, Ospedale degli Infermi, Biella, Italy
| | - Elisabetta Roscini
- Unit of Nephrology and Dialysis, Casale Monferrato and Novi Ligure Hospitals, Alessandria, Italy
| | | | | |
Collapse
|
14
|
Sciascia S, Miraglia P, Radin M, Giarin M, Charbonier N, Barreca A, Cecchi I, Lanzetta I, Fenoglio R, Menegatti E, Roccatello D. Chasing the Zebra: a case of membranous-like Glomerulopathy with SSA/RO52 deposits and no overt connective tissue disease. BMC Rheumatol 2023; 7:6. [PMID: 37016425 PMCID: PMC10074652 DOI: 10.1186/s41927-023-00330-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 03/14/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND The nature of the deposits in immune-mediated glomerulonephritis with a membranous pattern and masked IgG-Kappa deposits (MGMID) remains still to be elucidated. CASE PRESENTATION We present a case of 33-year-old woman developing a continuous asymptomatic proteinuria (0.8-1 g/24 h) with no overt connective tissue diseases. She tested positive at high titers for SSA antibodies (Ro52 838 UI/mL, Ro60 2716 UI/mL) and at the kidney biopsy histological findings were compatible with an immune-mediated glomerulonephritis with a membranous pattern and masked IgG-Kappa deposits. Also, we demonstrated a positive immunohistochemistry staining for anti-Ro52-SSA antibodies, with a granular positivity in mesangium and along rare glomerular capillaries. To date, only one case of a patient with overt diagnosis of Sjögren's syndrome with MGMID has been described but a pathogenic role for SSA and SSB antibodies has never been proven. CONCLUSIONS In this case, we described for the first time by immunohistochemistry a Ro52+ granular positivity in the mesangium and glomerular capillaries, potentially paving the way for a better understanding of MGMID.
Collapse
Affiliation(s)
- Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy.
| | - Paolo Miraglia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy
- School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy
| | - Manuela Giarin
- Pathology Unit, ''Città della Salute e della Scienza di Torino'' University Hospital, Turin, Italy
| | - Nicolas Charbonier
- Pathology Unit, ''Città della Salute e della Scienza di Torino'' University Hospital, Turin, Italy
| | - Antonella Barreca
- Pathology Unit, ''Città della Salute e della Scienza di Torino'' University Hospital, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy
| | - Irene Lanzetta
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy
| | - Elisa Menegatti
- School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Department of Clinical and Biological Sciences, University of Turin, 10154, Turin, Italy
| |
Collapse
|
15
|
Fenoglio R, Cozzi M, Del Vecchio G, Sciascia S, Barreca A, Comandone A, Roccatello D. The need for kidney biopsy in the management of side effects of target and immunotherapy. Front Nephrol 2023; 3:1043874. [PMID: 37675354 PMCID: PMC10479613 DOI: 10.3389/fneph.2023.1043874] [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] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/01/2023] [Indexed: 09/08/2023]
Abstract
Introduction The introduction of innovative therapies, resulting from revisiting cancer as a disease of the immune system, has changed the scenario of complications. These new classes of drugs, such as targeted therapies and immune checkpoint inhibitors, assure substantial advantages in cancer therapy, despite some side effects affecting various organs, including the kidney. Histological evaluations of kidney disorders induced by targeted/immunotherapy are limited. Method In this study we examined the histological features of patients treated with new cancer agents who underwent a kidney biopsy for new onset kidney failure and/or urinary abnormalities. Results The cohort included 30 adult patients. The most frequently administered therapies were immunotherapy (30%), targeted therapy (26.7%), immunotherapy plus targeted therapy (13.3%), immunotherapy plus chemotherapy (13.3%), targeted therapy plus chemotherapy (16.7%). The most common histological finding was tubular interstitial nephritis (30%) that was associated with acute tubular necrosis in 4 cases, and thrombotic microangiopathy (23.3%). After kidney biopsy, 16 of the 30 patients were treated according to the histological diagnosis. Fourteen patients were treated with steroids. One patient with membranous nephropathy was treated with a single dose of rituximab. A patient with severe thrombotic microangiopathy requiring dialysis received a treatment with eculizumab for 3 months. Overall some renal response was obtained in all patients treated with glucocorticoids, while complete kidney response was achieved in the patient treated with rituximab. Cancer treatment was resumed without change in 21 out of 30 patients. Conclusion Kidney biopsy is critical for the management of kidney toxicities and should be strongly encouraged for patients showing adverse kidney effects of novel cancer agents.
Collapse
Affiliation(s)
- Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-net, ERN-Reconnect and RITA-ERN Member), San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Martina Cozzi
- CMID-Nephrology and Dialysis Unit (ERK-net, ERN-Reconnect and RITA-ERN Member), San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Giulio Del Vecchio
- CMID-Nephrology and Dialysis Unit (ERK-net, ERN-Reconnect and RITA-ERN Member), San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Savino Sciascia
- CMID-Nephrology and Dialysis Unit (ERK-net, ERN-Reconnect and RITA-ERN Member), San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | | | - Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-net, ERN-Reconnect and RITA-ERN Member), San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| |
Collapse
|
16
|
Roccatello D, Sciascia S, Rossi D, Fenoglio R. Refractory Systemic Lupus Erythematosus: Identification and Pharmacological Management. Drugs 2023; 83:117-134. [PMID: 36729344 DOI: 10.1007/s40265-022-01824-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 02/03/2023]
Abstract
Systemic lupus erythematosus (SLE) is characterized by an aberrant immune response, leading to an extremely heterogeneous clinical presentation, potentially affecting different systems and organs. Despite the fact that SLE mortality has greatly decreased since the introduction of steroids, some forms of refractory/severe SLE still have the potential to result in permanent organ damage as well as increased mortality and morbidity. Furthermore, SLE patients with multiple comorbidities may face a clinical conundrum and have a bad prognosis. An improved prognosis for severe refractory SLE depends on prompt and appropriate treatment. Due to the scarcity of solid data from a well-characterized group of patients with refractory/severe SLE coming from randomized controlled studies, this review aims to shed light on this with real-world evidence from clinical research performed at our Unit, the University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID) (Turin, Italy). In order to determine the key clinical and prognostic features, and therapeutic approaches for severe and/or refractory SLE, our experience will be described together with existing literature, primarily focused on dermatological, neuropsychiatric, and renal symptoms.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| |
Collapse
|
17
|
Fenoglio R, Marchisio M, Baffa A, Quattrocchio G, Roccatello D. Semi-selective plasma filtration applied to the treatment of acquired thrombotic thrombocytopenic purpura following bnt162b2 administration. J Nephrol 2023; 36:229-232. [PMID: 36057036 PMCID: PMC9440330 DOI: 10.1007/s40620-022-01402-0] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/06/2022] [Indexed: 02/07/2023]
Abstract
Following the widespread use of anti SARS-CoV-2 vaccines, there have been reports of thrombocytopenia developing after the administration of different types of vaccine. We report a case of a 63-year-old male who developed neurological symptoms after receiving the second dose of the bnt162b2 vaccine. Blood tests performed upon admission to the Emergency Department revealed severe thrombocytopenia and microangiopathic hemolytic anemia. ADAMTS13 activity was undetectable and antibody titer was high. Due to the rapid neurological deterioration, steroid therapy with prednisone was started at an initial dose of 1 mg/kg/day. Rituximab therapy was started to prevent the formation of new antibodies. Given the slow response to this therapy, we added Caplacizumab, (a monoclonal antibody anti-Von Willebrand factor) in order to inhibit platelet hyperaggregation, combined with standard plasma exchange. The patient experienced repeated episodes of intolerance to fresh frozen plasma (FFP). Switching from plasma exchange to plasma filtration, remission was attained in this unusual case of vaccine-related thrombocytopenia with microangiopathic hemolytic anemia.
Collapse
Affiliation(s)
- Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-Net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10054, Turin, Italy
| | - Martina Marchisio
- CMID-Nephrology and Dialysis Unit (ERK-Net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10054, Turin, Italy
| | - Alessandra Baffa
- CMID-Nephrology and Dialysis Unit (ERK-Net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10054, Turin, Italy
| | - Giacomo Quattrocchio
- CMID-Nephrology and Dialysis Unit (ERK-Net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10054, Turin, Italy
| | - Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-Net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10054, Turin, Italy.
| |
Collapse
|
18
|
Sciascia S, Yazdany J, Moroni G, Becker JU, Seshan SV, Andrade D, Emmi G, Cuadrado MJ, Radin M, Cecchi I, De Simone E, Barreca A, Caroti L, Innocenti S, Fenoglio R, Roccatello D. Clinical-pathological characteristics of renal injuries identify different clusters in patients with antiphospholipid antibodies. Kidney Int Rep 2023; 8:754-763. [PMID: 37069974 PMCID: PMC10105059 DOI: 10.1016/j.ekir.2023.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction Significant heterogeneity still exists in the nomenclature of renal involvement in antiphospholipid syndrome (APS). Methods We applied a hierarchical cluster analysis to determine subgroups of patients according to clinical, laboratory, and renal histology characteristics in a cohort of subjects with confirmed antiphospholipid antibodies (aPL) positivity and biopsy proven aPL-related renal injuries. Kidney outcomes were then assessed at 12 months. Results A total of 123 aPL-positive patients were included in the study (101 [82%] female, 109 [88.6%] with systemic lupus erythematosus [SLE], 14 (11.4%) with primary APS [PAPS]). Three clusters were identified. Twenty-three patients (18.7%) were included in the first cluster (cluster 1), characterized by a higher prevalence of glomerular capillary and arteriolar thrombi and fragmented red blood cells in the subendothelial space. Cluster 2 included 33 patients (26.8%) and showed a higher prevalence of fibromyointimal proliferative lesions as seen in hyperplastic vasculopathy. Cluster 3 was the largest (67 patients, mainly with SLE) and was characterized by higher prevalence of subendothelial edema, of both glomerular capillaries and arterioles. Conclusion Three different clusters of patients with aPL and renal injuries emerged from our study as follows: the first, with the worst renal prognosis, was associated with features of thrombotic microangiopathy (TMA), thrombosis, triple aPL positivity and higher adjusted Global APS Score (aGAPSS) values; the second, characterized by hyperplastic vasculopathy with an intermediate prognosis, was seen more frequently in patients with cerebrovascular manifestations; and the third, more benign in terms of outcomes and with no overt association with thrombotic features, was characterized by endothelial swelling in concomitant lupus nephritis (LN).
