Relapse rate and renal prognosis in ANCA-associated vasculitis according to long-term ANCA patterns

Long-term observation of patients with ANCA-associated vasculitis (AAV) allows the identification of different longitudinal patterns of ANCA levels during follow-up. This study aimed to characterize these patterns and to determine their prognostic significance. All ANCA determinations performed in two university hospitals during a 2-year period were retrospectively reviewed. Patients were included in the analysis if they had high titers of anti-myeloperoxidase (anti-MPO) or anti-proteinase 3 (anti-PR3) antibodies at least once, ≥ 5 serial ANCA determinations and AAV diagnosed by biopsy or American College of Rheumatology (ACR) classification criteria. Patients' time-course ANCA patterns were classified as monophasic, remitting, recurrent or persistent. Associations between ANCA patterns and prognostic variables (relapse rate and renal outcome) were analysed by univariate and multivariate statistics. A total of 99 patients [55 with microscopic polyangiitis (MPA), 36 with granulomatosis with polyangiitis (GPA) and eight with eosinophilic granulomatosis with polyangiitis (EGPA)] were included. Median follow-up was 9 years. Among patients diagnosed with MPA or GPA, recurrent or persistent ANCA patterns were associated with a higher risk of clinical relapse [hazard ratio (HR) = 3·7, 95% confidence interval (CI) = 1·5-9·1 and HR = 2·9, 95% CI = 1·1-8·0, respectively], independently of clinical diagnosis or ANCA specificity. In patients with anti-MPO antibodies, the recurrent ANCA pattern was associated with worsening renal function [odds ratio (OR) = 5·7, 95% CI = 1·2-26·0]. Recurrent or persistent ANCA patterns are associated with a higher risk of clinical relapse. A recurrent ANCA pattern was associated with worsening renal function in anti-MPO-associated vasculitis.

Identification of Pen m 4 as a potential cause of occupational asthma to Gammarus shrimp

We present the case of a 34-year-old male patient employed for 8 years in a company manufacturing and packaging animal feed. The patient developed occupational asthma to dry Gammarus powder. The diagnosis was confirmed by specific bronchial provocation test. The determination of specific IgE antibodies was positive for Pen m 4, a sarcoplasmic calcium binding protein, with a level of 6.7 ISU-E. The sensitization to Pen m 4 described here may identify a new allergen causing occupational asthma in these workers.

Sperm telomere length in motile sperm selection techniques: A qFISH approach

Several studies have associated telomere shortening with alterations in reproductive function. The objective of the present study was to determine telomere length (TL) in spermatozoa selected by either density-gradient centrifugation (DGC) or swim-up. The analysis of TL was performed using quantitative fluorescent in situ hybridisation (qFISH) using PNA probes in combination with a chromatin decompaction protocol in sperm cells. Results of TL were 24.64 ± 5.00 Kb and 24.95 ± 4.60 Kb before and after DGC, respectively, and 19.59 ± 8.02 Kb and 20.22 ± 5.18 Kb before and after swim-up respectively. Sperm selected by DGC or swim-up did not show any significant differences in TL as compared to nonselected sperm (p > .05). Negative correlations between TL and sperm motility (r = -.308; p = .049) and concentration (r = -.353; p = .028) were found. Furthermore, exposure of sperm to increasing concentrations of hydrogen peroxide during incubation resulted in a reduction in TL. These data indicate that oxidative stress may be one of the main factors involved in the reduction of TL in sperm. Preliminary clinical results from patients included in this study indicate that TL was shorter in spermatozoa from couples who never achieved a pregnancy compared to couples who did achieve at least one natural pregnancy (p < .05); however, the clinical utility of this biomarker still needs to be confirmed in further studies.

Safe Reduction in CD4 Cell Count Monitoring in Stable, Virally Suppressed Patients With HIV Infection or HIV/Hepatitis C Virus Coinfection

BACKGROUND

It has been suggested that routine CD4 cell count monitoring in human immunodeficiency virus (HIV)-monoinfected patients with suppressed viral loads and CD4 cell counts >300 cell/μL could be reduced to annual. HIV/hepatitis C virus (HCV) coinfection is frequent, but evidence supporting similar reductions in CD4 cell count monitoring is lacking for this population. We determined whether CD4 cell count monitoring could be reduced in monoinfected and coinfected patients by estimating the probability of maintaining CD4 cell counts ≥200 cells/µL during continuous HIV suppression.

