Increased incidence of cardiovascular events in patients with antineutrophil cytoplasmic antibody-associated vasculitides: a matched-pair cohort study

Genetic and pharmacological inhibition of microRNA-92a maintains podocyte cell cycle quiescence and limits crescentic glomerulonephritis

Crescentic rapidly progressive glomerulonephritis (RPGN) represents the most aggressive form of acquired glomerular disease. While most therapeutic approaches involve potentially toxic immunosuppressive strategies, the pathophysiology remains incompletely understood. Podocytes are glomerular epithelial cells that are normally growth-arrested because of the expression of cyclin-dependent kinase (CDK) inhibitors. An exception is in RPGN where podocytes undergo a deregulation of their differentiated phenotype and proliferate. Here we demonstrate that microRNA-92a (miR-92a) is enriched in podocytes of patients and mice with RPGN. The CDK inhibitor p57^Kip2 is a major target of miR-92a that constitutively safeguards podocyte cell cycle quiescence. Podocyte-specific deletion of miR-92a in mice de-repressed the expression of p57^Kip2 and prevented glomerular injury in RPGN. Administration of an anti-miR-92a after disease initiation prevented albuminuria and kidney failure, indicating miR-92a inhibition as a potential therapeutic strategy for RPGN. We demonstrate that miRNA induction in epithelial cells can break glomerular tolerance to immune injury.

Crescentic rapidly progressive glomerulonephritis is a severe form of glomerula disease characterized by podocyte proliferation and migration. Here Henique et al. demonstrate that inhibition of miRNA-92a prevents kidney failure by promoting the expression of CDK inhibitor p57^Kip2 that regulates podocyte cell cycle.

Avoidance of Harm From Treatment for ANCA-Associated Vasculitis

Purpose of review With established immunosuppressant treatment regimens for anti-neutrophil cytoplasm antibody-associated vasculitides (AAV), prognosis has significantly improved. The mainstay of treatment still comprises high-dose corticosteroids and cyclophosphamide for severe forms, although rituximab is being increasingly utilised instead of cyclophosphamide as induction therapy. AAV patients experience an excess of infections, malignancies and cardiovascular events as compared to the general population, which is a combination of the systemic inflammatory process associated with vasculitis and the adverse events from treatment.

Recent findings Successful therapy should focus on suppressing disease activity and minimising treatment-related toxicity. Infection is the largest contributor to morbidity and mortality in the first year of treatment, and annual pneumococcal and influenza vaccinations, Pneumocystis jiroveci prophylaxis and tuberculosis (TB) and Hepatitis B virus screening are advised. Patients on high-dose corticosteroid treatment should have regular blood sugar monitoring, a FRAX assessment with vitamin D and calcium supplementation, consideration of prophylaxis for gastric ulcers and a cardiovascular risk assessment. Patients who are treated with cyclophosphamide could also receive MESNA to reduce the risk of chemical cystitis. Cyclophosphamide, methotrexate and azathioprine all require blood monitoring schedules due to the risk of bone marrow suppression, liver and renal toxicity. Hypogammaglobulinaemia is a recognised risk of rituximab treatment. Patients of reproductive age need to be counselled on the infertility risks with cyclophosphamide and the teratogenicity associated with it, methotrexate and mycophenolate mofetil.

Summary A greater focus on identifying clinical and biological markers that will help identify those patients at greatest risk of relapse, e.g. GPA and PR3-ANCA specificity, from those patients at greatest risk of toxicity, e.g. increasing age and declining GFR, is required to allow treatment to be tailored accordingly.

Effect of Disease Activity, Glucocorticoid Exposure, and Rituximab on Body Composition During Induction Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

OBJECTIVE

We investigated the relationships between glucocorticoid use, disease activity, and changes in body mass index (BMI) in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

We analyzed AAV patients enrolled in the Rituximab in AAV trial. Glucocorticoid use, BMI, and disease activity were measured regularly during the trial period. We performed mixed-effects regressions to examine the associations of time-dependent cumulative average glucocorticoid use and disease activity with changes in BMI over time, while adjusting for potential confounders.

RESULTS

The mean ± SD baseline BMI of the 197 patients enrolled was 28.8 ± 6.3 kg/m² . Patients with newly diagnosed AAV tended to have a lower mean ± SD BMI than those with relapsing disease (28.0 ± 5.7 kg/m² versus 29.6 ± 6.8 kg/m² ) and higher disease activity (mean ± SD Birmingham Vasculitis Activity Score for Wegener's Granulomatosis 8.7 ± 3.3 versus 7.4 ± 2.7). The most significant change in BMI occurred during the first 6 months of the trial (mean ± SD increase of 1.1 ± 2.2 kg/m² ; P < 0.0001). Disease activity improvement, glucocorticoid exposure, and randomization to rituximab were each independently associated with an increase in BMI (P < 0.001 for all analyses).

