David Jayne

University of Cambridge, Cambridge, England, United Kingdom

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Publications (186)1171.93 Total impact

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    ABSTRACT: Extracorporeal treatments have been used since the 1970s in the management of systemic lupus erythematosus (SLE). A randomised controlled trial comparing the efficacy of standard of care (SOC) combined with plasma exchange against SOC alone in patients with lupus nephritis revealed no difference in terms of renal outcome. Subsequently, initial expectations have been dampened and further experience with plasma exchange is mainly limited to observational studies and single case reports. Beneficial effects have been reported in patients with refractory disease course or in pregnancy with prior complications due to SLE and antiphospholipid syndrome. A more specific form of extracorporeal treatment, immunoadsorption (IAS), has emerged as a valuable option in the treatment of SLE. In line with the plasma exchange experience, IAS seems to have beneficial effects in patients with refractory disease, contraindications to standard immunosuppression or during pregnancy. The mechanism IAS relates to autoantibody removal but for plasma exchange removal of activated complement components, coagulation factors, cytokines and microparticles may also be relevant. Both treatment forms have good safety profiles although reactions to blood product replacement in plasma exchange and procedure related complications such as bleeding or catheter-related infections have occurred. There is a need to more clearly define the clinical utility of plasma exchange and IAS in refractory lupus and APS subgroups. Copyright © 2015. Published by Elsevier B.V.
    Autoimmunity Reviews 08/2015; DOI:10.1016/j.autrev.2015.08.010 · 7.10 Impact Factor
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    ABSTRACT: Objectives To assess the long-term outcome in eosinophilic granulomatosis with polyangiitis (EGPA) Methods 101 patients fulfilling the American College of Rheumatology (ACR) criteria for Churg-Strauss syndrome (CSS) were included between 1990 and 2011. Clinical features, antineutrophil cytoplasm autoantibodies (ANCA) and 'five-factor score' (FFS) were assessed at diagnosis. Overall and cumulative survivals, relapse-free survival and sequelae were studied based on ANCA status and FFS. Results The rate of cardiomyopathy did not differ according to ANCA status. 79.6% of patients achieved first remission but 81.1% relapsed. ANCA-positive patients did not relapse more frequentlybut exhibited more severe disease with mononeuritis (MN) (p=0.0004) and renal involvement (p=0.02). Being Italian was the only one prognostic factor associated withahigher relapse-free survival (p=0.01) thanks to a longer maintenance of immunosuppressive (IS) drugs, suggesting the need for prolonged low dose corticosteroids (CS). Overall survival reached 93.1% after a median follow-up of 6 years. No factor was associated with mortality but patients over 65 years, with cardiomyopathy, or ANCA positivity had more serious outcomes. Sequelae affected 83.2% of patients. Ear-nose-throat (ENT) involvement was a protective factor for renal (p=0.04) and cardiac (p=0.03) morbidity. ANCA positivity was correlated with chronic kidney disease (CKD) (p=0.03) and chronic neurologic disability (p=0.02). Conclusions The actual challenges of EGPA management concern morbidity prevention and quality of life improvement. Long-term CS treatment appears to reduce relapse risk. ENT involvement is associated with less renal and cardiac morbidity. ANCA positivity predicts renal and neurologic damage. This article is protected by copyright. All rights reserved. © 2015, American College of Rheumatology.
