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Treatment of refractory Wegener's granulomatosis with antithymocyte globulin (ATG): An open study in 15 patients
Kidney International, Vol. 65 (2004), pp. 1440–1448
Treatment of refractory Wegener’s granulomatosis with antithymocyte globulin (ATG): An open study in 15 patients WILHELM H. SCHMITT, E. CHRISTIAAN HAGEN, IRMGARD NEUMANN, RAINER NOWACK, LUIS FELIPE ´ FLORES-SUAREZ ,1 and FOKKO J. VAN DER WOUDE, FOR THE EUROPEAN VASCULITIS STUDY GROUP Fifth Department of Medicine, University Hospital Mannheim of the University of Heidelberg, Mannheim, Germany; Eemland Ziekenhuis, Locatie “Lichtenberg,” Department of Internal Medicine, Amersfoort, The Netherlands; and Wilhelminenspital Wien, Department of Nephrology, Vienna, Austria
Treatment of refractory Wegener’s granulomatosis with antithymocyte globulin (ATG): An open study in 15 patients. Background. A subset of patients with Wegener’s granulomatosis does not respond sufficiently to cyclophosphamide and glucocorticosteroids or suffers of intolerable side effects. Anecdotal data suggest that antithymocyte globulin (ATG) may be a treatment option for these patients. We now describe 15 patients treated with ATG for refractory Wegener’s granulomatosis. Methods. Fifteen patients with histologically proven active refractory Wegener’s granulomatosis (seven unresponsive to cyclophosphamide, eight intolerant) were treated with ATG by a protocol (SOLUTION protocol) designed by the European Vasculitis Study (EUVAS) Group. Results. Before ATG administration, patients had received a mean of 5.2 (range 2 to 7) different therapeutic approaches including glucocorticosteroids and cyclophosphamide in all and experimental therapies in six, without control of disease activity [2.8 (range 1 to 7) relapses during a disease duration of 63.2 (range 18 to 180) months]. Thirteen of 15 patients showed a favorable response to ATG with partial (N = 9) or complete (N = 4) remission. During a follow-up of 21.8 (range 6 to 68) months, seven patients relapsed after a mean of 8.4 (range 2 to 24) months (five minor and two major relapses). Six patients are free of relapse for 22.3 (range 7 to 64) months. Two patients died, 1 and 3 days following the first dose of ATG, due to pulmonary hemorrhage and infection (one each). Although further immunosuppressive treatment was required in all surviving patients, a less intensive regimen could be applied in 12. Beside fever and chills associated with the first gift of ATG, ATG was well tolerated, with infections being observed in five cases and serum sickness in two. Conclusion. Anti-T-cell–directed treatment with ATG may be a therapeutic option for severe refractory Wegener’s granulomatosis if simultaneous infections and fluid overload have 1 Dr. Flores-Suarez is currently at the Instituto Nacional de Ciencias Medicinas ´ y Nutricion ´ Salvador Zubiran, Mexico City, Mexico.
Key words: Wegener’s granulomatosis, antineutrophil cytoplasmic antibodies (ANCA), vasculitis, antithymocyte globulin (ATG). Received for publication June 22, 2003 and in revised form August 24, 2003 Accepted for publication December 1, 2003 C
2004 by the International Society of Nephrology
been ruled out. In patients with alveolar hemorrhage, ATG should only be used under special caution.
Wegener’s granulomatosis, the most common systemic vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA), commonly takes a lethal course or results in severe organ damage if left untreated. About 90% of cases respond to daily oral cyclophosphamide and glucocorticosteroids, at the cost of substantial treatmentinduced morbidity. Relapses are experienced in at least 50% of cases [1–3]. The usual therapeutic management of such cases is prolonged or readministration of cyclophosphamide. In frequent relapsers this often results in high cumulative doses. Severe side-effects of cyclophosphamide such as malignancies and bone-marrow toxicity were seen in 42% of patients in an important follow-up study [2]. The greatest challenges in the management of Wegener’s granulomatosis are the maintenance of remission, the avoidance of treatment related morbidity, and the care of refractory cases who do not tolerate or respond to standard therapy. In the latter, there is a definite need to replace cyclophosphamide by other immunsuppressive drugs. There is increasing evidence for a pathogenetic role of T cells in Wegener’s granulomatosis (reviewed in [4, 5]), including the finding of T cells in active vasculitic lesions [6–11], the proliferation of T-helper cells from patients with Wegener’s granulomatosis on stimulation with proteinase 3 (PR3) [12–14], an overproduction of interferonc (INF-c) and tumor necrosis factor-a (TNF-a) by T cells from Wegener’s granulomatosis patients [15], and the correlation of soluble markers of T-cell activation with disease activity [16, 17]. Thus, there is sufficient evidence for a pathogenetic role of T cells in Wegener’s granulomatosis to justify anti-T-cell–directed experimental therapeutic designs in refractory patients. Initial reports have favored a beneficial effect of a treatment using humanized antibodies against lymphocyte
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Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
antigens such anti-CD4 and anti-CD52 [18, 19]. Administration of antithymocyte globulin (ATG), a polyclonal preparation of antibodies directed against surface antigens of activated lymphocytes, results in profound lymphocyte depletion of rapid onset and thereby modifies (auto-) immunologically triggered inflammation [20]. Mechanisms of action of ATG include classic complement-mediated lysis of lymphocytes, clearance of lymphocytes due to reticuloendothelial uptake, masking of T-cell antigens, or expansion of negative regulatory cells [21]. ATG, an established agent for the treatment of allograft rejection [22], has been successfully administered to patients with autoimmune disorders such as systemic sclerosis, systemic lupus erythematosus (SLE), autoimmune hemolytic anemia, and rheumatoid arthritis [23–26]. In 1995, a favorable response was observed in four of five patients with refractory Wegener’s granulomatosis [27]. Encouraged by these results, the European Vasculitis Study Group (EUVAS Group) prospectively studied ATG in an open, multicenter protocol (SOLUTION protocol) to investigate the efficacy of ATG in Wegener’s granulomatosis patients refractory to standard treatment. METHODS Patients Within an open, prospective, uncontrolled protocol, patients with refractory Wegener’s granulomatosis were treated with ATG in nine academic centers of five European countries. Patients gave written informed consent before the inclusion. Ethical approval was obtained in each participating center. Ten patients were enrolled in the study from February 1997 to October 2001. Furthermore, five patients were treated with ATG on compassionate use, but according to the protocol. Thus, 15 patients were used for safety and efficacy analysis. Unfortunately, no data are available on the number of patients who were considered for ATG treatment but did not receive the drug. Although the protocol was open also for patients suffering of microscopic polyangiitis (MPA), no MPA patients were included. Wegener’s granulomatosis was histologically proven in all patients, and all were cANCA/PR3-ANCA positive. Eight were male and seven were female, with a mean age of 50.7 (range 36 to 65) years. Disease extent Diseae extent was assessed at entry, at 2 weeks, at 1, 3, 6, 9, 12 months, and then every 6 months, or at relapse using the disease extent index (DEI) as published previously [28]. Organ manifestations were recorded as follows: E, upper respiratory tract; L, lung; K, kidney; Ey, eye; H, cardiac involvement; S, skin; C, cen-
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tral nervous system, P, peripheral nervous system; A, arthritis/arthralgias and myalgias; GI, gastrointestinal manifestation (each organ was worth 2 points), and B, constitutional symptoms (fever >38◦ C, undesired weight loss >10% of body weight within less than 6 months) (worth 1 point). The maximum possible score was 21 points. All patients suffered of a generalized, severe course of Wegener’s granulomatosis with a cumulative DEI of 8.7 (range 3 to 12). During disease duration of 63.2 (range 18 to 180) months prior to the administration of ATG, the patients had suffered an average of 2.8 (range 1 to 7) relapses. Previous therapies consisted of 5.2 (range 2 to 7) different therapeutic approaches (Table 1), that included glucocorticosteroids and daily oral cyclophosphamide in all. The mean cumulative dose of cyclophosphamide was 56.5 g (range 10 to 150 g). Five cases had been treated with plasma exchange, six with experimental therapies [four mycophenolate mofetil, three intravenous immunoglobulins, two cyclosporine A, and two 15-deoxyspergualine (DSG)], without long-lasting control of disease activity. Refractory Wegener’s granulomatosis/MPA was defined by consensus within the EUVAS group as (1) progressive disease unresponsive to at least six weeks of standard treatment (cyclophosphamide/ glucocorticosteroids) or progressive disease in patients intolerant of standard treatment (progressive disease may include persistently active disease or major relapse threatening life or organ function); and (2) constant grumbling disease in patients who relapse after reduction or omission of cytotoxic agents. Definition of remission The activity of disease was evaluated according to clinical, radiologic, and serologic data. Complete remission was defined as the absence of pathologic findings in these variables attributable to active vasculitis, regardless of ANCA titers. The absence of clinical disease activity was indicated by a DEI of zero. Partial remission was defined as partial regression of disease activity. Response to ATG therapy was defined as induction of partial or complete remission for at least 1 month. As a delayed response to ATG had been observed previously [27], any improvement of disease extent within 3 months of ATG treatment was regarded to be an effect of therapy (for example, patients who changed status from partial to complete remission). Definition of relapse Major relapse required the recurrence of active disease threatening the function of major organs (for example, glomerulonephritis, pulmonary infiltrates, or granulomata) [29]. Minor relapse required the recurrence of disease activity of less severity, such as active vasculitis
4
3
1 2
7 3 1
1 5
4
2
3
3
2
2
3
4 5
6 7 8
9 10
11
12
13
14
15
CYC, GC, AZA
CYC, GC, AZA, MTX, PS CYC, GC, MMF, MTX, CYA, PS CYC, GC, AZA, MTX, CYA, PS, IVIG
CYC, GC, MMF, DSG
CYC, GC CYC, GC, AZA, IVIG, PS
CYC, GC, AZA, T/S CYC, GC, AZA, CYA, IVIG CYC, GC, MMF, DSG, T/S CYC, GC CYC, GC, AZA, MMF, MTX, IVIG CYC, GC, AZA CYC, GC, AZA CYC, GC
None
—
E,L,B
None
None
L (improved)
L, K, A, S
Partial remission Partial remission
Partial remission
Complete remission
Partial remission
Clinical Response to ATG
Complete remission
Died 1 day after first dose of ATG
Partial remission
Complete remission
Complete remission
Partial remission Partial remission Died 3 days after first dose of ATG (pulmonary hemorrhage) E + L (residual) Partial remission L + K (residual) Partial remission
L (residual) K (residual) —
K (residual) L (improved)
L (residual)
None
L (residual)
Disease extent after ATG administrationa
L
E, Ey, L, S
K, A, P
E, L, K, B L, K
E, L K, A, P L, K, B
K L, B
E, L, B
Ey, P
E, L, B
Disease extent at ATG administrationa
GC
GC
CYC, GC
T/S, GC
MMF, GC
CYC, GC IVIG, GC
CYC, GC CYC CYC, GC
CYC, GC MMF, GC
DSG, T/S, GC
CYA, GC
CYC, T/S, GC
Not reported Fever/chills Fever/chills Fever/chills Not reported
Fever/chills Urinary tract/CMV infection, Clostridium difficile colitis Fever/chills, serum sickness, abscess labia majora Fever/chills
MMF, GC ↓ MMF, GC → T/S, GC → AZA, GC ↓ —
AZA, GC → CYA, GC ↓
MMF, GC ↓
—
CYC, GC ↓
T/S, GC ↓
MMF, a-TNF-a, GC ↓
Died 1 day after first dose of ATG (Staphylococcus aureus + coliform pneumonia, probably preexisting) Fever/chills
Bacterial pneumonia
Fever/chills, serum sickness Fever/chills
MMF, GC ↓ MMF, GC ↓
Fever/chills
MMF, GC ↓
Therapy directly Therapy after before ATG ATG
Side effects attributable to ATG
S, A (minor)
—
—
4
None
7
E, L infiltrate (major)
A (minor)
24 6
None L bronchitis (minor)
None None —
None S, A (minor)
L granuloma (major)
None
Ey (minor)
Clinical manifestations of relapsea
12 14
15 64 —
12 2.5
6
64
2
Duration of remission months
Abbreviations are: CYC, cyclophosphamide; GC, glucocorticosteroids; CMV, cytomegalovirus; ↓, dose could be reduced; →, dose was kept equal; IVIG, intravenous immunoglobulins; AZA, azathioprine; MMF, mycophenolate mofetil; PS, plasma separation; DSG, 15-deoxyspergualin; CYA, cyclosporin A; T/S, trimethoprim/sufamethoxazole, a-TNF, anti-TNF-a–directed therapy (etanercept); E, ear, nose, and throat (ENT) region; L, lungs; K, kidneys; Ey, eye; S, skin; P, polyneuropathy; A, arthritis, arthralgia, and myalgia; GI, gastrointestinal tract; B, constitutional symptoms. a ELK classification used to assess disease extent [28].
