A.L. Zignego

Treatment with rituximab in patients with mixed cryoglobulinemia syndrome: Results of multicenter cohort study and review of the literature

OBJECTIVE Mixed cryoglobulinemia syndrome (MCs) is a systemic vasculitis characterized by multiple organ involvement due to the vascular deposition of immune-complexes, mainly the cryoglobulins. B-lymphocyte expansion represents the underlying pathological alteration frequently triggered by hepatitis C virus (HCV) infection. The treatment of MCs syndrome is generally based on antiviral drugs and/or immunosuppressors, among which rituximab, an anti-CD20 monoclonal antibody, has been usefully employed for both cutaneous and visceral MCs organ involvement. This multicenter study retrospectively evaluated the effects of rituximab in a large series of patients with active MCs. The observed results were compared to those emerging from the updated review of the literature on this topic. METHODS The study included 87 patients (male/female 19/68, mean age 62.3±11.4SD years, mean disease duration 9±6.2SD years, HCV infection in 92% of cases) with active cryoglobulinemic vasculitis evaluated before rituximab monotherapy and after 6-month follow-up by means of main clinico-serological parameters. A PubMed search up to May 31, 2011, was done to find published clinical studies, including case reports of MCs treated with rituximab. RESULTS A significant clinical improvement was observed in a relevant percentage of cases, regardless the presence/absence of associated HCV infection; namely, complete/partial remission of pre-treatment active manifestations was observed in 74% of skin purpuric lesions, up to 87% of non-healing vasculitic leg ulcers, and 44% of the peripheral neuropathy, mainly paresthesias (patients visual analogical scale from 62±25 to 37±27; p≤.0001). Moreover, cryoglobulinemic nephropathy, observed in 38 patients, significantly improved in 95% of cases (serum creatinine from 1.8±1.1SD to 1.4±0.8SD mg/dl, p≤.0001; 24-hour proteinuria from 2.2±2.1SD to 0.9±1.7SD g/24h, p≤.0001), with complete remission in the 50%. Among 6 patients with complicating non-Hodgkins B-cell lymphoma a complete or partial remission was observed in 5/6. A complete remission of abdominal vasculitis was also observed in one patient. These beneficial effects were mirrored by the improvement of cryoglobulinemic serological hallmarks, namely cryocrit and low complement C4, in half cases. The safety of rituximab was confirmed by the small number of side effects recorded during the 6-month follow-up. On the whole, the results of the present study are in keeping with those reported in 39 papers present in world literature, including a total of 279 MCs patients. CONCLUSIONS Rituximab may be regarded as useful and safe pathogenetic treatment of cryoglobulinemic vasculitis. The actual role of this drug should be definitely confirmed by randomized controlled trials, as well as its position in the therapeutical strategy, mainly with respect to antiviral treatment in HCV-associated MCs.

Preliminary classification criteria for the cryoglobulinaemic vasculitis

Background To develop preliminary classification criteria for the cryoglobulinaemic syndrome or cryoglobulinaemic vasculitis (CV). Methods Study part I developed a questionnaire for CV to be included in the formal, second part (study part II). Positivity of serum cryoglobulins was defined by experts as an essential condition for CV classification. In study part II, a core set of classification items (questionnaire, clinical and laboratory items, as agreed) was tested in three groups of patients and controls—that is, group A (new patients with the CV), group B (controls with serum cryoglobulins but lacking CV) and group C (controls without serum cryoglobulins but with features which can be observed in CV). Results In study part I (188 cases, 284 controls), a positive response to at least two of three selected questions showed a sensitivity of 81.9% and a specificity of 83.5% for CV. This questionnaire was employed and validated in study part II, which included 272 patients in group A and 228 controls in group B. The final classification criteria for CV, by pooling data from group A and group B, required the positivity of questionnaire plus clinical, questionnaire plus laboratory, or clinical plus laboratory items, or all the three, providing a sensitivity of 88.5% and a specificity of 93.6% for CV. By comparing data in group A versus group C (425 controls), the same classification criteria showed a sensitivity 88.5% and a specificity 97.0% for CV. Conclusion Classification criteria for CV were developed, and now need validation.