Collapse
|
19
|
Burballa C, Cantero-Recasens G, Prikhodina L, Lugani F, Schlingmann K, Ananin PV, Besouw M, Bockenhauer D, Madariaga L, Bertholet-Thomas A, Taroni F, Parolin M, Conlon P, Delprete D, Chauveau D, Koster-Kamphuis L, Fila M, Pasini A, Castro I, Colussi G, Gil M, Mohidin B, Wlodkowski T, Schaefer F, Ariceta G, Bacchetta J, Paglialonga F, Murer L, Andersone I, Sayer JA, Boyer O, Levart TK, Rus R, Paripović D, Gonzalez ER, Nieto F, Zieg J, Caballero JÁ, Vara J, Keijzer-Veen M, Ferraro PM, Gonzalez R, Rotaeche RMS, Fenoglio R, Ballesteros SS, Lobo ST, Ghuysen MS, Ordóñez Álvarez FA, Vandyck M, Rosenberg M, Thorsteinsdottir H, Tasic V, Bayram MT, Mir S, Costea GC, Yildiz N, Lumbreras J, Yel S, Cerkauskiene R, La Manna A, Elhassan E, Ciurli F, Meseguer A, Duran M. Clinical and genetic characteristics of Dent's Disease type 1 in Europe. Nephrol Dial Transplant 2022; 38:1497-1507. [DOI: 10.1093/ndt/gfac310] [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] [Received: 07/30/2022] [Indexed: 11/30/2022] Open
Abstract
Abstract
Background
Dent's disease type 1 (DD1) is a rare X-linked nephropathy caused by CLCN5 mutations, characterized by proximal tubule dysfunction, including low-molecular-weight proteinuria (LMWP), hypercalciuria, nephrolithiasis-nephrocalcinosis, progressive chronic kidney disease (CKD) and kidney failure (KF). Current management is symptomatic and does not prevent disease progression. Here we describe the contemporary DD1 picture across Europe to highlight its unmet needs.
Methods
A physician-based anonymous international e-survey supported by several European Nephrology Networks/Societies was conducted. Questions focused on DD1 clinical features, diagnostic procedure and mutation spectrum.
Results
Two-hundred seven DD1 male patients were reported, being clinical data available for 163 with confirmed CLCN5 mutations. Proteinuria was the most common leading manifestation (49.1%). During follow-up, all patients showed LMWP, 66.4% nephrocalcinosis, 44.4% hypercalciuria and 26.4% nephrolithiasis. After 5.5 years, ∼50% of patients presented renal dysfunction, 20.7% developed CKD ≥ 3, and 11.1% KF. At last visit, hypercalciuria was more frequent in pediatric patients than in adults (73.4% vs. 19.0%). Conversely, nephrolithiasis, nephrocalcinosis and renal dysfunction were more prominent in adults. Furthermore, CKD progressed with age. Despite no clear phenotype/genotype correlation was observed, decreased glomerular filtration rate was more frequent in subjects with CLCN5 mutations affecting the pore or CBS domains compared to those with early-stop mutations.
Conclusions
Results from this large DD1 cohort confirm previous findings and provide new insights regarding age and genotype impact on CKD progression. Our data strongly support that DD1 should be considered in male patients with CKD, nephrocalcinosis/hypercalciuria and non-nephrotic proteinuria and provide additional support for new research opportunities.
Collapse
Affiliation(s)
- Carla Burballa
- Vall d'Hebron University Hospital (HUVH) - Vall d'Hebron Research Institute (VHIR) , Barcelona , Spain
| | - Gerard Cantero-Recasens
- Vall d'Hebron University Hospital (HUVH) - Vall d'Hebron Research Institute (VHIR) , Barcelona , Spain
| | - Larisa Prikhodina
- Veltishev Research & Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University , Moscow , Russia
| | | | | | - Petr V Ananin
- Scientific Centre of Children Health 2 , Moscow , Russia
| | | | - Detlef Bockenhauer
- UCL Division of Medicine and Great Ormond Street Hospital , London , United Kingdom
| | - Leire Madariaga
- Hospital Universitario Cruces, Biocruces-Bizkaia, UPV/EHU , Barakaldo , Spain
| | | | - Francesca Taroni
- Pediatric Nephrology Dialysis and Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Mattia Parolin
- Nefrologia Pediatrica, Dialisi e Trapianto, Università di Padova , Italy
| | | | | | | | - Linda Koster-Kamphuis
- Amalia Children's Hospital, Radboud University Medical Center , Nijmegen , the Netherlands
| | - Marc Fila
- Arnaud de Villeneuve , Montpellier , France
| | - Andrea Pasini
- Azienda Ospedaliero-Universitaria Santorsola-Malpighi Bologna , Italy
| | - Isabel Castro
- Complexo Hospitalario de Pontevedra , Pontevedra , Spain
| | | | - Marta Gil
- Hospital Universitario Santiago de Compostela , Santiago de Compostela , Spain
| | | | | | | | - Gema Ariceta
- Vall d'Hebron University Hospital (HUVH) - Vall d'Hebron Research Institute (VHIR) , Barcelona , Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Mazzaro C, Adinolfi LE, Pozzato G, Nevola R, Zanier A, Serraino D, Andreone P, Fenoglio R, Sciascia S, Gattei V, Roccatello D. Extrahepatic Manifestations of Chronic HBV Infection and the Role of Antiviral Therapy. J Clin Med 2022; 11:6247. [PMID: 36362478 PMCID: PMC9657147 DOI: 10.3390/jcm11216247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/27/2022] [Accepted: 10/12/2022] [Indexed: 08/30/2023] Open
Abstract
The hepatitis B virus (HBV) infection leads to chronic hepatitis, cirrhosis, and hepatocarcinoma. However, about 20% of patients experience extrahepatic manifestations such as polyarteritis nodosa, non-rheumatoid arthritis, non-Hodgkin lymphoma, cryoglobulinemic vasculitis, and glomerulonephritis. These influence the patient's morbidity, quality of life and mortality. The treatment of an HBV infection is based on nucleotide analogues (NAs) which are safe and effective for the suppression of HBV-DNA in almost 100% of cases. A few studies have shown that NAs induce a viral response and an improvement of extrahepatic diseases. There is a lack of a thorough analysis of the available treatments for extrahepatic HBV manifestations. In 90% to 100% of cases, the NAs stop the HBV replication, and they produce a clinical response in the majority of patients with mild to moderate extrahepatic signs/symptoms. Arthritis can definitely disappear after the HBV elimination and, in some cases, the HBV eradication following NAs therapy appears to improve the renal function in HBV-related nephropathies. Plasma exchange can be used in subjects who are suffering from the most aggressive forms of cryoglobulinemic vasculitis and glomerulonephritis, progressive peripheral neuropathy, and life-threatening cases, and this can be combined with glucocorticosteroids and antiviral agents. In selected refractory patients, the use of rituximab in conjunction with NAs therapy can be considered. The review provides an update on extrahepatic conditions that are linked to HBV and the impact of treating HBV with NAs.
Collapse
Affiliation(s)
- Cesare Mazzaro
- Clinical of Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Luigi Elio Adinolfi
- Unit Internal Medicine, Department of Advanced Medical and Surgery Sciences, Luigi Vanvitelli University of Campania, 80138 Naples, Italy
| | - Gabriele Pozzato
- Department of Clinical and Surgical Sciences, Maggiore Hospital University of Trieste, 34149 Trieste, Italy
| | - Riccardo Nevola
- Unit Internal Medicine, Department of Advanced Medical and Surgery Sciences, Luigi Vanvitelli University of Campania, 80138 Naples, Italy
| | - Ada Zanier
- Department of Internal Medicine, Pordenone General Hospital, 33170 Pordenone, Italy
| | - Diego Serraino
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Pietro Andreone
- Division of Internal Medicine, Department of Medical and Surgical Sciences, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy
| | - Valter Gattei
- Clinical of Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy
| |
Collapse
|
21
|
Roccatello D, Sciascia S, Barreca A, Naretto C, Alpa M, Quattrocchio G, Radin M, Fenoglio R. Renal involvement as a unique manifestation of hemophagocytic syndrome. Front Med (Lausanne) 2022; 9:796121. [PMID: 36275824 PMCID: PMC9579315 DOI: 10.3389/fmed.2022.796121] [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] [Received: 10/15/2021] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Renal-limited hemophagocytic syndrome (HPS) is a rare clinical setting characterized by abnormal activation of the immune system. Fever associated with pancytopenia, hepatosplenomegaly with liver dysfunction, and hypofibrinogenemia are usually observed in HPS. From a histological level, the presence of non-malignant macrophages infiltrating bone marrow and organs represents the hallmark of this condition. Non-malignant macrophages are associated with phagocytizing activities involving other blood cells. While primary HPS is usually associated with inherited dysregulation of the immune system, secondary HPS usually occurs in the context of infection or is linked to a neoplastic process. Clinical presentation varies and can potentially lead to life-threatening settings. While renal involvement has frequently been reported, however, detailed descriptions of the kidney manifestations of HPS are lacking. More critically, the diagnosis of HPS is rarely supported by renal biopsy specimens. We report four rare cases of biopsy-proven renal-limited HPS in patients presenting with acute kidney injury (AKI). The available evidence on this topic is critically discussed in light of the possible emergence of an autonomous entity characterized by an isolated kidney involvement.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy,*Correspondence: Dario Roccatello
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | | | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Mirella Alpa
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Giacomo Quattrocchio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| |
Collapse
|
22
|
Roccatello D, Sciascia S, Naretto C, Barreca A, Solfietti L, Battaglia L, Viziello L, Fenoglio R, Rossi D. Recognizing the new disorder "idiopathic hypocryoglobulinaemia" in patients with previously unidentified clinical conditions. Sci Rep 2022; 12:14904. [PMID: 36050335 PMCID: PMC9437023 DOI: 10.1038/s41598-022-18427-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
A considerable number of patients with high clinical suspicion for cryoglobulinaemic vasculitis either show negative results for the detection of cryoglobulins or show only trace amounts which cannot be characterized for composition. We aimed at establishing whether the failure to detect or the detection of trace amounts of cryoglobulin with conventional methods either identifies a peculiar subset of low level cryoglobulinaemia (from now on hypocryoglobulinaemia) or represents a separate entity. Using a modified precipitation technique in hypo-ionic medium, we prospectively identified between 2008 and 2021 237 patients (median age 60.8 years [22-97], 137 females) having < 0.5% cryocrit and clinical suspicion of autoimmune disorder. Of these 237 patients, only 54 (22.7%) had a history of HCV infection. One hundred and sixty-nine out of 237 patients (71%) had an established underlying disease, while 68 patients (28.6%) (median age 62.9 years [29-93], 35 females) did not show either laboratory markers or clinical symptoms consonant with an underlying aetiology. These 68 cases with only trace amounts of cryoglobulins were defined as having a putatively idiopathic hypocryoglobulinaemia. Nineteen of these 68 patients (27.9%) had a history of HCV infection. Twenty-four patients out of 68 (35.3%) were positive for rheumatoid factor (RF), while 25 (36.7%) patients had signs of complement consumption (i.e., C4 < 15 mg/dl and/or C3 < 80 mg/dl ), and 36 (52.9%) had increased inflammatory indexes. Seven patients only had arthralgia and constitutional symptoms while 61 out of 68 (89.7%) presented with at least one of the three cardinal signs of cryoglobulinaemic vasculitis including skin lesions, peripheral nerve involvement, and glomerulonephritis. Seventy-five percent of the subjects had type III hypocryoglobulins. In patients with hypocryoglobulinaemia the histologic features of glomerulonephritis (also examined by electron microscopy) resembled those of mixed cryoglobulinaemia-associated glomerulonephritis. In conclusion, hypocryoglobulins are often polyclonal and are mainly unrelated to HCV infection. Patients who present high clinical suspicion for vasculitis, especially glomerulonephritis and yet test negative for cryoglobulinaemia detected by standard techniques, could require deeper investigation even in the absence of HCV infection, RF activity or signs of complement consumption.