1
1
No. of relapses Patient prior Previous therapies No. to ATG before ATG
Table 1. Patient course and treatment results of antineutrophil cytoplasmic antibodies (ANCA)-associated systemic vasculitis patients treated with antithymocyte globulin (ATG)
1442 Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
in nonvital organs (for example, arthralgia or nasal crusting), or involvement of vital organs without threatening organ function (for example, pulmonary symptoms such as cough or wheeze without radiologic changes) [29]. Treatment protocol It was the hypothesis of the study that ATG is able to induce remission of refractory active or grumbling Wegener’s granulomatosis/MPA. Inclusion criteria were biopsy proven, ANCAassociated Wegener’s granulomatosis/MPA with a refractory course as defined by the criteria given above. Exclusion criteria included allergy against rabbit proteins, previous treatment with antilymphocyte antibodies, patient age under 18 or over 75 years, previous malignancies, uncontrolled infection, including any human immunodeficiency virus (HIV) infection, inadequate contraception in fertile women, pregnancy, refractory congestive heart failure or fluid overload, or coexistence of any other multisystem autoimmune disease. End points. For patients with progressive disease, induction of remission was the primary end point. Maintenance of remission, sparing of immunosuppressants, and side effects of ATG were secondary end points. For patients with constant grumbling disease, maintenance of remission and dose reduction of immunosuppressants was the primary end point. Side effects of ATG were the secondary end points. Administration of ATG. Cytotoxic agents, intravenous immunoglobulins, or plasma exchange had to be discontinued before ATG-treatment. Intracutaneous or conjunctival testing of ATG was performed prior to the infusion to exclude a presensitization. Fourteen patients initially received 2.5 mg/kg body weight of rabbit antihuman ATG (Thymoglobulin) (IMTIX SangStat, Lyon, France). The ATG was infused via a central venous line or a large caliber vein over 4 hours. The first dose was 2.5 mg/kg body weight. During a 10-day regimen, further doses were adjusted to daily lymphocyte counts. If lymphocyte counts were <150/lL no ATG was given. In case of a lymphocyte count >150/lL and <300/lL, 1.5 mg/kg ATG was infused. Patients with lymphocyte counts ≥300/lL received 2.5 mg/kg ATG. One patient, who was treated with ATG on a compassionate basis, received ATG-Fresenius (Fresenius AG, Bad Homburg, Germany). The scheme of treatment described in the Results section. To prevent allergy, all patients received 100 mg methylprednisolone before the first administration of ATG, and azathioprine (2 mg/kg) was given throughout ATG-treatment to prevent serum sickness. If pyrexia, and/or rigors occurred, the infusion rate was decreased. When chills had passed (usually within 1 to 2 hours), the infusion was to be continued. After the course of ATG, the further use of immunosuppres-
1443
sive drugs followed clinical demands and local practice. Prophylaxis with cotrimoxazol and amphotericin-B suspension was suggested by the protocol to prevent Pneumocystis carinii and Candida infection, cytomegalovirus (CMV) prophylaxis was also optional. RESULTS Indication of ATG All 15 patients suffered of active, refractory generalized Wegener’s granulomatosis at the time of ATG administration. No patient with grumbling disease was included because of the inability to stop or reduce cytotoxic treatment. Seven patients received ATG due to progressive disease under cyclophosphamide. Eight patients were intolerant of cyclophosphamide (four developed hemorrhagic cystitis, four had marrow failure, one had jaundice, and one had nausea) and had a relapse of disease. At the time of ATG administration, the patients showed a mean DEI of 4.9 (range 2 to 8) with major organ involvement threatening organ function in all (Table 1). Noteworthy, 11 of the 15 patients had severe pulmonary disease (five had suspected pulmonary granulomata, three had massive pulmonary infiltrates with overt pulmonary hemorrhage in two, and three were unspecified), and six suffered of progressive renal involvement. Fourteen of 15 patients were already on glucocorticosteroids when ATG was administered. The 14 patients who were treated with ATG from IMTIX SangStat (Thymoglobulin) received a mean of 2.2 (range 1 to 5) infusions of ATG with a mean total dose of 300 mg (150 mg to 500 mg). The patient who was treated with ATG-Fresenius received five infusions of a total dose of 1050 mg. Response to ATG Thirteen of 15 patients showed a favorable response with partial (N = 9) or complete (N = 4) remission of disease activity (Table 1), including two of three cases with pulmonary infiltrates/hemorrhage. Following the ATG administration, the mean DEI declined from 4.9 prior to ATG to 1.8 (range 0 to 4). Remaining disease activity in the nine patients with partial remission was restricted to residual lesions such as residual pulmonary opacities, nasal crusting, or persisting proteinuria in the absence of microhaematuria with a stable creatinine. Interestingly, lesions of (suspected) granulomatous nature such as pulmonary opacities and nasal crusting seemed less likely to disappear completely (complete resolution in three of nine patients affected; 33%) as compared with lesions thought to be of merely vasculitic origin such as pulmonary infiltrates, episcleritis, and glomerulonephritis (complete resolution in 17 of 21; 81%) (Table 2). All patients who entered remission showed at least a
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Table 2. Response to antithymocyte globulin (ATG) treatment in suspected granulomatous versus suspected vasculitic lesionsa Granulomatous lesionsb
Organs involved Ear, nose, and throat (ENT) Lungs Skin Peripheral nerves Kidneys Eys Joints Constitutional symptoms Sum
Vasculitic lesionsc
Partial response number
Complete response number
Partial response number
Complete response number
4
1
—
—
2 — — — — — —
2 — — — — —
1 — — 3 — — —
1 2 4 2 2 2 4
6/9 (67%)
3/9 (33%)
4/21 (19%)
17/21 (81%)
a
In three patients, pulmonary findings could not be classified, among them a patient who died 3 days after the first administration of ATG (patient 8). b Lesions were classified as granulomatous if granuloma formation was proven by histology, or if it was suspected by the clinical appearance of the lesion (pulmonary nodules or severe nasal crusting, orbital pseudotumor). c Lesions were classified as vasculitic if vasculitis was demonstrated by histology (including crescentic glomerulonephritis) in the absence of granuloma formation or giant cells, or if the vasculitic nature of the lesion was suspected by its clinical appearance (transient pulmonary infiltrates, purpura of the skin, episcleritis, arthralgias, mononeuritis multiplex, or constitutional symptoms).