Mixed cryoglobulinaemia: a cross-road between autoimmune and lymphoproliferative disorders

Mixed cryoglobulinaemia (MC) is a systemic vasculitis, secondary to the deposition in small and medium-sized blood vessels of circulating immune complexes, mainly the cryoglobulins, and complement. MC is characterised by a typical clinical triad (purpura, weakness, arthralgias) and by one or more organ involvement: chronic hepatitis, glomerulonephritis, peripheral neuropathy, skin ulcers and diffuse vasculitis. In a limited number of MC patients, a malignancy, that is B-cell non-Hodgkins lymphoma or hepatocellular carcinoma, may also develop. Hepatitis C virus (HCV) infection has been found in the majority of patients with MC; the frequency of HCV markers (91%) was significantly higher than other rheumatic diseases (6.4%), namely systemic lupus, Sjùgrens syndrome, rheumatoid arthritis and systemic sclerosis, or healthy controls (1.2%). The HCV infection of lymphoid tissues may represent the remote event leading to B-lymphocyte proliferation responsible for autoantibodies and immune-complex production. In a similar way, HCV infection may also be involved in the pathogenesis of other autoimmune (glomerulonephritis, thyroiditis, lung fibrosis, autoimmune hepatitis, porphyria cutanea tarda) and lymphoproliferative disorders (monoclonal gammopathies, B-cell lymphomas). MC shares numerous clinico-serological and pathological features with the above disorders. HCV seems to be their common etiological agent; however, a variable combination of unknown co-factors (infectious, genetic, environmental) should be determinant for the appearance of different clinical patterns.

High circulating chemokines (C-X-C motif) ligand 9, and (C-X-C motif) ligand 11, in hepatitis C-associated cryoglobulinemia.

(C-X-C motif) ligand 9 and (C-X-C motif) ligand 11 (CXCL9 and CXCL11), are potent chemoattractants for activated T cells, and play an important role in T helper 1 (Th) 1 cell recruitment in chronic hepatitis C. No study has evaluated CXCL9, together with CXCL11, circulating levels in patients with mixed cryoglobulinemia and hepatitis C (MC+HCV-p). The aim of the present study therefore was to measure serum CXCL9, and CXCL11 levels, in MC+HCV-p, and to relate the findings to the clinical phenotype. Serum CXCL9 and CXCL11 were measured in 71 MC+HCV-p and in matched controls. MC+HCV-p showed significantly higher mean CXCL9 and CXCL11 levels than controls (P < 0.001, for both), in particular, in 32 patients with active vasculitis (P < 0.001). By defining high CXCL9 or CXCL11 level as a value of at least 2 SD above the mean value of the control group (> 100 pg/mL): 89% MC+HCV-p and 5% controls had high CXCL9 (P < 0.0001, chi-square); 90% MC+HCV-p and 6% controls had high CXCL11 (P < 0.0001, chi-square). In a multiple linear regression model of CXCL9 vs age, ALT, CXCL11, only CXCL11 was significantly (r = 0.452, P < 0.0001) and independently related to CXCL9. Our study demonstrates in MC+HCV-p vs controls: (i) high serum CXCL9, and CXCL11, significantly associated with the presence of active vasculitis; (ii) a strong relationship between circulating CXCL9 and CXCL11. Future studies on a larger cohort of patients are needed to evaluate the relevance of serum CXCL9 and CXCL11 determination as clinico-prognostic marker of MC+HCV.

OP0274 Cryoglobulinemic Vasculitis and Primary sjögren's Syndrome are Independent Risk Factors for Lymphoma in a Large Worldwide Population of Patients with Positive Serum Cryoglobulins

Background Serum cryoglobulins (SC) may be found in many diseases (1), and the presence of serum cryoglobulins is a known risk factor for lymphoma evolution in some non malignant diseases. Objectives The aim of this study was to distiguish the role of cryoglobulinemic vasculitis (CV), classified according to the recent validated criteria (1,2), and primary Sjögrens syndrome (pSS) as risk factors of lymphoma in patients positive serum cryoglobulins. Importantly, SC, CV and pSS may occur together. Methods 950 charts from consecutive patients with positive SC were evaluated. Patients carrying both pSS and HCV infection, as well as incomplete charts, were excluded. Results 657 patients with SC were selected, 374 with CV and 283 without CV, according to the published criteria (2,3). PSS, classified according to the American-European Group Criteria was present in 96 patients (44 with CV, 52 without). Lymphoma was reported in 61/657 (9.8%) patients with SC. Among them, CV was present in 44/61 (72,1%; 14 also with pSS), and pSS in 17/61 (27,9%; and 14/17 had CV). Patients with SC with CV showed an higher prevalence of lymphoma than patients with SC without CV (44/374, 11.5% vs.17/283, 6.3%; p=0.025, OR=1.93 [95%IC: 1.08-3.39]. Patients with pSS, SC and CV also showed a higher prevalence of lymphoma than patients with pSS, SC but without CV (14/44, 31.8% vs. 3/52, 7.4%; p=0.001, OR=7.62 [95%CI 2.02-28.74]. CV and pSS were confirmed as independent risk factor for lymphoma by multivariate analysis (OR 2,18 95%CI 1,18-3,83, p=0,012; OR 2,65 95%CI 1,04-6,76, p=0,042, respectively). Infection by the hepatitis C virus (HCV) was detected in 467/561 (83,2%) patients with SC without pSS, and did not statistically predispose to lymphoma when associated with CV in this subset (p=1,0). Conclusions Cryoglobulinemic vasculitis and pSS are independent risk factors for lymphoma in patients with evidence of SC. Patients with both the conditions (CV and pSS) have the highest risk. In the follow-up of SC positive patients, a very high attention should be deserved to pSS, in particular when CV is present. References De Vita S, et al. Ann Rheum Dis. 2011; 2) Quartuccio L, et al. Rheumatology (Oxford). 2014 Disclosure of Interest None declared