METHODS

The PISCIS Cohort study included data from 14 539 patients aged ≥16 years from 10 hospitals in Catalonia and 2 in the Balearic Islands (Spain) since January 1998. All patients who had at least one period of 6 months of continuous HIV suppression were included in this analysis. Cumulative probabilities with 95% confidence intervals were calculated using the Kaplan-Meier estimator stratified by the initial CD4 cell count at the period of continuous suppression initiation.

RESULTS

A total of 8695 patients were included. CD4 cell counts fell to <200 cells/µL in 7.4% patients, and the proportion was lower in patients with an initial count >350 cells/µL (1.8%) and higher in those with an initial count of 200-249 cells/µL (23.1%). CD4 cell counts fell to <200 cells/µL in 5.7% of monoinfected and 11.1% of coinfected patients. Of monoinfected patients with an initial CD4 cell count of 300-349 cells/µL, 95.6% maintained counts ≥200 cells/µL. In the coinfected group with the same initial count, this rate was lower, but 97.6% of coinfected patients with initial counts >350 cells/µL maintained counts ≥200 cells/µL.

CONCLUSIONS

From our data, it can be inferred that CD4 cell count monitoring can be safely performed annually in HIV-monoinfected patients with CD4 cell counts >300 cells/µL and HIV/HCV-coinfected patients with counts >350 cells/µL.

Effectiveness of omalizumab in non-allergic severe asthma

Omalizumab is an effective drug for allergic asthma. The purpose of this study was to evaluate the effectiveness and tolerance of this drug in non-allergic GINA step V asthma patients. This study was single-centre, prospective, open-label, observational, naturalistic. Non-allergic asthma patients requiring a mean dose of oral prednisolone of at least 5 mg/day during greater than or equal to 1 year or an accumulated oral corticosteroid dose/year greater than or equal to 1500 mg were enrolled. At entry and the end of the 12-month follow-up we measured blood eosinophilia and IgE concentration; at every monthly visit a forced spirometry and exhaled fraction of nitric oxide (NO) were carried out. The subjects were seven adult patients (5 female), age range 37-63 years, with the following mean values: IgE: 226.7+/-176 IU/mL; FVC 74+/-18 percent; FEV1 57+/-11 percent; NO: 21.2+/-7 ppb. The study was approved by the IRB of the hospital. One patient decided to stop treatment after 12 weeks and was excluded from the evaluation. We did not observe changes in eosinophil count, spirometry or NO values. Three patients considered responders did not need prednisolone during the follow-up. The mean daily dose of prednisolone fell from 6.6+/-8.1 mg/day at entry to 1.5+/-2.3 mg/day (p less than 0.16) at the end of follow-up. The mean monthly accumulated dose fell from 92+/-112 to 12+/-26 mg/month (p=0.26). Total blood IgE increased 1.93-fold. Side effects were only local: treatment tolerance was excellent; three out of six patients seemed to slightly benefit from anti-IgE treatment; to date there is no evidence strong enough to systematically prescribe omalizumab in non-allergic asthma patients.

[Type II essential mixed cryoglobulinemia and renal disease. Hepatitis C virus association]

Recently a number of studies have implicated C virus as a major cause of mixed cryoglobulinemia. Several authors described that up to 95% of "essential" mixed cryoglobulinemia could be attributed to this viral infection. Nevertheless, its prevalence and clinical significance are not well known. We review our experience in relation with the clinical, biological and evolutive characteristics of patients diagnosed of type II mixed cryoglobulinemia.

METHODS

Descriptive and protocolized study of all cases found to have type II mixed cryoglobulinemia over a period of 8 years. Secondary cryoglobulinemic nephropathy was defined in a restrictive way: a plasma creatinine > 1.5 mg/dl and/or proteinuria > 500 mg/24 h and/or hematuria (> 15 red blood cells) need to be present in the absence of any other pathological conditions that could justify these alterations. Furthermore, the information obtained from available kidney biopsies was considered.