Collapse
Affiliation(s)
- Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
| | - Savino Sciascia
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Carla Naretto
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Antonella Barreca
- Pathology Division, Città della Salute e Della Scienza, Torino, Italy
| | - Laura Solfietti
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Laura Battaglia
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Lucia Viziello
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Daniela Rossi
- CMID-Nephrology and Dialysis Unit (ERK-Net, ERN-ReConnet, RITA-ERN Member), Research Center of Immunopathology and Coordinating Center of the Network of Rare Disease of Piedmont and Aosta Valley, S. Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| |
Collapse
|
23
|
Roccatello D, Fenoglio R, Oddone V, Sciascia S. How the availability of anti-C5a agents could change the management of ANCA-associated Vasculitis. Kidney Blood Press Res 2022; 47:506-513. [PMID: 35665698 DOI: 10.1159/000525357] [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: 02/01/2022] [Accepted: 05/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a cluster of potentially life-threatening disorders often involving the kidney with a necrotizing crescentic glomerulonephritis with scanty deposition of immunoglobulins and complement. Historically the role of complement has been considered ancillary. Recently, an anti-myeloperoxidase (MPO) AAV model in complement-deficient mice has shown an involvement for the complement cascade in the development of the renal injuries. Further animal studies showing that in contrast to mice deficient for factor B and C5 animals deficient for C4 were susceptible to AAV development by injection of anti-MPO antibodies emphasized the specific involvement of the alternative pathway. Consonantly, the C5a receptor (Cd88) blockade was found to protect mice from MPO AAV. CCX168, i.e., Avacopan, a powerful inhibitor of C5a receptor that can be administered orally, was shown to reduce the pro-inflammatory effects of C5a and abolish the activation of neutrophils, their migration and adherence to endothelium, and the vascular endothelial cell retraction that increases permeability. SUMMARY Avacopan was found to be safe in healthy volunteers given a wide range of doses in a Phase 1 clinical trial. The Phase 2 trial CLEAR assessed the possibility to decrease dose or entirely replace glucocorticosteroids in the Standard of Care (SoC) therapy of AAV. Avacopan, added to CYC or RTX either in combination with GCs or not, shortened the time to remission in patients with either newly diagnosed or relapsing AAV. The Phase 3 ADVOCATE study compared the ability of an Avacopan-associated regimen to induce and sustain remission in AAV patients vs a conventional GC-associated scheme. Remission at week 26 was observed in 72.3% of patients given Avacopan and in 70.1% of those given prednisone. Sustained remission at week 52 (second primary endpoint) was obtained in 65.7% of patients given Avacopan and in 54.9% receiving prednisone. The Avacopan-associated regimen was non-inferior at week 26, and superior at week 52 in sustaining remission as compared to the GC-based scheme. KEY POINT The results of the ADVOCATE trial opened new prospects for the treatment of AAV and also other immune-mediated diseases with renal involvement. The possible position of Avacopan in a routinary clinical setting and its possible indications in specific subsets of patients with AAV are extensively discussed.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseasesof Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseasesof Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy,
| | - Valentina Oddone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseasesof Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseasesof Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| |
Collapse
|
24
|
Roccatello D, Sciascia S, Murgia S, Quattrocchio G, Ferro M, De Simone E, Naretto C, Barreca A, Rossi D, Fenoglio R. POS0824 SAFETY AND EFFICACY OF THE INTENSIFIED B CELL DEPLETION INDUCTION THERAPY FOR PATIENTS WITH ANCA-ASSOCIATED VASCULITIS AND SEVERE RENAL INJURY: A CONTROLLED STUDY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundRituximab (RTX), an anti-CD20 monoclonal antibody, has shown to be an effective induction treatment for small-vessel vasculitides associated with antineutrophil cytoplasm antibodies (AAV) in both newly diagnosed and relapsing patients. However, the role of RTX in the management of the most severe cases of AAV remains to be fully elucidated.Objectivesto assess both safety and efficacy of an intensified B-cell depletion therapy (IBCDT) protocol, including RTX, cyclophosphamide (CYC), and methylprednisolone pulses without additional maintenance immunosuppressive therapy compared to conventional therapy regimen based on oral CYC and steroids and prolonged maintenance therapy with azathioprine (AZA) in patients with AAV and severe renal injury.MethodsA cohort of 15 AAV patients with the most severe features of AVV renal involvement (as <15 ml/min GFR and histological findings of paucimmune necrotizing glomerulonephritis with more than 50% crescents of non-sclerotic glomeruli at the renal biopsy) was treated IBCDT and compared to compared toa control group of 10 patients with AAV treated with a conventional therapy regimen based on oral CYC and steroids and prolonged maintenance therapy with azathioprine (AZA). Independently on the pharmacologic regimen, plasma exchange (7 procedures with 1-1.5 plasma volume replacement) was performed in the presence of 1. alveolar haemorrhage, and 2. more than 50% florid crescents in the nonsclerotic glomeruli, or 3. dialysis dependence.ResultsComplete clinical remission (BVAS 0) was observed at 6 months in 14 of 15 patients (93%). All cases treated with IBCDT who achieved a complete clinical remission experienced a depletion of peripheral blood B cells at the end of therapy. Of the 10 dialysis dependent patients at onset, 6 subjects (60%) experienced a functional recovery allowing the suspension of dialysis treatment. When compared to the control group, no statistically significant difference was observed in patients treated with IBCDT in terms of overall survival, 6-month therapeutic response rate, and 6-, and 12-month functional renal recovery. The cumulative total dose of CYC in the case group was on average 1 g/patient while in the control group on average 8.5 g / patient (p = 0.00008). Plasmapheresis sessions were performed at part of the induction therapy among 13 patients (87%) in the case group and 8 (80%) in the control group.ConclusionThe results of this study showed that IBCDT appeared to be safe and has the same efficacy profile when compared to conventional therapy with CYC plus AZA in the management of the most severe patients with AAV. Additionally, this avoids the need of prolonged maintenance therapy for long, and limits the exposure to CYC with consequent reduced toxicity and drug-related side effect rates.Disclosure of InterestsNone declared
Collapse
|
25
|
Sciascia S, Radin M, Barinotti A, Cecchi I, Rossi D, Fenoglio R, Roccatello D. POS1448 DICKKOPF HOMOLOG 3 (DKK3) AS A PROGNOSTIC MARKER IN LUPUS NEPHRITIS: A PROSPECTIVE MONOCENTRIC EXPERIENCE. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundLupus nephritis (LN) is a major cause of mortality/morbidity in patients affected by systemic lupus erythematosus (SLE). Reliable prognostic markers, especially related to the degree of interstitial fibrosis, are still lacking and renal biopsy still represents the gold standard. Recent data suggests a role of Dickkopf homolog 3 (DKK3) as a marker of tissue fibrosis in different diseases, however its role in autoimmune diseases still needs to be elucidated.ObjectivesTo investigate DKK3 serum levels in SLE patients with and without LN, assessing its changes in relation to kidney function, flares and interstitial renal fibrosis, as well as its association with the IFN signature.Methods132 SLE patients, 57 of whom diagnosed with LN, were included in this study, as well as 50 healthy donors. DKK3 and Myxovirus resistance protein 1 (MxA) were measured in serum samples, using enzyme-linked immunosorbent assays. Biopsies were evaluated for glomerular involvement, interstitial renal fibrosis and tubular atrophy according to 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification and the revised 2018 version. Patients were followed-up for at least 36 months.ResultsDKK3 serum levels were significantly higher in patients with biopsy-proven LN when compared to those without (median[min-max]: 215ng/ml [81-341] vs 21.1ng/ml [1-69], p<0.01). When focusing on patients with LN, DKK3 levels resulted to be associated with the presence of chronic kidney disease (OR: 4.31[C.I. 2.01-6.61] per DKK3 doubling, p<0.01), higher chronicity index at biopsy (OR: 1.75[C.I. 1.59-2.13] per DKK3 doubling, p<0.01) and flares rate (OR: 1.45[C.I. 1.1-5.71] per DKK3 doubling, p<0.044). DKK3 levels correlated with the IFN signature as expressed by MxA (correlation coefficient: 0.71, p<0.037).ConclusionWhile kidney biopsy remains the gold standard for diagnostic and prognostic assessment in LN, DKK3 could represent an additional useful prognostic tool to monitor SLE patients and eventually to guide therapeutic choices.Disclosure of InterestsNone declared
Collapse
|
26
|
Sciascia S, Barinotti A, Radin M, Cecchi I, Menegatti E, Terzolo E, Rossi D, Baldovino S, Fenoglio R, Roccatello D. Dickkopf Homolog 3 (DKK3) as a Prognostic Marker in Lupus Nephritis: A Prospective Monocentric Experience. J Clin Med 2022; 11:jcm11112977. [PMID: 35683365 PMCID: PMC9181809 DOI: 10.3390/jcm11112977] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
Background: The gold standard for diagnosis of lupus nephritis (LN) is still represented by renal biopsy, and serological prognostic biomarkers are still lacking. Dickkopf homolog-3 (DKK3) has been suggested as a marker of tissue fibrosis in different conditions; however, its role in autoimmune diseases needs to be elucidated. Here, we investigated the prognostic role of DKK3 in systemic lupus erythematosus (SLE) patients with and without LN, assessing its changes in relation to kidney function, flares, and interstitial fibrosis. Methods: Overall, 132 SLE patients (57 with LN) were included and prospectively followed up for at least 36 months. DKK3 was measured in serum at baseline. Biopsies were evaluated for glomerular involvement, interstitial fibrosis, and tubular atrophy. Results: Patients with biopsy-proven LN had significantly higher levels of DKK3 than those without (median [min−max]: 215 ng/mL [81−341] vs. 21.1 ng/mL [1−69], p < 0.01). DKK3 levels were associated with prevalent chronic kidney diseases (OR: 4.31 [C.I. 2.01−6.61] per DKK3 doubling, p < 0.01), higher chronicity index at biopsy (1.75 [1.51−2.77] per DKK3 doubling, p < 0.01), and flares rate (OR: 1.45 [C.I. 1.1−5.71] per DKK3 doubling, p < 0.044). Conclusions: While kidney biopsy still represents the gold standard for diagnostic and prognostic assessment in LN, DKK3 could represent an additional prognostic tool to monitor SLE patients and guide therapeutic choices.
Collapse
Affiliation(s)
- Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-0112-402-056; Fax: +39-0112-402-052
| | - Alice Barinotti
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Elisa Menegatti
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, 10126 Turin, Italy
| | - Edoardo Terzolo
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Simone Baldovino
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatolgy and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (E.M.); (E.T.); (D.R.); (S.B.); (R.F.); (D.R.)