CONCLUSION

Our findings suggest that changes in BMI, as well as glucocorticoid exposure, are independently associated with improvements in disease activity in AAV. Rituximab may also have effects on BMI independent of its impact on disease activity.

Management of cardiovascular risk factors in patients with ANCA-associated vasculitis

OBJECTIVES

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is accompanied by increased cardiovascular (CV) risk. Treatment of AAV patients includes the management of conventional CV risk factors, primarily hypertension and hypercholesterolemia, while lipoprotein(a) (LP(a)) is an emerging potential target.

METHODS

We performed a multicenter, retrospective study in Germany. Patients were considered if they were between 18 and 90 years old and presented with AAV. Patients with arterial hypertension but no autoimmune disease were used as a control group (HTN reference group).

RESULTS

Compared to the reference group (n = 52), CV disease burden was significantly greater in patients with AAV (n = 53). Hypercholesterolemia was also more common in the AAV patients (71.7% vs 46.2% for the HTN; P = .008). Lipoprotein(a) levels were elevated in both groups, with 11.3% and 17.3% of the AAV and HTN groups, respectively, displaying a level above 0.6 g/l (P = .083). Guideline-recommended targets for low-density lipoprotein cholesterol and blood pressure levels were rarely met. According to Kidney Disease: Improving Global Outcomes guidelines, 72.5% of the patients with AAV should have been taking statins and/or ezetimibe for treatment of hyperlipidemia; however, only 24.3% of them were receiving such treatment. Blood pressure below ≤140/90 mmHg was reached in 78.6% of the patients with chronic kidney disease. However, for patients with chronic kidney disease and an albumin excretion rate of >30 mg/day, the recommended blood pressure is ≤130/80 mmHg, a value that was not reached in 65% of the AAV patients.

CONCLUSION

Patients with AAV are at high CV risk, but management of the associated risk factors is poor. In addition to improving the treatment of hypercholesterolemia and hypertension, lipoprotein(a) is a further potential target for reducing CV risk in individuals with AAV.

Clinically Apparent Arterial Thrombosis in Persons with Systemic Vasculitis

Objective

To estimate the incidence rate of clinically apparent arterial thrombotic events and associated comorbidities in patients with primary systemic vasculitis.

Methods

Using large cohort administrative data from Quebec, Canada, we identified patients with vasculitis, including polyarteritis nodosa (PAN) and granulomatosis with polyangiitis (GPA). Incident acute myocardial infarctions (AMIs) and cerebrovascular accidents (CVAs) after the diagnosis of vasculitis were ascertained in the PAN and GPA group via billing and hospitalization data. These were compared to rates of a general population comparator group. The incidences of comorbidities (type 2 diabetes mellitus, dyslipidemia, and hypertension) were also collected.

Results

Among the 626 patients identified with vasculitis, 19.7% had PAN, 2.9% had Kawasaki disease, 23.8% had GPA, 52.4% had GCA, and 1.3% had Takayasu arteritis. The AMI rate was substantially higher in males aged 18–44 with PAN, with rates up to 268.1 events per 10,000 patient years [95% CI 67.1–1070.2], approximately 30 times that in the age- and sex-matched control group. The CVA rate was also substantially higher, particularly in adults aged 45–65. Patients with vasculitis had elevated incidences of diabetes, dyslipidemia, and hypertension versus the general population.

Conclusion

Atherothrombotic rates were elevated in patients identified as having primary systemic vasculitis. While incident rates of cardiovascular comorbidities were also increased, the substantial elevation in AMIs seen in young adults suggests a disease-specific component which requires further investigation.

Nationwide Trends in Hospitalizations and In-Hospital Mortality in Granulomatosis With Polyangiitis (Wegener's)

OBJECTIVE

Granulomatosis with polyangiitis (Wegener's) (GPA) is a type of antineutrophil cytoplasmic antibody-associated vasculitis that often entails severe end-organ damage and treatment-related complications that frequently lead to hospitalization and death. Nationwide trends in hospitalizations and in-hospital mortality over the past 2 decades are unknown and were evaluated in this study.

METHODS

Using the National Inpatient Sample, the largest all-payer inpatient database in the US, trends in hospitalizations with a discharge diagnosis of GPA (formerly Wegener's granulomatosis; International Classification of Disease, Ninth Revision, Clinical Modification code 446.4) between 1993 and 2011 were studied. Analyses were performed using hospital-level sampling weights to obtain US national estimates.

RESULTS

From 1993 to 2011, the annual hospitalization rate for patients with a principal diagnosis of GPA increased by 24%, from 5.1 to 6.3 per 1 million US persons (P < 0.0001 for trend); however, in-hospital deaths in this group declined by 73%, from 9.1% to 2.5% (P < 0.0001 for trend), resulting in a 66% net reduction in the annual in-hospital mortality rate. The median length of stay declined by 20%, from 6.9 days in 1993 to 5.5 days in 2011 (P = 0.0002 for trend). Infection was the most common principal discharge diagnosis when GPA was a secondary diagnosis, including among those who died during hospitalization.