P1158 EFFICACY AND SAFETY OF BOCEPREVIR-BASED THERAPY IN HCVG1 TREATMENT-EXPERIENCED PATIENTS WITH ADVANCED FIBROSIS/CIRRHOSIS: THE ITALIAN AND SPANISH NPP EARLY ACCESS PROGRAM

P1158 EFFICACY AND SAFETY OF BOCEPREVIR-BASED THERAPY IN HCVG1 TREATMENT-EXPERIENCED PATIENTS WITH ADVANCED FIBROSIS/CIRRHOSIS: THE ITALIAN AND SPANISH NPP EARLY ACCESS PROGRAM S. Bruno, S. Bollani, J.M. Pascasio, A.L. Zignego, V. Di Marco, C. Magni, M. Rizzetto, A. Ciancio, A. Alberti, S. Piovesan, A. Mangia, J. De la Revilla, J.R. Larrubia, F. Gea, S. Babudieri, R. Perez-Alvarez, C. Colletta, R. Barcena, X. Forns, M. Romero-Gomez, M. Koch, M. Massari, M. Caremani, J. Crespo, J.M. Navarro, J. Arenas, M.B. Delgado, M. Pirisi, M. Zuin, A. Licata, F. Mazzotta, A. Colombo, M. Russello, I. Fermandez, T. Santantonio, C.M. Fernandez-Rodriguez, F. Farina, B. Ruiz Antoran, P. Maisonneuve, A. Craxì, J.L. Calleja, Italian and Spanish (IAS)-BOC Study Group. AO Fatebenefratelli e Oftalmico, Milano, Italy; Hospital Universitario Virgen del Rocio, Sevilla, Spain; Università degli Studi di Firenze, Firenze, Università degli Studi di Palermo, Palermo, AO L Sacco, Milano, Università di Torino, Torino, Università di Padova, Padova, IRCCS Casa del Sollievo e della Sofferenza, San Giovanni Rotondo, Italy; Hospital Universitario Puerta de Hierro, Madrid, Hospital Universitario de Guadalajara, Guadalajara, Hospital U. La Paz, Madrid, Spain; Università degli Studi di Sassari, Sassari, Italy; Hospital Universitario Central de Asturias, Oviedo, Spain; COQ Ospedale Madonna del Popolo, Omegna, Italy; Hospital Universitario Ramon y Cajal, Madrid, Hospital Clinic, Barcelona, Hospital Universitario de Valme, Sevilla, Spain; AO S Filippo Neri, Roma, IRCCS – ASMN Reggio Emilia, Reggio Emilia, AO di Arezzo, Arezzo, Italy; Hospital Universitario Marques de Valdecilla., Santander, Hospital Costa del Sol, Marbella, Hospital Donostia, Donostia, Hospital Universitario A Coruña, La Coruna, Spain; Università degli Studi di Novara, Novara, Università degli Studi di Milano, Milano, Azienda Ospedaliera di Siena, Siena, AO S Anna, Como, ARNAS Garibaldi, Catania, Italy; Hospital Universitario 12 de Octubre, Madrid, Spain; Università di Foggia, Foggia, Italy; Hospital U. Fundacion Alcorcon, Alcorcon, Spain; Ospedale Cà Foncello, Treviso, Epidemiology and Biostatistics, Istituto Europeo di Oncologia, Milano, Italy E-mail: savino.bruno@fbf.milano.it

SAT0175 Results of the Classification Criteria for Cryoglobulinemic Vasculitis Validation Study

