Does a gating policy for ANCA overlook patients with ANCA associated vasculitis? An audit of 263 patients

BACKGROUND

Antineutrophil cytoplasm antibodies (ANCA) are used as diagnostic markers for small-vessel vasculitis of the Wegener Granulomatosis-microscopic polyangiitis (WG-MPA) spectrum, but if testing is applied indiscriminately, its value is diminished. The authors measured the effect of a targeted ANCA testing policy introduced in our institution in an attempt to improve the diagnostic value of testing in patients with suspected vasculitis.

METHODS

The authors measured the rate of ANCA requests at a single regional centre in the year prior to and following the introduction of clinical guidelines to ensure appropriate test usage. The authors also audited clinical outcomes in patients in whom ANCA testing was declined.

RESULT

Following implementation of the antineutrophil cytoplasm antibodies (ANCA) gating policy, the number of monthly ANCA tests carried out fell from 287+/-30 to 143+/-18 (p<0.0001) and was associated with an increased rate of positivity, from 18.5% (95% CI 17.0 to 20.1%) to 30.3% (27.5 to 33.1%; p<0.0001). The authors undertook a careful review of the case records from 263 patients in whom testing was declined according to the gating policy over an 8-month period. After 6 months' follow-up, no diagnoses of small-vessel vasculitis of the WG-MPA spectrum were reached.

CONCLUSIONS

The rational use of ANCA testing to aid in the diagnosis of vasculitis should include a clinical gating policy to improve diagnostic performance. Adherence to a gating policy for ANCA testing coupled with close liaison between clinician and laboratory does not result in either a missed or delayed diagnosis of small-vessel vasculitis belonging to the WG-MPA spectrum.

Pulse versus daily oral cyclophosphamide for induction of remission in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized trial

BACKGROUND

Current therapies for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis are limited by toxicity.

OBJECTIVE

To compare pulse cyclophosphamide with daily oral cyclophosphamide for induction of remission.

DESIGN

Randomized, controlled trial. Random assignments were computer-generated; allocation was concealed by faxing centralized treatment assignment to providers at the time of enrollment. Patients, investigators, and assessors of outcomes were not blinded to assignment.

SETTING

42 centers in 12 European countries.

PATIENTS

149 patients who had newly diagnosed generalized ANCA-associated vasculitis with renal involvement but not immediately life-threatening disease.

INTERVENTION

Pulse cyclophosphamide, 15 mg/kg every 2 to 3 weeks (76 patients), or daily oral cyclophosphamide, 2 mg/kg per day (73 patients), plus prednisolone.

MEASUREMENT

Time to remission (primary outcome); change in renal function, adverse events, and cumulative dose of cyclophosphamide (secondary outcomes).

RESULTS

Groups did not differ in time to remission (hazard ratio, 1.098 [95% CI, 0.78 to 1.55]; P = 0.59) or proportion of patients who achieved remission at 9 months (88.1% vs. 87.7%). Thirteen patients in the pulse group and 6 in the daily oral group achieved remission by 9 months and subsequently had relapse. Absolute cumulative cyclophosphamide dose in the daily oral group was greater than that in the pulse group (15.9 g [interquartile range, 11 to 22.5 g] vs. 8.2 g [interquartile range, 5.95 to 10.55 g]; P < 0.001). The pulse group had a lower rate of leukopenia (hazard ratio, 0.41 [CI, 0.23 to 0.71]).

LIMITATIONS

The study was not powered to detect a difference in relapse rates between the 2 groups. Duration of follow-up was limited.

CONCLUSION

The pulse cyclophosphamide regimen induced remission of ANCA-associated vasculitis as well as the daily oral regimen at a reduced cumulative cyclophosphamide dose and caused fewer cases of leukopenia.

PRIMARY FUNDING SOURCE

The European Union.

