As the worldwide burden of COVID-19 increases exponentially, healthcare systems are plagued by unprecedented pressure. In this setting, many rheumatologists across the globe have been recruited to ...support the front line, facing several unexpected challenges, but also providing valuable skills in combating COVID-19. At the same time, the rheumatic disease patient population may be especially vulnerable to such a rapidly contagious infectious disease, and thus needs care and support that has to be provided quickly and efficiently. Clear advice on viral spread mitigation, precise guidelines on immunosuppressive treatment use, and alternative methods of providing care, such as telemedicine, are a few of the rheumatologists’ new challenges in caring for their patients in the COVID-19 era. Finally, among other specialties, rheumatologists hold a unique place in the fight against the hyperinflammatory state caused by severe SARS-CoV-2 infection, leading to increased morbidity and mortality. Given their vast experience in the use of biologic and targeted therapies, rheumatologists should lead the way in developing reliable scientific evidence for the optimal treatment of severe COVID-19.
The effect of biologic treatment on quantitative Hepatitis B surface Antigen (qHBsAg) levels and HBsAg clearance in rheumatic patients with chronic HBV infection has not been well studied. We ...prospectively followed rheumatic patients with HBeAg‐negative chronic HBV infection (n = 28) treated with biologics and oral antivirals, categorized into patients with chronic hepatitis B (CHB, group A n = 13) and chronic HBV infection (group B n = 15) and matched them to appropriate non‐rheumatic controls. qHBsAg kinetics were serially measured and compared between groups. No HBV reactivation (HBVr) was recorded during the 108.25 patient‐year follow‐up. Among patients with CHB, the annual rapid qHBsAg decline (i.e. decline >0.5 log10 IU/mL/year) as well as HBsAg clearance did not differ between rheumatic patients n = 4 (32.7%), n = 1 (7.7%) and controls n = 6 (28.4%), p = .726 and n = 2 (7.7%), p = .818, respectively. In contrast, there was a slower annual qHBsAg decline in rheumatic patients with chronic HBV compared to non‐rheumatic controls (−0.04 vs −0.13 log10 IU/mL at year 1, p = .019) with no cases of rapid qHBsAg decline or HBsAg clearance in rheumatic patients (0%) compared to a cumulative incidence of 24% and a rate of 20%, respectively in controls. In biologic‐treated rheumatic patients with HBeAg‐negative HBV receiving antiviral prophylaxis, there was slower qHBsAg decline, lower cumulative rates of rapid qHBsAg decline and HBsAg clearance compared to non‐rheumatic controls.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background and Aims
The glomerulonephritis (GN) is a rare and complicated disease with high demand of hospital resources while the chronic kidney disease and end-stage renal disease present ...increased prevalence in these patients.
Method
We retrospectively assessed the inpatient and outpatient service of a Greek reference centre for glomerular diseases during the pre-Covid-19 period 2018-2020.
Results
267 patients (38% female, median age 65 ± 23 years) included. All patients underwent a kidney biopsy by the nephrologist without complications. ANCA associated GN (18%), Focal Segmental Glomerulosclerosis/Minimal Change Disease (17.5%), IgA nephropathy (17%), Membranous Nephropathy (12.6%), Lupus Nephritis (5%), Membranoproliferative GN (3%), Fibrillary GN (3%), Monoclonal Gammopathy of Renal Significance (3.3%) and IgG4-related disease (2%.) are encompassed. We reported median 75 new patients per year. Regarding the inpatient service, we observed an increasing trend to the hospitalizations during this period (274, 452, 461 hospitalizations in 2018, 2019, 2020 respectively). The AAGN was the most common disease of hospitalizations through this period (53% in 2018, 33% in 2019, 39% in 2020), whereas the second most common was the FSGS/MCD (28% in 2018, 13% in 2019, 23.8% in 2020). The outpatient's service review also revealed an increasing number of visits per person per year (279, 456 and 464 total visits in 2018, 2019 and 2020 respectively). The disease with the highest number of visits per person was reported the AAV (median 3.25 visits per patient per year). All the patients were managed in adherence to the latest guidelines for GN in collaboration with a multidisciplinary team, consisting of nephrologist, rheumatologist, cardiologist, and pathologist. Finally, we reported complete response at 76% of the patients and in terms of renal improvement, 46% presented eGFR≥60 ml/min/1.73 m2, 45% eGFR<60 ml/min/1.73 m2 and only 9% progressed to ESRD after the first year of treatment.