    08/2015; DOI:10.1002/acr.22686
  • Annals of the Rheumatic Diseases 06/2015; 74(Suppl 2):162.1-162. DOI:10.1136/annrheumdis-2015-eular.2697 · 10.38 Impact Factor
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    Andreas Kronbichler · David RW Jayne
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    ABSTRACT: Rituximab has enriched our armamentarium in the treatment of anti-neutrophil cytoplasmic antibody (ANCA)- associated vasculitis. Two randomised controlled trials have shown that rituximab is non-inferior compared with cyclophosphamide followed by azathioprine for the induction of remission. The newly diagnosed patients in the Rituximab in ANCA-Associated Vasculitis (RAVE) and Rituximab Versus Cyclophosphamide in ANCA-Associated Vasculitis (RITUXVAS) trials had a numerically higher response rate in the cyclophosphamide/azathioprine arm, and the number of such patients treated with rituximab numbered <90.We are arguing that in newly diagnosed patients, the evidence for rituximab requires further confirmation and the length of experience with a cyclophosphamide-based induction therapy supports it continuing as the preferred first choice for induction. Also, there is an absence of information regarding rituximab as ‘sole’ remission induction along with steroids in patients with advanced renal presentations or lung haemorrhage. Reported side effects were similar in both trials; however, the number of participants with at least one serious adverse event following rituximab induction treatment was numerically higher in the RAVE trial. In addition, hypogammaglobulinaemia with the need of substitution in some cases and late-onset neutropaenia are complications not seen with cyclophosphamide. Over the longer term it is unclear what relapse prevention strategy should be employed after rituximab, and there was a trend to a higher relapse risk after rituximab in the RITUXVAS trial at 2 years. Further health economic studies are required to understand all the costs associated with rituximab. In the context of concomitant underlying infectious complications, in terms of fertility concerns, especially in young patients, and when malignancy is underlying we would recommend the use of rituximab as first-line therapy.
    Nephrology Dialysis Transplantation 05/2015; 30(7):1075-81. DOI:10.1093/ndt/gfv216 · 3.49 Impact Factor
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    ABSTRACT: Rituximab (RTX) is approved for remission induction in ANCA associated vasculitis (AAV). However, data on use of RTX in patients with severe renal disease is lacking. We conducted a retrospective multi-center study to evaluate the efficacy and safety of RTX with glucocorticoids (GC) with and without use of concomitant cyclophosphamide (CYC) for remission induction in patients presenting with e GFR less than 20 ml/min/1.73 m(2). We evaluated outcomes of remission at 6 months (6 M), renal recovery after acute dialysis at diagnosis, e-GFR rise at 6 M, patient and renal survival and adverse events. A total 37 patients met the inclusion criteria. The median age was 61 years. (55-73), 62 % were males, 78 % had new diagnosis and 59 % were MPO ANCA positive. The median (IQR) e-GFR at diagnosis was 13 ml/min/1.73 m(2) (7-16) and 15 required acute dialysis. Eleven (30 %) had alveolar hemorrhage. Twelve (32 %) received RTX with GC, 25 (68 %) received RTX with GC and CYC and seventeen (46 %) received plasma exchange. The median (IQR) follow up was 973 (200-1656) days. Thirty two of 33 patients (97 %) achieved remission at 6 M and 10 of 15 patients (67 %) requiring dialysis recovered renal function. The median prednisone dose at 6 M was 6 mg/day. The mean (SD) increase in e-GFR at 6 months was 14.5 (22) ml/min/m(2). Twelve patients developed ESRD during follow up. There were 3 deaths in the first 6 months. When stratified by use of concomitant CYC, there were no differences in baseline e GFR, use of plasmapheresis, RTX dosing regimen or median follow up days between the groups. No differences in remission, renal recovery ESRD or death were observed. This study of AAV patients with severe renal disease demonstrates that the outcomes appear equivalent when treated with RTX and GC with or without concomitant CYC.
