1
|
Bettacchioli E, Foulquier JB, Chevet B, Cornec-Le Gall E, Hanrotel C, Lanfranco L, de Moreuil C, Lambert Y, Dueymes M, Foulquier N, Cornec D. Dual MPO/PR3 ANCA positivity and vasculitis: insights from a 7-cases study and an AI-powered literature review. Rheumatology (Oxford) 2024; 63:2557-2568. [PMID: 38552316 DOI: 10.1093/rheumatology/keae170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/21/2024] [Indexed: 09/05/2024] Open
Abstract
OBJECTIVES Anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitides (AAV) are rare conditions characterized by inflammatory cell infiltration in small blood vessels, leading to tissue necrosis. While most patients with AAV present antibodies against either myeloperoxidase (MPO) or proteinase 3 (PR3), rare cases of dual positivity for both antibodies (DP-ANCA) have been reported, and their impact on the clinical picture remains unclear. The goal of this study was to investigate the clinical implications, phenotypic profiles and outcomes of patients with DP-ANCA. METHODS A retrospective screening for DP-ANCA cases was conducted at Brest University Hospital's immunology laboratory (France), analysing ANCA results from March 2013 to March 2022. Clinical, biological, imaging, and histological data were collected for each DP-ANCA case. Additionally, a comprehensive literature review on DP-ANCA was performed, combining an artificial intelligence (AI)-based search using BIBOT software with a manual PUBMED database search. RESULTS The report of our cases over the last 9 years and those from the literature yielded 103 described cases of patients with DP-ANCA. We identified four distinct phenotypic profiles: (i) idiopathic AAV (∼30%); (ii) drug-induced AAV (∼25%); (iii) autoimmune disease associated with a low risk of developing vasculitis (∼20%); and (iv) immune-disrupting comorbidities (infections, cancers, etc) not associated with AAV (∼25%). CONCLUSION This analysis of over a hundred DP-ANCA cases suggests substantial diversity in clinical and immunopathological presentations. Approximatively 50% of DP-ANCA patients develop AAV, either as drug-induced or idiopathic forms, while the remaining 50%, characterized by pre-existing dysimmune conditions, demonstrates a remarkably low vasculitis risk. These findings underscore the complex nature of DP-ANCA, its variable impact on patient health, and the necessity for personalized diagnostic and management approaches in these cases.
Collapse
Affiliation(s)
- Eléonore Bettacchioli
- Immunology and Immunotherapy Laboratory, CHU de Brest, Brest, France
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
| | | | | | - Emilie Cornec-Le Gall
- Nephrology Department, CHU de Brest, Brest, France
- GGB Inserm UMR 1078, Univ Brest, Brest, France
| | | | | | - Claire de Moreuil
- Internal Medicine Department, CHU de Brest, Brest, France
- GETBO Inserm UMR 1304, Univ Brest, Brest, France
| | - Yannick Lambert
- Internal Medicine Department, Morlaix Hospital Centre, Morlaix, France
| | - Maryvonne Dueymes
- Immunology and Immunotherapy Laboratory, CHU de Brest, Brest, France
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
| | | | - Divi Cornec
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
- Rheumatology Department, CHU de Brest, Brest, France
| |
Collapse
|
2
|
Hu P, Xiao H, Alba MA, Atkins HM, Gou S, Hu Y, Gomez JC, Jania CM, Martin JR, Morrison TE, Tilley SL, Heise MT, Doerschuk CM, Falk RJ, Jennette JC. Myeloperoxidase-ANCA IgG induces different forms of small vessel vasculitis based on type of synergistic immune stimuli. Kidney Int 2024:S0085-2538(24)00628-8. [PMID: 39216658 DOI: 10.1016/j.kint.2024.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 07/29/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis has diverse patterns of injury including microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Necrotizing and crescentic glomerulonephritis (NCGN) occurs in all syndromes and as renal limited vasculitis (RLV). Single dose intravenous ANCA IgG-specific for mouse myeloperoxidase (MPO) causes RLV in mice. Although multiple mouse models have elucidated ANCA-IgG induced necrotizing and crescentic glomerulonephritis (NCGN), pathogenesis of ANCA-induced granulomatosis and vasculitis outside the kidney has not been clarified. To investigate this, we used intravenous MPO-ANCA IgG in the same strain of mice to induce different patterns of lung disease mirroring patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Repeated intravenous MPO-ANCA IgG induced GPA with NCGN, lung capillaritis, arteritis and granulomatosis. Lung leukocyte phenotypes were evaluated by immunohistochemical image analysis and by flow cytometry. ANCA lung capillaritis and microabscesses began within one day and evolved into granulomas in under seven days. Influenza plus single dose MPO-ANCA IgG induced MPA with NCGN, lung capillaritis and arteritis, but no granulomatosis. Allergic airway disease caused by house dust mites or ovalbumin plus single dose intravenous MPO-ANCA IgG induced EGPA with eosinophilic bronchiolitis, NCGN, capillaritis, arteritis, and granulomatosis. Thus, our study shows that the occurrence and pattern of lung lesions are determined by the same ANCA IgG accompanied by different synergistic immune factors.