- Department of Clinical and Biological Sciences, University of Turin, 10126 Turin, Italy
| |
Collapse
|
27
|
Fenoglio R, Sciascia S, Rossi D, Naretto C, Alpa M, Roccatello D. Non HCV-Related Mixed Cryoglobulinemic Vasculitis With Biopsy-Proven Renal Involvement: The Effects of Rituximab. Front Med (Lausanne) 2022; 9:819320. [PMID: 35419372 PMCID: PMC8995745 DOI: 10.3389/fmed.2022.819320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/21/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022] Open
Abstract
In the countries where HCV infection is still endemic, about 90% of subjects with mixed cryoglobulinemia had previously been infected with HCV and about 80% are RNA positive. Remarkable results in severe HCV-related cryoglobulinemic vasculitis have been obtained with Rituximab. Details of the clinical characteristics and effective treatment of non HCV-related cryogloulinemic syndromes are presently lacking. This paper reports on a prospective single-Center open study aimed at evaluating the clinical presentation and effects of Rituximab administered alone in patients with severe non HCV-related cryoglobulinemic syndrome. The study group included 11 patients followed for at least 6 months. Three patients had type I cryoglobulinemia, 6 had type II and the remaining 2 patients had type III. Mean cryocrit was 2.5%. Four out of 11 patients had symptomatic sicca complex with anti-SSA (Ro)/anti SSB (La) antibodies. All 11 patients presented with biopsy-proven renal involvement, 4 out of 11 with leukocytoclastic vasculitis, and 8 with involvement of the peripheral nervous system. Renal biopsy revealed diffuse membranoproliferative glomerulonephritis (MPGN) in 9 out of 11 patients. Extracapillary proliferation and necrosis of the glomerular tuft was observed in 1 of these 9 cases. Interstitial nephritis together with mesangial expansion and capillary immune deposits were observed in 1 patient. Prevalent interstitial fibrosis and glomerular sclerosis were detected in the remaining case. Patients underwent treatment with rituximab alone. After 6 months we observed a remarkable improvement in the necrotizing skin ulcers and a substantial amelioration of the electrophysiological parameters of motor and sensory peripheral neuropathy. Improvement in both renal function (from 2.8 to 1.4 mg/dl, p < 0.001) and proteinuria (from 4.2 g/24 to 0.4 g/24 h, p < 0.001) was found in 10 out of 11 patients, while 1 could not be fully treated because of a severe infusion reaction and sudden development of anti-Rituximab antibodies. Good renal response was confirmed at the end of follow-up (38.4 months). Three patients had a relapse at 6, 12, and 48 months, respectively. In our cohort the administration of 4 once-weekly infusions of Rituximab followed by 2 more infusions after 1 and 2 months proved to be effective in the management of these rare patients.
Collapse
Affiliation(s)
- Roberta Fenoglio
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Daniela Rossi
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Carla Naretto
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Mirella Alpa
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| |
Collapse
|
28
|
Roccatello D, Sciascia S, Murgia S, Quattrocchio G, Ferro M, De Simone E, Naretto C, Barreca A, Sammartino A, Rossi D, Fenoglio R. Treating Patients With ANCA-Associated Vasculitis and Very Severe Renal Injury With an Intensified B Cell Depletion Therapy: Comparison With a Control Cohort Receiving a Conventional Therapy. Front Immunol 2022; 13:777134. [PMID: 35401565 PMCID: PMC8988143 DOI: 10.3389/fimmu.2022.777134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/14/2021] [Accepted: 03/01/2022] [Indexed: 01/04/2023] Open
Abstract
Rituximab (RTX), an anti-CD20 monoclonal antibody, has shown to be an effective induction treatment for small-vessel vasculitides associated with antineutrophil cytoplasm antibodies (AAV) in both newly diagnosed and relapsing patients. However, the role of RTX in the management of the most severe cases of AAV remains to be fully elucidated. The aim of this study was to assess both safety and efficacy of an intensified B-cell depletion therapy (IBCDT) protocol, including RTX, cyclophosphamide (CYC), and methylprednisolone pulses without additional maintenance immunosuppressive therapy in a cohort of 15 AAV patients with the most severe features of AVV renal involvement (as <15 ml/min GFR and histological findings of paucimmune necrotizing glomerulonephritis with more than 50% crescents of non-sclerotic glomeruli at the renal biopsy). Results of the IBCDT regimen have been compared to those obtained in a control cohort of 10 patients with AAV treated with a conventional therapy regimen based on oral CYC and steroids followed by a prolonged maintenance therapy with azathioprine (AZA). Plasma exchange was equally employed in the study and the control group. Complete clinical remission (BVAS 0) was observed at 6 months in 14 of 15 patients treated with IBCDT (93%). All cases who achieved a complete clinical remission experienced a depletion of peripheral blood B cells at the end of therapy. Of the 10 dialysis dependent patients at onset, 6 subjects (60%) experienced a functional recovery allowing the suspension of dialysis treatment. When compared to the control group, no statistically significant difference was observed in patients treated with IBCDT in terms of overall survival, 6-month therapeutic response rate, and 6-, and 12-month functional renal recovery. The cumulative total dose of CYC in the case group was on average 1 g/patient while in the control group on average 8.5 g/patient (p = 0.00008). Despite the retrospective design and relative limited sample size, IBCDT appeared to be safe and had the same efficacy profile when compared to the conventional therapy with CYC plus AZA in the management of the most severe patients with AAV. Additionally, this avoided the need of prolonged maintenance therapy for long, and limited the exposure to CYC with consequent reduced toxicity and drug-related side effect rates.
Collapse
Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Stefano Murgia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Giacomo Quattrocchio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Michela Ferro
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Emanuele De Simone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | | | - Andrea Sammartino
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| |
Collapse
|
29
|
Fenoglio R, Lalloni S, Marchisio M, Oddone V, De Simone E, Del Vecchio G, Sciascia S, Roccatello D. New Onset Biopsy-Proven Nephropathies after COVID Vaccination. Am J Nephrol 2022; 53:325-330. [PMID: 35354140 PMCID: PMC9059008 DOI: 10.1159/000523962] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/03/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION To date, almost 7 billion doses of the different types of vaccine against SARS-CoV-2 have been administered worldwide. Although the severity of new cases of SARS-CoV-2 has progressively decreased, and the pressure on national health systems has declined, the development of de novo glomerular injuries has been suggested. METHODS This study aimed to examine the patients who were hospitalized in our Unit between April and November 2021 and underwent renal biopsy for new-onset urinary abnormalities (UA) and/or renal impairment within 3 months of SARS-CoV-2 vaccination. RESULTS We identified 17 patients who developed UA and/or renal insufficiency within 3 months of vaccination. Minimal change disease was the most common disease in our cohort (5 patients, 29.4%) followed by acute tubulointerstitial nephritis (TIN; 3 patients, 17.6%), membranous nephropathy (3 patients, 17.6%), and rapidly progressive IgA nephropathy (2 patients, 11.8%). The other 4 patients had a diagnosis of membranoproliferative glomerulonephritis (1 patient), systemic lupus erythematosus (1 patient), ANCA-associated vasculitis (1 patient), and tip-variant focal segmental glomerulosclerosis (1 patient), respectively. Eight out of the 17 patients (47.1%) developed acute kidney injury. Two patients with acute TIN had to start hemodialysis that was discontinued after 1 and 2 months, respectively, due to the recovery of renal function. All patients underwent treatment with corticosteroids and/or immunosuppressants. DISCUSSION Although it is not possible to conclusively determine whether there is a causal relationship between SARS-CoV-2 vaccination and new-onset nephropathies, based on the appearance of UA and/or renal insufficiency shortly after vaccination, we hypothesize that the immune response to the COVID-19 vaccine may be a trigger of nephropathies. Therefore, our results highlight the need for pharmacovigilance. However, this report should not lead to vaccine hesitation during this pandemic as the benefits of vaccination strongly outweigh the potential risks.
Collapse
Affiliation(s)
- Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Fenoglio R, Baldovino S, Barreca A, Bottasso E, Sciascia S, Sbaiz L, Papotti M, Roccatello D. Renal Involvement in Transthyretin Amyloidosis: The Double Presentation of Transthyretin Amyloidosis Deposition Disease. Nephron Clin Pract 2022; 146:481-488. [DOI: 10.1159/000522370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/27/2022] [Indexed: 12/22/2022] Open
Abstract
Transthyretin (TTR) amyloidosis (ATTR) is either an inherited condition or a non hereditary disease due to misfolding of wild-type (WT) TTR. Amyloid deposits can be mainly detected in nerves in the inherited form and in myocardium in the acquired variant. Renal involvement has been described only in the Val30Met mutation of the familial form and is thought to be extremely rare in the WT TTR. However, ATTR is multi-organ disease, and even in the WT forms, apparently limited to the heart, carpal tunnel syndrome and lumbar or cervical spine amyloid deposition have been described. A series of 4 cases of biopsy-proven renal TTR amyloid deposition is reported in the present paper. We describe 2 WT ATTR patients, 1 patient with c.424G>A (p.(Val142Ile)) mutation of the TTR gene, and 1 patient with Val30Met mutation of the TTR gene. In all patients, the biopsy showed the presence of amyloid deposits with different distribution (#1 pericapsular, #2–3 vessels, #4 vessels, interstitium of medulla and cortex, and tubular basement membrane). The use of immunohistochemistry has enabled the identification of TTR, and identify the precursor protein. The possibility of kidney involvement in TTR amyloidosis should be taken into account in patients with renal impairment and unexplained cardiomyopathy and/or neuropathy. This is even of greater interest to the elderly for the possible confounding co-existence of plasma cell dyscrasia that could lead the clinician, in the presence of renal amyloid deposits, to misdiagnose AL amyloidosis and undertake inappropriate treatments.
Collapse
|
31
|
Sciascia S, Radin M, Cecchi I, Barinotti A, Rubini E, Rossi D, Fenoglio R, Vaccarino A, Menegatti E, Roccatello D. Open-label, prospective, phase II descriptive pilot trial of belimumab therapy for refractory and/or non-criteria manifestations of antiphospholipid syndrome: study protocol. Clin Exp Rheumatol 2022; 41:597-604. [PMID: 36305361 DOI: 10.55563/clinexprheumatol/qa2yb4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/02/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate the safety and tolerability of belimumab given for 24 months in patients persistently positive for antiphospholipid antibodies (aPL) with clinical features attributable to aPL [refractory and/or non-criteria manifestations of the antiphospholipid syndrome (APS)]. METHODS In this investigator-initiated, single-centre, open-label, prospective, phase II descriptive pilot trial, belimumab will be administered in 15 patients attending San Giovanni Bosco Hospital (Turin) showing refractory and/or non-criteria manifestations of APS. Subjects will receive belimumab 10 mg/kg intravenously (in addition to their ongoing APS treatment) with regimen at 0, 2, 4 weeks and every 4 weeks thereafter (up to week 104). Study endpoints determined at 4, 16, 24, 36, 52 and 104 weeks will include: primary (safety and adverse events) and secondary outcomes, such as changes in clinical outcomes (recurrent thromboses, thrombocytopenia, haemolytic anaemia, cardiovascular events, skin ulcer, aPL-related nephropathy and cognitive dysfunction), laboratory outcomes (routine tests, aPL, ENA and anti-dsDNA tests, thrombin generation assay, interferon-signature analysis, lymphocytes immunophenotyping, BLyS determination) and QoL evaluation. RESULTS Study endpoints determined at 4, 16, 24, 36, 52 and 104 weeks will include: primary (safety and adverse events) and secondary outcomes, such as changes in clinical outcomes (recurrent thromboses, thrombocytopenia, haemolytic anaemia, cardiovascular events, skin ulcer, aPL-related nephropathy and cognitive dysfunction), laboratory outcomes (routine tests, aPL, ENA and anti-dsDNA tests, thrombin generation assay, interferon-signature analysis, lymphocytes immunophenotyping, BLyS determination) and QoL evaluation. CONCLUSIONS Targeting B-cells is emerging as an appealing strategy for patients with APS. Preliminary observations showed aPL negativisation after starting therapy with belimumab. The clinical relevance of these findings will be investigated in this prospective study. If confirmed, the current 'anti-thrombotic' approach to APS patients could be complemented, at least in selected cases, with an 'immunomodulatory' strategy.
Collapse
Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy.