partial response within the first month following treatment. However, six patients further improved within the following 2 months, and two of these patients changed status from partial to complete remission. However, the administration of ATG was associated with fatal complications, as two patients died, both in the setting of extended pulmonary and renal involvement. Patient 8 (pulmonary renal syndrome) died due to uncontrolled pulmonary hemorrhage 3 days after the first administration of ATG. The second death occurred due to pulmonary failure and sepsis the day following the first administration of ATG in a patient with extensive pulmonary cavitation (patient 14). Here, autopsy demonstrated that pulmonary disease was complicated by bacterial infection that had not been recognized prior to the administration of ATG (methicillin-resistant Staphylococcus aureus plus Coliform bacteriae). No further deaths occurred during a mean follow up of 21.8 (range 6 to 68) months. Further immunosuppressive treatment, including glucocorticosteroids, was required in all surviving patients. However, the intensity of immunosuppression could be reduced in 11 cases (Table 1). Ten patients were able to reduce the dose of corticosteroids, from a mean dose of 48.5 mg/day (range 5 mg to 100 mg) prior to ATG administration to a mean dose of 12.75 mg/day (range 2.5 mg to 25 mg). Noteworthy, only one of the seven patients who were treated with cyclophosphamide directly before ATG administration remained on this drug thereafter, and the use of myelosuppressive agents was restricted to three cases (one patient bolus cyclophosphamide, two azathioprine). Currently, six of the 13 surviving patients
are free of relapse for a mean of 22.3 (range 7 to 64) months. Seven patients relapsed after a mean of 8.4 (2 to 24) months. Compared with the mean DEI 5.6 (3 to 8) at the time of ATG administration in these seven patients, the subsequent relapses were of a minor extent (mean DEI 2.9) (range 2 to 4). Five of the relapses were classified as minor (mean DEI 2.8) (bronchitis, arthralgias, purpura, and episcleritis), and two as major relapses (mean DEI 3.0) involving the lungs in both patients (one with pulmonary infiltrates and one with an increase in size of pulmonary granulomata). The pulmonary granulomata (patient 3) responded to the addition of etanercept, a TNF-a blocker. The patient who developed pulmonary infiltrates (patient 12) showed progressive disease despite reinstitution of cyclophosphamide treatment and finally responded to plasma exchange. The likelihood of subsequent relapse was increased in patients who were not treated with cyclophosphamide directly before the ATG administration (relapse in six of seven surviving patients) as compared to patients who were on treatment regimens with cyclophosphamide (subsequent relapse in one of six cases). The cumulative dose of cyclophosphamide seemed to be lower in patients who did relapse following ATG administration as compared to those who did not (37.8 g versus 70.2 g), but the difference was statistically not significant. ANCA were positive in all patients directly before ATG treatment as detected by indirect fluorescence and/or PR3 enzyme-linked immunosorbent assay (ELISA). Follow-up on ANCA titers was available on nine surviving cases. Within 6 months, ANCA titers became negative in four of nine, declined by more than 2 titer steps in two and remained unchanged in three further cases. Notably, in one of the patients, ANCA remained negative despite subsequent relapse after 6 months. Side effects of ATG Ten patients experienced fever and chills associated with the first application of ATG. Further side effects were restricted to a minority of cases: Two patients (patients 2 and 11) suffered from serum sickness, clinically manifested with purpura, arthralgias, dyspnea, and fever. Both cases quickly responded to plasma exchanges without any additional immunosuppressive therapy. One of the patients was tested for IgM rheumatoid factor and showed a positive test. Infections. Besides the patient who died of pulmonary bacterial infection, five further episodes of severe infections were observed. Three weeks after ATG administration, one patient developed an abscess of a labium majus (S. aureus) that required surgical drainage. Further infections (each in one case) included urinary tract infection,
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pneumonia (10 days after last dose of ATG, most likely of bacterial origin, response to antibiotic treatment), CMV infection, and Clostridium difficile colitis. DISCUSSION The present study shows that a 10-day regimen of ATG induced remission in six of seven Wegener’s granulomatosis patients who showed progressive disease under treatment with cyclophosphamide and in seven of eight additional patients in whom cyclophosphamide had to be avoided due to severe side effects. Importantly, the effect of ATG may be long-lasting, as six patients are still free of relapse for a mean of 22.3 (range 7 to 64) months. But also in the seven patients who subsequently relapsed, the disease extent at the time of relapse was limited in comparison to the disease extent directly before ATG administration (mean DEI 2.9 vs. 5.6). Thus, ATG may have contributed to a less aggressive course in these refractory cases. However, two fatalities occurred which was not unexpected due to the fact that all patients were very ill at the time they received ATG. Patient 8, who died 3 days after the first administration of ATG due to pulmonary hemorrhage might have received the drug too late during his fulminant course. It has been described previously and also we observed here that response to ATG in some patients may be delayed by an interval of several weeks [27]. Autopsy of patient 14, who died the day following the first administration of ATG, demonstrated uncontrolled pulmonary infection as well as active vasculitic lesions. This case has to be regarded as a protocol violation, as uncontrolled infection was a contraindication for ATG treatment. In large cohorts of Wegener’s granulomatosis patients, including cases with mild-to-severe disease, deaths due to infections have been observed to occur in 3% to 12% of cases during a mean follow-up of 7 to 12 years (reviewed in [2]). The relatively high death rate reported here (two of 15 cases) must be interpreted in the context of the most severe course of these patients with an increased likelihood of infection. Retrospectively, however, this case should not have been treated with ATG, and it should be stressed that infections must be actively excluded prior to the use of ATG, in order to archive an optimal risk benefit ratio. If it is not possible to sufficiently rule out simultaneous infections, the use of ATG should be discouraged. The present study confirms and extends an earlier report, that demonstrated a positive response to rabbit ATG in four of five Wegener’s granulomatosis patients, with partial (N = 3) or complete (N = 1) remission of disease activity, during a follow-up of 5 months to 51/2 years [27, 31]. This cohort was not included in the current study. The patients were recruited on similar grounds as in this study. All five cases suffered of
Table 3. Summarized experience with antithymocyte globulin (ATG) in refractory antineutrophil cytoplasmic antibodies (ANCA)-associated systemic vasculitis
Reference [27] [31], follow-up of [27] [30] EUVAS Group SOLUTION
Intensity reduction of Partial Complete immunosupNumber remission remission pressants of cases Diagnosis number number number 5 1
all WG WG
4 —
none 1
4 yes
1 15
MPA all WG
1 9
— 4
? 12
Abbreviations are: WG, Wegener’s granulomatosis; MPA, microscopic polyangiitis; EUVAS, European Vasculitis Study Group.
active, severe refractory Wegener’s granulomatosis, had been treated previously with cyclophosphamide and glucocorticosteroids and received a similar regimen of ATG. Interestingly, granulomatous lesions such as orbital pseudotumors and nasal/sinus granulomata (improvement at one of three sites of active disease) did not respond as well as vascular lesions (episcleritis and glomerulonephritis; improvement at five of five sites of active disease) [27]. A similar trend was seen in the cohort presented here, with a complete response to ATG of 81% of the vasculitis in contrast to 33% of the granulomatous lesions (Table 2). Although the numbers are too small to perform any meaningful statistical tests, it may be speculated that granulomatous lesions do not respond as good to ATG as lesions of a purely vasculitic nature. This is in line with a relative resistance of retro-orbital pseudotumors and subglottic/bronchial stenosis observed under standard treatment with cyclophosphamide and glucocorticosteroids [1]. Extensive fibrotic changes in some of the lesions may partially explain the problem [1]. It is well known that active T cells can be demonstrated in granulomatous lesions in Wegener’s granulomatosis [7, 9]. It has not been investigated, to which extend these T-cell infiltrates persist after treatment with ATG. Regression of active vasculitis has also been documented in a case of pANCA associated MPA (pulmonary and renal involvement, dialysisdependent), who was treated with ATG and glucocorticosteroid pulses (clinical remission, off dialysis) [30]. A PubMed search performed on May 25, 2003, using the search terms “ATG” and “ANCA,” “vasculitis,” “angiitis,” and “arteritis” did not reveal any further reports on cases of Wegener’s granulomatosis/MPA treated with ATG. Table 3 summarizes the experience published on ATG treatment of these disorders. It is unclear at present whether patients with pulmonary disease, especially cases with pulmonary hemorrhage, should be considered for ATG treatment. Nine of the 11 patients described here with active pulmonary disease responded to treatment. Among the responders were two of three cases with suspected/overt alveolar bleeding. But one of these three cases (a patient with
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Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