CONCLUSION

The findings from these nationally representative, contemporary inpatient data indicate that the in-hospital mortality of GPA has declined substantially over the past 2 decades, while the overall hospitalization rate for GPA increased slightly. Infection remains a common principal hospitalization diagnosis among GPA patients, including hospitalizations resulting in mortality.

CD4+CD28null T Cells are related to previous cytomegalovirus infection but not to accelerated atherosclerosis in ANCA-associated vasculitis

Previous studies have suggested an increased risk for cardiovascular events in antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV). We analyzed the presence of atherosclerotic damage in patients with AAV in relation to the presence of CD4⁺CD28^null T cells and antibodies against cytomegalovirus (CMV) and human Heat-Shock Protein 60 (hHSP60). In this cross-sectional study, patients with inactive AAV were compared with healthy controls (HC). Carotid intima-media thickness (IMT) and aortic pulse-wave velocity (PWV) were measured. In addition, CD4⁺CD28^null T cells, anti-CMV, and anti-hHSP60 levels were determined. Forty patients with AAV were included. Patients’ spouses were recruited as HC (N = 38). CD4⁺CD28^null T cells are present in patients with AAV in a higher percentage (median 3.1, range 0.01–85) than in HC (0.28, 0–36, P < 0.0001). No significant difference in IMT (mm) between patients and controls was detected (mean 0.77 ± standard deviation 0.15 and 0.73 ± 0.11, respectively, P = 0.20). PWV standardized for MAP was increased in AAV patients (9.80 ± 2.50 m/s, compared to 8.72 ± 1.68 in HC, P = 0.04). There was a strong association between a previous CMV infection and the presence and percentage of CD4⁺CD28^null T cells (0.33 vs 13.8, P < 0.001). There was no relationship between CD4⁺CD28^null T cells and/or a previous CMV infection and IMT or PWV. There was no relation between anti-hHSP60 and CD4⁺CD28^null T cells. Increased PWV values suggest atherosclerotic damage in patients with AAV. Plaque size, as determined by IMT, did not differ. CD4⁺CD28^null T cells are increased in AAV and related to the previous CMV infection.

Endothelial progenitor cells are differentially impaired in ANCA-associated vasculitis compared to healthy controls

Background

Endothelial progenitor cells (EPC) are of major importance in vascular repair under healthy circumstances. Vascular injury in need of repair occurs frequently in ANCA-associated vasculitis (AAV). A specialized T cell subset enhancing EPC function and differentiation has recently been described. These angiogenic T cells (T_ang) may have an important impact on the vascular repair process. Therefore, the aim of our study was to investigate EPC and T_ang in AAV.

Methods

Fifty-three patients suffering from AAV and 29 healthy controls (HC) were enrolled in our study. Forty-four patients were in remission, nine patients were in active state of disease. Patients were either untreated or were under monotherapy with low-dose steroids (max. 5 mg/day) at the time of sampling. Circulating EPC and T_ang were determined by flow cytometry (FACS). The functional capacity of EPC was assessed by established cell culture methods.

Results

Circulating EPC were significantly decreased in AAV as compared to HC. The capacity of EPC to differentiate and proliferate was differentially impaired in patients as compared to HC. The outgrowth of endothelial colony-forming cells (ECFC) was severely decreased in patients whereas colony-forming units-endothelial cell (CFU-EC) outgrowth was unaffected. ECFC and CFU-EC differentiation was strictly T cell-dependent. Patients with a relapsing disease course had an impaired ECFC outgrowth and expansion of T_ang as compared to patients with a stable, nonrelapsing disease.

Conclusions

The differentiation process of EPC is impaired in AAV. This may favor insufficient vascular repair promoting a relapsing disease course. Finally, these factors may explain a higher cardiovascular morbidity as has been previously documented in AAV.

Comorbidities in Patients with Antineutrophil Cytoplasmic Antibody-associated Vasculitis versus the General Population

Objective.

To evaluate the consultation rates of selected comorbidities in patients with antineutrophil cytoplasmic antibody–associated vasculitis (AAV) compared with the general population in southern Sweden.

Methods.

We used data from a population-based cohort of patients with AAV diagnosed between 1998 and 2010 in Southern Sweden (701,000 inhabitants). For each patient we identified 4 reference subjects randomly sampled from the general population and matched for year of birth, sex, area of residence, and index year. Using the population-based Skåne Healthcare Register, we identified relevant diagnostic codes, registered between 1998 and 2011, for selected comorbidities assigned after the date of diagnosis of AAV or the index date for the reference subjects. We calculated rate ratios for comorbidities (AAV:reference subjects).