Necrotic granulomatous pseudotumours in bilateral resurfacing hip arthoplasties: evidence for a type IV immune response

Clinical, radiological and histological findings were analysed in four patients who developed bilateral pseudotumours following metal-on-metal (MoM) resurfacing arthroplasties of both hips. Using a panel of monoclonal antibodies directed against HLA-DR, macrophages (CD14, CD68), dendritic cells (DC-SIGN, S100, CD11c), B cells (CD20), and T cells (CD3, CD4, CD8), the nature of the heavy inflammatory response seen in these cases was examined. Bilateral masses developed in periprosthetic soft tissues following the second MoM arthroplasty; these were characterised histologically by extensive coagulative necrosis, a heavy macrophage infiltrate and the presence of granulomas containing macrophages and giant cells; there was also a diffuse lymphocyte and variable plasma cell and eosinophil polymorph infiltrate. Immunohistochemistry showed strong expression of HLA-DR, CD14 and CD68 in both granulomatous and necrotic areas; lymphocytes were predominantly CD3+/CD4+ T cells. The clinical, morphological and immunophenotypic features of these necrotic granulomatous pseudotumours, which in all cases develop following a second resurfacing hip arthroplasty, is suggestive of a type IV immune response, possibly to MoM metal alloy components.

Mortality in systemic vasculitis: a systematic review

There has been a considerable improvement in the survival of patients with systemic vasculitis since the introduction of immunosuppressive therapy and improved diagnostic tools to allow earlier diagnosis. We review the published literature on current risk of mortality in patients with small vessel antineutrophil cytoplasm antibody- (ANCA) associated vasculitis including Wegener's granulomatosis (survival rate of approximately 75% at 5 years), microscopic polyangiitis (survival rate of 45% to 75% at 5 years), Churg-Strauss syndrome (survival rate of 68% to 100% at 5 years), and Henoch-Schönlein purpura (survival rate of 75% in adult-onset, greater in childhood onset); medium vessel vasculitis including polyarteritis nodosa (survival rate of 75% to 80% at 5 years), Kawasaki disease (survival rate of greater than 99% at 5 years); large vessel vasculitis including giant cell arteritis (survival rate equivalent to the age-matched population), and Takayasu arteritis (survival of 70% to 93% at 5 years). Mortality rates are falling as a result of more effective intervention but remain elevated substantially in severe disease. Early deaths are usually attributable to active vasculitis with multiorgan failure or infection, or both. The incidence of late deaths may be increased by long-term effects of therapy and development of comorbidities. These findings highlight the need to improve early diagnosis and initiation of targeted therapy, thereby reducing treatment-related toxicity and comorbidities.

Comparison of disease activity measures for anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis

AIM

Currently, several different instruments are used to measure disease activity and extent in clinical trials of anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis, leading to division among investigative groups and difficulty comparing study results. An exercise comparing six different vasculitis instruments was performed.

METHODS

A total of 10 experienced vasculitis investigators from 5 countries scored 20 cases in the literature of Wegener granulomatosis or microscopic polyangiitis using 6 disease assessment tools: the Birmingham Vasculitis Activity Score (BVAS), The BVAS for Wegener granulomatosis (BVAS/WG), BVAS 2003, a Physician Global Assessment (PGA), the Disease Extent Index (DEI) and the Five Factor Score (FFS). Five cases were rescored by all raters.

RESULTS

Reliability of the measures was extremely high (intraclass correlations for the six measures all = 0.98). Within each instrument, there were no significant differences or outliers among the scores from the 10 investigators. Test/retest reliability was high for each measure: range = 0.77 to 0.95. The scores of the five acute activity measures correlated extremely well with one another.

CONCLUSIONS

Currently available tools for measuring disease extent and activity in ANCA-associated vasculitis are highly correlated and reliable. These results provide investigators with confidence to compare different clinical trial data and helps form common ground as international research groups develop new, improved and universally accepted vasculitis disease assessment instruments.

EULAR recommendations for the management of primary small and medium vessel vasculitis

OBJECTIVES

To develop European League Against Rheumatism (EULAR) recommendations for the management of small and medium vessel vasculitis.