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Daniela Rossi
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Roberta Fenoglio
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Antonella Vaccarino
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Elisa Menegatti
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| |
Collapse
|
32
|
Murgia S, Quattrocchio G, Forneris G, Pozzato M, Fenoglio R, Ferro M, De Simone E, Del Vecchio G, Di Benedetto C, Roccatello D. Management of acute kidney injury in frail patients with biopsy-proven cast nephropathy: a combined approach with chemotherapy plus Supra-hemodiafiltration with post-adsorption endogenous reinfusion. J Nephrol 2022; 35:1243-1249. [PMID: 34982413 DOI: 10.1007/s40620-021-01226-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 12/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with multiple myeloma often have kidney involvement with acute kidney injury which is frequently due to cast nephropathy. Hemodiafiltration with endogenous reinfusion (HFR) allows removal from the circulation of significant amounts of free light chains (FLCs) responsible for tubular damage. METHODS Between 2014 and 2018, 13 patients affected by multiple myeloma (64% λ chain and 36% k), including 10 cases with biopsy-proven cast nephropathy, were treated with this technique. Each patient had high free light chains levels at diagnosis: median 8586 mg/l for λ and 4200 mg/l for k, and stage III acute kidney injury (median serum creatinine 7.5 mg/dl). We initially performed daily HFR-Supra sessions and then modulated them based on renal response (mean 10 sessions/patient). At the same time, the patients also received various chemotherapy regimens, depending on their hematological criteria. RESULTS Forty-six percent of patients showed at least partial renal function recovery within the third month, thus allowing dialysis discontinuation; 38% remained on dialysis. Two patients died. The mean reduction rate of free light chains at the end of the HFR-Supra cycle was 85% (k) and 40% (λ), respectively. Serum albumin remained stable during the whole treatment. DISCUSSION In our experience, the synergistic effect of chemotherapy and HFR-Supra led to a recovery of renal function in 6 out of 13 patients presenting with severe dialysis-requiring acute kidney injury. HFR-Supra allowed stable albumin levels, with high free light chains removal rate, at a relatively low costs.
Collapse
Affiliation(s)
- Stefano Murgia
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giacomo Quattrocchio
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giacomo Forneris
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Marco Pozzato
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Michela Ferro
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Emanuele De Simone
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Carlo Di Benedetto
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
| |
Collapse
|
33
|
Sciascia S, Fenoglio R, Roccatello D. Moving toward personalized approaches in the management of lupus nephritis. Expert Opin Biol Ther 2021; 21:1547-1550. [PMID: 34702113 DOI: 10.1080/14712598.2022.1998449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Savino Sciascia
- CMID-Nephrology and Dialysis Unit (Erk-net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (Erk-net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Dario Roccatello
- CMID-Nephrology and Dialysis Unit (Erk-net Member), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| |
Collapse
|
34
|
Radin M, Miraglia P, Barinotti A, Fenoglio R, Roccatello D, Sciascia S. Prognostic and Diagnostic Values of Novel Serum and Urine Biomarkers in Lupus Nephritis: A Systematic Review. Am J Nephrol 2021; 52:559-571. [PMID: 34515043 DOI: 10.1159/000517852] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/14/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION While renal biopsy remains the gold standard for diagnosing lupus nephritis (LN), the prognostic and diagnostic role of non-invasive biomarkers for LN is currently debated. METHODS Available studies published in last 5 years (2015-2020) assessing the diagnostic and prognostic value of urinary and/or serological biomarkers in subjects with LN were analyzed in this systematic review. RESULTS Eighty-five studies were included (comprehending 13,496 patients with systemic lupus erythematosus [SLE], 8,872 LN, 487 pediatric LN, 3,977 SLE but no LN, 160 pediatric SLE but no LN and 7,679 controls). Most of the studies were cross-sectional (62; 73%), while 14 (17%) were prospective. In sixty studies (71%), the diagnosis of LN was biopsy-confirmed. Forty-four out of 85 (52%) investigated only serological biomarkers, 29 studies (34%) tested their population only with urinary biomarkers, and 12 (14%) investigated the presence of both. Outcome measures to assess the clinical utility of the analyzed biomarkers were heterogeneous, including up to 21 different activity scores, with the SLEDAI (in 60%) being the most used. Despite some heterogeneity, promising results have been shown for biomarkers such as urinary monocyte chemoattractant protein, urinary adiponectin, and urinary vascular cell adhesion protein 1. DISCUSSION/CONCLUSION While serum and urine biomarkers have the potential to improve diagnostic and prognostic pathways in patients with LN, the vast heterogeneity across studies severely limits their applicability in current clinical practice. With the kidney biopsy still representing the gold standard, future efforts should focus on harmonizing study inclusion criteria and outcomes, particularly in clinical trials, in order to improve comparability and facilitate the implementations of available biomarkers into the daily practice.
Collapse
Affiliation(s)
- Massimo Radin
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Paolo Miraglia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy,
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy,
| | - Alice Barinotti
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- Department of Clinical and Biological Sciences, Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
- Department of Clinical and Biological Sciences, Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
- Department of Clinical and Biological Sciences, Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| |
Collapse
|
35
|
Roccatello D, Sciascia S, Naretto C, Alpa M, Fenoglio R, Ferro M, Quattrocchio G, Rubini E, Rahbari E, Rossi D. POS0704 LONG-TERM CLINICAL OUTCOMES OF PATIENTS WITH LUPUS NEPHRITIS TREATED WITH AN INTENSIFIED B-CELL DEPLETION PROTOCOL: A PROSPECTIVE STUDY. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.3803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:B cells play a key role In the pathogenesis of Lupus Nephritis (LN).Objectives:we aim to investigate the safety and efficacy of an intensified B-cell depletion induction therapy (IBCDT)without immunosuppressive maintenance regimen compared to standard of care in biopsy-proven LN.Methods:Thirty patients were administered an IBCDT (4 weekly Rituximab 375mg/m2 and 2more doses after 1&2 months;2 infusions of 10 mg/kg cyclophosphamide (CYC),3 methylprednisolone pulses), followed by oral prednisone (tapered to 5 mg/day by the 3rd month). No immunosuppressive maintenance therapy was given. Thirty patients matched for LN class and age were selected as controls: 20 received 3 methylprednisolone pulses days followed by oral prednisone and mycophenolate mofetil (MMF) 2-3 g/day, while 10 were given the Euro Lupus CYC.Results:At 12 months, complete renal remission was observed in 93% of patients on IBCDT, in 62.7% on MMF, and in 75% on CYC (p=0,03); the dose of oral prednisone was lower in the IBCDT group (mean±SD 2.9±5.0mg/dl) than MMF (10.5±8.0 mg/day,p<0.01) or CYC group (7.5±9.0mg/day,p<0.01). Mean follow-up after treatment was 44.5 months (IQR 36–120months), 48.6 months (IQR36–120months), and 45.3 (IQR36–120months) for IBCDT, MMF and CYC, respectively. At their last follow-up visit, we observed no significant differences in proteinuria and serum creatinine, nor in the frequency of new flares among the three groups.Conclusion:In biopsy proven LN, the IBCDT without further immunosuppressive maintenance therapy was shown to be as effective as conventional regimen of MMF or CYC followed by a 3-year maintenance MMF regimen. Moreover, the use of IBCDT was associated with a marked reduction of glucocorticoid cumulative dose.Disclosure of Interests:None declared
Collapse
|
36
|
Trivioli G, Canzian A, Maritati F, Fenoglio R, Pillebout E, Urban ML, Mohammad A, Nogueira E, Silvestri E, Eriksson P, Segelmark M, Novikov P, Harris H, Smitienko I, Moiseev S, Farisogullari B, O'Sullivan D, Ponte C, Lamprecht P, Hocevar A, Karadag O, Little M, Emmi G, Jayne D, Mcadoo S, Roccatello D, Vaglio A. FC 039RENAL OUTCOME AFTER RITUXIMAB IN ADULT-ONSET IGA VASCULITIS AND CRESCENTIC IGA NEPHROPATHY: A MULTICENTRE STUDY. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab117.003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Glucocorticoids (GC) and/or immunosuppressive agents are the mainstay of therapy for adult-onset IgA Vasculitis (IgAV), but their efficacy is often partial while their toxicity is relevant. Recently, rituximab (RTX) has been reported as a safe and effective option but only few data on renal outcome are available.1 RTX has also been used in a few cases of crescentic IgA Nephropathy (cIgAN), an IgAN subset with vasculitic lesions and poor response to conventional immunosuppressive regimens.2 We present the results of a multicentre cohort of patients with IgAV and cIgAN treated with RTX.
Method
The databases of 16 consorted European centres were investigated to screen for patients with adult-onset, biopsy-proven IgAV and cIgAN (crescents in ≥25% glomeruli and rapid eGFR worsening at presentation), who received RTX as induction therapy. We selected patients with active renal manifestations at the time of RTX. Remission was defined as a Birmingham Vasculitis Activity Score (BVAS)=0 or <5 if it was due to persistent proteinuria and relapse as an increase in BVAS requiring change in immunosuppressive therapy.
Results
We identified 38 patients with IgAV and 12 patients with cIgAN who received RTX and had active renal involvement at the time of treatment. The median age at onset was 40 years (interquartile range, IQR, 25-53) and more than two-thirds of patients were male (Table 1). The median follow-up after RTX was 41 months (IQR 18-60).
Renal outcomes are reported in Table 2. At the time of treatment, 24 patients (48%) had eGFR ≥60 mL/min/1.73 m2. All had IgAV and their median BVAS was 17 (IQR 10-22). Furthermore, all had microhaematuria and proteinuria. Renal histology showed mesangial or focal endocapillary proliferation in 12/17 (71%) patients who underwent biopsy (class II-IIIA according to Pillebout3). Twenty patients (83%) achieved remission; after a median of 12 months (range 9-14), four experienced a minor relapse and one had a major relapse with significant renal disease progression. Renal function remained stable in all but two patients who developed end-stage renal disease (ESRD). Micro-haematuria subsided in 14/24 (58%) and median 24h proteinuria decreased from 1750 mg (IQR 865-3275) to 175 mg (IQR 100-800) at last follow-up (p=0.029).
Of the 26 patients with eGFR <60 mL/min/1.73 m2, 14 had IgAV and 12 had cIgAN. All were biopsied and 20 (77%) had diffuse endo/extra-capillary proliferation (classes IIIB-IV). Five patients required dialysis but recovered soon after treatment start. Remission was achieved by 16/26 (61%); eight (50%) subsequently relapsed and two (12%) reached ESRD. At last follow-up, eGFR was ≥60 mL/min/1.73 m2 in 8/26 (31%), 10/26 (48%) had stable renal function as compared to the time of RTX, while 8/26 (31%) had developed ESRD. Median 24h proteinuria decreased from 3400 mg (IQR 2150-6500) to 770 mg (177-1315) (p=0.016).
Remission rate and ESRD-free survival were respectively 86% and 92% in patients with IgAV, while they were respectively 42% and 42% in cIgAN patients. Furthermore, 21/24 (87%) patients who received RTX alone or combined to glucocorticoids but not to immunosuppressive agents achieved remission and 22/24 (92%) were ESRD-free at last follow-up. Of the 26 patients receiving immunosuppressive agents, 17 (65%) obtained remission and 18 (69%) were ESRD-free at last assessment. Over the whole follow-up, only one patient reported a severe adverse effect related to RTX (pneumonia).