Collapse
Affiliation(s)
- Peiqi Hu
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA; University of North Carolina Kidney Center, UNC CH, NC, USA
| | - Hong Xiao
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA; University of North Carolina Kidney Center, UNC CH, NC, USA
| | - Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA
| | - Hannah M Atkins
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA
| | - Shenju Gou
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA
| | - Yanglin Hu
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA
| | - John C Gomez
- Marsico Lung Institute, School of Medicine, UNC CH, Chapel Hill, NC, USA
| | - Corey M Jania
- Marsico Lung Institute, School of Medicine, UNC CH, Chapel Hill, NC, USA
| | - Jessica R Martin
- Marsico Lung Institute, School of Medicine, UNC CH, Chapel Hill, NC, USA
| | - Thomas E Morrison
- Department of Microbiology and Immunology, School of Medicine, UNC CH, Chapel Hill, NC, USA
| | - Stephen L Tilley
- Marsico Lung Institute, School of Medicine, UNC CH, Chapel Hill, NC, USA
| | - Mark T Heise
- Department of Microbiology and Immunology, School of Medicine, UNC CH, Chapel Hill, NC, USA
| | - Claire M Doerschuk
- Marsico Lung Institute, School of Medicine, UNC CH, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, UNC CH
| | - Ronald J Falk
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA; University of North Carolina Kidney Center, UNC CH, NC, USA; Department of Medicine, School of Medicine, UNC CH
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC CH), Chapel Hill, NC, USA; University of North Carolina Kidney Center, UNC CH, NC, USA; Department of Medicine, School of Medicine, UNC CH.
| |
Collapse
|
3
|
Bizzaro N, Mazzoni A, Carbone T, Cinquanta L, Villalta D, Radice A, Pesce G, Manfredi M, Infantino M. Issues in autoantibody tests used in the classification criteria for autoimmune rheumatic diseases: the laboratory autoimmunologist's perspective. Autoimmun Rev 2024:103604. [PMID: 39187223 DOI: 10.1016/j.autrev.2024.103604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/21/2024] [Accepted: 08/21/2024] [Indexed: 08/28/2024]
Abstract
Classification criteria of autoimmune rheumatic diseases are an important means to define homogenous groups of patients that can be compared across studies for clinical trials and research purposes. The measurement of autoantibodies is a relevant aspect in the definition of classification criteria, with a significant weight in the scores necessary to classify patients with autoimmune rheumatic diseases. The impact of autoantibodies has gradually increased over the years, contributing to the evolution and improvement of the classification criteria. However, these criteria often do not take into consideration how autoantibodies are measured, i.e. differences in diagnostic accuracy of the methods. This is a critical point especially when obsolete analytical methods that are no longer used in many clinical laboratories are taken into consideration. In this review we have critically examined assays and methods for the determination of autoantibodies that are (or could be) included among the classification criteria of autoimmune rheumatic diseases in light of more recent evidence and technology evolution.
Collapse
Affiliation(s)
- Nicola Bizzaro
- Laboratory of Clinical Pathology, Azienda Sanitaria Universitaria Integrata, Udine, Italy.
| | - Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Flow Cytometry Diagnostic Center and Immunotherapy Unit, Careggi University Hospital, Florence, Italy
| | - Teresa Carbone
- Immunopathology Laboratory, San Carlo Hospital, Potenza, Italy
| | | | - Danilo Villalta
- Immunology and Allergology, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Antonella Radice
- Autoimmunity and Allergology Laboratory, ASST Santi Paolo e Carlo, P.O. San Paolo Hospital, Milan, Italy
| | - Giampaola Pesce
- Autoimmunity Laboratory, IRCCS Ospedale Policlinico San Martino, Genua, Italy; Department of internal Medicine and Specialties (DiMI), University of Genua, Genua, Italy
| | - Mariangela Manfredi
- Immunology and Allergology Laboratory, S. Giovanni di Dio Hospital, Florence, Italy
| | - Maria Infantino
- Immunology and Allergology Laboratory, S. Giovanni di Dio Hospital, Florence, Italy
| |
Collapse
|
4
|
Gisslander K, White A, Aslett L, Hrušková Z, Lamprecht P, Musiał J, Nazeer J, Ng J, O'Sullivan D, Puéchal X, Rutherford M, Segelmark M, Terrier B, Tesař V, Tesi M, Vaglio A, Wójcik K, Little MA, Mohammad AJ. Data-driven subclassification of ANCA-associated vasculitis: model-based clustering of a federated international cohort. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00187-5. [PMID: 39182506 DOI: 10.1016/s2665-9913(24)00187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/19/2024] [Accepted: 06/19/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a heterogenous autoimmune disease. While traditionally stratified into two conditions, granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), the subclassification of ANCA-associated vasculitis is subject to continued debate. Here we aim to identify phenotypically distinct subgroups and develop a data-driven subclassification of ANCA-associated vasculitis, using a large real-world dataset. METHODS In the collaborative data reuse project FAIRVASC (Findable, Accessible, Interoperable, Reusable, Vasculitis), registry records of patients with ANCA-associated vasculitis were retrieved from six European vasculitis registries: the Czech Registry of ANCA-associated vasculitis (Czech Republic), the French Vasculitis Study Group Registry (FVSG; France), the Joint Vasculitis Registry in German-speaking Countries (GeVas; Germany), the Polish Vasculitis Registry (POLVAS; Poland), the Irish Rare Kidney Disease Registry (RKD; Ireland), and the Skåne Vasculitis Cohort (Sweden). We performed model-based clustering of 17 mixed-type clinical variables using a parsimonious mixture of two latent Gaussian variable models. Clinical validation of the optimal cluster solution was made through summary statistics of the clusters' demography, phenotypic and serological characteristics, and outcome. The predictive value of models featuring the cluster affiliations were compared with classifications based on clinical diagnosis and ANCA specificity. People with lived experience were involved throughout the FAIRVASVC project. FINDINGS A total of 3868 patients diagnosed with ANCA-associated vasculitis between Nov 1, 1966, and March 1, 2023, were included in the study across the six registries (Czech Registry n=371, FVSG n=1780, GeVas n=135, POLVAS n=792, RKD n=439, and Skåne Vasculitis Cohort n=351). There were 2434 (62·9%) patients with GPA and 1434 (37·1%) with MPA. Mean age at diagnosis was 57·2 years (SD 16·4); 2006 (51·9%) of 3867 patients were men and 1861 (48·1%) were women. We identified five clusters, with distinct phenotype, biochemical presentation, and disease outcome. Three clusters were characterised by kidney involvement: one severe kidney cluster (555 [14·3%] of 3868 patients) with high C-reactive protein (CRP) and serum creatinine concentrations, and variable ANCA specificity (SK cluster); one myeloperoxidase (MPO)-ANCA-positive kidney involvement cluster (782 [20·2%]) with limited extrarenal disease (MPO-K cluster); and one proteinase 3 (PR3)-ANCA-positive kidney involvement cluster (683 [17·7%]) with widespread extrarenal disease (PR3-K cluster). Two clusters were characterised by relative absence of kidney involvement: one was a predominantly PR3-ANCA-positive cluster (1202 [31·1%]) with inflammatory multisystem disease (IMS cluster), and one was a cluster (646 [16·7%]) with predominantly ear-nose-throat involvement and low CRP, with mainly younger patients (YR cluster). Compared with models fitted with clinical diagnosis or ANCA status, cluster-assigned models demonstrated improved predictive power with respect to both patient and kidney survival. INTERPRETATION Our study reinforces the view that ANCA-associated vasculitis is not merely a binary construct. Data-driven subclassification of ANCA-associated vasculitis exhibits higher predictive value than current approaches for key outcomes. FUNDING European Union's Horizon 2020 research and innovation programme under the European Joint Programme on Rare Diseases.
Collapse
Affiliation(s)
- Karl Gisslander
- Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden.
| | - Arthur White
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland; ADAPT Centre, Trinity College Dublin, Dublin, Ireland
| | - Louis Aslett
- Department of Mathematical Sciences, Durham University, Durham, UK
| | - Zdenka Hrušková
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Jacek Musiał
- II Chair of Internal Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - James Ng
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | | | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France; French Vasculitis Study Group, Paris, France
| | | | - Mårten Segelmark
- Department of Clinical Sciences, Lund University and Department of Endocrinology, Nephrology and Rheumatology, Skåne University Hospital, Lund, Sweden
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France; French Vasculitis Study Group, Paris, France
| | - Vladimir Tesař
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Azienda Ospedaliera Universitaria Meyer IRCCS, Florence, Italy
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Azienda Ospedaliera Universitaria Meyer IRCCS, Florence, Italy; Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Krzysztof Wójcik
- II Chair of Internal Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Mark A Little
- ADAPT Centre, Trinity College Dublin, Dublin, Ireland; Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Aladdin J Mohammad
- Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
5
|
Vegting Y, Hanford KM, Jongejan A, Gajadin GR, Versloot M, van der Bom-Baylon ND, Dekker T, Penne EL, van der Heijden JW, Houben E, Bemelman FJ, Neele AE, Moerland PD, Vogt L, Kroon J, Hilhorst ML. Cardiovascular risk in ANCA-associated vasculitis: Monocyte phenotyping reveals distinctive signatures between serological subsets. Atherosclerosis 2024; 397:118559. [PMID: 39186910 DOI: 10.1016/j.atherosclerosis.2024.118559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 08/05/2024] [Accepted: 08/07/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND AND AIMS Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) is associated with an increased cardiovascular risk, particularly the myeloperoxidase AAV serotype (MPO-AAV). Distinct alterations in monocyte phenotypes may cause accelerated atherosclerotic disease in AAV. METHODS A cohort including 43 AAV patients and 19 healthy controls was included for downstream analyses. Extensive phenotyping of