Results.

There were 186 patients with AAV (95 women, mean age 64.5 yrs) and 744 reference persons included in the analysis. The highest rate ratios (AAV:reference) were obtained for osteoporosis (4.6, 95% CI 3.0–7.0), followed by venous thromboembolism (4.0, 95% CI 1.9–8.3), thyroid diseases (2.1, 95% CI 1.3–3.3), and diabetes mellitus (2.0, 95% CI 1.3–2.9). For ischemic heart disease, the rate ratio of 1.5 (95% CI 1.0–2.3) did not reach statistical significance. No statistically significant differences were found for cerebrovascular accidents.

Conclusion.

AAV is associated with increased consultation rates of several comorbidities including osteoporosis and thromboembolic and endocrine disorders. Comorbid conditions should be taken into consideration when planning and providing care for patients with AAV.

Accelerated atherosclerosis in patients with chronic inflammatory rheumatologic conditions

Atherosclerosis is a complex inflammatory disease involving aberrant immune and tissue healing responses, which begins with endothelial dysfunction and ends with plaque development, instability and rupture. The increased risk for coronary artery disease in patients with rheumatologic diseases highlights how aberrancy in the innate and adaptive immune system may be central to development of both disease states and that atherosclerosis may be on a spectrum of immune-mediated conditions. Recognition of the tight association between chronic inflammatory disease and complications of atherosclerosis will impact the understanding of underlying pathogenic mechanisms and change diagnostic and therapeutic approaches in patients with rheumatologic syndromes as well as patients with coronary artery disease. In this review, we provide a summary of the role of the immune system in atherosclerosis, discuss the proposed mechanisms of accelerated atherosclerosis seen in association with rheumatologic diseases, evaluate the effect of immunosuppression on atherosclerosis and provide updates on available risk assessment tools, biomarkers and imaging modalities.

Thrombosis in vasculitic disorders-clinical manifestations, pathogenesis and management

Inflammation and coagulation are known to affect each other in many ways. Vasculitis represents a group of disorders where blood vessels (small, medium, large or variable) are infiltrated with inflammatory cells. Accumulating evidence in the literature suggests both clinical and physiological association between vasculitis and thrombosis. Vasculitis-associated thrombosis involves arteries and veins, and a tight connection has been reported between the activity of vasculitis and the appearance of thrombosis. Pathophysiology of these relations is complex and not completely understood. While thrombophilic factors are associated with vasculitis, it remains unclear whether a true association with clinical thrombosis is present. Furthermore, several factors leading to hemostasis, endothelial injury and induction of microparticles were described as possibly accounting for thrombosis. Management of thrombosis in vasculitis patients is challenging and should be further assessed in randomized controlled studies. The current review describes clinical manifestations, pathogenesis and management of thrombosis associated with different vasculitides.

Phosphorylcholine antibodies are diminished in ANCA-associated vasculitis

BACKGROUND/AIM

ANCA-associated (AAV) vasculitis is an autoimmune small-vessel vasculitis and may be associated with accelerated atherosclerosis as suggested by current literature. Antibodies against oxidized lipoproteins (OxLDL) and phosphorylcholine (Pc) protect from atherosclerosis. This study characterizes these antibodies in AAV.

METHODS

Pc- and anti-OxLDL antibodies were determined in sera of 39 AAV patients and 44 healthy controls (HC). Intima-media thickness (IMT, carotids) and pulse wave velocity (PWV, A. femoralis) were measured.

RESULTS

Pc-/OxLDL IgM antibodies were significantly reduced in AAV. IMT and PWV were negatively associated with anti-Pc antibodies in HC only.

CONCLUSION

Atheroprotective anti-Pc/anti-OxLDL antibodies are significantly reduced in AAV possibly explaining accelerated atherosclerosis in vasculitis patients.

Cardiac Involvement in Granulomatosis with Polyangiitis

OBJECTIVE

To determine frequency and outcomes of granulomatosis with polyangiitis (GPA)-related cardiac disease in a North American GPA cohort.

METHODS

Analysis was done of all patients in the Vasculitis Clinical Research Consortium Longitudinal Study of GPA. Demographic and clinical characteristics of patients with and without GPA-related cardiac involvement were compared.

RESULTS

Of 517 patients with GPA, 3.3% had cardiac involvement. No differences were observed between patients with or without cardiac involvement in terms of demographics, antineutrophil cytoplasmic antibody positivity, or relapse rate.

CONCLUSION

Cardiac involvement in GPA is rare and heterogeneous. In this cohort, cardiac involvement was not associated with a higher rate of relapse or premature death.

Thrombosis in vasculitis: from pathogenesis to treatment

In recent years, the relationship between inflammation and thrombosis has been deeply investigated and it is now clear that immune and coagulation systems are functionally interconnected.

