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Letter to the Editor
Rheumatoid Arthritis and Chronic Kidney Disease Under Dialysis – Are Anti-TNF an Option?
Artritis reumatoide y enfermedad renal crónica en diálisis: ¿son los anti-TNF una opción?
Raquel Viterbo de Freitas
Corresponding author
raquelvifreitas@gmail.com

Corresponding author.
, Fátima Godinho
Hospital Garcia de Orta, Rheumatology Department, Almada, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The management of a patient with rheumatoid arthritis &#40;RA&#41; and chronic kidney disease &#40;CKD&#41; represents a recognized therapeutic dilemma&#46; CKD is a limiting factor for the use of synthetic DMARD &#40;disease modifying antirheumatic drugs&#41; such as methotrexate&#44; because of an increased risk of toxicity making them unsafe&#46; Therefore&#44; the availability of therapeutic alternatives would improve our treatment options in CKD patients with RA&#46; Clinical studies addressing the efficacy and safety of biological DMARD in patients with CKD on dialysis are rare&#44; and usually these patients are excluded from clinical trials&#46; We only found a few clinical cases in the literature regarding the use of anti-TNF in patients with CKD undergoing dialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;4</span></a> Therefore&#44; we decided to report a clinical case of a patient with RA and CKD on hemodialysis that we successfully treated with an anti-TNF&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of a 71-year old women with RA with more than 15 years of disease duration&#46; She was previously treated with methotrexate&#44; which was interrupted by end-stage CKD&#44; and hemodialysis was started&#46; Disease activity was controlled for 2 years with low-dose prednisolone&#46; However&#44; due to clinical RA worsening &#40;DAS-28 &#40;Disease Activity Score-28&#41; of 5&#46;25&#41; and development of an osteoporotic fracture&#44; it was decided to modify the therapy to better control RA and tapper corticosteroid dose&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Anti-TNF agents are hydrolyzed by lysosomes and their excretion does not appear to be influenced by renal function&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;5</span></a> Thus&#44; these agents are a possible therapeutic alternative in patients with CKD&#46; There are some case series with a small number of patients that show efficacy and safety of Infliximab&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Adalimumab<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and Etanercept<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a> in patients with CKD on dialysis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Based on these data&#44; we decided to start Etanercept on monotherapy&#46; Etanercept is usually used in RA at a dose of 50<span class="elsevierStyleHsp" style=""></span>mg once a week&#46; In our patient&#44; a 25<span class="elsevierStyleHsp" style=""></span>mg dose twice per week was chosen &#40;injection after hemodialysis session&#41;&#46; Although Don and collaborators demonstrated that hemodialysis did not affect Etanercept excretion&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> we decided to choose 25<span class="elsevierStyleHsp" style=""></span>mg twice a week instead of 50<span class="elsevierStyleHsp" style=""></span>mg once a week&#46; At one year of follow-up&#44; the patient has a good response &#40;DAS-28 2&#46;81&#41; and there were no adverse events registered&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We present the first case of our center with the use of an anti-TNF in a patient undergoing hemodialysis&#44; with good response and no adverse events&#46; Anti-TNF drugs appear to be safe and effective in CKD under dialysis&#44; however&#44; clinical experience is still insufficient&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Article information
ISSN: 21735743
Original language: English
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