Conclusion
Patients with GN present an increased need for hospitalization and regular outpatient visits. Addressing these diseases necessitates the expertise of a multidisciplinary team to provide comprehensive care that maximizes the potential for sustained positive long-term outcomes.
Abstract
BACKGROUND AND AIMS
Immunosuppressed patients are in general less likely to achieve a detectable antibody response to SARS-CoV-2 after the primary doses of vaccine administration. However, ...there are limited data for the effect of a third booster dose in this patient population, especially for those with vasculitides and renal involvement treated with rituximab (RTX).
METHOD
We retrospectively assessed the antibody responses to SARS-CoV-2 vaccination, after completion of the primary vaccine series (two doses) and after the booster third dose, in patients with vasculitides and renal involvement. IgG antibodies to the spike protein S1 subunit of SARS-CoV-2 were measured using ELISA >1 month after completion of the primary vaccination series (two doses of Pfizer or AstraZeneca vaccines) and 15–30 days after the third booster dose (Pfizer, given 3–6 months after the second dose).
RESULTS
We included 20 patients with vasculitis AAV, n = 16 (80%), IgAV, n = 4 (20%) and renal involvement. All patients received immunosuppressives, including RTX (80%), MMF/AZA (15%), cyclophosphamide (5%), while half of patients were on glucocorticoids. The seroconversion rate after the primary two doses (Pfizer n = 8/16, Astra-Zeneca n = 1/1) was 53%, which increased to 67% after the third booster dose (Pfizer, n = 12/18). Similarly, the median antibody titers increased from 451 U/mL interquartile range (IQR) 81–10.845 after the second dose to 1016 U/mL (ΙQR: 64–37.568) after the booster dose. Regarding patients treated with RTX, the respective response rates after the second and third dose were 58% and 62%. Seropositive patients after the third dose tended to have lower previous cumulative exposure to RTX compared with seronegative ones (4.55 versus 5.5 g, P = .62, respectively). No vaccine side effects or disease relapses were noted after the three vaccine doses.
CONCLUSION
In our patient cohort with systemic vasculitis and renal involvement treated mainly with RTX, a third booster vaccine dose increased the seropositivity rate from 53% to 67%. Nevertheless, one-third of patients did not achieve seroconversion. Whether a fourth booster dose could benefit these patients is still unknown.
To determine the rate of tuberculosis (TB) screening test conversion during anti-tumour necrosis factor (TNF) therapy in rheumatic patients with negative baseline screening.
This was a prospective ...study of rheumatic patients with negative baseline TB screening (tuberculin skin test (TST): <5 mm, and negative T-SPOT.TB, QuantiFERON-TB Gold In Tube (QFT-GIT) and chest X-ray) treated with anti-TNF agents. All patients underwent re-screening for TB with all assays 1 year later. Factors associated with TB test conversion were analysed and compared between 'converters' and 'non-converters'.
Seventy patients (mean age 50.6±15.5 years) with rheumatic disease (33 with rheumatoid arthritis, 33 with spondyloarthropathies and 4 with other conditions) were enrolled. Patients were treated with different anti-TNFs (27 with adalimumab, 14 etanercept, 16 infliximab, 8 golimumab, 5 certolizumab pegol) for 1 year. Twenty patients (29%) displayed conversion of at least one screening assay 12 months after anti-TNF therapy: conversion of TST occurred in 9 (13%), T-SPOT.TB in 7 (10%) and QFT-GIT in 5 (7%). Only one patient had concomitant conversion of more than one screening test. Univariate and multivariate analysis revealed that only infliximab was associated with a decreased rate of TB screening assay conversion (OR 0.048, 95% CI 0.004 to 0.606, p=0.017). No patient (40% received isoniazid therapy) developed active TB during follow-up (27±12 months).