Inflammation-induced thrombosis is by now considered a feature not only of autoimmune rheumatic diseases, but also of systemic vasculitides such as Behçet’s syndrome, ANCA-associated vasculitis or giant cells arteritis, especially during active disease.

These findings have important consequences in terms of management and treatment. Indeed, Behçet’syndrome requires immunosuppressive agents for vascular involvement rather than anticoagulation or antiplatelet therapy, and it is conceivable that also in ANCA-associated vasculitis or large vessel-vasculitis an aggressive anti-inflammatory treatment during active disease could reduce the risk of thrombotic events in early stages.

In this review we discuss thrombosis in vasculitides, especially in Behçet’s syndrome, ANCA-associated vasculitis and large-vessel vasculitis, and provide pathogenetic and clinical clues for the different specialists involved in the care of these patients.

Cardiovascular disease in patients with chronic inflammation: mechanisms underlying premature cardiovascular events in rheumatologic conditions

A variety of systemic inflammatory rheumatic diseases associate with an increased risk of atherosclerotic events and premature cardiovascular (CV) disease. Although this recognition has stimulated intense basic science and clinical research, the precise nature of the relationship between local and systemic inflammation, their interactions with traditional CV risk factors, and their role in accelerating atherogenesis remains unresolved. The individual rheumatic diseases have both shared and unique attributes that might impact CV events. Understanding of the positive and negative influences of individual anti-inflammatory therapies remains rudimentary. Clinicians need to adopt an evidence-based approach to develop diagnostic techniques to identify those rheumatologic patients most at risk of CV disease and to develop effective treatment protocols. Development of optimal preventative and disease-modifying approaches for atherosclerosis in these patients will require close collaboration between basic scientists, CV specialists, and rheumatologists. This interface presents a complex, important, and exciting challenge.

The long-term outcomes of systemic vasculitis

Patients with generalized ANCA-associated small vessel vasculitis (AAV) have a very poor outcome if the ANCA-associated vasculitis is not diagnosed, evaluated and treated properly. The introduction of treatment with immunosuppressive therapy has improved patient survival dramatically but with considerable side effects. Besides, almost 50% of surviving patients experience a relapse of vasculitis. Since 1995, the European Vasculitis Society (EUVAS) has designed and conducted several clinical trials on patients with AAV independently of pharmaceutical companies. The studies included patients with newly diagnosed AAV and were stratified according to renal function and generalized versus more localized forms. As the immediate patient survival has improved, the longer term outcome has become more important. There are several reports on outcome of patients with ANCA-associated vasculitis, but the patient groups were heterogeneous regarding diagnosis as well as treatment and follow-up. Therefore, EUVAS decided to further evaluate the effect and possible adverse events of the original randomized trials. This review presents an overview on long-term follow-up of patients with ANCA-associated vasculitis, with focus on relapse rate, patient and renal survival and development of cardiovascular disease and malignancy.

Immunomodulation with eicosapentaenoic acid supports the treatment of autoimmune small-vessel vasculitis

Small-vessel vasculitis is a life-threatening autoimmune disease that is frequently associated with anti-neutrophil cytoplasmic antibodies (ANCAs). Conventional immunotherapy including steroids and cyclophosphamide can cause serious adverse events, limiting the efficacy and safety of treatment. Eicosapentaenoic acid (EPA), a key component of fish oil, is an omega-3 polyunsaturated fatty acid widely known to be cardioprotective and beneficial for vascular function. We report two elderly patients with systemic ANCA-associated vasculitis (AAV) in whom the administration of EPA in concert with steroids safely induced and maintained remission, without the use of additioal immunosuppressants. To explore the mechanisms by which EPA enhances the treatment of AAV, we employed SCG/Kj mice as a spontaneous murine model of AAV. Dietary enrichment with EPA significantly delayed the onset of crescentic glomerulonephritis and prolonged the overall survival. EPA-derived anti-inflammatory lipid mediators and their precursors were present in the kidney, plasma, spleen, and lungs in the EPA-treated mice. Furthermore, a decrease in ANCA production and CD4/CD8-double negative T cells, and an increase in Foxp3(+) regulatory T cells in the lymph nodes of the kidney were observed in the EPA-treated mice. These clinical and experimental observations suggest that EPA can safely support and augment conventional therapy for treating autoimmune small-vessel vasculitis.