Background the preliminary Classification Criteria for cryoglobulinemic vasculitis (CV) have been developed in 2011 by an European cooperative study (1). Objectives to validate these Classification Criteria for CV with the participation of non-European Countries. Methods 20 Centres from Europe, Egypt, and Japan partecipated. New consecutive, unselected patients with CV (Group A) and controls (subjects with cryoglobulins without a CV based on the golden standard clinical judgment; Group B) were studied. A sample size of 140 patients for each group was estimated to obtain a sensitivity (SE) and a specificity (SP) of at least 90±5%, according to the previous results (1). A dedicated chart was distributed to the Centres. The sensitivity and specificity of the 2011 Classification Criteria were calculated in the present validation series by comparing Group A versus Group B. Results 251 patients in Group A and 175 controls in Group B were recruited. The questionnaire (at least 2/3 positive answers) showed a SE of 89.2% (95% CI 85.4-93.1) and a SP of 93.7% (95% CI 90.1-97.3); the clinical item (at least 3/4 clinical items among constitutional, articular, vascular and neurologic involvement) showed a SE of 76.1% (95% CI 70.8-81.4) and a SP of 88.6% (95% CI 83.8-93.9), and the laboratory item (at least 2/3 tests, among positive rheumatoid factor, low C4, and the presence of serum monoclonal component) showed 75.1% (95% CI 69.5-80.7) of SE and 71.5% (95% CI 64.6-78.4) of SP. The final 2011 Classification Criteria (at least 2/3 positive items) showed a SE of 89.3% (95% CI 85.3-93.3) and a SP of 93.9 % (95% CI 90.3-97.6). Conclusions: Conclusion : The 2011 International Classification Criteria for the cryoglobulinemic vasculitis have been validated in a new cohort of real cases and controls. Patients where CV is suspected on clinical grounds, but where cryoglobulins are negative, cannot be classified, since positive serum cryoglobulinemia is a conditio sine qua non for classification (1). However, the performance of these criteria on this subset of patients is under evaluation. References De Vita S, et al. Ann Rheum Dis 2011;70:1183-90. Disclosure of Interest None Declared

OP0186 Etiological therapy in HCV-related mixed cryoglobulinemia syndrome: The role of IL28B genotype as predictor of response

Background Mixed cryoglobulinemia syndrome (MCS) is a HCV-related, invalidating lymphoproliferative disorder (LPD) whose manifestations are related to a systemic vasculitis. The pathogenesis of MCS is a multistep process involving a strong and sustained B-cell proliferation and genetic events on the basis of host predisposing factors [1]. Standard of care (SOC: PegIFN+RBV) anti-HCV therapy is now the first therapeutic option in HCV+ MCS, however, due to its side effects, the therapeutic decision is often difficult, especially in MCS patients with HCV-G1/4 [2]. Consequently, the possibility to better predict the therapy outcome would be precious. In hepatitis C, genetic variations in the IL28B gene, are strongly associated with the response to anti-HCV therapy [3]. Nowadays, IL28B polymorphisms in HCV-related MCS has been never investigated and it is not possible to exclude that the complex modifications of the immune system characterizing MCS could modify its predictive value. Objectives The aim of this study was to evaluate the role of IL28B genotype in influencing the response to IFN-based treatment and in predisposing to MCS. Methods The IL28B polymorphism was investigated by using allele-specific real-time PCR tecniques in 515 HCV-positive patients: 267 with MCS and 248 without MCS or any LPD (controls). Results A comparable distribution of the IL28B alleles (rs12979860/rs8099917) for HCV-positive patients with and without MCS was recorded, suggesting that this polymorphism do not play a major role in conditioning MCS evolution. Among the 267 HCV-MCS, 123 patients completed a SOC anti-HCV treatment and at least 24 weeks of follow-up. A significant correlation between IL28B major allele homozygosis and MCS response was observed (p=0.0021); the clinical response almost coincided with the virological one. The logistic regression analysis defined the IL28B genotype as a strong independent predictor of MCS response (p=0.0069, odds ratio 6.11; C.I. 1.58-21.22). According to HCV genotype, the predictive value was limited to the most frequent and difficult-to-treat HCV genotypes. Conclusions For the first time, we showed that in HCV-G1/4-MCS patients, IL28B genotype is an useful predictor of response to IFN-based therapy. This would greatly help in the management of this difficult category of HCV patients. This study also suggests that IL28B genotype do not influence the evolution of HCV infection to MCS References Zignego AL, Giannini C, Ferri C: Hepatitis C virus-related lymphoproliferative disorders: an overview. World J Gastroenterol 2007, 13:2467-2478. EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol 2011, 55:245-264. Ge D, Fellay J, Thompson AJ, Simon JS, Shianna KV, Urban TJ, et al. Genetic variation in IL28B predicts hepatitis C treatment-induced viral clearance. Nature 2009; 461:399-401 Disclosure of Interest None Declared