    Journal of nephrology 05/2015; DOI:10.1007/s40620-015-0208-y · 2.00 Impact Factor
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    ABSTRACT: This study describes the incidence and outcomes of European patients requiring renal replacement therapy (RRT) for kidney failure due to antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Cohort study. 12 renal registries providing individual RRT patient data to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry in 1993-2012 participated. Cause of primary kidney disease: AAV (ie, granulomatosis with polyangiitis [Wegener] and microscopic polyangiitis) versus 3 separate matched control groups without AAV: (1) primary glomerulonephritis, (2) diabetes mellitus, and (3) disease other than diabetes mellitus as the cause of primary kidney disease, including glomerulonephritis (termed "nondiabetes"). Incidence, causes of death, and survival. ERA-EDTA primary renal disease codes. 2,511 patients with AAV (1,755, granulomatosis with polyangiitis; 756, microscopic polyangiitis) were identified, representing an incidence of 1.05 per million population (pmp) for granulomatosis with polyangiitis (predominating in Northern Europe) and 0.45 pmp for microscopic polyangiitis (prevailing in Southern Europe). Kidney transplantation was performed in 558 (22.2%) patients with vasculitis. The 10-year probability for survival on RRT after day 91 was 32.5% (95% CI, 29.9%-35.1%) in patients with vasculitis. Survival on RRT after day 91 did not differ between AAV and matched nondiabetes patients. Patient and transplant survival after kidney transplantation, adjusted for time period and country, was better in AAV than in matched nondiabetes patients (HRs of 0.81 [95% CI, 0.67-0.99] and 0.82 [95% CI, 0.69-0.96], respectively). No data for extrarenal manifestations, treatment, and relapses. Geographical differences in the incidence of RRT for kidney failure due to granulomatosis with polyangiitis and microscopic polyangiitis copied their distribution in the general population. Overall survival on RRT after day 91 for patients with AAV was similar to that for patients with nondiabetes diagnoses. Our results suggest that patients with AAV are suitable candidates for kidney transplantation with favorable survival outcomes. Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
    American Journal of Kidney Diseases 05/2015; DOI:10.1053/j.ajkd.2015.03.025 · 5.76 Impact Factor
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    ABSTRACT: To develop disease-specific recommendations for the diagnosis and management of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) (EGPA). The EGPA Consensus Task Force experts comprised 8 pulmonologists, 6 internists, 4 rheumatologists, 3 nephrologists, 1 pathologist and 1 allergist from 5 European countries and the USA. Using a modified Delphi process, a list of 40 questions was elaborated by 2 members and sent to all participants prior to the meeting. Concurrently, an extensive literature search was undertaken with publications assigned with a level of evidence according to accepted criteria. Drafts of the recommendations were circulated for review to all members until final consensus was reached. Twenty-two recommendations concerning the diagnosis, initial evaluation, treatment and monitoring of EGPA patients were established. The relevant published information on EGPA, antineutrophil-cytoplasm antibody-associated vasculitides, hypereosinophilic syndromes and eosinophilic asthma supporting these recommendations was also reviewed. These recommendations aim to give physicians tools for effective and individual management of EGPA patients, and to provide guidance for further targeted research. Copyright © 2015. Published by Elsevier B.V.
    European Journal of Internal Medicine 05/2015; DOI:10.1016/j.ejim.2015.04.022 · 2.30 Impact Factor
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    ABSTRACT: To analyse the differences between patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) entered into randomised clinical trials (RCTs) and those followed in large observational cohorts. The main characteristics and outcomes of patients with generalised and/or severe GPA or MPA with a five-factor score ≥1 enrolled in the French Vasculitis Study Group (FVSG) or the US-Canadian-based Vasculitis Clinical Research Consortium cohorts were compared to those enrolled in one of 2 FVSG clinical RCTs (WEG91, WEGENT) or 3 European Vasculitis Society clinical trials (CYCLOPS, CYCAZAREM, IMPROVE). 657 patients (65.3% with GPA) in RCTs were compared to 437 in cohorts (90.6% with GPA). RCT patients were older at diagnosis than the cohort patients (56.6±13.9 vs. 46.8±17.3 years), had higher Birmingham vasculitis activity score (19.5±9.1 vs. 16.9±7.4), and more frequent kidney disease (84.0% vs. 54.9%) but fewer ear, nose, and throat symptoms (56.8% vs. 72.2%). At 56 months post-diagnosis, mortality and relapse rates, adjusted for age and renal function, were higher for patients with GPA in RCTs vs. cohorts (10.7% vs. 2.5% [p=0.001] and 22.5% vs. 15.6% [p=0.03], respectively) but similar for patients with MPA (6.2% vs. 6.6% [p=0.92] and 16.6% vs. 10.1% [p=0.39], respectively). Patients with GPA or MPA in RCTs and those in observational cohorts show important differences that should be remembered when interpreting results based on these study populations.