massive alveolar hemorrhage) died of pulmonary failure 1 day after the first dose of ATG. Because the administration of ATG may lead to pulmonary infiltrates [32], acute respiratory distress syndrome [33], and to pulmonary edema [34], the risk of ATG must be balanced against the possible benefits in patients with serious pulmonary problems, and alternative options should be considered. Especially, fluid overload should be treated accordingly before the administration of ATG. The experience gained from the three patients presented here is too limited to give any other meaningful recommendations, and previous case series of Wegener’s granulomatosis patients treated with ATG did not include patients with alveolar hemorrhage [27]. However, a good response to ATG has been described in a case of pulmonary renal syndrome due to MPA, without pulmonary complications following the administration of ATG [30]. Because pulmonary infiltrates may be caused both by alveolar bleeding and by lung infections, special care must be taken to exclude underlying pulmonary infections in these patients before ATG is administered. In the patients reported previously [27, 30], glucocorticosteroid doses could be reduced in all four responders, and all except two patients were free of other immunosuppressive agents for up to 31/2 years. Although long-term remissions of up to 51/2 years were also observed in the present study, all patients published now are on continued immuosuppressive therapy. Furthermore, all patients still receive glucocorticosteroids, but a dosesparing effect was observed in ten of 13 cases. It could be argued that concomitant treatment with glucocortocosteroids added significantly to the favorable response of ATG. However, it is known that glucocortocosteroids alone are not capable to induce or maintain remission in Wegener’s granulomatosis [1]. Also, 14 of the 15 patients received glucocorticosteroids before the administration of ATG, without control of disease activity. T cells and Wegener’s granulomatosis The clinical response to ATG favors a pathogenetic role of T cells in Wegener’s granulomatosis and supports existing evidence of a dysregulated cellular immunity in this disorder, although the participation of antigen specific T cells in the pathogenesis of Wegener’s granulomatosis at initiation and effector stages of the immune response has not been formally proven. Although not universally accepted [15], there is some evidence from in vitro studies that T-helper cells and peripheral blood mononuclear cells from Wegener’s granulomatosis patients proliferate on stimulation with PR3 [12–14], but no specific PR3 sequence could be identified that was preferentially recognized [35]. However, effectors of cellmediated immunity such as CD4+ and CD45 RO-positive T cells have been demonstrated in active vasculitic lesions
in lung and nasal biopsies as well as in glomeruli affected by pauci-immune crescentic glomerulonephritis [6, 7, 10, 36]. An abundance of CD28− T cells was found in granulomatous lesions of the respiratory tract and in bronchoalveolar lavage fluid from Wegener’s granulomatosis patients [11]. Although there are conflicting data on Thelper cell 1/T-helper cell 2 dominance [6, 8, 9, 15], a polarization toward T-helper cell 1 immune response is favored by most authors and was recently shown to be reversible by immunosuppressive treatment [36]. Peripheral CD4+ T cells of patients with Wegener’s granulomatosis were shown to exhibit increased proliferative responses and to overproduce IFN-c and TNF-a, which might be of significance for the generation of the granulomatous lesions via their effects on cellular recruitment [15]. Production of these cytokines has also been demonstrated by CD4+ CD28− T cells within granulomatous lesions of Wegener’s granulomatosis patients [9]. Elevated levels of T-cell activation markers such as soluble interleukin 2 (IL-2) receptor and soluble CD30 were shown to correlate with the clinical activity of Wegener’s granulomatosis and remain elevated during periods of complete remission [16, 17]. In animal models of crescentic (although not ANCA-associated) glomerulonephritis (summarized by Tipping et al [37]), evidence of a pivotal role of cell-mediated immunity continues to accumulate. This includes the requirement of CD4+ cells (dominance of T-helper cell1 immune response), but not B cells for the induction of disease [37, 38], with no IgG binding to glomerular basement membrane (GBM) or C3 deposition being detected in a recent model [39]. Therapy with anti-CD8 monoclonal antibody was shown to be effective in the prevention and treatment of the disease [40]. A pathogenetic role of lymphocytes in crescentic pauciimmune glomerulonephritis is further substantiated by a randomized trial that demonstrated a similar efficacy of lymphocyte apheresis as compared with pulse glucocorticosteroids [41]. DSG, which is thought to selectively inhibit cell-mediated immunity [42], was also shown to induce remission in 14 of 20 patients with refractory Wegener’s granulomatosis and MPA [43]. Anisperimus (LF 15-0195), a substance closely related to DSG, may be of similar efficacy (induction of remission in seven of nine cases of refractory systemic vasculitis) [abstract; The Laboratories Fournier LF 15-0195 Vasculitis Study Group, Cleve Clin J Med 69 (Suppl 2):SII 191, 2002]. The good response of refractory Wegener’s granulomatosis to ATG reported here also favors the development of less toxic therapeutic concepts that selectively suppress the cellmediated immune response. These concepts are urgently awaited to overcome the era of cyclophosphamide and high dose glucocorticosteroids [44]. Finally, the depletion of autoreactive T cells by ATG may also affect B-cell function, as indicated by the observation that ANCA titers declined or became negative
Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
in the majority of cases described here and in an earlier study [27]. Because ANCA by themselves also seem to be of pathogenetic significance in Wegener’s granulomatosis, this may have also influenced the outcome. Possibly, the relative roles of cell-mediated immunity and antibody-mediated effects may relate to the phase of disease. The pathogenetic role of the humoral immune response is further substantiated by a recent report on the induction of crescentic glomerulonephritis and vasculitis by passive infusion of mouse antimyeloperoxidase IgG into both immune-deficient and immune-competent mice [45]. Correspondingly, an excellent response of refractory Wegener’s granulomatosis was observed following the administration of a monoclonal anti-CD20 antibody (rituximab) [46], and plasma exchange, which has been tested in a large EUVAS trial in severe renal Wegener’s granulomatosis/MPA, appears to be superior to glucocorticosteroid boli in this setting [abstract; Gaskin G, et al, J Am Soc Nephrol 13:F-FC110, 2002]. Furthermore, on a more downstream level compared to ATG, anti-TNF-a treatment has been used successfully to treat refractory Wegener’s granulomatosis [47]. Side effects Beside fever and chills experienced by most patients, side effects were restricted to a minority of cases: serum sickness, previously observed in two of five Wegener’s granulomatosis patients [27] and in about 10% of renal transplant patients [22], was now seen in two cases and rapidly improved after institution of plasma exchange. IgM rheumatoid factor, demonstrated in the patient tested here, may have contributed to this reaction, as it may cross react with rabbit IgG and is frequently present in active Wegener’s granulomatosis [1]. Whether azathioprine, which the patients received during ATG treatment in order to prevent serum sickness, had any positive effect remains speculative. CMV infection occurred in only one case, but is frequently associated with ATG treatment after allograft transplantation and may show an aggravated course. Further infectious complications of the present cohort responded to treatment and did not lead to permanent morbidity. Special care is necessary to protect the patients from infections, and the use of prophylactic treatment against bacterial, fungal, and viral infections such as CMV should be recommended. Follow-up studies after kidney transplantation demonstrate that ATG increases the risk for malignant disorders [48], but no malignancies were observed here during a mean follow-up of 21.8 months. CONCLUSION Using a standardized regimen of ATG in patients with active, refractory Wegener’s granulomatosis, we were
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able to induce remission in 13 of 15 cases. None of the patients was able to quit immunsuppressive therapy, but the intensity of immunosuppression could be reduced in 12. With few exceptions, ATG treatment was well tolerated. The response to ATG supports the concept that T cells play a pathogenetic role in ANCA-associated systemic vasculitis. Outside controlled randomized trials, which are unlikely to be performed due to the rarity of the condition, patients suffering of refractory Wegener’s granulomatosis should be managed with individualized treatment schemes. Although the present study was open and uncontrolled, ATG seems to be a promising treatment option for these severely ill patients. However, in order to avoid fatal side effects, ATG should only be administrated if simulatenous infections and fluid overload have been ruled out or treated sufficiently. In patients with alveolar hemorrhage, who are known to be especially prone to infections, alternative options for treatment should be considered. ACKNOWLEDGMENTS In addition to the authors, the following members of the European Vasculitis Study Group (EUVAS) participated in this study: G. Gaskin, Hammersmith Hospital, Renal Section, London, England, UK; D. R. Jayne, Addenbrooke’s Hospital, Cambridge UK; R. Luqmani, Western General Hospital, University Department of Rheumatology, Edinburgh, Scotland, UK; M. Molzahn, Department of Nephrology, Humboldt Krankenhaus, Berlin, Germany; J. Verbanck, Department of Nephrology, H. Hartziekenhuis, Roselare, Belgium; K.M. Wissing, Department of Nephrology, Hopital ˆ Erasme, Universite Libre Bruxelles, Brussels, Belgium. The EUVAS group was supported by grants from the EU (Contract no. CIPD-CT94-0307 and IC20-CT97-0019). L.F. Flores-Suarez ´ was supported by Consejo Nacional de Ciencia y Technologia (CONACYT) Mexico ´ grant 110912. Thymoglobulin (ATG) was provided by IMTIX SangStat, Lyon, France without further financial contributions to the study. Reprint requests to Wilhelm H. Schmitt, M.D., Fifth Medical Clinic, University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1–3, 68167 Mannheim, Germany. E-mail: [email protected]
REFERENCES 1. HOFFMAN GS, KERR GS, LEAVITT RY, et al: Wegener’s granulomatosis: an analysis of 158 patients. Ann Intern Med 116:488, 1992 2. REINHOLD-KELLER E, BEUGE N, LATZA U, et al: An interdisciplinary approach to the care of patients with Wegener’s granulomatosis. Arthritis Rheum 43:1021–1032, 2000 3. JAYNE DRW: Conventional treatment and outcome of Wegener’s granulomatosis and microscopic polyangiitis. Cleve Clin J Med 69 (Suppl 2):SII 110–115, 2002 4. FRANSSEN CFM, STEGEMAN CA, KALLENBERG CGM, et al: Antiproteinase 3- and antimyeloperoxidase associated vasculitis. Kidney Int 57:2195–2206, 2000 5. HARPER L, SAVAGE COS: Pathogenesis of ANCA-associated vasculitis. J Pathol 190:349–359, 2000 6. BOLTON WK, INNES D, STURGILL BC, KAISER DL: T cells and macrophages in rapidly progressive glomerulonephritis: Clinicopathological correlates. Kidney Int 32:869–876, 1987 ¨ 7. CSERNOK E, TRABANDT A, MULLER A, et al: Cytokine profiles in Wegener’s granulomatosis: predominace of type 1 (Th1) in the granulomatous inflammation. Arthritis Rheum 42:742–750, 1999