Key advances in the clinical approach to ANCA-associated vasculitis

The updated nomenclature for vasculitis defines this varied group of disorders by aetiology, specific features of pathogenesis and clinical symptoms; diagnostic and classification criteria for clinical practice are in development. Here, I review some important advances in the management of vasculitis within the category of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), which encompasses microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The clinical approach to the management of the patient with AAV should include testing for ANCA specificity; proteinase 3 (PR3)-specific ANCAs are most often associated with GPA, whereas myeloperoxidase (MPO)-ANCAs are usually associated with MPA. Also important to the management of AAV is an assessment of the disease stage and severity, to enable tailored treatment based on an algorithm derived from controlled-trial data. Remaining questions pertain to the dosage and duration of corticosteroid treatment, the selection of patients for, and duration of, maintenance treatment after induction of remission, and the identification of safer and more effective therapies than are currently in use. Outcome measures should assess not only disease activity, but also damage and quality of life. Infections, cardiovascular events and malignancies also contribute to outcome, and their prevention should therefore be part of the clinical approach to managing patients with AAV.

Factors associated with major cardiovascular events in patients with systemic necrotizing vasculitides: results of a longterm followup study

OBJECTIVE

Systemic necrotizing vasculitides (SNV) are associated with more frequent subclinical atherosclerosis, suggesting that SNV might be associated with a higher risk of major cardiovascular events (MCVE). We aimed to identify factors predictive of MCVE in patients with SNV.

METHODS

Patients in remission from SNV were assessed for CV risk factors and subclinical atherosclerosis. MCVE was defined as myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, and/or death from CV causes. MCVE-free survival curves were compared using the log-rank test.

RESULTS

Forty-two patients were followed for 7.1±2.6 years. Eight patients (18.9%) had MCVE. The respective 5- and 10-year MCVE rates were 9.5% and 26.8%. National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III)-defined high-risk status [hazard ratio (HR) 5.02 (95% CI: 1.17-27.4), p=0.03], BMI>30 kg/m2 [HR 4.84 (95% CI: 1.46-116), p=0.02], and plaque detection in the abdominal aorta (p=0.01) were significantly associated with MCVE. SNV characteristics, corticosteroid maintenance therapy, and C-reactive protein>5 mg/l were not associated with MCVE. Plaque in the aorta was significantly associated with high-risk status (p<0.001), while BMI and high-risk status were independent variables. Thus, a BMI>30 kg/m2 and/or a high-risk status were strongly associated with MCVE (p=0.004). Carotid intima-media thickness (IMT) identified patients with early MCVE and was correlated with the time to MCVE (r2=0.68, p=0.01).

CONCLUSION

These results suggest that factors associated with a higher MCVE risk in patients with SNV are NCEP/ATP III-defined high-risk status and BMI>30 kg/m2. Carotid IMT could help identify patients with SNV at risk of early MCVE.

Predictors of treatment outcomes in ANCA-associated vasculitis with severe kidney failure

BACKGROUND AND OBJECTIVES

In ANCA-associated GN, severe renal dysfunction portends a poor prognosis for renal recovery and patient survival. This study evaluated the prognostic factors affecting renal and patient outcomes in patients presenting with severe kidney failure to guide immunosuppressive therapy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study retrospectively evaluated clinical and histopathologic characteristics of 155 patients who underwent biopsy between October 1985 and February 2011 (median eGFR at presentation, 7.1 ml/min per 1.73 m(2); 87% required hemodialysis), all treated with immunosuppressive medications. Three outcomes of interest were measured: patient survival, renal survival, and treatment response (defined as dialysis-free survival without active vasculitis by 4 months after biopsy). Competing risk, Cox, and logistic regression analyses were conducted for each outcome measure.

RESULTS

Within 4 months after biopsy, treatment response was attained in 51% of patients, 35% remained on dialysis, and 14% died. In a competing risk analysis, estimated cumulative incidence rates of ESRD and disease-related mortality were 26% and 17% at 1 year and 32% and 28% at 5 years, respectively. Cyclophosphamide therapy and treatment response by 4 months were independently associated with patient and renal survival, adjusting for the percentage of normal glomeruli, histopathologic chronicity index score, and baseline clinical characteristics. Only 5% of patients still dialysis dependent at 4 months subsequently recovered renal function. Low chronicity index score (odds ratio [OR], 1.16; 95% confidence interval [95% CI], 1.04 to 1.30, per unit decrease) and baseline eGFR>10 ml/min per 1.73 m(2) (OR, 2.77; 95% CI, 1.09 to 7.01) were significantly associated with treatment response by 4 months. Among cyclophosphamide-treated patients, the likelihood of treatment response was >14% even with highest chronicity index score and eGFR<10 ml/min per 1.73 m(2).

CONCLUSIONS

Although low baseline renal function and severe renal scarring are associated with lower treatment response rate, no "futility" threshold could be identified. Conversely, continued immunosuppressive therapy beyond 4 months is unlikely to benefit patients who remain dialysis dependent.

Thrombosis in vasculitis

PURPOSE OF REVIEW

To review the association of thrombosis and vasculitis and discuss some of the proposed causal mechanisms.

