Carla Naretto

Intensive short-term treatment with rituximab, cyclophosphamide and methylprednisolone pulses induces remission in severe cases of SLE with nephritis and avoids further immunosuppressive maintenance therapy

BACKGROUND B cells play a central role in systemic lupus erythematosus (SLE). Rituximab is expected to induce apoptosis of all the CD20-positive B cells. A proportion of patients are refractory or intolerant to standard immunosuppression. These are candidate to new therapeutic options. METHODS Eight patients [six women, two men, mean age 41-year-old (27-51), with severe multiorgan involvement (kidney, skin, nervous system, polyarthritis, polyserositis, antiphospholipid antibody syndrome)] were considered eligible for an intensive combination therapy including rituximab. Rituximab was administered (dose 375 mg/m(2)) on Days #2, 8, 15 and 22. Two more doses were administered 1 and 2 months following the last weekly infusion. This treatment was combined with two pulses of 750 mg cyclophosphamide (Days #4 and 17) and three pulses of 15 mg/kg (Days #1, 4 and 8) methylprednisolone followed by oral prednisone, 50 mg for 2 weeks rapidly tapered until 5 mg in 2 months. Response was evaluated by assessing the changes in clinical signs and symptoms [Systemic Lupus Erythematosus Disease Activity Index (SLEDAI score)] and laboratory parameters for at least 12 months. RESULTS Levels of erythrocyte sedimentation rate and anti-double-strand DNA antibodies significantly decreased (P < 0.01 at 12 months), whereas C3 and mainly C4 values increased at 6 months (P < 0.01 for C4). Proteinuria improved in the cases with renal involvement (P < 0.01 at 3, 6 and 12 months). SLEDAI score improved moving from the mean 17.3 (12-27) before therapy to 3.1 (1-5) after rituximab treatment. Constitutional symptoms including arthralgia, weakness and fever disappeared in all the previously affected patients; paresthesia improved in the four patients with polyneuropathy and skin lesions gradually resolved in the patients with necrotizing skin ulcers at presentation. Drug side effects were negligible. CONCLUSIONS Long-lasting remissions were obtained in patients with severe SLE and major organ involvement by this intensive administration of rituximab combined with low doses of intravenous cyclophosphamide and methylprednisolone pulses followed by a rapid tapering of prednisone to 5 mg/day as a sole maintenance therapy.

Long-Term Effects of Rituximab Added to Cyclophosphamide in Refractory Patients with Vasculitis

Background: Current therapies have changed systemic vasculitis from a disease with a high rate of mortality to a chronic curable condition. A limited percentage of patients either remains refractory to conventional treatment or experiences dose-limiting side effects. Methods: 11 patients (4 affected by idiopathic systemic microscopic polyangiitis, 5 by Wegener’s granulomatosis, and 2 by Churg-Strauss syndrome) intolerant or refractory to conventional therapies including cyclophosphamide were enrolled. All patients received rituximab as a rescue therapy and were followed for 30–54 months. Following rituximab administration, immunosuppressive drugs were rapidly tapered and no immunosuppressive maintenance therapy was given. Results: Significant decreases in levels of serum creatinine, proteinuria, erythrocyte sedimentation rate, C-reactive protein, and ANCA titers were observed during the follow-up (at least 30 months after rituximab administration). Arthralgia and weakness rapidly disappeared in all patients. Out of 7 patients, 5 reported a decrease in the degree of paresthesia and in the electrophysiologic parameters. Six months after rituximab administration the mean dose of prednisone was 5.5 mg/day. Conclusion: In this sample of patients with systemic vasculitis who were refractory or intolerant to more conventional treatment, rituximab proved to be safe and effective in a long-term follow-up, and showed steroid- and immunosuppressive-sparing effects allowing the persistence of long-lasting remissions without maintenance therapy.