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8. BALDING CEJ, HOWIE AJ, DRAKE-LEE AB, SAVAGE COS: Th2 dominance in nasal mucosa in patients with Wegener’s granulomatosis. Clin Exp Immunol 125:332–339, 2001 9. KOMOCSI A, LAMPRECHT P, CSERNOK E, et al: Peripheral blood and granuloma CD4+ CD28− T cells are a major source of interferonc and tumor necrosis factor-a in Wegener’s granulomatosis. Am J Pathol 160:1717–1724, 2002 10. CUNNINGHAM MA, HUANG XR, DOWLING JP, et al: Effectors of cellmediated immunity are prominent in “pauci-immune” glomerulonephritis. J Am Soc Nephrol 10:499–506, 1999 11. LAMPRECHT P, MOOSIG F, CSERNOK E, et al: CD28 negative T cells are enriched in the granulomatous lesions of the respiratory tract in Wegener’s granulomatosis. Thorax 56:751–757, 2001 12. VAN DER WOUDE FJ, VAN ES LA, DAHA MR: The role of c-ANCA antigen in the pathogenesis of Wegener’s granulomatosis. A hypothesis based on both humeral and cellular mechanisms. Neth J Med 36:169–171, 1990 13. BROUWER E, STEGEMAN C, MUITEMA M, et al: T-cell reactivity to proteinase 3 and myeloperoxidase in patients with Wegener’s granulomatosis. Clin Exp Immunol 98:448–453, 1994 14. KING WJ, BROOKS CJ, HOLDER R, et al: T lymphocyte responses to anti-neutrophil cytoplasmic antibody (ANCA) antigens are present in patients with ANCA associated systemic vasculitis and persist during disease remission. Cin Exp Immunol 112:539–546, 1998 15. LUDVIKSSON BJ, SNELLER MC, CHUA KS, et al: Active Wegener’s granulomatosis is associated with HLA-DR+ CD4+ T cells exhibiting an unbalanced Th1-type T cell cytokine pattern: Reversal with IL-10. J Immunol 160:3602–3609, 1998 16. SCHMITT WH, HEESEN C, CSERNOK E, et al: Elevated serum levels of soluble interleukin-2 receptor in patients with Wegener’s granulomatosis. Arthritis Rheum 35:1088–1096, 1992 17. WANG G, CSERNOK E, GROSS WL: High plasma levels of the soluble form of CD30 activation molecule reflect disease activity in patients with Wegener’s granulomatosis. Am J Med 102:517–523, 1997 18. LOCKWOOD CM, THIRU S, ISAACS J, et al: Long-term remission of intractable systemic vasculitis with monoclonal antibody therapy. Lancet 341:1620, 1993 19. MATHIESON PW, COBBOLD SP, HALE G, et al: Monoclonal antibody therapy in systemic vasculitis. N Engl J Med 323:250, 1990 20. MESTRE M, BAS J, ALSINA J, et al: Depleting effects of antithymocyte globulin on T-lymphocyte subsets in kidney transplantation. Transplant Proc 31:2254–2255, 1999 21. BURDICK JF: The biology of immunosuppression mediated by antilymphocyte antibodies, in Kidney Transplant Rejection: Diagnosis and Treatment, edited by William GM, Burdick JF, Solez K, New York, Marcel Dekker, 1986, pp 307–312 22. HOITSMA AJ, VAN LIER HJJ, REEKERS P, KOENE RAP: Improved patients and graft survival after treatment of acute rejections of cadaveric renal allografts with rabbit anticymocyte globulin. Transplantation 39:274, 1985 23. TARKOWSKI A, ANDERSON-GARE B, AURELL M: Use of antithymocyte globulin in the management of refractory systemic autoimmune diseases. Scand J Rheumatol 22:261–266, 1993 24. TARKOWSKI A, LINDGREN I: Beneficial effects of antithymocyte globulin in severe cases of progressive systemic sclerosis. Transplant Proc 26:3197–3199, 1994 25. STRATTON RJ, WILSON, H, BLACK CM: Pilot study of anti-thymocyte globulin plus mycophenolate mofetil in recent-onset diffuse scleroderma. Rheumatology (Oxford) 40:84–88, 2001 26. MORISHITA Y, MATSUKAWA Y, KURA Y, et al: antithymocyte globulin for a patient with systemic lupus erythematosus complicated by severe pancytopenia. J Int Med Res 25:219–223, 1997 27. HAGEN EC, DE KEIZER RJW, ANDRASSY K, et al: Compassionate treatment of Wegener’s granulomatosis with rabbit anti-thymocyte globulin. Clinical Nephrology 43:351–359, 1995 28. DE GROOT K, GROSS WL, HERLYN K, REINHOLD-KELLER E: De-
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velopment and validation of a disease extent index for Wegener’s granulomatosis. Clin Nephrol 55:31–38, 2001 KALLENBERG CGM: A disease activity index in Wegener’s granulomatosis. APMIS 98 (Suppl 19):37–39, 1990 LUKAS R, KELLER F: Anti-thymocyte globulin therapy in a patient with pANCA vasculitis and crescentic glomerulonephritis [letter]. Nephron 78:231, 1998 KOOL J, DE KEIZER RJW, SIEGERT CEH: Antithymocyte globulin treatment of orbital Wegener granulomatosis: A follow-up study. Am J Opthalmol 127:738–739, 1999 MAILLARD N, FOUCHER P, CAILLOT D, et al: Transient pulmonary infiltrates during treatment with anti-thymocyte globulin. Respiration 66:279–282, 1999 SHORR, AF, ABOTT KC, AGADOA LY: Acute repiratory distress syndrome after kidney transplantation: Epidemiology, risk factors, and outcomers. Crit Care Med 31:1325–1330, 2003 BOCK HA, GALLATI H, ZURCHER RM, et al: A randomized prospective trial of prophylactic immunosuppression with ATG-fresenius versus OKT3 after renal transplantation. Transplantation 59:830– 840, 1995 VAN DER GELD YM, HUITEMA MG, FRANSSEN CFM, et al: In vitro T lymphocyte responses to proteinase 3 (PR3) and linear peptides of PR3 in patients with Wegener’s granulomatosis. Clin Exp Immunol 122:504–513, 2000 MASUTANI K, TOKUMOTO M, NAKASHIMA H, et al: Strong polarization toward Th1 immune response in ANCA-associated glomerulonaphritis. Clin Nephrol 59:395–405, 2003 TIPPING PG, KITCHING AR, CUNNINGHAM MA, HOLDSWORTH SR: Immunopathogenesis of crescentic glomerulonephritis. Curr Opin Nephrol Hypertens 8:281–286, 1999 LI S, HOLDSWORTH SR, TIPPING PG: Antibody independent crescentic glomerulonephritis in m chain deficient mice. Kidney Int 51:672– 678, 1997 WU J, HICKS J, BORILLO J, et al: CD4(+) T cells specific to a glomerular basement membrane antigen mediate glomerulonephritis. J Clin Invest 109:517–524, 2002 REYNOLDS J, NORGAN VA, BHAMBRA U, et al: Anti-Cd8 monoclonal antibody therapy is effective in the prevention and treatment of experimental autoimmune glomerulonephritis. J Am Soc Nephrol 13:359–369, 2002 FURUTA T, HOTTA O, YUSA N, et al: Lymphocytapharesis to treat rapidly progressive glomerulonephritis: A randomised comparison with GC-pulse treatment [letter]. Lancet 352:203–204, 1998 NIKOLIC-PATERSON DJ, KERR PG, LAN HY, et al: Deoxyspergualin: A new immunosuppressive drug for the auto-immune disease. Nephron 70:391–396, 1995 BIRCK R, WARNATZ K, LORENZ HM, et al: 15-deoxyspergualin in patients with refractory ANCA associated systemic vasculitis. A six months open label trial to evaluate safety and efficacy. J Am Soc Nephrol 14:440–447, 2003 COUSER WG: Sensitized cells come of age: A new era in renal immunology with important therapeutic implications. J Am Soc Nephrol 10:664–665, 1999 XIAO H, HEERINGA P, HU P, et al: Antineutrophil cytoplasmic autoantibodies specific for myeloperoxidase cause glomerulonephritis and vasculitis in mice. J Clin Invest 110:955–963, 2002 SPECKS U, FERVENZA FC, MCDONALD TJ, HOGAN MC: Response of Wegener’s granulomatosis to anti-CD20 chimeric monoclonal antibody therapy. Arthritis Rheum 44:2836–2840, 2001 LAMPRECHT P, VOSSWINKEL J, LILIENTHAL T, et al: Effectiveness of TNF-alpha blockade with infliximab in refractory Wegener’s granulomatosis. Rheumatology (Oxford) 41:1303–1307, 2002 FARGE D, LEBBE C, MARJANOVIC Z, et al: Human herpes virus-8 and other risk factors for Kaposi’s sarcoma in kidney transplant recipients. Group Cooperatif de Transplantation d’ Ile de France (GCIF). Transplantation 67:1236–1242, 1999
Treatment of refractory Wegener’s granulomatosis with antithymocyte globulin (ATG): An open study in 15 patients WILHELM H. SCHMITT, E. CHRISTIAAN HAGEN, IRMGARD NEUMANN, RAINER NOWACK, LUIS FELIPE ´ FLORES-SUAREZ ,1 and FOKKO J. VAN DER WOUDE, FOR THE EUROPEAN VASCULITIS STUDY GROUP Fifth Department of Medicine, University Hospital Mannheim of the University of Heidelberg, Mannheim, Germany; Eemland Ziekenhuis, Locatie “Lichtenberg,” Department of Internal Medicine, Amersfoort, The Netherlands; and Wilhelminenspital Wien, Department of Nephrology, Vienna, Austria
Treatment of refractory Wegener’s granulomatosis with antithymocyte globulin (ATG): An open study in 15 patients. Background. A subset of patients with Wegener’s granulomatosis does not respond sufficiently to cyclophosphamide and glucocorticosteroids or suffers of intolerable side effects. Anecdotal data suggest that antithymocyte globulin (ATG) may be a treatment option for these patients. We now describe 15 patients treated with ATG for refractory Wegener’s granulomatosis. Methods. Fifteen patients with histologically proven active refractory Wegener’s granulomatosis (seven unresponsive to cyclophosphamide, eight intolerant) were treated with ATG by a protocol (SOLUTION protocol) designed by the European Vasculitis Study (EUVAS) Group. Results. Before ATG administration, patients had received a mean of 5.2 (range 2 to 7) different therapeutic approaches including glucocorticosteroids and cyclophosphamide in all and experimental therapies in six, without control of disease activity [2.8 (range 1 to 7) relapses during a disease duration of 63.2 (range 18 to 180) months]. Thirteen of 15 patients showed a favorable response to ATG with partial (N = 9) or complete (N = 4) remission. During a follow-up of 21.8 (range 6 to 68) months, seven patients relapsed after a mean of 8.4 (range 2 to 24) months (five minor and two major relapses). Six patients are free of relapse for 22.3 (range 7 to 64) months. Two patients died, 1 and 3 days following the first dose of ATG, due to pulmonary hemorrhage and infection (one each). Although further immunosuppressive treatment was required in all surviving patients, a less intensive regimen could be applied in 12. Beside fever and chills associated with the first gift of ATG, ATG was well tolerated, with infections being observed in five cases and serum sickness in two. Conclusion. Anti-T-cell–directed treatment with ATG may be a therapeutic option for severe refractory Wegener’s granulomatosis if simultaneous infections and fluid overload have 1 Dr. Flores-Suarez is currently at the Instituto Nacional de Ciencias Medicinas ´ y Nutricion ´ Salvador Zubiran, Mexico City, Mexico.
Key words: Wegener’s granulomatosis, antineutrophil cytoplasmic antibodies (ANCA), vasculitis, antithymocyte globulin (ATG). Received for publication June 22, 2003 and in revised form August 24, 2003 Accepted for publication December 1, 2003 C
2004 by the International Society of Nephrology
been ruled out. In patients with alveolar hemorrhage, ATG should only be used under special caution.