RECENT FINDINGS

It is becoming increasingly evident that various systemic inflammatory diseases such as vasculitis are associated with an increased risk of both venous and arterial thrombosis. Increasing evidence supports the use of immunosuppression in the management of venous thrombosis in Behçet's disease. An increased incidence of thromboembolic disease in antineutrophil cytoplasmic antibody-associated vasculitis has been recognized, especially during periods of active disease. In addition, a higher risk of ischemic heart disease in these patients has also been observed. As in giant cell arteritis, recent evidence supports the role of aspirin in the prevention of ischemic events in Takayasu's disease.

SUMMARY

Thromboembolic disease is an important complication of several forms of systemic vasculitis, and it may result in significant morbidity and mortality. Many questions such as the role for screening of asymptomatic patients, prevention of thrombosis, and duration of anticoagulation in patients with vasculitis remain unanswered. Future studies exploring the mechanisms of thrombosis and its link to inflammation may provide insights in predicting patients at a higher risk for thrombosis and improve outcomes.

Thrombosis in vasculitis

Thrombo-embolic disease is an increasingly recognised complication of several vasculitides. A common observation is that thrombo-embolic complications coincide with periods of increased vasculitis disease activity, but the mechanism through which this happens is still unknown. Thrombo-embolic disease has been recognised for decades as a significant contributor to the morbidity and mortality of Behçet's disease, and the role of anticoagulation in its management is being minimised in favour of immunosuppression, although evidence from randomised controlled trials is lacking. Ancillary data from a randomised clinical trial and retrospective observational studies have confirmed an association between venous thrombo-embolic disease and vasculitides associated with anti-neutrophil cytoplasmic antibodies (ANCAs). An increased cardiovascular risk is now also recognised for vasculitides associated with ANCAs. Thrombosis plays a prominent role in the pathogenesis of thromboangiitis obliterans (Buerger's disease). The association of thrombosis with other vasculitides such as giant-cell arteritis and levamisole-induced vasculopathy is under investigation.

Complications of long-term therapy for ANCA-associated systemic vasculitis

The antineutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitides (AASVs) include granulomatosis with polyangiitis and microscopic polyangiitis. These conditions are characterized by small-vessel inflammation and necrosis, predominantly in pulmonary and renal vascular beds. Untreated AASV has a poor prognosis, although the advent of effective immunosuppressive therapy (the mainstay of which remains cyclophosphamide with high-dose corticosteroids) has markedly improved patients' survival (78% at 5 years). Patients with AASV, however, continue to have an increased mortality compared to the general population. Mortality is greatest in the first year after diagnosis and remains consistently elevated in subsequent years. Patients with AASV also experience increased rates of infections, malignancies and cardiovascular events as compared to the general population. Current treatments for AASV, although effective in controlling the aggressive systemic disease, incur substantial long-term toxic effects. Long-term immunosuppressive therapy also has notable deleterious effects on bone health and fertility. The long-term safety profiles of biological therapies (such as rituximab) are yet to be evaluated in patients with AASV, but represent a promising treatment option. The challenge for the future is to develop specific therapies with improved safety profiles that can cure these diseases.

[Development of morbidity and mortality in ANCA-associated vasculitis]

The outcome of ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis (AAV) has been significantly improved due to the combined use of cyclophosphamide (CYC) and glucocorticosteroids. Recent studies demonstrated a normalization of life expectancy for several subgroups of AAV patients. Mortality is highest in the first year after diagnosis and infections are the most frequent cause of death. Older age and renal failure are associated with worse outcome. The use of Pneumocystis jiroveci prophylaxis and subsequent activity-adapted GC dose reduction (target: below 10 mg per day) can substantially reduce the risk of severe infections. Late sequelae of CYC medication, such as cystitis and malignancy should be recognized and can be minimized by the usage of uroprotection with mesna and avoidance of high cumulative CYC doses.

Increased risk of cardiovascular events and mortality among non-diabetic chronic kidney disease patients with hypertensive nephropathy: the Gonryo study

To examine the clinical significance of hypertensive nephropathy (HN) among non-diabetic chronic kidney disease (CKD) patients. The study comprised 2692 CKD patients recruited from 11 outpatient nephrology clinics; these included 1306 patients with primary renal disease (PRD), 458 patients with HN, 283 patients with diabetic nephropathy (DN) and 645 patients with other nephropathies (ONs). All patients fulfilled the criteria of CKD, with a persistent low estimated glomerular filtration rate (eGFR) <60 ml min(-1) per 1.73 m(2) or proteinuria as determined by a urine dipstick test. The risk factors for cardiovascular disease (CVD), such as ischemic heart disease, congestive heart failure and stroke; all-cause mortality; and progression to end-stage renal failure (dialysis induction) were analyzed using a Cox proportional hazards model in each group. During a mean follow-up period of 22.6 months from recruitment, 100 patients were lost to follow-up and 192 patients began chronic dialysis therapy. A total of 115 CVD events occurred (stroke in 37 cases), and 44 patients died. Regarding CVD events and death, there were significant differences in the hazard ratios (HRs) for the groups of patients with different underlying renal diseases as determined by both univariate and multivariate analysis adjusted for confounding factors including estimated glomerular filtration rate: PRD, 1.0 (reference); HN, 3.33 (95% confidence interval, 1.82-6.09); DN, 5.93 (2.80-12.52); and ON, 2.22 (1.22-4.05). However, there were no differences in the hazard ratio for dialysis induction for the groups of patients with different underlying renal diseases. HN is associated with an increased risk of CVD events and death among non-diabetic CKD patients, which highlights the clinical significance of HN.