Conclusion
Renal involvement in adult-onset IgAV and cIgAN is frequently severe. RTX, combined or not with other immunosuppressive agents, may improve renal manifestations and is well tolerated. IgAV patients show higher remission rates and a longer ESRD-free survival as compared to cIgAN patients.
Collapse
Affiliation(s)
- Giorgio Trivioli
- Meyer Children's Hospital, Nephrology and Dialysis Unit, Florence, Italy
| | - Alice Canzian
- Parma University Hospital, Obstetrics and Gynecologic Unit, Parma, Italy
| | | | - Roberta Fenoglio
- San Giovanni Bosco Hospital, Centre of Research of Rheumatologic, Nephrologic and Rare Diseases, Turin, Italy
| | - Evangeline Pillebout
- Sant-Louis Hospital and University Paris Diderot, Department for Nephrology, Paris, France
| | - Maria Letizia Urban
- University of Firenze, Department of Experimental and Clinical Sciences, Florence, Italy
| | - Aladdin Mohammad
- Lund University, Department of Rheumatology, Clinical Science , Lund, Sweden
| | - Estela Nogueira
- Centro Hospitalar Universitário Lisboa Norte, Division of Nephrology and Renal Transplantation, Lisboa, Portugal
| | - Elena Silvestri
- University of Firenze, Department of Experimental and Clinical Sciences, Florence, Italy
| | - Per Eriksson
- Linkoeping University, 10. Department of Medical and Health Sciences, Linkoping, Sweden
| | - Mårten Segelmark
- Linkoeping University, Department of Nephrology, Linkoping, Sweden
| | - Pavel Novikov
- Sechenov First Moschow State Medical University, Clinic of Nephrology, Internal and Occupational Diseases, Moscow, Russia
| | - Helen Harris
- Whyteman’s Brae Hospital, Rheumatology Unit, Kirkcaldy, United Kingdom
| | | | - Sergey Moiseev
- Sechenov First Moschow State Medical University, Clinic of Nephrology, Internal and Occupational Diseases, Moscow, Russia
| | | | | | - Cristina Ponte
- Lisbon Academic Medical Centre, Rheumatology, Lisboa, Portugal
| | - Peter Lamprecht
- University of Lübeck, Department of Rheumatology and Clinical Immunology, Lübeck, Germany
| | - Alojzija Hocevar
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia
| | - Omer Karadag
- Hacetteppe University, Vasculitis Research Centre, Ankara, Turkey
| | - Mark Little
- Tallgath Hospital, Trinity Health Kidney Centre, Dublin, Ireland
| | - Giacomo Emmi
- University of Firenze, Department of Experimental and Clinical Sciences, Florence, Italy
| | - David Jayne
- University of Cambridge, Department of Medicine, Cambridge, United Kingdom
- Addenbrooke’s Hospital, Vasculitis and Lupus Clinic, Cambridge, United Kingdom
| | - Stephen Mcadoo
- Imperial College London, Centre for Inflammatory Disease, London, United Kingdom
| | - Dario Roccatello
- San Giovanni Bosco Hospital, Centre of Research of Rheumatologic, Nephrologic and Rare Diseases, Turin, Italy
- University of Turin, Centre of Research of Rheumatologic, Nephrologic and Rare Diseases, Turin, Italy
| | - Augusto Vaglio
- Meyer Children's Hospital, Nephrology and Dialysis Unit, Florence, Italy
- University of Florence, Department of Biomedical Experimental and Clinical Sciences, Florence, Italy
| |
Collapse
|
37
|
Roccatello D, Sciascia S, Fenoglio R, Rossi D. A new challenge for lupus nephritis management: Induction therapy without immunosuppressive maintenance regimen. Autoimmun Rev 2021; 20:102844. [PMID: 33971336 DOI: 10.1016/j.autrev.2021.102844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy.
| | - Savino Sciascia
- CMID-Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Daniela Rossi
- CMID-Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| |
Collapse
|
38
|
Mancardi D, Arrigo E, Cozzi M, Cecchi I, Radin M, Fenoglio R, Roccatello D, Sciascia S. Endothelial dysfunction and cardiovascular risk in lupus nephritis: New roles for old players? Eur J Clin Invest 2021; 51:e13441. [PMID: 33128260 DOI: 10.1111/eci.13441] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 09/11/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022]
Abstract
In systemic lupus erythematosus (SLE) patients, most of the clinical manifestation share a vascular component triggered by endothelial dysfunction. Endothelial cells (ECs) activation occurs both on the arterial and venous side, and the high vascular density of kidneys accounts for the detrimental outcomes of SLE through lupus nephritis (LN). Kidney damage, in turn, exerts a negative feedback on the cardiovascular (CV) system aggravating risk factors for CV diseases such as hypertension, stroke and coronary syndrome among others. Despite the intensive investigation on SLE and LN, the role of endothelial dysfunction, as well as the underlying mechanisms, remains to be fully understood, with no specifically targeted pharmacological treatment. It is not known, in fact, if the activation pathway(s) in venous ECs are similar to the one in arterial ECs and doubts persist on the shared manifestation of microcirculation compared to macrocirculation. In this work, we aim to review the recent literature about the role of endothelial activation and dysfunction in the development of CV complications in SLE and LN patients. We, therefore, focus on arteriovenous similarities and differences and on specific pathways of great vessels compared to capillaries. Critically summarising the available data is of pivotal importance for both basic researchers and clinicians in order to develop and test new pharmacological approaches in the treatment of basic components of SLE and LN.
Collapse
Affiliation(s)
- Daniele Mancardi
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Elisa Arrigo
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Martina Cozzi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.,School of Specialization in Nephrology, University of Verona, Verona, Italy
| | - Irene Cecchi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Massimo Radin
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| |
Collapse
|
39
|
Quattrocchio G, Barreca A, Vaccarino A, Del Vecchio G, De Simone E, Fenoglio R, Ferro M, Pagliaro M, Pini M, Manes M, Roccatello D. Monoclonal Gammopathy of Renal Significance: Clinical and Histological Efficacy of a Bortezomib-Based Regimen. Front Med (Lausanne) 2020; 7:587345. [PMID: 33392216 PMCID: PMC7772466 DOI: 10.3389/fmed.2020.587345] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/23/2020] [Indexed: 12/20/2022] Open
Abstract
Monoclonal Gammopathy of Renal Significance (MGRS) is a group of heterogeneous disorders characterized by renal dysfunction secondary to the production of a monoclonal immunoglobulin by a nonmalignant B cell or plasma cell clone. We report the clinical and histological outcomes of two patients with biopsy-proven MGRS: one patient showed membranoproliferative glomerulonephritis with monoclonal k-light chain and C3 deposits, the second patient showed immunotactoid glomerulopathy. Both patients were treated with a 9-month chemotherapy protocol including bortezomib, cyclophosphamide, and dexamethasone. Renal biospy was repeated after 1 year. The estimated glomerular filtration rate (eGFR) increased from 22.5 (baseline) to 40 ml/min per 1.73 m2 after 12 months, then to 51.5 ml/min per 1.73 m2 after 24 months; proteinuria decreased from 4.85 (baseline) to 0.17 g/day after 12 months, then to 0.14 g/day after 24 months. Repeat renal biopsies showed a dramatic improvement of the glomerular proliferative lesions and near complete disappearance of the immune deposits. A bortezomib-based treatment proved very effective and was well-tolerated in the two patients presenting with clinically and histologically aggressive MGRS.
Collapse
Affiliation(s)
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Antonella Vaccarino
- Hematology and Thrombotic Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Roberta Fenoglio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Maria Pagliaro
- Hematology and Thrombotic Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Pini
- Hematology and Thrombotic Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Manes
- Nephrology and Dialysis Unit, Umberto Parini Hospital, Aosta, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, Turin, Italy.,Center of Research of Immunopathology and Rare Diseases (CMID), Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| |
Collapse
|
40
|
Fenoglio R, Roccatello D, De Simone E, Del Vecchio G, Ferro M, Quattrocchio G, Barreca A, Sciascia S. The Challenging Management of Cancer: An Immunonephrologist's Perspective. Kidney Blood Press Res 2020; 46:114-120. [PMID: 33326976 DOI: 10.1159/000511256] [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] [Received: 06/19/2020] [Accepted: 08/31/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Onconephrology is an emerging medical subspecialization that focuses on the numberless interrelations between cancer and kidney diseases. Tumor cells evade immune surveillance through activation of immune checkpoint pathways that suppress antitumor immune responses. By blocking checkpoints, new anticancer agents disrupt immune homeostasis but potentially induce immune-mediated diseases. Nephrologists and nephroimmunologists should be able to treat the nephrotoxic sequelae of cancer therapy and ensure continuation of the life-saving treatment. METHODS Thirty-seven renal biopsies have been carried out over 42 months in oncologic patients, that is, 5.2% of the total native renal biopsies were carried out in the same period. The commonest diagnoses (>6 cases) were interstitial tubular nephritis, membranous glomerulopathy, IgA nephropathy, vasculitis, and focal and segmental glomerulosclerosis. CASE PRESENTATION Three example cases, including focusing on key questions which could involve the nephrologists are reported in detail. They include a cancer-related Goodpasture Syndrome, the peculiar toxic effects of pemetrexed on tubular cells, and the intriguing relationship between bevacizumab and cryoglobulinemic glomerulonephritis. CONCLUSION As shown by these 3 example cases, nephrologists need to be open-minded with regard to kidney biopsy in order to get a timely diagnosis. Nephrologists also need to improve their knowledge of cancer biology and therapy in order to prevent kidney problems, manage therapy-related immune-mediated disorders, and improve patient life expectancy.
Collapse
Affiliation(s)
- Roberta Fenoglio
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy,
| | - Emanuele De Simone
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giacomo Quattrocchio
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| |
Collapse
|
41
|
Quattrocchio G, Barreca A, Demarchi A, Fenoglio R, Ferro M, Del Vecchio G, Massara C, Rollino C, Sciascia S, Roccatello D. Long-term effects of intensive B cell depletion therapy in severe cases of IgG4-related disease with renal involvement. Immunol Res 2020; 68:340-352. [PMID: 33174125 PMCID: PMC7674183 DOI: 10.1007/s12026-020-09163-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 08/05/2020] [Accepted: 10/30/2020] [Indexed: 12/19/2022]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated disorder often showing elevated serum IgG4 concentrations, dense T and B lymphocyte infiltration, and IgG4-positive plasma cells and storiform fibrosis. We prospectively evaluated for 4 years 5 patients with histologically proven IgG4-RD of whom 3 had tubulointerstitial nephritis (TIN) and 2 had retroperitoneal fibrosis (RPF). They received an intensive B depletion therapy with rituximab. The estimated glomerular filtration rate of TIN patients after 1 year increased from 9 to 24 ml/min per 1.73 m2. IgG/IgG4 dropped from 3236/665 to 706/51 mg/dl, C3/C4 went up from 49/6 to 99/27 mg/dl, and the IgG4-RD responder index fell from 10 to 1. CD20+ B cells decreased from 8.7 to 0.5%. A striking drop in interstitial plasma cell infiltrate as well as normalization of IgG4/IgG-positive plasma cells was observed at repeat biopsy. Both clinical and immunological improvement persisted over a 4-year follow-up. Treating these patients who were affected by aggressive IgG4-RD with renal involvement in an effort to induce a prolonged B cells depletion with IgG4 and cytokine production decrease resulted in a considerable rise in eGFR, with IgG4-RD RI normalization and a noteworthy improvement in clinical and histological features. Furthermore, the TIN subgroup was shown not to need for any maintenance therapy.