    Clinical and experimental rheumatology 05/2015; 33(2 Suppl 89):77-83. · 2.97 Impact Factor
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    ABSTRACT: In the past years, many (randomized) trials have been performed comparing the treatment strategies for lupus nephritis. In 2012, these data were incorporated in six different guidelines for treating lupus nephritis. These guidelines are European, American and internationally based, with one separate guideline for children. They offer information on different aspects of the management of lupus nephritis including induction and maintenance treatment of the different histological classes, adjunctive treatment, monitoring of the patient, definitions of response and relapse, indications for (repeat) renal biopsy, and additional challenges such as the presence of vascular complications, the pregnant SLE patient, treatment in children and adolescents and considerations about end-stage renal disease and transplantation. In this review, we summarize the guidelines, determine the common ground between them, highlight the differences and discuss recent literature. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
    Nephrology Dialysis Transplantation 04/2015; DOI:10.1093/ndt/gfv102 · 3.49 Impact Factor
  • David Jayne · Niels Rasmussen
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    ABSTRACT: This special edition reviews the progress in understanding of systemic vasculitis associated with autoantibodies to neutrophil cytoplasmic antigens (ANCA). European research groups have contributed to this research including the original observations of the association between ANCA and vasculitis. Areas of interest include classification and epidemiology, genetics and pathogenesis, disease assessment, histology and long-term outcomes. Clinical trials conducted by the European Vasculitis Study group have helped to define the current standard of care for the treatment of patients with vasculitis and provided a platform for the investigation of newer therapies. The prognosis of patients with ANCA-associated vasculitis has improved over this period as a result of facilitated diagnosis and development of consensus, evidence-based, treatment recommendations. The ANCA story represents an example of the power of a biomarker in influencing a disease area, inspiring research and providing physicians with better tools to treat patients with these disorders. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
    Nephrology Dialysis Transplantation 04/2015; 30(suppl 1):i1-i7. DOI:10.1093/ndt/gfv060 · 3.49 Impact Factor
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    ABSTRACT: Definitive sample sizes for clinical trials in rare diseases are usually infeasible. Bayesian methodology can be used to maximise what is learnt from clinical trials in these circumstances. We elicited expert prior opinion for a future Bayesian randomised controlled trial for a rare inflammatory paediatric disease, polyarteritis nodosa (MYPAN, Mycophenolate mofetil for polyarteritis nodosa). A Bayesian prior elicitation meeting was convened. Opinion was sought on the probability that a patient in the MYPAN trial treated with cyclophosphamide would achieve disease remission within 6-months, and on the relative efficacies of mycophenolate mofetil and cyclophosphamide. Expert opinion was combined with previously unseen data from a recently completed randomised controlled trial in ANCA associated vasculitis. A pan-European group of fifteen experts participated in the elicitation meeting. Consensus expert prior opinion was that the most likely rates of disease remission within 6 months on cyclophosphamide or mycophenolate mofetil were 74% and 71%, respectively. This prior opinion will now be taken forward and will be modified to formulate a Bayesian posterior opinion once the MYPAN trial data from 40 patients randomised 1:1 to either CYC or MMF become available. We suggest that the methodological template we propose could be applied to trial design for other rare diseases.
    PLoS ONE 03/2015; 10(3):e0120981. DOI:10.1371/journal.pone.0120981 · 3.23 Impact Factor
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    ABSTRACT: The RITUXVAS trial reported similar remission induction rates and safety between rituximab and cyclophosphamide based regimens for antineutrophil cytoplasm antibody (ANCA)-associated vasculitis at 12 months; however, immunosuppression maintenance requirements and longer-term outcomes after rituximab in ANCA-associated renal vasculitis are unknown. Forty-four patients with newly diagnosed ANCA-associated vasculitis and renal involvement were randomised, 3:1, to glucocorticoids plus either rituximab (375 mg/m(2)/week×4) with two intravenous cyclophosphamide pulses (n=33, rituximab group), or intravenous cyclophosphamide for 3-6 months followed by azathioprine (n=11, control group). The primary end point at 24 months was a composite of death, end-stage renal disease and relapse, which occurred in 14/33 in the rituximab group (42%) and 4/11 in the control group (36%) (p=1.00). After remission induction treatment all patients in the rituximab group achieved complete B cell depletion and during subsequent follow-up, 23/33 (70%) had B cell return. Relapses occurred in seven in the rituximab group (21%) and two in the control group (18%) (p=1.00). All relapses in the rituximab group occurred after B cell return. At 24 months, rates of the composite outcome of death, end-stage renal disease and relapse did not differ between groups. In the rituximab group, B cell return was associated with relapse. ISRCTN28528813. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Annals of the Rheumatic Diseases 03/2015; 74(6). DOI:10.1136/annrheumdis-2014-206404 · 10.38 Impact Factor