Treatment-induced downregulation of antiphospholipid antibodies: effect of rituximab alone on clinical and laboratory features of antiphospholipid syndrome

Sir, In 2000, a 20-year-old woman came to our attention with aphasia, transitory dysarthria, (CT scan compatible with stroke) and thrombocytopenia (platelet count 29 10/l). Laboratory tests revealed anticardiolipin antibodies (aCL) 328/ 15U/l (ELISA kit Phadia, Uppsala, Sweden, EliA Cardiolipin IgG/IgM, normal value <40 U/l), antibeta-2 glycoprotein I antibodies 104/9U/l (ELISA kit Phadia, Uppsala, Sweden, EliA ß2 Glycoprotein I IgG/IgM, normal value <40U/l), and positivity for lupus anticoagulant (LAC). LAC measurement included: dilute Russell’s viper venom time (dRVVT) (Hemosil, LA-screen/confirm, Instrumentation Laboratory, Lexington, USA), partial thromboplastin time-LA (PTT-LA) (Diagnostica Stago, Asnières, France), silica clotting time (SCT) (HemosIL, DiaPharma Group, Inc. Ohio, USA) and kaolin clotting time (KCT) (homemade, according to Exner). If PTT-LA was prolonged, the hexagonal phospholipid neutralization test was performed as confirmatory (STACLOT-LA, Diagnostica Stago, Asnières, France). A diagnosis of primary antiphospholipid syndrome (APS) was made when antiphospholipid antibody (aPL) positivity was confirmed 3 months later. Therapy with prednisone (50mg/day) and intravenous immunoglobulins (IVIG, 400mg/kg/ day for 5 days) was started, resulting in an increase in platelet count. Oral anticoagulation therapy (OAT) was started when the platelet count reached 60 10/l. Platelet levels increased up to 110 10/l within 4 weeks and remained stable between 130 and 140 10/l for 4 months, when they dropped again to 70 10/l. The patient was then treated with adjusted doses of prednisone (37.5mg/day) and IVIG (400mg/kg/day for five more days). Prednisone treatment was slowly tapered to a daily dose of 7.5mg and finally discontinued in May 2007, when platelet counts were between 120 and 150 10/l. In 2009, the patient presented with a worsening of thrombocytopenia (platelet count 40 10/l) and was treated with the same regime of IVIG, with partial response (platelet count up to 90 10/l). She relapsed within 3 weeks. Splenectomy was not performed due to the high risk of thromboembolic and/or haemorrhagic complications. After ruling out possible contraindications, treatment with rituximab (RTX) was started at the conventional weekly dose of 375mg/m (days 1, 8, 15 and 22). Two more monthly doses after the last infusion (day 22) were administered, based on the protocol we employ for mixed cryoglobulinaemia with good results on long-lasting disease remission. Prednisone treatment (daily dose of 10mg at day 1) was tapered and finally discontinued 4 weeks after first RTX infusion. No other immunosuppressive drugs were associated. Treatment was well tolerated and no side effects were observed. RTX administration led to an increase in the platelet count (Figure 1). In addition, aCL, antibeta2-GPI antibodies and LAC ratio were downregulated (Figure 1). In this case, RTX-induced downregulation of aPL was observed. It was associated with a significant improvement in thrombocytopenia, thus allowing OAT to be administered. Successful amelioration of thrombocytopenia in APS after treatment with immunosuppressive therapy has previously been reported. However, a non-negligible percentage of patients become resistant/non-responsive to immunosuppression, and sometimes splenectomy cannot be performed because of the high risk of bleeding and/or thrombotic events. Some authors have reported that RTX is effective in treating APS and reducing aPL, but drug-induced aPL downregulation remains a challenge. Notably, in a observational study in patients with systemic lupus erythematosus, RTX resulted in a significant reduction in levels of IgG aCL. To our knowledge, this is the first report showing downregulation of aPL after RTX alone in a patient with primary APS who was not treated with immunosuppressive drugs prior to anti-CD20 antibody therapy. Some authors reported a close correlation between aCL titre reduction and an improvement in platelet count in patients with primary APS who were treated with RTX Correspondence to: Dario Roccatello, Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID), Struttura Complessa a Direzione Universitaria di Immunologia Clinica, Ospedale Torino Nord Emergenza San G. Bosco ed Università di Torino, Piazza del Donatore di Sangue 3, 10154 Torino, Italy Email: dario.roccatello@unito.it Received 29 September 2010; accepted 17 January 2010

A 4-year observation in lupus nephritis patients treated with an intensified B-lymphocyte depletion without immunosuppressive maintenance treatment—Clinical response compared to literature and immunological re-assessment