Collapse
Affiliation(s)
- Giacomo Quattrocchio
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
| | - Antonella Barreca
- Department of Biomedical Sciences, University of Turin, Turin, Italy
| | | | - Roberta Fenoglio
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Carlo Massara
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Cristiana Rollino
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| |
Collapse
|
42
|
Vaisitti T, Sorbini M, Callegari M, Kalantari S, Bracciamà V, Arruga F, Vanzino SB, Rendine S, Togliatto G, Giachino D, Pelle A, Cocchi E, Benvenuta C, Baldovino S, Rollino C, Fenoglio R, Sciascia S, Tamagnone M, Vitale C, Calabrese G, Biancone L, Bussolino S, Savoldi S, Borzumati M, Cantaluppi V, Chiappero F, Ungari S, Peruzzi L, Roccatello D, Amoroso A, Deaglio S. Clinical exome sequencing is a powerful tool in the diagnostic flow of monogenic kidney diseases: an Italian experience. J Nephrol 2020; 34:1767-1781. [PMID: 33226606 PMCID: PMC8494711 DOI: 10.1007/s40620-020-00898-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Received: 05/28/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
Background A considerable minority of patients on waiting lists for kidney transplantation either have no diagnosis (and fall into the subset of undiagnosed cases) because kidney biopsy was not performed or histological findings were non-specific, or do not fall into any well-defined clinical category. Some of these patients might be affected by a previously unrecognised monogenic disease. Methods Through a multidisciplinary cooperative effort, we built an analytical pipeline to identify patients with chronic kidney disease (CKD) with a clinical suspicion of a monogenic condition or without a well-defined diagnosis. Following the stringent phenotypical and clinical characterization required by the flowchart, candidates meeting these criteria were further investigated by clinical exome sequencing followed by in silico analysis of 225 kidney-disease-related genes. Results By using an ad hoc web-based platform, we enrolled 160 patients from 13 different Nephrology and Genetics Units located across the Piedmont region over 15 months. A preliminary “remote” evaluation based on well-defined inclusion criteria allowed us to define eligibility for NGS analysis. Among the 138 recruited patients, 52 (37.7%) were children and 86 (62.3%) were adults. Up to 48% of them had a positive family history for kidney disease. Overall, applying this workflow led to the identification of genetic variants potentially explaining the phenotype in 78 (56.5%) cases. Conclusions These results underline the importance of clinical exome sequencing as a versatile and highly useful, non-invasive tool for genetic diagnosis of kidney diseases. Identifying patients who can benefit from targeted therapies, and improving the management of organ transplantation are further expected applications. Electronic supplementary material The online version of this article (10.1007/s40620-020-00898-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tiziana Vaisitti
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy
| | - Monica Sorbini
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy
| | - Martina Callegari
- Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Silvia Kalantari
- Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Valeria Bracciamà
- Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Francesca Arruga
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy
| | - Silvia Bruna Vanzino
- Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Sabina Rendine
- Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Gabriele Togliatto
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy
| | - Daniela Giachino
- Service of Genetic Counseling, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy.,Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Alessandra Pelle
- Service of Genetic Counseling, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Enrico Cocchi
- Pediatric Nephrology Dialysis and Transplantation Unit, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Chiara Benvenuta
- Pediatric Nephrology Dialysis and Transplantation Unit, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Simone Baldovino
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Cristiana Rollino
- Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Roberta Fenoglio
- Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | | | - Corrado Vitale
- Nephrology and Dialysis Unit, Ordine Mauriziano di Torino, Turin, Italy
| | | | - Luigi Biancone
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy.,Renal Transplantation Unit 'A. Vercellone,' Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy
| | | | | | - Maurizio Borzumati
- Nephrology and Dialysis Unit of Verbania ASL VCO, Verbano Cusio Ossola, Verbania, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Maggiore Della Carità University Hospital, Novara, Italy
| | | | - Silvana Ungari
- Struttura Semplice Genetics and Molecular Biology, ASL CN1, Cuneo, Italy
| | - Licia Peruzzi
- Pediatric Nephrology Dialysis and Transplantation Unit, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Antonio Amoroso
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy. .,Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy.
| | - Silvia Deaglio
- Department of Medical Sciences, University of Turin, via Santena 19, 10126, Turin, Italy.,Immunogenetics and Transplant Biology Service, Città della Salute e della Scienza University Hospital, Turin, Italy
| |
Collapse
|
43
|
Rossi D, Sciascia S, Fenoglio R, Ferro M, Baldovino S, Kamgaing J, Ventrella F, Kalikatzaros I, Viziello L, Solfietti L, Barreca A, Roccatello D. Cryoglobulinemic glomerulonephritis: clinical presentation and histological features, diagnostic pitfalls and controversies in the management. State of the art and the experience on a large monocentric cohort treated with B cell depletion therapy. Minerva Med 2020; 112:162-174. [PMID: 33198442 DOI: 10.23736/s0026-4806.20.07076-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cryoglobulinemia is defined by the presence of immunoglobulins having the following characteristics: forming a gel when temperature is <37 °C, precipitate in a reversible manner in the serum, and redissolve after rewarming. The presence of both polyclonal IgG and monoclonal IgM (type II), or of polyclonal IgG and polyclonal IgM (type III) identifies the mixed cryoglobulinemia (MC). The identification of the Hepatitis C virus (HCV) infection in most of the cases previously defined as "essential" represented a cornerstone in the understanding the pathogenesis of this condition. The picture of MC comprehends heterogeneous clinical presentations: from arthralgias, mild palpable purpura, fatigue to severe vasculitis features with skin necrotic pattern, peripheral neuropathy and, less commonly, lungs, central nervous system, gastrointestinal tract, and heart involvement. The kidney represents the most common organ presentation, and the presence of glomerulonephritis is a key element when considering prognosis. We discuss the clinical presentation and histological features, diagnostic pitfalls, and controversies in the management of patients with cryoglobulinemic glomerulonephritis, with a special focus on reporting our experience in treating patients with B cell depletion therapy.
Collapse
Affiliation(s)
- Daniela Rossi
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Savino Sciascia
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Michela Ferro
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Simone Baldovino
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Joelle Kamgaing
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Federica Ventrella
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Ileana Kalikatzaros
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Lucia Viziello
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Laura Solfietti
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Antonella Barreca
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy.,Patology Division, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Dario Roccatello
- Unit of Nephrology and Dialysis (ERKnet Member), Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, University of Turin, Turin, Italy -
| |
Collapse
|
44
|
Fenoglio R, Roccatello D, Sciascia S. Rituximab, Cyclophosphamide, and Corticosteroids for ANCA Vasculitis: The Good, the Bad, and the Ugly. Kidney Blood Press Res 2020; 45:784-791. [PMID: 33045710 DOI: 10.1159/000509608] [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] [Received: 06/09/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUNDS ANCA-associated vasculitis (AAV) frequently present with a chronic relapsing course. Relapse leads to an increased need for therapeutic agents and consequent toxicity. SUMMARY When referring to the available options for the management of AAV, the efficacy of glucocorticoids (GCs) is unquestionable. However, similarly unquestionable are their side effects. It has been more than 40 years since the efficacy of cyclophosphamide (CYC) as an add-on therapy to GCs in the management of necrotizing vasculitis has been proven. At the same time, concerns about the devastating side effects related to a prolonged exposure to this agent were raised. Despite the well-known side effects, the management of AAV remained centred on CYC until the early 2000s, when the pilot data first supporting the anecdotal efficacy of rituximab (RTX) were reported. However, it was not until 2010 that the non-inferiority of RTX to CYC for remission-induction in AAVs was demonstrated in 2 randomized controlled trials. Key Messages: Treatment of AAV has improved over the last decade, and currently available strategies are able to induce remission in the majority of the cases. Herewith, we aim to critically review available evidence and to critically address the following question: How can we reduce the GCs use the management of patients with AAV? Novel strategies that avoid the toxicity associated with currently used agents should be the goal. Ideally, these approaches should be GC-free.
Collapse
Affiliation(s)
- Roberta Fenoglio
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy,
| | - Savino Sciascia
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| |
Collapse
|
45
|
Roccatello D, Fenoglio R, Naretto C, Baldovino S, Sciascia S, Ferro M, Rossi D. Daratumumab Monotherapy in Severe Patients with AL Amyloidosis and Biopsy-Proven Renal Involvement: A Real Life Experience. J Clin Med 2020; 9:jcm9103232. [PMID: 33050272 PMCID: PMC7600836 DOI: 10.3390/jcm9103232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Objectives: This paper aims to describe the clinical experience with Daratumumab (DARA), a first-in-class anti-CD38 human monoclonal IgG1κ antibody monotherapy, in severe patients with AL and biopsy-proven renal involvement. Immunoglobulin light chain (AL) amyloidosis with multi-organ involvement is characterized by short survival. Novel powerful drugs are expanding the therapeutic options. Current treatment of AL amyloidosis, which has been adopted from multiple myeloma (MM), is based on chemotherapy targeting the underlying plasma cell clone. DARA is effective in treating MM. The clinical activity and toxicity profile of DARA as a single agent in the treatment of AL amyloidosis is currently under evaluation. Patients and Methods: DARA was administered in a series of patients with severe AL amyloidosis and biopsy-proven renal involvement. Five patients(mean age 64.2 years) were treated. One patient was refractory and one intolerant to conventional bortezomib-based therapy, two were treated with DARA for relapsing disease, and one was treated front-line. Results: Data showed that DARA monotherapy resulted in good clinical results, with the disappearance of M-proteins in four out of five patients and with serum free light chains (sFLC) ratio normalization in three out of four and a remarkable amelioration in the remaining patient. The four patients with still preserved renal function at baseline also showed serum creatinine stabilization or improvement and a decrease in proteinuria. These data were paralleled by the reduction of the N-terminal prohormone of brain natriuretic peptide (NT pro-BNP)values. Conclusions: Our data show that monotherapy with DARA had significant clinical efficacy in pretreated/naïve patients with severe AL amyloidosis and biopsy-proven renal involvement.
Collapse
|
46
|
Sciascia S, Radin M, Ramirez C, Seaman A, Bentow C, Casas S, Cecchi I, Rubini E, Foddai SG, Baldovino S, Fenoglio R, Menegatti E, Roccatello D, Mahler M. Evaluation of novel assays for the detection of autoantibodies in antiphospholipid syndrome. Autoimmun Rev 2020; 19:102641. [PMID: 32801044 DOI: 10.1016/j.autrev.2020.102641] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 03/07/2020] [Accepted: 03/16/2020] [Indexed: 12/31/2022]
Abstract
Patients with antiphospholipid syndrome (APS) present with clinical features of recurrent thrombosis and pregnancy morbidity and persistently test positive for the presence of antiphospholipid antibodies (aPL). At least one clinical (vascular thrombosis or pregnancy morbidity) and one lab-based (positive test result for lupus anticoagulant, anticardiolipin antibodies and/or anti-β2-glycoprotein 1 antibodies) criterion have to be met for a patient to be classified as having APS. Nevertheless, the clinical variety of APS encompasses additional signs and symptoms, potentially affecting any organ, that cannot be explained exclusively by a prothrombotic state. Those manifestations, also known as extra-criteria manifestations, include haematologic (thrombocytopenia and haemolytic anaemia), neurologic (chorea, myelitis and migraine) manifestations as well as the presence of livedo reticularis, nephropathy and valvular heart disease. The growing body of evidence describing the clinical aspect of the syndrome has been paralleled over the years by emerging research interest focusing on the development of novel biomarkers that might improve the diagnostic accuracy for APS when compared to the current aPL tests. This review will focus on the clinical utility of extra-criteria aPL specificities. Besides, the promising role of a new technology using particle based multi-analyte testing that supports aPL panel algorithm testing will be discussed. Diagnostic approaches to difficult cases, including real-world case studies investigating the diagnostic added value of extra criteria aPL, particularly anti-phosphatidylserine/prothrombin, will also be examined.