Approximately one third of patients with negative baseline TB screening develop conversion of at least one screening test during anti-TNF treatment. These findings should be considered when designing re-screening strategies and contemplating latent TB therapy.
Abstract
Background and Aims
Interstitial inflammatory infiltrates in ANCA associated glomerulonephritis (AAGN) are frequently observed but their correlation to clinicopathological parameters remains ...elusive.
Method
Retrospective study of 40 patients with newly diagnosed AAGN. Histological assessments using the presence of interstitial inflammatory cells were performed. Biopsy tissues were investigated by CD3, CD20, CD4, CD8, CD68+ (PG-M1), CD138 immunohistochemical staining. We assessed the presence of inflammatory cells in terms of clinical, histopathological parameters as well as the renal prognosis in a large follow-up period 47.87 months (12-216).
Results
The interstitial infiltrates were consisted of lymphocytes (CD3 T cell> CD 20 B cell) at 83%, followed by plasma cells at 43%, neutrophils at 43%, macrophages at 40% and eosinophils at 20% of the biopsies. CD8 T cells dominated the interstitial area in focal and sclerotic class, while CD8 and CD4 tended to have different expression patterns in the interstitial area (figures 1,2). Interestingly, we reported that the presence of macrophages was correlated with higher chronicity index interstitial fibrosis (39% vs 24%, p = 0.015) and creatinine at diagnosis (4.4 vs 2.6 mg/dL, p = 0.01), while the presence of neutrophils, lymphocytes and eosinophils was correlated with higher activity index cellular crescents (37% vs 6%, p<0.001, 26% vs 9%, p = 0.021, 49% vs 24%, p = 0.021, respectively). In terms of short-term renal prognosis, only the macrophages were correlated with worst renal function at the 1st year (Cre 3.2 vs 1.8 mg/dL, p = 0.042). Regarding the long-term renal prognosis, we validated as the most reliably predictive score, amongst Berden classification and Mayo Clinic chronicity score, the ANCA renal risk score (AUC 0.694, p = 0.05) and we found that the low-risk group tended to present less severe inflammation (p = 0.029), while the presence of macrophages and eosinophils was less often present (p = 0.03 and 0.05, respectively) compared to the higher risk groups.
Conclusion
Identifying the differences in histopathological subtypes, in yet underestimated active tubulointerstitial lesions, could be the first step toward improving our understanding of distinct pathophysiological mechanisms and anticipating to specific treatment regimens.
There are limited data regarding health-related quality of life (HRQoL) in patients with ANCA-associated vasculitides (AAVs). We aimed to evaluate the HRQoL in patients with AAVs and compare it to ...another chronic inflammatory disease like RA and to healthy controls (HC).
This was a multicentre, cross-sectional study of patients with AAVs and RA recruited from three tertiary rheumatology clinics. HRQoL was assessed with the Short Form 36 Health Survey, which included the physical and mental component summary scores (PCS and MCS). Data from 1007 HC served as historical controls.
Sixty-six patients with AAVs and 71 with RA were included. Both AAV and RA patients had significantly lower PCS and MCS scores compared with HC (P < 0.05). HRQoL in AAV patients was worse in patients with microscopic polyangiitis compared with granulomatosis with polyangiitis (physical components) and those with high (VDI ≥ 3) vs low (VDI < 3) damage scores while it did not differ between those with active (BVASv3 ≥ 1) vs. inactive (BVASv3 < 1) disease. In contrast, in RA patients, HRQoL correlated both with disease activity (assessed by the DAS28-ESR) and functional impairment/damage (assessed by the HAQ). Although overall patients with RA had similar HRQoL compared with those with AAVs, those with active RA had worse HRQoL compared with those with active AAV.
In patients with AAVs, HRQoL correlated more with organ damage and less with disease activity whereas in RA patients, it correlated with both. These data emphasize the need for AAV therapies aiming at preventing organ damage and thus improving HRQoL.