BACKGROUND B cells (BC) play a critical role in systemic lupus erythematosus (SLE). BC depletion therapy still remains an attractive option, despite the disappointing results of randomized controlled trials (RTCs). METHODS Twelve patients with SLE [3 males, mean age 43.8 yrs (25-55)] with severe multiorgan involvement all including kidney (3 patients with Class IV, 4 with Class III/V and 5 with Class V, according to the International Society of Nephrology/Renal Pathology Society glomerulonephritis classification), skin lesions [10], severe polyarthralgias with arthritis [10], polyserositis [2], and lymphadenopathy [5] have been prospectively treated with an intensified B cell depletion therapy (IBCDT) protocol due to their resistance or intolerance to previous therapy (six cases) or as a front line immunosuppressive treatment in 6 women with unsatisfactory therapeutic compliance or as a specific request of a short-time immunosuppression for gestational perspectives. PROTOCOL Rituximab (RTX) 375 mg/sm on days 1, 8, 15, 22, and 2 more doses after 1 and 2 months, associated with 2 IV administrations of 10mg/kg of cyclophosphamide and 3 methylprednisolone pulses (15mg/kg) followed by oral prednisone (0.8 mg/kg/day, rapidly tapered to 5mg/day by the end of the 3rd month after RTX). No further immunosuppressive maintenance therapy has been given. RESULTS Patients had been followed-up for a mean of 44.5 (24-93)months. Significant decreases (p<0.05) were found in the levels of ESR (baseline mean value: 55.0mm; 3 months: 36; end of follow-up: 13), anti-dsDNA antibodies (baseline: 185 U; 3 months: 107; end of follow-up: 15), and proteinuria (baseline: 4.9 g/24h; 3 months: 0.97; end of follow-up: 0.22). C4 values (baseline 11 mg/dl) significantly increased (p<0.05) after 3 months (22 mg/dl) and at the end of the follow-up (20mg/dl). Of the 12 patients, 9 (75%) have remained well after one cycle of IBCDT, with no flare (mean 51.6 months [25-93]). Three patients relapsed after 36, 41, and 72 months, respectively. Following re-treatment, they again showed complete remission over 18-48 months of observation. CONCLUSIONS A promising role of RTX in an intensified protocol of induction therapy can be envisaged in patients for whom avoiding immunosuppressive maintenance therapy and sparing steroids are particularly appealing. Moreover, our data confirm in one of the longest follow-up available, the opportunity to reconsider the regimens of BL depletion in the treatment of the most severe or refractory forms of SLE despite the disappointing results of RCTs.

Anti-neuronal antibodies in patients with HCV-related mixed cryoglobulinemia

Mixed cryoglobulinemia (MC) is an immunological disorder characterized by immune-complex-mediated systemic vasculitis involving small vessels, which may present with renal, cutaneous, rheumatologic, and/or neurological manifestations. Until recently, the possible appearance of anti-neuronal autoantibodies in peripheral neuropathy occurring in the context of hepatitis C virus (HCV)-associated IgMk/IgG MC has not been extensively addressed. Therefore, a sample of these patients were evaluated by means of immuno-enzyme methods of anti-neuronal autoantibody detection. A significant increase in plasma titers of both anti-GM1 ganglioside and anti-sulfatide was observed. Abnormal titers were associated with evidence of active neuropathy as assessed by electrophysiologic studies. While peripheral neuropathy was traditionally thought to result from axonal ischemic damage caused by deposits of cryoprecipitable immune complexes in the vasa nervorum, a significant association between anti-GM1 and anti-sulfatide antibodies and involvement of the peripheral nervous system was observed in HCV-associated mixed IgMk/IgG cryoglobulinemia. Anti-neuronal reactivity could be a direct trigger of neurologic injury in this disorder.