RESULTS

62 patients have been detected. C virus infection was demonstrated in 44 (72%). 52% had clinical symptoms related with cryoglobulinemia. 56% had alteration of renal tests, and 17 (27%) fulfil the conditions for the diagnosis of cryoglobulinemic nephropathy (nearly all with persistent microhematuria, median proteinuria 4.2 +/- 3.9 g/24 h; median plasma creatinine 2.8 +/- 1.8 mg/dl). Nine patients had been histologically examined, showing 6 cases a membranoproliferative glomerulonephritis pattern, one with associated extraglomerular vasculitis; two with mesangial proliferative pattern and one with membranous glomerulonephritis. The most striking differences between cryoglobulinemic nephropathy patients and the rest has been: higher amount of cryoglobulins (49 +/- 28 vs 20 +/- 22); more frequent hypocomplementemia, especially C4 (93% vs 59%) and recurrent purpura (75% vs 32%). No differences in the presence of C virus infection could be observed (75% vs 71%).

IN CONCLUSION

72% of patients with type II mixed cryoglobulinemia are infected by C virus (so 28% in our serie are "essential"); 52% have symptoms related with the presence of cryoglobulins, half of them with cryoglobulinemic nephropathy.

Plasma levels of tumor necrosis factor alpha in patients with Mediterranean spotted fever: clinical and analytical correlations

Twenty consecutive patients with serologically confirmed Mediterranean spotted fever were analyzed for determination of plasma levels of tumor necrosis factor alpha (TNF-alpha) by means of an ELISA. Increased levels of TNF-alpha in plasma were found during the acute phase of the disease (52.3 +/- 49.8 pg/mL) compared to levels in the convalescent phase (9.0 +/- 9.3 pg/mL; P < .001) or in healthy controls (6.5 +/- 3.2 pg/mL; P < .001). Plasma TNF-alpha levels were significantly higher in patients with severe Mediterranean spotted fever. Levels of TNF-alpha correlated significantly with serum levels of C-reactive protein and triglycerides and inversely with serum levels of sodium.

Autoantibodies against a novel DNA-binding protein: DNA-protein interaction as a requisite for expression of antigenic reactivity

A novel DNA-binding protein complex, the HB complex, has been characterized by means of autoantibodies. Three proteins of 9000, 7500, and 7000 Da constitute the HB complex. The 9000- and 7500-Da proteins are phosphorylated. Autoantibodies recognize the 7000-Da protein when it is bound to DNA. No reactivity against any protein was observed when the complex was dissociated from DNA. The three proteins are acidic (pI 5-6.2), and the complex was able to bind to synthetic double-stranded DNAs of different composition.

Serological profile of tissue autoantibodies during acute and chronic delta hepatitis

In order to assess the serological profile in relation to other serological and histological markers of hepatitis delta virus (HDV) infection we have investigated the presence of autoantibodies during acute and chronic delta infection in 353 serum samples from different patients with acute and chronic hepatitis and autoimmune diseases. Basal cell layer antibodies (BCLA) were found in 58% acute hepatitis B, in 73% chronic hepatitis D and in 4% primary biliary cirrhosis. Stellate thymic epithelial cell antibodies (SECA) were detected in 40% acute D hepatitis and in 49% chronic D hepatitis. No tissue autoantibodies were detected in 50 acute B hepatitis, 35 autoimmune chronic liver diseases, 24 connective tissue diseases or 25 controls. In addition, two previously unreported specificities of anti-thymic antibodies reacting with reticular (TRA) and perithymocytic cells (PTA) were identified in 33% and 9% acute D hepatitis, respectively, and in 13% and 6% chronic D hepatitis cases. Among patients with acute HBV-HDV coinfection these antibodies were detected transiently (less than 4 weeks) and at low titer, whereas in those with chronic infection autoantibodies levels tend to be high and persistent throughout the follow-up. Among patients with chronic HDV infection no correlation was found between the presence of tissue autoantibodies and hepatic delta antigen expression and serum HDV-RNA which suggest that autoimmune phenomena observed during chronic delta infection are not related to the level of viral replication.

Autoantibodies in chronic delta virus infection recognize a common protein of 46 kD in rat forestomach basal cell layer and stellate thymic epithelial cells

Chronic hepatitis delta virus infection is associated with the presence of autoantibodies to rat forestomach and thymus in approximately 60% of patients' sera. We have characterized the antigen against which these autoantibodies are directed as a protein of 46 kD by immunoblotting studies on rat forestomach and thymus extracts. Normal human sera or sera from patients with other hepatic or non-hepatic autoimmune disorders did not bind to this protein. The immunoblot assay was more sensitive than immunofluorescence. Maximal titre was 1:10,000 versus 1:5120. By techniques of elution of specific antibodies from immunoblots, our results showed that the same antigen was present in both tissues. This antigen did not share common epitopes with hepatitis delta virus (HDV). Patients' sera depleted of basal cell layer and thymic stellate epithelial cell antibodies by absorption with the corresponding tissue extract maintained the HDV antibody titres. The autoimmune phenomena observed in patients with HDV infection seems to be a colateral process induced by the replication of delta virus in the host.