Wegener’s granulomatosis, the most common systemic vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA), commonly takes a lethal course or results in severe organ damage if left untreated. About 90% of cases respond to daily oral cyclophosphamide and glucocorticosteroids, at the cost of substantial treatmentinduced morbidity. Relapses are experienced in at least 50% of cases [1–3]. The usual therapeutic management of such cases is prolonged or readministration of cyclophosphamide. In frequent relapsers this often results in high cumulative doses. Severe side-effects of cyclophosphamide such as malignancies and bone-marrow toxicity were seen in 42% of patients in an important follow-up study [2]. The greatest challenges in the management of Wegener’s granulomatosis are the maintenance of remission, the avoidance of treatment related morbidity, and the care of refractory cases who do not tolerate or respond to standard therapy. In the latter, there is a definite need to replace cyclophosphamide by other immunsuppressive drugs. There is increasing evidence for a pathogenetic role of T cells in Wegener’s granulomatosis (reviewed in [4, 5]), including the finding of T cells in active vasculitic lesions [6–11], the proliferation of T-helper cells from patients with Wegener’s granulomatosis on stimulation with proteinase 3 (PR3) [12–14], an overproduction of interferonc (INF-c) and tumor necrosis factor-a (TNF-a) by T cells from Wegener’s granulomatosis patients [15], and the correlation of soluble markers of T-cell activation with disease activity [16, 17]. Thus, there is sufficient evidence for a pathogenetic role of T cells in Wegener’s granulomatosis to justify anti-T-cell–directed experimental therapeutic designs in refractory patients. Initial reports have favored a beneficial effect of a treatment using humanized antibodies against lymphocyte
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antigens such anti-CD4 and anti-CD52 [18, 19]. Administration of antithymocyte globulin (ATG), a polyclonal preparation of antibodies directed against surface antigens of activated lymphocytes, results in profound lymphocyte depletion of rapid onset and thereby modifies (auto-) immunologically triggered inflammation [20]. Mechanisms of action of ATG include classic complement-mediated lysis of lymphocytes, clearance of lymphocytes due to reticuloendothelial uptake, masking of T-cell antigens, or expansion of negative regulatory cells [21]. ATG, an established agent for the treatment of allograft rejection [22], has been successfully administered to patients with autoimmune disorders such as systemic sclerosis, systemic lupus erythematosus (SLE), autoimmune hemolytic anemia, and rheumatoid arthritis [23–26]. In 1995, a favorable response was observed in four of five patients with refractory Wegener’s granulomatosis [27]. Encouraged by these results, the European Vasculitis Study Group (EUVAS Group) prospectively studied ATG in an open, multicenter protocol (SOLUTION protocol) to investigate the efficacy of ATG in Wegener’s granulomatosis patients refractory to standard treatment. METHODS Patients Within an open, prospective, uncontrolled protocol, patients with refractory Wegener’s granulomatosis were treated with ATG in nine academic centers of five European countries. Patients gave written informed consent before the inclusion. Ethical approval was obtained in each participating center. Ten patients were enrolled in the study from February 1997 to October 2001. Furthermore, five patients were treated with ATG on compassionate use, but according to the protocol. Thus, 15 patients were used for safety and efficacy analysis. Unfortunately, no data are available on the number of patients who were considered for ATG treatment but did not receive the drug. Although the protocol was open also for patients suffering of microscopic polyangiitis (MPA), no MPA patients were included. Wegener’s granulomatosis was histologically proven in all patients, and all were cANCA/PR3-ANCA positive. Eight were male and seven were female, with a mean age of 50.7 (range 36 to 65) years. Disease extent Diseae extent was assessed at entry, at 2 weeks, at 1, 3, 6, 9, 12 months, and then every 6 months, or at relapse using the disease extent index (DEI) as published previously [28]. Organ manifestations were recorded as follows: E, upper respiratory tract; L, lung; K, kidney; Ey, eye; H, cardiac involvement; S, skin; C, cen-
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tral nervous system, P, peripheral nervous system; A, arthritis/arthralgias and myalgias; GI, gastrointestinal manifestation (each organ was worth 2 points), and B, constitutional symptoms (fever >38◦ C, undesired weight loss >10% of body weight within less than 6 months) (worth 1 point). The maximum possible score was 21 points. All patients suffered of a generalized, severe course of Wegener’s granulomatosis with a cumulative DEI of 8.7 (range 3 to 12). During disease duration of 63.2 (range 18 to 180) months prior to the administration of ATG, the patients had suffered an average of 2.8 (range 1 to 7) relapses. Previous therapies consisted of 5.2 (range 2 to 7) different therapeutic approaches (Table 1), that included glucocorticosteroids and daily oral cyclophosphamide in all. The mean cumulative dose of cyclophosphamide was 56.5 g (range 10 to 150 g). Five cases had been treated with plasma exchange, six with experimental therapies [four mycophenolate mofetil, three intravenous immunoglobulins, two cyclosporine A, and two 15-deoxyspergualine (DSG)], without long-lasting control of disease activity. Refractory Wegener’s granulomatosis/MPA was defined by consensus within the EUVAS group as (1) progressive disease unresponsive to at least six weeks of standard treatment (cyclophosphamide/ glucocorticosteroids) or progressive disease in patients intolerant of standard treatment (progressive disease may include persistently active disease or major relapse threatening life or organ function); and (2) constant grumbling disease in patients who relapse after reduction or omission of cytotoxic agents. Definition of remission The activity of disease was evaluated according to clinical, radiologic, and serologic data. Complete remission was defined as the absence of pathologic findings in these variables attributable to active vasculitis, regardless of ANCA titers. The absence of clinical disease activity was indicated by a DEI of zero. Partial remission was defined as partial regression of disease activity. Response to ATG therapy was defined as induction of partial or complete remission for at least 1 month. As a delayed response to ATG had been observed previously [27], any improvement of disease extent within 3 months of ATG treatment was regarded to be an effect of therapy (for example, patients who changed status from partial to complete remission). Definition of relapse Major relapse required the recurrence of active disease threatening the function of major organs (for example, glomerulonephritis, pulmonary infiltrates, or granulomata) [29]. Minor relapse required the recurrence of disease activity of less severity, such as active vasculitis
4
3
1 2
7 3 1
1 5
4
2
3
3
2
2
3
4 5
6 7 8
9 10
11
12
13
14
15
CYC, GC, AZA
CYC, GC, AZA, MTX, PS CYC, GC, MMF, MTX, CYA, PS CYC, GC, AZA, MTX, CYA, PS, IVIG
CYC, GC, MMF, DSG
CYC, GC CYC, GC, AZA, IVIG, PS
CYC, GC, AZA, T/S CYC, GC, AZA, CYA, IVIG CYC, GC, MMF, DSG, T/S CYC, GC CYC, GC, AZA, MMF, MTX, IVIG CYC, GC, AZA CYC, GC, AZA CYC, GC
None
—
E,L,B
None
None
L (improved)
L, K, A, S
Partial remission Partial remission
Partial remission
Complete remission
Partial remission
Clinical Response to ATG
Complete remission
Died 1 day after first dose of ATG
Partial remission
Complete remission
Complete remission
Partial remission Partial remission Died 3 days after first dose of ATG (pulmonary hemorrhage) E + L (residual) Partial remission L + K (residual) Partial remission
L (residual) K (residual) —
K (residual) L (improved)
L (residual)
None
L (residual)
Disease extent after ATG administrationa
L
E, Ey, L, S
K, A, P
E, L, K, B L, K
E, L K, A, P L, K, B
K L, B
E, L, B
Ey, P
E, L, B
Disease extent at ATG administrationa
GC
GC
CYC, GC
T/S, GC
MMF, GC
CYC, GC IVIG, GC
CYC, GC CYC CYC, GC
CYC, GC MMF, GC
DSG, T/S, GC
CYA, GC
CYC, T/S, GC
Not reported Fever/chills Fever/chills Fever/chills Not reported
Fever/chills Urinary tract/CMV infection, Clostridium difficile colitis Fever/chills, serum sickness, abscess labia majora Fever/chills
MMF, GC ↓ MMF, GC → T/S, GC → AZA, GC ↓ —
AZA, GC → CYA, GC ↓
MMF, GC ↓
—
CYC, GC ↓
T/S, GC ↓
MMF, a-TNF-a, GC ↓
Died 1 day after first dose of ATG (Staphylococcus aureus + coliform pneumonia, probably preexisting) Fever/chills
Bacterial pneumonia
Fever/chills, serum sickness Fever/chills
MMF, GC ↓ MMF, GC ↓
Fever/chills
MMF, GC ↓
Therapy directly Therapy after before ATG ATG
Side effects attributable to ATG
S, A (minor)
—
—
4
None
7
E, L infiltrate (major)
A (minor)
24 6
None L bronchitis (minor)
None None —
None S, A (minor)
L granuloma (major)
None
Ey (minor)
Clinical manifestations of relapsea
12 14
15 64 —
12 2.5
6
64
2
Duration of remission months
Abbreviations are: CYC, cyclophosphamide; GC, glucocorticosteroids; CMV, cytomegalovirus; ↓, dose could be reduced; →, dose was kept equal; IVIG, intravenous immunoglobulins; AZA, azathioprine; MMF, mycophenolate mofetil; PS, plasma separation; DSG, 15-deoxyspergualin; CYA, cyclosporin A; T/S, trimethoprim/sufamethoxazole, a-TNF, anti-TNF-a–directed therapy (etanercept); E, ear, nose, and throat (ENT) region; L, lungs; K, kidneys; Ey, eye; S, skin; P, polyneuropathy; A, arthritis, arthralgia, and myalgia; GI, gastrointestinal tract; B, constitutional symptoms. a ELK classification used to assess disease extent [28].
1
1
No. of relapses Patient prior Previous therapies No. to ATG before ATG
Table 1. Patient course and treatment results of antineutrophil cytoplasmic antibodies (ANCA)-associated systemic vasculitis patients treated with antithymocyte globulin (ATG)
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Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
in nonvital organs (for example, arthralgia or nasal crusting), or involvement of vital organs without threatening organ function (for example, pulmonary symptoms such as cough or wheeze without radiologic changes) [29]. Treatment protocol It was the hypothesis of the study that ATG is able to induce remission of refractory active or grumbling Wegener’s granulomatosis/MPA. Inclusion criteria were biopsy proven, ANCAassociated Wegener’s granulomatosis/MPA with a refractory course as defined by the criteria given above. Exclusion criteria included allergy against rabbit proteins, previous treatment with antilymphocyte antibodies, patient age under 18 or over 75 years, previous malignancies, uncontrolled infection, including any human immunodeficiency virus (HIV) infection, inadequate contraception in fertile women, pregnancy, refractory congestive heart failure or fluid overload, or coexistence of any other multisystem autoimmune disease. End points. For patients with progressive disease, induction of remission was the primary end point. Maintenance of remission, sparing of immunosuppressants, and side effects of ATG were secondary end points. For patients with constant grumbling disease, maintenance of remission and dose reduction of immunosuppressants was the primary end point. Side effects of ATG were the secondary end points. Administration of ATG. Cytotoxic agents, intravenous immunoglobulins, or plasma exchange had to be discontinued before ATG-treatment. Intracutaneous or conjunctival testing of ATG was performed prior to the infusion to exclude a presensitization. Fourteen patients initially received 2.5 mg/kg body weight of rabbit antihuman ATG (Thymoglobulin) (IMTIX SangStat, Lyon, France). The ATG was infused via a central venous line or a large caliber vein over 4 hours. The first dose was 2.5 mg/kg body weight. During a 10-day regimen, further doses were adjusted to daily lymphocyte counts. If lymphocyte counts were <150/lL no ATG was given. In case of a lymphocyte count >150/lL and <300/lL, 1.5 mg/kg ATG was infused. Patients with lymphocyte counts ≥300/lL received 2.5 mg/kg ATG. One patient, who was treated with ATG on a compassionate basis, received ATG-Fresenius (Fresenius AG, Bad Homburg, Germany). The scheme of treatment described in the Results section. To prevent allergy, all patients received 100 mg methylprednisolone before the first administration of ATG, and azathioprine (2 mg/kg) was given throughout ATG-treatment to prevent serum sickness. If pyrexia, and/or rigors occurred, the infusion rate was decreased. When chills had passed (usually within 1 to 2 hours), the infusion was to be continued. After the course of ATG, the further use of immunosuppres-
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sive drugs followed clinical demands and local practice. Prophylaxis with cotrimoxazol and amphotericin-B suspension was suggested by the protocol to prevent Pneumocystis carinii and Candida infection, cytomegalovirus (CMV) prophylaxis was also optional. RESULTS Indication of ATG All 15 patients suffered of active, refractory generalized Wegener’s granulomatosis at the time of ATG administration. No patient with grumbling disease was included because of the inability to stop or reduce cytotoxic treatment. Seven patients received ATG due to progressive disease under cyclophosphamide. Eight patients were intolerant of cyclophosphamide (four developed hemorrhagic cystitis, four had marrow failure, one had jaundice, and one had nausea) and had a relapse of disease. At the time of ATG administration, the patients showed a mean DEI of 4.9 (range 2 to 8) with major organ involvement threatening organ function in all (Table 1). Noteworthy, 11 of the 15 patients had severe pulmonary disease (five had suspected pulmonary granulomata, three had massive pulmonary infiltrates with overt pulmonary hemorrhage in two, and three were unspecified), and six suffered of progressive renal involvement. Fourteen of 15 patients were already on glucocorticosteroids when ATG was administered. The 14 patients who were treated with ATG from IMTIX SangStat (Thymoglobulin) received a mean of 2.2 (range 1 to 5) infusions of ATG with a mean total dose of 300 mg (150 mg to 500 mg). The patient who was treated with ATG-Fresenius received five infusions of a total dose of 1050 mg. Response to ATG Thirteen of 15 patients showed a favorable response with partial (N = 9) or complete (N = 4) remission of disease activity (Table 1), including two of three cases with pulmonary infiltrates/hemorrhage. Following the ATG administration, the mean DEI declined from 4.9 prior to ATG to 1.8 (range 0 to 4). Remaining disease activity in the nine patients with partial remission was restricted to residual lesions such as residual pulmonary opacities, nasal crusting, or persisting proteinuria in the absence of microhaematuria with a stable creatinine. Interestingly, lesions of (suspected) granulomatous nature such as pulmonary opacities and nasal crusting seemed less likely to disappear completely (complete resolution in three of nine patients affected; 33%) as compared with lesions thought to be of merely vasculitic origin such as pulmonary infiltrates, episcleritis, and glomerulonephritis (complete resolution in 17 of 21; 81%) (Table 2). All patients who entered remission showed at least a
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Table 2. Response to antithymocyte globulin (ATG) treatment in suspected granulomatous versus suspected vasculitic lesionsa Granulomatous lesionsb
Organs involved Ear, nose, and throat (ENT) Lungs Skin Peripheral nerves Kidneys Eys Joints Constitutional symptoms Sum
Vasculitic lesionsc
Partial response number
Complete response number
Partial response number
Complete response number
4
1
—
—
2 — — — — — —
2 — — — — —
1 — — 3 — — —
1 2 4 2 2 2 4
6/9 (67%)
3/9 (33%)
4/21 (19%)
17/21 (81%)
a
In three patients, pulmonary findings could not be classified, among them a patient who died 3 days after the first administration of ATG (patient 8). b Lesions were classified as granulomatous if granuloma formation was proven by histology, or if it was suspected by the clinical appearance of the lesion (pulmonary nodules or severe nasal crusting, orbital pseudotumor). c Lesions were classified as vasculitic if vasculitis was demonstrated by histology (including crescentic glomerulonephritis) in the absence of granuloma formation or giant cells, or if the vasculitic nature of the lesion was suspected by its clinical appearance (transient pulmonary infiltrates, purpura of the skin, episcleritis, arthralgias, mononeuritis multiplex, or constitutional symptoms).