monocytes and monocyte-derived macrophages was performed using bulk RNA-sequencing and flow cytometry. An in vitro transendothelial migration assay reflecting intrinsic adhesive and migratory capacities of monocytes was employed. Subsequent sub-analyses were performed to investigate differences between serological subtypes. RESULTS Monocyte subset analysis showed increased classical monocytes during active disease, whereas non-classical monocytes were decreased compared to healthy controls (HC). RNA-sequencing revealed upregulation of distinct inflammatory pathways and lipid metabolism-related markers in monocytes of active AAV patients. No differences were detected in the intrinsic monocyte adhesion and migration capacity. Compared to proteinase-3(PR3)-AAV, monocytes of MPO-AAV patients in remission expressed genes related to inflammation, coagulation, platelet-binding and interferon signalling, whereas the expression of chemokine receptors indicative of acute inflammation and monocyte extravasation (i.e., CCR2 and CCR5) was increased in monocytes of PR3-AAV patients. During active disease, PR3-AAV was linked with elevated serum CRP and increased platelet counts compared to MPO-AAV. CONCLUSIONS These findings highlight changes in monocyte subset composition and activation, but not in the intrinsic migration capacity of AAV monocytes. MPO-AAV monocytes are associated with sustained upregulation of inflammatory genes, whereas PR3-AAV monocytes exhibit chemokine receptor upregulation. These molecular changes may play a role in elevating cardiovascular risk as well as in the underlying pathophysiology of AAV.
Collapse
Affiliation(s)
- Yosta Vegting
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Inflammatory Diseases, Amsterdam, the Netherlands
| | - Katie Ml Hanford
- Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aldo Jongejan
- Amsterdam Institute for Infection and Immunity, Inflammatory Diseases, Amsterdam, the Netherlands; Department of Epidemiology & Data Science (EDS), Bioinformatics Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Gayle Rs Gajadin
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Miranda Versloot
- Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nelly D van der Bom-Baylon
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tamara Dekker
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - E Lars Penne
- Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | | | - Eline Houben
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | - Frederike J Bemelman
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Inflammatory Diseases, Amsterdam, the Netherlands
| | - Annette E Neele
- Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Inflammatory Diseases, Amsterdam, the Netherlands; Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Perry D Moerland
- Amsterdam Institute for Infection and Immunity, Inflammatory Diseases, Amsterdam, the Netherlands; Department of Epidemiology & Data Science (EDS), Bioinformatics Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jeffrey Kroon
- Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Laboratory of Angiogenesis and Vascular Metabolism, VIB-KU Leuven Center for Cancer Biology, Leuven, Belgium; Laboratory of Angiogenesis and Vascular Metabolism, Department of Oncology, KU Leuven and Leuven Cancer Institute (LKI), Leuven, Belgium
| | - Marc L Hilhorst
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Inflammatory Diseases, Amsterdam, the Netherlands.
| |
Collapse
|
6
|
Cai X, Li J, Wu M, Liu Q. Causal relationship between immune cells and the risk of myeloperoxidase antineutrophil cytoplasmic antibody-associated vasculitis: A Mendelian randomization study. FASEB J 2024; 38:e23821. [PMID: 39018091 DOI: 10.1096/fj.202400141r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/13/2024] [Accepted: 07/03/2024] [Indexed: 07/18/2024]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare inflammatory disease categorized as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The majority of patients are ANCA-positive, predominantly against myeloperoxidase (MPO). Previous studies have predominantly concentrated on the association between EGPA and neutrophils, but recent research has emphasized the role of lymphocytes in the development of EGPA. The objective of our research was to examine the causal association between immune cells and MPO + ANCA EGPA. A two-sample bidirectional Mendelian randomization (MR) analysis was performed, which included 159 MPO + ANCA EGPA cases and 6688 controls and utilized Genome-Wind Associaton Studies (GWAS) summary statistics of immune traits from approximately 3757 individuals, encompassing around 22 million single nucleotide polymorphisms (SNPs). Our findings revealed that 23 immunophenotypes were associated with MPO + ANCA EGPA. Furthermore, the reverse MR analysis showed that MPO + ANCA EGPA had significant causal effects on three immunophenotypes within the Treg panel. By integrating existing research, our study unveiled the contributions of Tregs, B cells, and monocytes to the development of EGPA. Subgroup analysis specifically examined the roles of lymphocyte subtypes, cytokines, and their surface molecules in the pathogenic mechanisms of the disease. This comprehensive approach provides a novel perspective on the biological mechanisms and early intervention strategies for MPO + ANCA EGPA by focusing on immune cells.