METHODS

An expert group (consisting of 10 rheumatologists, 3 nephrologists, 2 immunologists, 2 internists representing 8 European countries and the USA, a clinical epidemiologist and a representative from a drug regulatory agency) identified 10 topics for a systematic literature search using a modified Delphi technique. In accordance with standardised EULAR operating procedures, recommendations were derived for the management of small and medium vessel vasculitis. In the absence of evidence, recommendations were formulated on the basis of a consensus opinion.

RESULTS

In all, 15 recommendations were made for the management of small and medium vessel vasculitis. The strength of recommendations was restricted by low quality of evidence and by EULAR standardised operating procedures.

CONCLUSIONS

On the basis of evidence and expert consensus, recommendations have been made for the evaluation, investigation, treatment and monitoring of patients with small and medium vessel vasculitis for use in everyday clinical practice.

EULAR recommendations for the management of large vessel vasculitis

OBJECTIVES

To develop European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis.

METHODS

An expert group (10 rheumatologists, 3 nephrologists, 2 immunolgists, 2 internists representing 8 European countries and the USA, a clinical epidemiologist and a representative from a drug regulatory agency) identified 10 topics for a systematic literature search through a modified Delphi technique. In accordance with standardised EULAR operating procedures, recommendations were derived for the management of large vessel vasculitis. In the absence of evidence, recommendations were formulated on the basis of a consensus opinion.

RESULTS

Seven recommendations were made relating to the assessment, investigation and treatment of patients with large vessel vasculitis. The strength of recommendations was restricted by the low level of evidence and EULAR standardised operating procedures.

CONCLUSIONS

On the basis of evidence and expert consensus, management recommendations for large vessel vasculitis have been formulated and are commended for use in everyday clinical practice.

Disease-specific quality indicators, guidelines, and outcome measures in vasculitis

Measuring quality of care in the anti neutrophil cytoplasm antibody (ANCA) associated vasculitides (AAV) has become more complex, because the introduction of immunosuppressive therapy has resulted in a substantial improvement in survival. Early diagnosis remains a problem, because many patients are seen by non-specialists who may not recognize vasculitis or fail to initiate therapy promptly. A comprehensive assessment to determine the pattern and severity of organ involvement allows a specialist to plan a therapeutic regimen, and to manage co-morbidity effectively. Recent guidelines from the European League Against Rheumatism (EULAR) address the conduct of high-quality clinical trials in vasculitis. Risk factors for poor outcome in vasculitis are probably similar in the different forms of AAV. The risk factors are discussed in the context of failing to achieve remission, relapse, organ failure, and death. Factors indicating a poor prognosis include: the presence of high disease activity at diagnosis (which increases mortality risk even though it is associated with a greater likelihood of response to therapy); the pattern of organ involvement, for example with cardiac features carrying an adverse outcome in Wegener's granulomatosis; significant damage; renal impairment; persistence of ANCA; elderly age at diagnosis; under-use of cyclophosphamide and glucocorticoids in the first 3 months of treatment; persistent nasal carriage of Staphylococcus aureus; and the increased risk of bladder cancer in patients who are given large amounts of cyclophosphamide.

Remission in antineutrophil cytoplasmic antibody-associated systemic vasculitis

The definition of remission in patients with systemic vasculitis must be distinguished from the term "cure," which implies that patients are well and not requiring ongoing therapy. Remission should be defined using a standardised approach to measuring clinical disease activity, and the definition should be qualified by the duration of the remission and the type of maintenance therapy required to sustain remission. Remission is an important goal of management in the systemic vasculitides and is achievable in most patients. Maintenance of remission is a more difficult target, and evidence from studies of patients with antineutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitis indicates that durable, lasting remission is unlikely to occur. Despite good disease control, damage or scarring from disease or its treatment is a common finding and is a separate outcome from remission. Future studies of vasculitis therapies should address the concept of rapid and sustained disease control, so that patients spend most of their time in a state of good health, with minimal damage.