partial response within the first month following treatment. However, six patients further improved within the following 2 months, and two of these patients changed status from partial to complete remission. However, the administration of ATG was associated with fatal complications, as two patients died, both in the setting of extended pulmonary and renal involvement. Patient 8 (pulmonary renal syndrome) died due to uncontrolled pulmonary hemorrhage 3 days after the first administration of ATG. The second death occurred due to pulmonary failure and sepsis the day following the first administration of ATG in a patient with extensive pulmonary cavitation (patient 14). Here, autopsy demonstrated that pulmonary disease was complicated by bacterial infection that had not been recognized prior to the administration of ATG (methicillin-resistant Staphylococcus aureus plus Coliform bacteriae). No further deaths occurred during a mean follow up of 21.8 (range 6 to 68) months. Further immunosuppressive treatment, including glucocorticosteroids, was required in all surviving patients. However, the intensity of immunosuppression could be reduced in 11 cases (Table 1). Ten patients were able to reduce the dose of corticosteroids, from a mean dose of 48.5 mg/day (range 5 mg to 100 mg) prior to ATG administration to a mean dose of 12.75 mg/day (range 2.5 mg to 25 mg). Noteworthy, only one of the seven patients who were treated with cyclophosphamide directly before ATG administration remained on this drug thereafter, and the use of myelosuppressive agents was restricted to three cases (one patient bolus cyclophosphamide, two azathioprine). Currently, six of the 13 surviving patients
are free of relapse for a mean of 22.3 (range 7 to 64) months. Seven patients relapsed after a mean of 8.4 (2 to 24) months. Compared with the mean DEI 5.6 (3 to 8) at the time of ATG administration in these seven patients, the subsequent relapses were of a minor extent (mean DEI 2.9) (range 2 to 4). Five of the relapses were classified as minor (mean DEI 2.8) (bronchitis, arthralgias, purpura, and episcleritis), and two as major relapses (mean DEI 3.0) involving the lungs in both patients (one with pulmonary infiltrates and one with an increase in size of pulmonary granulomata). The pulmonary granulomata (patient 3) responded to the addition of etanercept, a TNF-a blocker. The patient who developed pulmonary infiltrates (patient 12) showed progressive disease despite reinstitution of cyclophosphamide treatment and finally responded to plasma exchange. The likelihood of subsequent relapse was increased in patients who were not treated with cyclophosphamide directly before the ATG administration (relapse in six of seven surviving patients) as compared to patients who were on treatment regimens with cyclophosphamide (subsequent relapse in one of six cases). The cumulative dose of cyclophosphamide seemed to be lower in patients who did relapse following ATG administration as compared to those who did not (37.8 g versus 70.2 g), but the difference was statistically not significant. ANCA were positive in all patients directly before ATG treatment as detected by indirect fluorescence and/or PR3 enzyme-linked immunosorbent assay (ELISA). Follow-up on ANCA titers was available on nine surviving cases. Within 6 months, ANCA titers became negative in four of nine, declined by more than 2 titer steps in two and remained unchanged in three further cases. Notably, in one of the patients, ANCA remained negative despite subsequent relapse after 6 months. Side effects of ATG Ten patients experienced fever and chills associated with the first application of ATG. Further side effects were restricted to a minority of cases: Two patients (patients 2 and 11) suffered from serum sickness, clinically manifested with purpura, arthralgias, dyspnea, and fever. Both cases quickly responded to plasma exchanges without any additional immunosuppressive therapy. One of the patients was tested for IgM rheumatoid factor and showed a positive test. Infections. Besides the patient who died of pulmonary bacterial infection, five further episodes of severe infections were observed. Three weeks after ATG administration, one patient developed an abscess of a labium majus (S. aureus) that required surgical drainage. Further infections (each in one case) included urinary tract infection,
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pneumonia (10 days after last dose of ATG, most likely of bacterial origin, response to antibiotic treatment), CMV infection, and Clostridium difficile colitis. DISCUSSION The present study shows that a 10-day regimen of ATG induced remission in six of seven Wegener’s granulomatosis patients who showed progressive disease under treatment with cyclophosphamide and in seven of eight additional patients in whom cyclophosphamide had to be avoided due to severe side effects. Importantly, the effect of ATG may be long-lasting, as six patients are still free of relapse for a mean of 22.3 (range 7 to 64) months. But also in the seven patients who subsequently relapsed, the disease extent at the time of relapse was limited in comparison to the disease extent directly before ATG administration (mean DEI 2.9 vs. 5.6). Thus, ATG may have contributed to a less aggressive course in these refractory cases. However, two fatalities occurred which was not unexpected due to the fact that all patients were very ill at the time they received ATG. Patient 8, who died 3 days after the first administration of ATG due to pulmonary hemorrhage might have received the drug too late during his fulminant course. It has been described previously and also we observed here that response to ATG in some patients may be delayed by an interval of several weeks [27]. Autopsy of patient 14, who died the day following the first administration of ATG, demonstrated uncontrolled pulmonary infection as well as active vasculitic lesions. This case has to be regarded as a protocol violation, as uncontrolled infection was a contraindication for ATG treatment. In large cohorts of Wegener’s granulomatosis patients, including cases with mild-to-severe disease, deaths due to infections have been observed to occur in 3% to 12% of cases during a mean follow-up of 7 to 12 years (reviewed in [2]). The relatively high death rate reported here (two of 15 cases) must be interpreted in the context of the most severe course of these patients with an increased likelihood of infection. Retrospectively, however, this case should not have been treated with ATG, and it should be stressed that infections must be actively excluded prior to the use of ATG, in order to archive an optimal risk benefit ratio. If it is not possible to sufficiently rule out simultaneous infections, the use of ATG should be discouraged. The present study confirms and extends an earlier report, that demonstrated a positive response to rabbit ATG in four of five Wegener’s granulomatosis patients, with partial (N = 3) or complete (N = 1) remission of disease activity, during a follow-up of 5 months to 51/2 years [27, 31]. This cohort was not included in the current study. The patients were recruited on similar grounds as in this study. All five cases suffered of
Table 3. Summarized experience with antithymocyte globulin (ATG) in refractory antineutrophil cytoplasmic antibodies (ANCA)-associated systemic vasculitis
Reference [27] [31], follow-up of [27] [30] EUVAS Group SOLUTION
Intensity reduction of Partial Complete immunosupNumber remission remission pressants of cases Diagnosis number number number 5 1
all WG WG
4 —
none 1
4 yes
1 15
MPA all WG
1 9
— 4
? 12
Abbreviations are: WG, Wegener’s granulomatosis; MPA, microscopic polyangiitis; EUVAS, European Vasculitis Study Group.