Collapse
Affiliation(s)
- Xiaojing Cai
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junhua Li
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Manyi Wu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingquan Liu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
7
|
Rathmann J, Segelmark M, Mohammad AJ. Evaluation of the ACR/EULAR 2022 criteria for classification of ANCA-associated vasculitis in a population-based cohort from Sweden. Rheumatology (Oxford) 2024; 63:1965-1972. [PMID: 37758240 PMCID: PMC11215988 DOI: 10.1093/rheumatology/kead516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE To evaluate the ACR/EULAR 2022 criteria for ANCA-associated vasculitides (AAV) classification and compare them with the European Medicines Agency (EMA) algorithm and with classification based only on ANCA serology. METHODS In the analysis, 374 cases (47% female) were classified according to the EMA algorithm, ANCA serology and ACR/EULAR criteria. The agreement rate was calculated using the kappa (κ) statistic. RESULTS Under EMA, 192 patients were classified as granulomatosis with polyangiitis (GPA), 159 as microscopic polyangiitis (MPA) and 23 as eosinophilic granulomatosis with polyangiitis (EGPA). The ACR/EULAR criteria classified 199 patients as GPA, 136 as MPA and 22 as EGPA. Four patients (1.1%) met criteria of two disease categories, and 13 (3.5%) were unclassifiable. The observed agreement between EMA and ACR/EULAR was 85% for GPA, 75% for MPA and 96% for EGPA. The unweighted κ statistic was 0.66 (95% CI: 0.60, 0.74). Of the 188 PR3-ANCA positive patients, 186 (98.9%) were classified as GPA using ACR/EULAR criteria, and 135 of 161 (83.9%) MPO-ANCA positive patients were classified as MPA. With a classification solely based on ANCA specificity, agreement with ACR/EULAR was 99% for GPA and 88% for MPA. CONCLUSIONS EMA and ACR/EULAR classification give similar results. A small proportion of patients cannot be classified or fall into two categories. Some patients exhibiting granuloma, a key feature of GPA, are nevertheless classified as MPA, conflicting with the current view of histopathology of AAV. There is high agreement of ANCA-based classification with that of ACR/EULAR, reflected in the considerable weight granted to ANCA in the new criteria. These crucial elements within the new criteria necessitate a consensus discussion among field experts.
Collapse
Affiliation(s)
- Jens Rathmann
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Mårten Segelmark
- Nephrology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Aladdin J Mohammad
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Clinical Epidemiology Unit, Lund University, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
8
|
Mann SK, Bone JN, Bosman ES, Cabral DA, Morishita KA, Brown KL. Predictive utility of ANCA positivity and antigen specificity in the assessment of kidney disease in paediatric-onset small vessel vasculitis. RMD Open 2024; 10:e004315. [PMID: 38886004 PMCID: PMC11184192 DOI: 10.1136/rmdopen-2024-004315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/12/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES The objective of this study is to evaluate whether anti-neutrophil cytoplasmic antibody (ANCA) seropositivity and antigen specificity at diagnosis have predictive utility in paediatric-onset small vessel vasculitis. METHODS Children and adolescents with small vessel vasculitis (n=406) stratified according to the absence (n=41) or presence of ANCA for myeloperoxidase (MPO) (n=129) and proteinase-3 (PR3) (n=236) were compared for overall and kidney-specific disease activity at diagnosis and outcomes between 1 and 2 years using retrospective clinical data from the ARChiVe/Paediatric Vasculitis Initiative registry to fit generalised linear models. RESULTS Overall disease activity at diagnosis was higher in PR3-ANCA and MPO-ANCA-seropositive individuals compared with ANCA-negative vasculitis. By 1 year, there were no significant differences, based on ANCA positivity or specificity, in the likelihood of achieving inactive disease (~68%), experiencing improvement (≥87%) or acquiring damage (~58%). Similarly, and in contrast to adult-onset ANCA-associated vasculitis, there were no significant differences in the likelihood of having a relapse (~11%) between 1 and 2 years after diagnosis. Relative to PR3-ANCA, MPO-ANCA seropositivity was associated with a higher likelihood of kidney involvement (OR 2.4, 95% CI 1.3 to 4.7, p=0.008) and severe kidney dysfunction (Kidney Disease Improving Global Outcomes (KDIGO) stages 4-5; OR 6.04, 95% CI 2.77 to 13.57, p<0.001) at onset. Nonetheless, MPO-ANCA seropositive individuals were more likely to demonstrate improvement in kidney function (improved KDIGO category) within 1 year of diagnosis than PR3-ANCA seropositive individuals with similarly severe kidney disease at onset (p<0.001). CONCLUSIONS The results of this study suggest important paediatric-specific differences in the predictive value of ANCA compared with adult patients that should be considered when making treatment decisions in this population.