  • La Revue de Médecine Interne 12/2014; 35. DOI:10.1016/j.revmed.2014.10.020 · 1.32 Impact Factor
  • La Revue de Médecine Interne 12/2014; 35. DOI:10.1016/j.revmed.2014.10.021 · 1.32 Impact Factor
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    David Jayne · Vladimir Tesar
    Nephron Clinical Practice 12/2014; 128(3-4):203-204. DOI:10.1159/000369646 · 1.65 Impact Factor
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    ABSTRACT: Objective. Takayasu arteritis (TAK) and giant cell arteritis (GCA) are 2 major variants of large vessel vasculitis (LVV). The frequent involvement of large vessels in GCA has raised the possibility that TAK and GCA should be regarded as 1 disease. By detailed phenotyping of a single-center cohort, we aimed to define the differences between TAK and GCA. Methods. Forty-five patients (23 TAK, 22 GCA) were identified. Baseline characteristics, clinical symptoms, laboratory data, enhanced computed tomography/magnetic resonance imaging, treatments, and clinical courses were retrospectively assessed with descriptive statistics. In addition, latent class analysis of the 45 patients was performed to explore phenotypic differences. Results. Patients with GCA had more frequent headache (p < 0.01), higher C-reactive protein levels (p = 0.01), and higher erythrocyte sedimentation rates (p = 0.03) than did patients with TAK at diagnosis. With the exception of subdiaphragmatic lesions, the distributions of vessel lesions were not different between TAK and GCA. However, focusing on subclavian and carotid arteries, long tapered-type stenotic lesions were more frequent in GCA than in TAK (p < 0.01). The proportion of patients without relapse was higher in GCA (60%) than in TAK (22%, p = 0.01). Latent class analysis also divided patients with LVV into 2 separate groups consistent with TAK and GCA. Conclusion. The differences observed in clinical symptoms, inflammatory markers, radiological findings, and clinical courses suggested that TAK and GCA were 2 different diseases. Latent class analysis supported these results. The shape of stenotic lesions in the subclavian and carotid arteries is a useful discriminator between TAK and GCA.
    The Journal of Rheumatology 11/2014; 42(2). DOI:10.3899/jrheum.140562 · 3.17 Impact Factor
  • David Jayne
    New England Journal of Medicine 11/2014; 371(19):1839-40. DOI:10.1056/NEJMe1410394 · 54.42 Impact Factor
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    ABSTRACT: Importance Airway stenosis occurs in patients with granulomatosis with polyangiitis (GPA or Wegener granulomatosis). It produces significant morbidity and contributes to mortality.Objective To investigate the frequency and distribution of airway stenoses in GPA and evaluate the efficacy of local interventions in maintaining airway patency.Design, Setting, and Participants A retrospective single-center study of 44 patients with GPA and airway stenosis assessed and treated as needed by a multidisciplinary team at a university medical center between 1997 and 2012. The median duration of observation for each patient from the time of diagnosis was 146 months.Interventions Patients who had critical stenoses underwent either dilatation or laser radial cuts to the lesion. In some cases, intralesional administration of steroids or topical mitomycin C was used.Main Outcomes and Measures The main outcome measure was airway patency for at least 12 months and the number of interventions required to achieve this end point. Details of patients and interventions were recorded at baseline and at each treatment.Results The median age at diagnosis was 37.6 years; 73% of patients were women (n = 34). The median follow-up after the initial intervention was 62.5 months. Subglottic stenosis was found in 36 patients, lower airway stenosis in 30. There were 213 interventions in 39 patients, including balloon and bougie dilatation and laser treatment. Adjuvant local treatment was used in 71 interventions. A 12-month period of airway stability was achieved in 34 of 36 cases (97%) (5 had no procedures and 3 had follow-up shorter than 12 months). The median interval between procedures was 4.9 months, and after the last intervention recorded, patients had at least 27 months of airway stability. Fourteen adverse events were recorded (6.6%).Conclusions and Relevance The frequency and distribution of airway stenoses in 44 patients with GPA has been described. In the 39 patients who required intervention, multiple procedures were required, but 97% then achieved a prolonged period of airway patency. The procedures and adjuvant treatments were found to be safe. Our experience with a variety of techniques in this rare presentation has permitted design of a structured approach and an algorithm to manage and evaluate airway stenosis in GPA.