Collapse
Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy.
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | | | | | | | | | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Roberta Fenoglio
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Elisa Menegatti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | | |
Collapse
|
47
|
Roccatello D, Fenoglio R, Baldovino S, Naretto C, Ferro M, Barreca A, Rossi D, Sciascia S. Towards a novel target therapy for renal diseases related to plasma cell dyscrasias: The example of AL amyloidosis. Autoimmun Rev 2020; 19:102622. [PMID: 32663622 DOI: 10.1016/j.autrev.2020.102622] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/11/2020] [Indexed: 11/24/2022]
Abstract
Immunoglobulin light chain amyloidosis is a rare systemic disease caused by monoclonal light chains (LCs) depositing in tissue as insoluble fibrils resulting in irreversible damage of vital organs. The mechanisms involved in aggregation and deposition of LCs are not fully understood, but CD138/38 plasma cells are undoubtedly involved in monoclonal LC production. We are reporting favorable effects on AL amyloidosis patients with renal involvement using the anti-CD38 monoclonal antibody Daratumumab. We speculate that research for the near future should be devoted to design similar therapeutic approaches for other diseases attributable to a plasma cell dyscrasia.
Collapse
Affiliation(s)
- Dario Roccatello
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
| | - Roberta Fenoglio
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Simone Baldovino
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Carla Naretto
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Antonella Barreca
- Pathology Division, Department of Oncology, University of Turin, Italy
| | - Daniela Rossi
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Unit-CMID, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital of Turin, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| |
Collapse
|
48
|
Roccatello D, Fenoglio R, Sciascia S, Naretto C, Rossi D, Ferro M, Barreca A, Malavasi F, Baldovino S. CD38 and Anti-CD38 Monoclonal Antibodies in AL Amyloidosis: Targeting Plasma Cells and beyond. Int J Mol Sci 2020; 21:E4129. [PMID: 32531894 PMCID: PMC7312896 DOI: 10.3390/ijms21114129] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin light chain amyloidosis (AL amyloidosis) is a rare systemic disease characterized by monoclonal light chains (LCs) depositing in tissue as insoluble fibrils, causing irreversible tissue damage. The mechanisms involved in aggregation and deposition of LCs are not fully understood, but CD138/38 plasma cells (PCs) are undoubtedly involved in monoclonal LC production.CD38 is a pleiotropic molecule detectable on the surface of PCs and maintained during the neoplastic transformation in multiple myeloma (MM). CD38 is expressed on T, B and NK cell populations as well, though at a lower cell surface density. CD38 is an ideal target in the management of PC dyscrasia, including AL amyloidosis, and indeed anti-CD38 monoclonal antibodies (MoAbs) have promising therapeutic potential. Anti-CD38 MoAbs act both as PC-depleting agents and as modulators of the balance of the immune cells. These aspects, together with their interaction with Fc receptors (FcRs) and neonatal FcRs, are specifically addressed in this paper. Moreover, the initiallyavailable experiences with the anti-CD38 MoAb DARA in AL amyloidosis are reviewed.
Collapse
Affiliation(s)
- Dario Roccatello
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| | - Roberta Fenoglio
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| | - Savino Sciascia
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| | - Carla Naretto
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| | - Daniela Rossi
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| | - Michela Ferro
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| | - Antonella Barreca
- Pathology Division, Department of Oncology, University of Turin, 10154 Turin, Italy;
| | - Fabio Malavasi
- Department of Medical Science, University of Turin, and Fondazione Ricerca Molinette, 10154 Turin, Italy;
| | - Simone Baldovino
- Nephrology and Dialysis Unit & CMID (Center of Research of Immunopathology and Rare Diseases), Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital of Turin, and Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (R.F.); (S.S.); (C.N.); (D.R.); (M.F.); (S.B.)
| |
Collapse
|
49
|
Roccatello D, Fenoglio R, Kamgaing J, De Simone E, Del Vecchio G, Ferro M, Quattrocchio G, Rabajoli G, Concas MR. P0245PERCUTANEOUS RENAL BIOPSY IN FRAIL AND HIGH RISK PATIENTS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0245] [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: 11/13/2022] Open
Abstract
Abstract
Background and Aims:
Many patients with End Stage Kidney Disease do not undergo percutaneous kidney biopsy (KB) and do lack a definite diagnosis. Whether KB is beneficial in the extreme patients’ categories, i.e., age >75 years and very late referrals with kidney disease requiring renal replacement therapy at the first evaluation, remains controversial. Aim: To analyse the benefit/risk balance in terms of therapeutic options and general outcome of KB procedure in these borderline categories.
Method
Files for all biopsies performed in our Centre between 2013 and 2019 (# 903 inpatients’ native kidney) were retrospectively analysed with special focus on histological diagnosis, biopsy complications, and post-biopsy patient’s outcome. Two groups of high risk patients were identified 1. >75 years old patients, and 2. patients requiring dialysis at the first clinical evaluation. A rigorous protocol of screening of the bleeding risks was adopted.
Results
Of the 903 biopsies, 217 cases (24%) had group 1, and 92 (10%) group 2 criteria. Group 1: mean age 80 years (range 75-92), main histological diagnoses: ANCA associated vasculitis (AAV) (12,4%); membranous nephropathy (MN) (11,5%), diabetic nephropathy (10,1%), IgA glomerulonephritis (IgAGN) (9,2%), cast nephropathy (9,2%), renal amyloidosis (9.2%), focal segmental glomerulosclerosis (FSGS - 7,8 %). Group 2: mean age 60 years (range 20-92), most frequent histological diagnosis: AAV (26,1%); cast nephropathy (19,6 %), nephroangiosclerosis (9,8%), IgAGN (7,6 %), diabetic nephropathy (6,5%), renal amyloidosis (5,4%); FSGS (4,3%). Five major complications (2,3%), including AV fistula with spontaneous resolution in 4 patients and 1 case of severe bleeding requiring arterial embolization, and 14 minor complications (6,5%), including post biopsy haematomas <2cm in 12 patients and haematuria in 2 patients were observed in group 1. Only 1 (1%) major complication (AV fistula) and 4 minor complications (4,3%), including post biopsy <2cm haematomas in group 2 were identified in group 2. Histological diagnosis conditioned or changed treatment strategy in 71% of elderly patients (group 1), and 63% of patients in dialysis (group 2). Dialysis discontinuation was achieved in 30 out of 92 patients (36,6%) with a sparing of over 1 million euro/year.
Conclusion
Given its high diagnostic value (especially in patients who are willing to be transplanted), the prognostic significance (and the assessment of the extent of the renal sclerotic changes), and the potential impact on the treatment policy, indications to percutaneous kidney biopsy in elderly and dialysis patients should be probably revised.
Collapse
Affiliation(s)
- Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Joelle Kamgaing
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Emanuele De Simone
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Giulio Del Vecchio
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Michela Ferro
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Giacomo Quattrocchio
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Gianluca Rabajoli
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Maria Rosaria Concas
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| |
Collapse
|
50
|
Fenoglio R, Cozzi M, Sciascia S, De Simone E, Del Vecchio G, Ferro M, Quattrocchio G, Naretto C, Caputo G, Careddu A, Roccatello D. P0206RITUXIMAB IN ADULT ONSET OF IGA VASCULITIS WITH SEVERE RENAL INVOLVEMENT: A SINGLE CENTER EXPERIENCE. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0206] [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: 11/13/2022] Open
Abstract
Abstract
Background and Aims
IgA-vasculitis (IgAV) is a systemic small vessels vasculitis characterized by deposition of underglycosylated IgA1 immune complexes. Renal involvement indicates severity of illness and chronic kidney disease represents the most serious long-term complication of IgAV. Presently, no treatment is specifically recommended in IgAV Glucocorticoids (GC) have been traditionally thought to be effective in tempering systemic symptoms, but did not show long-term benefits either in reducing flares or progression of kidney disease. The effectiveness of conventional immunosuppressants is controversial. Recently Rituximab (RTX) has been proved to be effective in a few case series of adults with IgAV. However, long term results are lacking. Aim of the study: to evaluate the effectiveness of RTX as first line therapy in induction and maintenance of remission of adults with IgAV with biopsy-proven crescentic glomerulonephritis.
Method
We reviewed the clinical records of patients with adult-onset IgAV treated with RTX at our Center. Patients included 8 males and 4 females, mean age 45 years (range 19-75) with mean follow-up duration of 31 months (range 6-144). Diagnosis was based on the combination of clinical assessment, serological tests and histological analysis according to EULAR criteria. All patients (pts) had a biopsy proven IgAV- severe nephritis. RTX was given for the treatment of relapsing or refractory disease or because of definite contraindications to standard dose CS and/or conventional immunosuppressants. Patients received 4 weekly doses of RTX (375 mg/m2) given alone (8 pts) or in combination with CS (4 pts). Disease activity was evaluated by Birmingham Vasculitis Activity Score version 3 at the onset and at 1, 6 and 12 months and at the end of follow up. Complete remission (CR) was defined as BVAS of 0
Results
Eleven pts (91.7%) achieved a clinical response at 6 months. Ten pts had a CR while 1 pt had a partial response and was given an additional dose of RTX after 12 months from induction due to persistent proteinuria (1gr/24 hrs), despite systemic remission. He achieved a CR 6 months later. One patient did not respond to RTX and was switched to MMF. Among the 10 pts with CR, 1 patient needed maintenance doses of RTX every 6 months due to relapse of palpable purpura; 1 relapsed after 15 months and received a new induction course showing a CR again.
Significant decrease in 24-hour proteinuria (P = 0.043), BVAS (P = 0.031),and CRP level from RTX initiation through the last follow-up visit was detected. RTX was generally well tolerated. One patient, who had a CR with RTX alone died after 6 months of follow-up for cardiovascular cause.
Conclusion
This extended experience confirms our initial results supporting the use of RTX in the treatment of IgAV with severe renal involvement. Indeed, RTX proved to be effective and safe for induction and maintenance of long-lasting remission. Present data also suggest that RTX is not only effective for severe and refractory IgAV, but can be also proposed as a first line therapy.
Collapse
Affiliation(s)
- Roberta Fenoglio
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Martina Cozzi
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Savino Sciascia
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Emanuele De Simone
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Giulio Del Vecchio
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Michela Ferro
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Giacomo Quattrocchio
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Carla Naretto
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Giorgia Caputo
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Andrea Careddu
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| | - Dario Roccatello
- CMID-Nephrology and Dialysis Unit (ERK-net Member)-Center of Research of Nephrology, Rheumatology, and Rare Diseases, Interregional Coordinating Center of the Network of Rare Diseases,, G. Bosco Hospital and University of Turin, Italy, Turin, Italy
| |
Collapse
|