Collapse
Affiliation(s)
- Simranpreet K Mann
- Department of Microbiology and Immunology, Faculty of Science, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Else S Bosman
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Cabral
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Kimberly A Morishita
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Kelly L Brown
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
9
|
Acharya I, Weisman DS, Smith LW, Arend LJ. Diagnostic dilemma: drug-induced vasculitis versus systemic vasculitis. Drug Ther Bull 2024:dtb.2024.e254736rep. [PMID: 38857951 DOI: 10.1136/dtb.2024.e254736rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Affiliation(s)
- Indira Acharya
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - David S Weisman
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Lanaya Williams Smith
- Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA
| | - Lois Johanna Arend
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
10
|
Han XY, Li ZY, Zhao MH, Little MA, Chen M. Malignancy is increased in patients with antineutrophil cytoplasmic antibody-associated vasculitis in China. Arthritis Res Ther 2024; 26:113. [PMID: 38822382 PMCID: PMC11140968 DOI: 10.1186/s13075-024-03345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE It has been reported that in western countries malignancy risk was higher in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) compared with that in the general population. In the current study, we investigated the incidence, spectrum and risk factors of malignancy in Chinese AAV patients. METHODS AAV patients diagnosed from 1995 to 2021 in Peking University First Hospital with a follow-up more than 12 months were recruited. Standardized incidence ratios (SIR) were calculated to describe the risk of malignancy, adjusted for sex, age and follow-up time. RESULTS A total of 552 AAV patients were recruited, among which 23 patients had malignancies either preceding or concurrent with AAV diagnosis, and 43 of the remaining 529 patients developed malignancies within 4.3 ± 4.2 years post AAV diagnosis (SIR: 2.24; 95% CI: 1.68-2.99; p < 0.001). Among these 66 patients, twenty different sites of malignancy were observed, lung cancer being most frequent. To get exactly expected malignancies for the calculation of SIR, 529 patients without preceding or concurrent malignancies were included in the following analysis. Lung cancer was still the leading malignancy diagnosis (SIR: 5.01; 95% CI: 3.29-7.62), followed by malignancies in the kidney, bladder, ureter and prostate. Male gender (HR:2.84; 95%CI:1.36-5.96; p = 0.006) and older age (per year, HR:1.04; 95%CI:1.00-1.07; p = 0.038) were significantly associated with increased risk of malignancy. For patients with malignancy developed beyond 5 years after the diagnosis of AAV, a significantly higher malignancy risk was observed in those with a cumulative cyclophosphamide dose over 20.0 g (SIR: 11.54; 95% CI: 4.77-27.93; p < 0.001). Within the first 2 years after the diagnosis of AAV, the risk of malignancy was still significantly higher than that in the general population, but the cumulative cyclophosphamide dose was not significantly associated with malignancy occurrence in this subgroup of patients. CONCLUSIONS Malignancy risk is higher in Chinese AAV patients than that in the general population, with a different malignancy spectrum from western countries. Both the use of cyclophosphamide and AAV per se might be associated with higher incidence of malignancy occurrence.
Collapse
Affiliation(s)
- Xiang-Yu Han
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Zhi-Ying Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Mark A Little
- Trinity Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Irish Centre for Vascular Biology, Trinity College Dublin, Dublin, Ireland
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| |
Collapse
|
11
|
Fernandes-Serodio J, Prieto-González S, Espígol-Frigolé G, Ríos-Garcés R, Gómez-Caverzaschi V, Araújo O, Espinosa G, Jordà-Sánchez R, Alba MA, Quintana L, Blasco M, Guillen E, Viñas O, Ruiz-Ortiz E, Pelegrín L, Sainz de la Maza M, Sánchez-Dalmau B, García-Herrera A, Solé M, Castillo P, Aldecoa I, Cano MD, Sellarés J, Hernández-González F, Agustí C, Lucena CM, López-Rueda A, Sánchez M, Benegas M, Capurro S, Sanmartí R, Grau JM, Vilaseca I, Alobid I, Cid MC, Hernández-Rodríguez J. Significance of clinical-immunological patterns and diagnostic yield of biopsies in microscopic polyangiitis and granulomatosis with polyangiitis. J Intern Med 2024; 295:651-667. [PMID: 38462959 DOI: 10.1111/joim.13777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND Microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are the two major antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). OBJECTIVES To characterize a homogenous AAV cohort and to assess the impact of clinicopathological profiles and ANCA serotypes on clinical presentation and prognosis. Clinical differences in GPA patients according to ANCA serotype and the diagnostic yield for vasculitis of biopsies in different territories were also investigated. RESULTS This retrospective study (2000-2021) included 152 patients with AAV (77 MPA/75 GPA). MPA patients (96.1% myeloperoxidase [MPO]-ANCA and 2.6% proteinase 3 [PR3]-ANCA) presented more often with weight loss, myalgia, renal involvement, interstitial lung disease (ILD), cutaneous purpura, and peripheral nerve involvement. Patients with GPA (44% PR3-ANCA, 33.3% MPO, and 22.7% negative/atypical ANCA) presented more commonly with ear, nose, and throat and eye/orbital manifestations, more relapses, and higher survival than patients with MPA. GPA was the only independent risk factor for relapse. Poor survival predictors were older age at diagnosis and peripheral nerve involvement. ANCA serotypes differentiated clinical features in a lesser degree than clinical phenotypes. A mean of 1.5 biopsies were performed in 93.4% of patients in different territories. Overall, vasculitis was identified in 80.3% (97.3% in MPA and 61.8% in GPA) of patients. CONCLUSIONS The identification of GPA presentations associated with MPO-ANCA and awareness of risk factors for relapse and mortality are important to guide proper therapeutic strategies in AAV patients. Biopsies of different affected territories should be pursued in difficult-to-diagnose patients based on their significant diagnostic yield.