    JAMA Otolaryngology - Head and Neck Surgery 10/2014; 140(11). DOI:10.1001/jamaoto.2014.2430
  • Pediatric Rheumatology 09/2014; 12(Suppl 1):P125-P125. DOI:10.1186/1546-0096-12-S1-P125 · 1.62 Impact Factor
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    ABSTRACT: Background The use of mycophenolate mofetil (MMF) in autoimmune disease is often limited by adverse effects. In this single-centre, open label, parallel design study, we investigated whether enteric-coated mycophenolate sodium (MS) is better tolerated and therefore more efficacious than MMF in primary systemic vasculitis (PSV) and systemic lupus erythematosus (SLE). Methods Forty patients with vasculitis or systemic lupus erythematosus (SLE) due to commence MMF for active disease or remission maintenance were randomized to receive either 1440 mg/day MS or 2000 mg/day MMF (18 PSV, 2 SLE per group) in addition to corticosteroids. Random allocation was performed by minimization for age, diagnosis and renal function using a computer algorithm. Twenty-five were treated for active disease (5 first-line therapy, 20 salvage therapy) and 15 for remission maintenance. The composite primary end point was treatment failure and/or drug intolerance over 12 months. Treatment failure was defined as failure to achieve remission by 6 months or disease relapse and treatment intolerance was defined as inability to tolerate and maintain the target dose of MS or MMF within 12 months. Results Forty patients were included in the analyses. MS was associated with a lower primary end point rate [hazard ratio (HR) 0.37; 95% CI 0.17–0.80; P = 0.012] (11/20, 55% patients) compared with MMF (17/20, 85% patients). Treatment failure alone was less common in the MS group (HR 0.28; 95% CI 0.095–0.82; P = 0.020), although drug intolerance did not differ between groups (HR 0.53; 95% CI 0.20–1.42; P = 0.21). Despite randomization, patients in the MMF group may have had a higher baseline risk for treatment failure; more MMF patients had refractory disease and granulomatosis with polyangiitis (Wegener's). A glomerular filtration rate (GFR) ≤40 mL/min was associated with intolerance. Serious adverse events were common (55% MMF and 45% MS patients). Conclusions No differences in treatment tolerance were observed between the MS and MMF groups. Despite similar treatment intolerance, MS was associated with improved efficacy in PSV and SLE compared with MMF. However, baseline group imbalances in factors potentially affecting remission and relapse may have influenced the results. Treatment intolerance was common and strongly associated with low GFR. Further treatment trials are warranted to investigate the effect of GFR on mycophenolic acid pharmacokinetics and clinical outcomes (ISRCTN83027184; EUDRACT 2005-002207-16; Funding Novartis UK).
    CKJ: Clinical Kidney Journal 09/2014; 7(6):562. DOI:10.1093/ckj/sfu096

Publication Stats

6k Citations
1,171.93 Total Impact Points

Institutions

  • 1996–2015
    • University of Cambridge
      • Department of Medicine
      Cambridge, England, United Kingdom
  • 2014
    • CHU de Lyon - Groupement Hospitalier Edouard Herriot
      Lyons, Rhône-Alpes, France
  • 2009–2014
    • Cambridge University Hospitals NHS Foundation Trust
      • Addenbrooke's Hospital
      Cambridge, England, United Kingdom
  • 2013
    • University of Aberdeen
      • School of Medicine and Dentistry
      Aberdeen, Scotland, United Kingdom
  • 2009–2013
    • University of Oxford
      Oxford, England, United Kingdom
  • 2012
    • McMaster University
      • Department of Clinical Epidemiology and Biostatistics
      Hamilton, Ontario, Canada
  • 2011
    • University of Birmingham
      • School of Immunity and Infection
      Birmingham, England, United Kingdom
  • 2007–2011
    • Papworth Hospital NHS Foundation Trust
      Papworth, England, United Kingdom
  • 2004
    • University of Udine
      Udine, Friuli Venezia Giulia, Italy
  • 2000–2001
    • Epsom and St Helier University Hospitals NHS Trust
      Эпсом, England, United Kingdom