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BACKGROUND: Rituximab is a human monoclonal antibody directed against the B-cell transmembrane protein CD20. Although well-tolerated, given its mechanism of action, rituximab can induce a state of severe immunosuppression, increasing the risk of opportunistic and fulminant infection and mortality. AIM: To evaluate the risk of infection, mortality, and hypogammaglobulinemia and their associated factors among rituximab receivers. METHOD: This was a single-center retrospective cohort study of adults treated with rituximab for various indications. Hypogammaglobulinemia was defined by a cut-off value below the normal limit (an IgG level of <7.51 g/L, an IgM level of <0.46 g/L, and/or an IgA level of <0.82 g/L). Patients who met the definition of hypogammaglobinemia solely based on IgA were excluded. Severe infection was defined as any infection that required intensive care unit admission. RESULTS: A total of 137 adults with a mean age of 47.69 ± 18.86 years and an average BMI of 28.57 ± 6.55 kg/m2 were included. Hematological malignancies and connective tissue diseases were the most common primary diagnoses for which rituximab was used. More than half of the patients received the 375 mg/m2 dose. Rituximab's mean cumulative dose was 3216 ± 2282 mg, and the overall mortality rate was 22.6%. Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more prevalent among males and the 375 mg/m2 and 500 mg doses. Hematological malignancy was the only predictor for infection. Patients with blood type AB or B, hematological malignancies, and corticosteroids had a significantly higher mortality rate. Receiving the 1000 mg dose and having a low CD19 were associated with a significantly lower risk of infection and mortality, respectively. CONCLUSIONS: Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more common among males and the 375 mg/m2 and 500 mg doses. Hematological malignancies were significantly associated with higher infection and mortality rates, while corticosteroids were significantly associated with a higher mortality. Since the culprit of mortality was infection, these findings highlight the critical need for more frequent immunological monitoring during rituximab treatment period to mitigate the burden of infection and identify candidates for immunoglobulin replacement.
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Introduction: Patients receiving rituximab (RTX) may be at increased risk for severe Coronavirus infections and worse outcomes compared with the general population. Because of the conflicting results concerning the effect of RTX on the clinical course and outcomes of COVID-19 infection, we aimed to share our experience with 35 patients infected with COVID-19 while treated with RTX for a variety of clinical indications. Methods: This was a single-centre retrospective cohort study that included 35 patients. All patients aged ≥14 years who were treated with RTX for various conditions and were found to have COVID-19 infection were included. Patients with poor outcomes or patients with suspected COVID-19 infection were excluded. Results: The patients' mean age was 42.8 ± 16.3 years with an average BMI of 29.9 ± 11.4 kg/m2. Over half (51.4%, n = 18) of the patients received RTX at a dose of 375 mg/m2 with a median frequency of 4 doses. More than a third (37.1%, n = 13) of the patients had hypogammaglobulinemia and 25.7% had low CD19. Over a third (42.9%, n= 15) of the patients required hospitalization and almost a third (25.7%, n = 9) required treatment in the intensive care unit. There was a statistically significant association between intensive care unit admission and age, steroid use, and low CD19. The mortality rate was 25.7%, and it was significantly higher in elderly, diabetics, corticosteroid users, patients who were hospitalized, treated in the intensive care unit, and had low immunoglobin or CD19. Conclusion: Treatment with RTX seems to be a potential risk factor for unfavorable outcomes in COVID-19 patients. RTX should be used with caution or avoided unless the benefit clearly outweighs the risk.
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Cardiovascular diseases (CVD) are the leading causes of death worldwide. Dyslipidemia is a cardiometabolic risk factor of CVD, yet it can be modifiable. Walnuts have been suggested as a dietary intervention to improve the lipid profile. Therefore, we reviewed the literature to assess the evidence linking walnut intake to the improvement of blood lipids, including total cholesterol (TC), low-density lipoprotein (LDL-C) cholesterol, high-density lipoprotein (HDL-C) cholesterol, and triglycerides (TG). PubMed and Embase databases were searched from 2010 up to March 2022. We limited our search to randomized controlled trials conducted on humans and published in English during the specified period. Cochrane's risk of bias tool for interventional studies was used. A random-effects model was used for the meta-analysis, and weighted mean differences were obtained (WMD) Thirteen trials from the U.S., Europe, and Asia were included. Walnut intake was associated with significant reductions in TC (WMD: -8.58 mg/dL), LDL-C (WMD: -5.68 mg/dL), and TG (WMD: -10.94 mg/dL). Walnut consumption was not associated with HDL-C. Subgroup analysis showed that overweight/obese and those with comorbidities had more lipid improvement. A longer trial duration did result in further improvements. However, our results may be prone to bias due to extraneous confounding factors. Additionally, levels of heterogeneity were considerable for some outcomes of interest. Results from this meta-analysis provide evidence for the health benefits of walnuts on blood lipids. Walnuts possibly reduce the risk of CVD; thus, they can be successfully added to a dietary pattern to enhance health benefits.