Collapse
Affiliation(s)
- João Fernandes-Serodio
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
- Systemic Immuno-mediated Diseases Unit (UDIMS), Department of Internal Medicine IV, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Sergio Prieto-González
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Roberto Ríos-Garcés
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Verónica Gómez-Caverzaschi
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Olga Araújo
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Raül Jordà-Sánchez
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Marco A Alba
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Luis Quintana
- Department of Nephrology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Elena Guillen
- Department of Nephrology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Odette Viñas
- Department of Immunology, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
| | - Estíbaliz Ruiz-Ortiz
- Department of Immunology, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
| | - Laura Pelegrín
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maite Sainz de la Maza
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Bernardo Sánchez-Dalmau
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Adriana García-Herrera
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Manel Solé
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Paola Castillo
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Iban Aldecoa
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - María D Cano
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Jacobo Sellarés
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Fernanda Hernández-González
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carlos Agustí
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carmen M Lucena
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antonio López-Rueda
- Interventional Neuroradiology Unit, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marcelo Sánchez
- Department of Radiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Mariana Benegas
- Department of Radiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Sebastián Capurro
- Department of Radiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Raimon Sanmartí
- Department of Rheumatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Josep M Grau
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Isabel Vilaseca
- Department of Otorhinolaryngology, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Isam Alobid
- Department of Otorhinolaryngology, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria C Cid
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Hernández-Rodríguez
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| |
Collapse
|
12
|
Falde SD, Fussner LA, Tazelaar HD, O'Brien EK, Lamprecht P, Konig MF, Specks U. Proteinase 3-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e314-e327. [PMID: 38574742 DOI: 10.1016/s2665-9913(24)00035-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/13/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024]
Abstract
Proteinase 3 (PR3)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is one of two major ANCA-associated vasculitis variants and is pathogenically linked to granulomatosis with polyangiitis (GPA). GPA is characterised by necrotising granulomatous inflammation that preferentially affects the respiratory tract. The small vessel vasculitis features of GPA are shared with microscopic polyangiitis. Necrotising granulomatous inflammation of GPA can lead to PR3-ANCA and small vessel vasculitis via activation of neutrophils and monocytes. B cells are central to the pathogenesis of PR3-ANCA-associated vasculitis. They are targeted successfully by remission induction and maintenance therapy with rituximab. Relapses of PR3-ANCA-associated vasculitis and toxicities associated with current standard therapy contribute substantially to remaining mortality and damage-associated morbidity. More effective and less toxic treatments are sought to address this unmet need. Advances with cellular and novel antigen-specific immunotherapies hold promise for application in autoimmune disease, including PR3-ANCA-associated vasculitis. This Series paper describes the inter-related histopathological and clinical features, pathophysiology, as well as current and future targeted treatments for PR3-ANCA-associated vasculitis.
Collapse
Affiliation(s)
- Samuel D Falde
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, Ohio State University, Columbus, OH, USA
| | - Henry D Tazelaar
- Department of Anatomic Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maximilian F Konig
- Division of Rheumatology, Department of Medicine & Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA.
| |
Collapse
|
13
|
Ambrogi E, Cavazza A, Smith ML, Graziano P. Pulmonary pathology in vasculitis. Pathologica 2024; 116:93-103. [PMID: 38767542 PMCID: PMC11138764 DOI: 10.32074/1591-951x-988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 05/22/2024] Open
Abstract
Pulmonary involvement is frequent in vasculitis, particularly in ANCA-associated small vessel vasculitis. Laboratory and radiological data alone are often sufficient to confirm the clinical hypothesis, but sometimes the pathologist plays a crucial role in the differential diagnosis and the patient's management. In this review, the pathologic features of pulmonary vasculitis and the pathologist's role in this field are illustrated.