Mycophenolate mofetil as steroid-sparing treatment for elderly patients with giant cell arteritis: report of three cases

Background and aims: Glucocorticoids have never been studied in a placebo-controlled manner in giant cell arteritis (GCA), but their effectiveness is well established. However, evidence for the efficacy of immunosuppressant drugs as steroid-sparing agents in this disease is highly desirable, especially in elderly patients. We report the use of mycophenolate mofetil (MMF) as a steroid-sparing agent in three patients (mean age 78 years) with GCA, at high risk of longterm high dose glucocorticoids because of type II diabetes mellitus, obesity, hypertension or osteoporosis. Methods: clinical monitoring and assessment of laboratory parameters were carried out weekly (first month) and then patients were seen in the clinic every 2 weeks. Vascular lesions were also monitored at the onset and during the follow-up by Doppler ultrasonography (every 3 months). Results: all three patients showed clinical benefit, and were also able to taper steroid use to a more rapid regimen compared with the recently suggested steroid reduction approach. MMF was well tolerated, and no signs of toxicity were observed in a mean of 21.6 months (12-29) of follow- up. Conclusion: mycophenolate mofetil may be considered a steroid-sparing agent in elderly patients with GCA but, before results of controlled trials become available, MMF may be considered only for patients who do not improve or stabilize with conventional therapy, or in patients for whom reduced steroid dosage is highly recommended.

Long-term effects of methylprednisolone pulses and mycophenolate mofetil in IgA nephropathy patients at risk of progression.

BACKGROUND IgA nephropathy (IgAN) is a microcosm of glomerular lesions. Some histologic lesions are irreversible and progress toward obliteration of glomerular capillaries. Others are acute inflammatory processes potentially susceptible to reversal by means of immunosuppressive therapies. METHODS The effects of a combined schedule of steroids and mycophenolate mofetil (MMF) was prospectively examined in a subset of IgAN patients with acute inflammatory histologic changes associated with proteinuria (mean 2,400 mg/day, range 1,130-5,250), hematuria (76 red cells per high-power microscopic field, range 30-100) and renal failure (serum creatinine 1.6 mg/dL, range 1.2-2.9). Patients had diffuse mesangial proliferation with at least 10% florid crescents, mild to moderate degrees of glomerular sclerosis and interstitial changes, and both mesangial and capillary deposition of immunoreactants at immunofluorescence. Treatment consisted of 3 pulses of methylprednisolone (15 mg/kg) followed by oral prednisone (0.8 mg/kg body weight, tapered until discontinuation within 4 months) and MMF 2 g for 6 months. RESULTS Serum creatinine, proteinuria and microscopic hematuria significantly dropped at 6 months compared with baseline values (p=0.01) and remained lower at the end of follow-up 51 months (range 24-90) later (p<0.01, for proteinuria and hematuria; p=0.08, for serum creatinine). CONCLUSION Therapy with steroids and MMF may be considered in a subset of IgAN patients with florid glomerular changes, functional impairment and major urinary abnormalities, to prevent subsequent progression toward renal failure.

New insights into immune mechanisms underlying response to Rituximab in patients with membranous nephropathy: A prospective study and a review of the literature.