active, severe refractory Wegener’s granulomatosis, had been treated previously with cyclophosphamide and glucocorticosteroids and received a similar regimen of ATG. Interestingly, granulomatous lesions such as orbital pseudotumors and nasal/sinus granulomata (improvement at one of three sites of active disease) did not respond as well as vascular lesions (episcleritis and glomerulonephritis; improvement at five of five sites of active disease) [27]. A similar trend was seen in the cohort presented here, with a complete response to ATG of 81% of the vasculitis in contrast to 33% of the granulomatous lesions (Table 2). Although the numbers are too small to perform any meaningful statistical tests, it may be speculated that granulomatous lesions do not respond as good to ATG as lesions of a purely vasculitic nature. This is in line with a relative resistance of retro-orbital pseudotumors and subglottic/bronchial stenosis observed under standard treatment with cyclophosphamide and glucocorticosteroids [1]. Extensive fibrotic changes in some of the lesions may partially explain the problem [1]. It is well known that active T cells can be demonstrated in granulomatous lesions in Wegener’s granulomatosis [7, 9]. It has not been investigated, to which extend these T-cell infiltrates persist after treatment with ATG. Regression of active vasculitis has also been documented in a case of pANCA associated MPA (pulmonary and renal involvement, dialysisdependent), who was treated with ATG and glucocorticosteroid pulses (clinical remission, off dialysis) [30]. A PubMed search performed on May 25, 2003, using the search terms “ATG” and “ANCA,” “vasculitis,” “angiitis,” and “arteritis” did not reveal any further reports on cases of Wegener’s granulomatosis/MPA treated with ATG. Table 3 summarizes the experience published on ATG treatment of these disorders. It is unclear at present whether patients with pulmonary disease, especially cases with pulmonary hemorrhage, should be considered for ATG treatment. Nine of the 11 patients described here with active pulmonary disease responded to treatment. Among the responders were two of three cases with suspected/overt alveolar bleeding. But one of these three cases (a patient with
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Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
massive alveolar hemorrhage) died of pulmonary failure 1 day after the first dose of ATG. Because the administration of ATG may lead to pulmonary infiltrates [32], acute respiratory distress syndrome [33], and to pulmonary edema [34], the risk of ATG must be balanced against the possible benefits in patients with serious pulmonary problems, and alternative options should be considered. Especially, fluid overload should be treated accordingly before the administration of ATG. The experience gained from the three patients presented here is too limited to give any other meaningful recommendations, and previous case series of Wegener’s granulomatosis patients treated with ATG did not include patients with alveolar hemorrhage [27]. However, a good response to ATG has been described in a case of pulmonary renal syndrome due to MPA, without pulmonary complications following the administration of ATG [30]. Because pulmonary infiltrates may be caused both by alveolar bleeding and by lung infections, special care must be taken to exclude underlying pulmonary infections in these patients before ATG is administered. In the patients reported previously [27, 30], glucocorticosteroid doses could be reduced in all four responders, and all except two patients were free of other immunosuppressive agents for up to 31/2 years. Although long-term remissions of up to 51/2 years were also observed in the present study, all patients published now are on continued immuosuppressive therapy. Furthermore, all patients still receive glucocorticosteroids, but a dosesparing effect was observed in ten of 13 cases. It could be argued that concomitant treatment with glucocortocosteroids added significantly to the favorable response of ATG. However, it is known that glucocortocosteroids alone are not capable to induce or maintain remission in Wegener’s granulomatosis [1]. Also, 14 of the 15 patients received glucocorticosteroids before the administration of ATG, without control of disease activity. T cells and Wegener’s granulomatosis The clinical response to ATG favors a pathogenetic role of T cells in Wegener’s granulomatosis and supports existing evidence of a dysregulated cellular immunity in this disorder, although the participation of antigen specific T cells in the pathogenesis of Wegener’s granulomatosis at initiation and effector stages of the immune response has not been formally proven. Although not universally accepted [15], there is some evidence from in vitro studies that T-helper cells and peripheral blood mononuclear cells from Wegener’s granulomatosis patients proliferate on stimulation with PR3 [12–14], but no specific PR3 sequence could be identified that was preferentially recognized [35]. However, effectors of cellmediated immunity such as CD4+ and CD45 RO-positive T cells have been demonstrated in active vasculitic lesions
in lung and nasal biopsies as well as in glomeruli affected by pauci-immune crescentic glomerulonephritis [6, 7, 10, 36]. An abundance of CD28− T cells was found in granulomatous lesions of the respiratory tract and in bronchoalveolar lavage fluid from Wegener’s granulomatosis patients [11]. Although there are conflicting data on Thelper cell 1/T-helper cell 2 dominance [6, 8, 9, 15], a polarization toward T-helper cell 1 immune response is favored by most authors and was recently shown to be reversible by immunosuppressive treatment [36]. Peripheral CD4+ T cells of patients with Wegener’s granulomatosis were shown to exhibit increased proliferative responses and to overproduce IFN-c and TNF-a, which might be of significance for the generation of the granulomatous lesions via their effects on cellular recruitment [15]. Production of these cytokines has also been demonstrated by CD4+ CD28− T cells within granulomatous lesions of Wegener’s granulomatosis patients [9]. Elevated levels of T-cell activation markers such as soluble interleukin 2 (IL-2) receptor and soluble CD30 were shown to correlate with the clinical activity of Wegener’s granulomatosis and remain elevated during periods of complete remission [16, 17]. In animal models of crescentic (although not ANCA-associated) glomerulonephritis (summarized by Tipping et al [37]), evidence of a pivotal role of cell-mediated immunity continues to accumulate. This includes the requirement of CD4+ cells (dominance of T-helper cell1 immune response), but not B cells for the induction of disease [37, 38], with no IgG binding to glomerular basement membrane (GBM) or C3 deposition being detected in a recent model [39]. Therapy with anti-CD8 monoclonal antibody was shown to be effective in the prevention and treatment of the disease [40]. A pathogenetic role of lymphocytes in crescentic pauciimmune glomerulonephritis is further substantiated by a randomized trial that demonstrated a similar efficacy of lymphocyte apheresis as compared with pulse glucocorticosteroids [41]. DSG, which is thought to selectively inhibit cell-mediated immunity [42], was also shown to induce remission in 14 of 20 patients with refractory Wegener’s granulomatosis and MPA [43]. Anisperimus (LF 15-0195), a substance closely related to DSG, may be of similar efficacy (induction of remission in seven of nine cases of refractory systemic vasculitis) [abstract; The Laboratories Fournier LF 15-0195 Vasculitis Study Group, Cleve Clin J Med 69 (Suppl 2):SII 191, 2002]. The good response of refractory Wegener’s granulomatosis to ATG reported here also favors the development of less toxic therapeutic concepts that selectively suppress the cellmediated immune response. These concepts are urgently awaited to overcome the era of cyclophosphamide and high dose glucocorticosteroids [44]. Finally, the depletion of autoreactive T cells by ATG may also affect B-cell function, as indicated by the observation that ANCA titers declined or became negative
Schmitt et al: Antithymocyte globulin in Wegener’s granulomatosis
in the majority of cases described here and in an earlier study [27]. Because ANCA by themselves also seem to be of pathogenetic significance in Wegener’s granulomatosis, this may have also influenced the outcome. Possibly, the relative roles of cell-mediated immunity and antibody-mediated effects may relate to the phase of disease. The pathogenetic role of the humoral immune response is further substantiated by a recent report on the induction of crescentic glomerulonephritis and vasculitis by passive infusion of mouse antimyeloperoxidase IgG into both immune-deficient and immune-competent mice [45]. Correspondingly, an excellent response of refractory Wegener’s granulomatosis was observed following the administration of a monoclonal anti-CD20 antibody (rituximab) [46], and plasma exchange, which has been tested in a large EUVAS trial in severe renal Wegener’s granulomatosis/MPA, appears to be superior to glucocorticosteroid boli in this setting [abstract; Gaskin G, et al, J Am Soc Nephrol 13:F-FC110, 2002]. Furthermore, on a more downstream level compared to ATG, anti-TNF-a treatment has been used successfully to treat refractory Wegener’s granulomatosis [47]. Side effects Beside fever and chills experienced by most patients, side effects were restricted to a minority of cases: serum sickness, previously observed in two of five Wegener’s granulomatosis patients [27] and in about 10% of renal transplant patients [22], was now seen in two cases and rapidly improved after institution of plasma exchange. IgM rheumatoid factor, demonstrated in the patient tested here, may have contributed to this reaction, as it may cross react with rabbit IgG and is frequently present in active Wegener’s granulomatosis [1]. Whether azathioprine, which the patients received during ATG treatment in order to prevent serum sickness, had any positive effect remains speculative. CMV infection occurred in only one case, but is frequently associated with ATG treatment after allograft transplantation and may show an aggravated course. Further infectious complications of the present cohort responded to treatment and did not lead to permanent morbidity. Special care is necessary to protect the patients from infections, and the use of prophylactic treatment against bacterial, fungal, and viral infections such as CMV should be recommended. Follow-up studies after kidney transplantation demonstrate that ATG increases the risk for malignant disorders [48], but no malignancies were observed here during a mean follow-up of 21.8 months. CONCLUSION Using a standardized regimen of ATG in patients with active, refractory Wegener’s granulomatosis, we were
1447
able to induce remission in 13 of 15 cases. None of the patients was able to quit immunsuppressive therapy, but the intensity of immunosuppression could be reduced in 12. With few exceptions, ATG treatment was well tolerated. The response to ATG supports the concept that T cells play a pathogenetic role in ANCA-associated systemic vasculitis. Outside controlled randomized trials, which are unlikely to be performed due to the rarity of the condition, patients suffering of refractory Wegener’s granulomatosis should be managed with individualized treatment schemes. Although the present study was open and uncontrolled, ATG seems to be a promising treatment option for these severely ill patients. However, in order to avoid fatal side effects, ATG should only be administrated if simulatenous infections and fluid overload have been ruled out or treated sufficiently. In patients with alveolar hemorrhage, who are known to be especially prone to infections, alternative options for treatment should be considered. ACKNOWLEDGMENTS In addition to the authors, the following members of the European Vasculitis Study Group (EUVAS) participated in this study: G. Gaskin, Hammersmith Hospital, Renal Section, London, England, UK; D. R. Jayne, Addenbrooke’s Hospital, Cambridge UK; R. Luqmani, Western General Hospital, University Department of Rheumatology, Edinburgh, Scotland, UK; M. Molzahn, Department of Nephrology, Humboldt Krankenhaus, Berlin, Germany; J. Verbanck, Department of Nephrology, H. Hartziekenhuis, Roselare, Belgium; K.M. Wissing, Department of Nephrology, Hopital ˆ Erasme, Universite Libre Bruxelles, Brussels, Belgium. The EUVAS group was supported by grants from the EU (Contract no. CIPD-CT94-0307 and IC20-CT97-0019). L.F. Flores-Suarez ´ was supported by Consejo Nacional de Ciencia y Technologia (CONACYT) Mexico ´ grant 110912. Thymoglobulin (ATG) was provided by IMTIX SangStat, Lyon, France without further financial contributions to the study. Reprint requests to Wilhelm H. Schmitt, M.D., Fifth Medical Clinic, University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1–3, 68167 Mannheim, Germany. E-mail: [email protected]
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29. 30. 31. 32. 33. 34.
35.
36. 37. 38. 39. 40.
41. 42. 43.
44. 45. 46. 47. 48.
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