Characterization of the CB antigen, a DNA-binding protein recognized by autoantibodies and which has a differential expression in lymphoid cells

We have analyzed the characteristics of the CB Ag, a nuclear protein recognized by autoantibodies. Approximately 4% (12 out of 280) of the antinuclear-positive sera examined contained anti-CB antibodies. By immunofluorescence, these sera brightly stained the nuclei of most cells analyzed, including peripheral lymphocytes, but only dull or no staining was observed in thymocytes or B cells of the bursa of Fabricius. The CB Ag has been characterized as a DNA-binding protein, dissociable from DNA at 1.5 M NaCl, and with a Mr of 40,000 Da. Moreover, the ability of the extracted Ag to bind back to DNA has enabled us to design an ELISA system for its detection.

Characterization of the CB antigen, a DNA-binding protein recognized by autoantibodies and which has a differential expression in lymphoid cells

We have analyzed the characteristics of the CB Ag, a nuclear protein recognized by autoantibodies. Approximately 4% (12 out of 280) of the antinuclear-positive sera examined contained anti-CB antibodies. By immunofluorescence, these sera brightly stained the nuclei of most cells analyzed, including peripheral lymphocytes, but only dull or no staining was observed in thymocytes or B cells of the bursa of Fabricius. The CB Ag has been characterized as a DNA-binding protein, dissociable from DNA at 1.5 M NaCl, and with a Mr of 40,000 Da. Moreover, the ability of the extracted Ag to bind back to DNA has enabled us to design an ELISA system for its detection.

Characterization of the antigen reactive with anti-Scl-70 antibodies and its application in an enzyme-linked immunosorbent assay

The characteristics of the Scl-70 antigen (topoisomerase I) have been analyzed by means of autoantibodies. This antigen is a DNA-binding protein, dissociable from DNA at 0.3M NaCl and bound to a fraction of DNA that is very sensitive to nucleases. The molecular weight of the antigen is 105,000 daltons, whether dissociation conditions are used or not. Using chicken erythrocytes, and taking advantage of the strong interaction of the antigen with hydroxyapatite, we have designed a simple and fast purification protocol that allows the determination of anti-topoisomerase I antibodies by enzyme-linked immunosorbent assay.

Autoantibodies against the H1(0) subtype of histone H1

The specificity of antinuclear autoantibodies in a patient with a sensory neuropathy associated with cancer has been analyzed. The autoantibodies recognize the histone H1(0) as shown by its dissociation from DNA, perchloric solubility, electrophoretic mobility in SDS or urea/acid polyacrylamide gels, and by the capacity of purified H1(0) to block the reactivity of these autoantibodies. Almost no reactivity was observed with other subtypes of H1. To our knowledge, this is the first autoantibody described with such specific reactivity for the H1(0) subtype.

Effect of enzymatic treatments on RNP and Sm antigenic reactivities--I. Loss of RNP but increase of Sm antigenic reactivity after RNase treatment of nuclear extract

Changes of RNP and Sm antigenic reactivities of a nuclear extract after enzymatic treatments were studied and quantified by the ELISA test. After RNase treatment of the nuclear extract, about a 300% increase of the Sm antigenic reactivity and more than a 95% decrease of RNP antigenic reactivity was found. Data from RNP-depleted nuclear extracts and column fractionation show that the increase in Sm antigenic reactivity after RNase treatment mainly comes from the RNP-Sm complex.

Diffusing lung capacity and cyclosporine in patients with heart transplants

Pulmonary function studies were performed in 10 patients undergoing surgery for heart transplantation. The study was repeated 6 to 12 months after surgery. The comparison between data before and after transplantation showed an overall improvement in lung function indices, except for the lung diffusing capacity (DLCO). A mean 14% reduction (p less than 0.01) of DLCO was observed. In the absence of evidence of other lung disease or rejection reaction in these patients, this finding may be related to a side effect of cyclosporine on the lung and deserves further investigation.