BACKGROUND Idiopathic membranous nephropathy (MN) is a common immune-mediated glomerular disease and the main cause of nephrotic syndrome (NS) in Caucasian adults. Rituximab (RTX) has been reported to safely reduce proteinuria in patients with primary MN and severe NS. However, the effects of RTX treatment on T-cells including regulatory T-cells (Treg) in MN have not been fully determined. METHODS Seventeen patients [mean age 67 (29-86) years, 6 women, 11 men] with biopsy-proven MN, and persistent proteinuria >3.5 g/24h were prospectively enrolled and received RTX, 375 mg/m(2) (iv) on days 1, 8, 15 and 22. Changes in circulating B and T cell homeostasis were examined in the peripheral blood by flow-cytometry studies; serum levels of IL-35 were measured using a high-sensitivity ELISA kits (baseline, at month 3, 6, 9 and 12). RESULTS Patients had been followed-up for a mean of 36.3 months (24-48). Proteinuria decreased from 5.6 (3.5-8) g/24h to 2.4 (0.06-13) g/24h at 6 months (p<0.05) and to 1.3 (0.06-8) at 12 months (p<0.01), respectively after therapy with RTX. Four patients received a 2nd course of RTX (one at 6 months because of persistent NS, and three at 12, 18, or 30 months for relapse). The three relapsing patients became proteinuria-free (<0.5 g/24h) in the following 6 months. Serum creatinine remained stable during the follow-up: median 1mg/dl (0.7-1.6) at 12 months and 1.1 (0.7-1.7) at 24 months as compared to 1 (0.5-2.4) at baseline. At 6 months after RTX, complete remission (CR) was observed in 7 patients, partial remission (PR) in 4, while 6 were non responders (NR) non responder (NR). At the end of the follow-up, 14 patients were in CR, 1 in PR, while 2 were NR. In the T-cell compartment, upon detection of B cell depletion, there was an increase in Treg up to 10-fold when comparing baseline and at month 12 (mean ± SD 1.2 ± 0.6%, and 5.8 ± 0.7% p=0.02, respectively). When stratifying patients in responders (CR+PR) and NRs at month 12, we observed a significant increase in Treg cells from month 6 which persisted till 12 months only in the responder group (5.5 ± 0.6% and 1.1 ± 0.6%, p=0.04, respectively in responders and NRs). A statistically significant decrease in the levels of active T-lymphocytes (HLA-DR+CD8+ cells) was observed, with a maximum reached at 12 months after treatment with RTX [6 ± 1.1% baseline, 4.7 ± 1.7% at 6 months (p=0.043) and 1.5 ± 1.4% at 12 months (p=0.05)]. A marked increase in IL-35 levels [defined as delta >40% (serum values at 6 months minus baseline values)] was seen in 68% of the patients who achieved clinical response (CR or PR) at 12 month, but in none of the patients who failed to respond (p=0.034). CONCLUSION Our findings and data from literature support the idea that RTX can be envisaged as a first-line therapy for patients at risk of progression because of persistent NS due to idiopathic MN. Insights into the putative T cell-related mechanisms of action have been discussed.

Rituximab therapy for IgA-vasculitis with nephritis: a case series and review of the literature.

Henoch–Schonlein purpura, also called IgA-vasculitis, is a systemic small vessels vasculitis with immunoglobulin A1-dominant immune deposits. The optimal treatment remains controversial. Because IgA-vasculitis is characterized by leukocyte infiltration of the blood vessel walls along with immunoglobulin A deposition, and because glucocorticosteroids inhibit inflammatory processes, early administration of glucocorticosteroids has been postulated to be effective, but this indication remains controversial. Immunosuppressive agents (azathioprine, cyclophosphamide, cyclosporine, mycophenolate) have been used in combination with glucocorticosteroids without definitive evidence of effectiveness. The efficacy of rituximab in adult IgA-vasculitis has been reported in few cases. We described a monocentric experience on the use of rituximab in adult IgA-vasculitis with biopsy-proven nephritis. The patients achieved a complete remission of nephritis and syndromic manifestations, and no patients experienced adverse reactions. These data have been compared with the limited literature nowadays available.

NEMO syndrome (incontinentia pigmenti) and systemic lupus erythematosus: A new disease association

Congenital diseases are increasingly being recognised in adults because of clinical mimicry, variable clinical picture or rarity of the disease; pregnancy is a valuable diagnostic occasion. The present case is the first report of an association report between NEMO syndrome (an acronym of the mutated, non-functioning gene, NF-kB essential modulator), a rare X-linked disease, characterised by developmental anomalies, immunodepression and skin lesions, and systemic lupus erythematosus (SLE). A 35-year-old patient affected by SLE sought clinical advice in the 8th week of gestation. The diagnosis of SLE dated back to the age of 24, when multisystemic manifestations (pleuropericarditis, weight loss, alopecia, skin involvement, joint pain, kidney involvement) were observed. She had been treated with steroids since 1999; immunosuppressive drugs had been added for short periods. Developmental anomalies werepresent, including oligodontia, retinal problems, anomalies of the corpus callosum and pes planovalgus. Family history included multiple miscarriages, dental malformations and oligodontia and skin blistering in the first months of life. On these bases, incontinentia pigmenti (IP; or NEMO syndrome) was diagnosed and confirmed by genetic testing. The NEMO gene is implicated in immune deficiencies as well as in autoimmune diseases. This report may suggest a role for NF-kB essential modulator in the pathogenesis of SLE, in the context of thecomplex immunologic deficiencies increasingly associated with autoimmune diseases.