A model to predict cardiovascular events in patients with newly diagnosed Wegener's granulomatosis and microscopic polyangiitis

OBJECTIVE

To create a prognostic tool to quantify the 5-year cardiovascular (CV) risk in patients with newly diagnosed Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA) without premorbid CV disease.

METHODS

We reviewed CV outcomes during the long-term followup of patients in the first 4 European Vasculitis Study Group (EUVAS) trials of WG and MPA. CV events were defined as CV death, stroke, myocardial infarction, coronary artery bypass graft, or percutaneous coronary intervention. Logistic regression was performed to create a model to predict the absolute risk of a CV event. The model was tested using the Wegener's Granulomatosis Etanercept Trial (WGET) cohort.

RESULTS

Seventy-four (13.8%) of 535 patients with 5 years of followup from the EUVAS trials had at least 1 CV event: 33 (11.7%) of 281 WG versus 41 (16.1%) of 254 MPA. The independent determinants of CV outcomes were older age (odds ratio [OR] 1.45, 95% confidence interval [95% CI] 1.11-1.90), diastolic hypertension (OR 1.97, 95% CI 0.98-3.95), and positive proteinase 3 (PR3) antineutrophil cytoplasmic antibody (ANCA) status (OR 0.39, 95% CI 0.20-0.74). The model was validated using the WGET cohort (area under the receiver operating characteristic curve of 0.80).

CONCLUSION

Within 5 years of diagnosis of WG or MPA, 14% of patients will have a CV event. We have constructed and validated a tool to quantify the risk of a CV event based on age, diastolic hypertension, and PR3 ANCA status in patients without prior CV disease. In patients with vasculitis, PR3 ANCA is associated with a reduced CV risk compared to myeloperoxidase ANCA or negative ANCA status.

The relationship between acute coronary syndrome and inflammation: a case of acute myocardial infarction associated with coronary involvement of Sweet's syndrome

Sweet's syndrome is characterized by skin lesions and fever. One of the rare extracutaneous manifestations of Sweet's syndrome is cardiovascular involvement including coronary artery occlusion. In this article, we present a case of acute myocardial infarction associated with exacerbation of Sweet's syndrome. Coronary angiography has demonstrated normal left coronary arterial system and the occlusion of distal right coronary artery. The patient underwent successful balloon angioplasty and subsequent coronary artery stenting. The presence of coronary ectasia, aneurysm and coronary occlusion of right coronary artery caused us to hypothesize that the coronary involvement including ectasia, aneurysm and occlusion might be associated with hyperreactive inflammatory response secondary to exacerbations of Sweet's syndrome.

Impaired health-related quality of life in patients treated for Wegener's granulomatosis

OBJECTIVE

To investigate whether patients with Wegener's granulomatosis (WG) experience reduced health-related quality of life (HRQOL) after accomplishment of remission, and to study the influence of WG-associated organ damage on HRQOL.

METHODS

Sixty-eight patients with inactive WG and 680 randomly selected, age- and sex-matched controls of the Danish background population completed the Medical Outcomes Study Short-Form 36 (SF-36) survey for evaluation of HRQOL. Irreversible organ damage attributable to WG and/or its treatment was assessed using the Vasculitis Damage Index (VDI).

RESULTS

The median disease duration was 7.5 (range 1-26) years in the WG group, and the median total VDI score was 2.0 (range 0-7). Compared to controls, WG patients reported impaired HRQOL reflected by significantly lower SF-36 physical component summary scores (PCS) and mental component summary scores (MCS) (p < 0.001) and by significantly lower scores in 7 out of 8 SF-36 subscales (p ≤ 0.001). In the WG group, no statistically significant correlations were found between the different SF-36 scores and the total VDI score, number of organ systems affected by damage, disease duration, or number of WG relapses. Patients with organ failure or other major forms of damage did not report significantly lower HRQOL than less severely affected patients.

CONCLUSION

WG patients experience significantly reduced HRQOL even in phases with no apparent vasculitis disease activity. Our data indicate that the level of HRQOL does not correlate well with the extent of vasculitis-associated organ damage in WG.