Collapse
Affiliation(s)
- Elisa Ambrogi
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Italy
| | | | - Maxwell L. Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Paolo Graziano
- Department of Radiology, Oncology and Pathology Sciences, Sapienza, University of Rome, Italy
| |
Collapse
|
14
|
Akbaba TH, Toor KK, Mann SK, Gibson KM, Alfaro GA, Balci-Peynircioglu B, Cabral DA, Morishita KA, Brown KL. Anti-LAMP-2 Antibody Seropositivity in Children with Primary Systemic Vasculitis Affecting Medium- and Large-Sized Vessels. Int J Mol Sci 2024; 25:3771. [PMID: 38612581 PMCID: PMC11011342 DOI: 10.3390/ijms25073771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Chronic primary systemic vasculitis (PSV) comprises a group of heterogeneous diseases that are broadly classified by affected blood vessel size, clinical traits and the presence (or absence) of anti-neutrophil cytoplasmic antibodies (ANCA) against proteinase 3 (PR3) and myeloperoxidase (MPO). In small vessel vasculitis (SVV), ANCA are not present in all patients, and they are rarely detected in patients with vasculitis involving medium (MVV) and large (LVV) blood vessels. Some studies have demonstrated that lysosome-associated membrane protein-2 (LAMP-2/CD107b) is a target of ANCA in SVV, but its presence and prognostic value in childhood MVV and LVV is not known. This study utilized retrospective sera and clinical data obtained from 90 children and adolescents with chronic PSV affecting small (SVV, n = 53), medium (MVV, n = 16), and large (LVV, n = 21) blood vessels. LAMP-2-ANCA were measured in time-of-diagnosis sera using a custom electrochemiluminescence assay. The threshold for seropositivity was established in a comparator cohort of patients with systemic autoinflammatory disease. The proportion of LAMP-2-ANCA-seropositive individuals and sera concentrations of LAMP-2-ANCA were assessed for associations with overall and organ-specific disease activity at diagnosis and one-year follow up. This study demonstrated a greater time-of-diagnosis prevalence and sera concentration of LAMP-2-ANCA in MVV (52.9% seropositive) and LVV (76.2%) compared to SVV (45.3%). Further, LAMP-2-ANCA-seropositive individuals had significantly lower overall, but not organ-specific, disease activity at diagnosis. This did not, however, result in a greater reduction in disease activity or the likelihood of achieving inactive disease one-year after diagnosis. The results of this study demonstrate particularly high prevalence and concentration of LAMP-2-ANCA in chronic PSV that affects large blood vessels and is seronegative for traditional ANCA. Our findings invite reconsideration of roles for autoantigens other than MPO and PR3 in pediatric vasculitis, particularly in medium- and large-sized blood vessels.
Collapse
Affiliation(s)
- Tayfun Hilmi Akbaba
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Department of Medical Biology, Faculty of Medicine, Hacettepe University, 06800 Ankara, Turkey
| | - Kirandeep K. Toor
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Women+ and Children’s Health Sciences, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Simranpreet K. Mann
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Kristen M. Gibson
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | | | - Banu Balci-Peynircioglu
- Department of Medical Biology, Faculty of Medicine, Hacettepe University, 06800 Ankara, Turkey
| | - David A. Cabral
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- BC Children’s Hospital, Vancouver, BC V6H 3V4, Canada
| | - Kimberly A. Morishita
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- BC Children’s Hospital, Vancouver, BC V6H 3V4, Canada
| | - Kelly L. Brown
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- BC Children’s Hospital, Vancouver, BC V6H 3V4, Canada
| |
Collapse
|
15
|
Saowapa S, Chaisrimaneepan N, Adu Y, Thongpiya J, Yingchoncharoen P, Bell AL, Polpichai N, Siladech P, Payne JD. Massive hemoptysis with end stage renal disease (ESRD): An initial symptom of rare disease. Clin Case Rep 2024; 12:e8614. [PMID: 38455858 PMCID: PMC10918702 DOI: 10.1002/ccr3.8614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Microscopic polyangiitis is a rare autoimmune vasculitis, that could present with renal-pulmonary symptoms, posing diagnostic challenges in patients with preexisting kidney disease. Timely diagnosis is crucial to improve patient outcomes.
Collapse
Affiliation(s)
- Sakditad Saowapa
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | | | - Yaw Adu
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Jerapas Thongpiya
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | | | - Amanda L. Bell
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Natchaya Polpichai
- Department of Internal MedicineWeiss Memorial HospitalChicagoIllinoisUSA
| | - Pharit Siladech
- Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - J. Drew Payne
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| |
Collapse
|
16
|
Rifai ZJ, Kohli A, Gilani S, Chen X. Unexpected Relapse: Insights Into Granulomatosis With Polyangiitis. Cureus 2024; 16:e56883. [PMID: 38659507 PMCID: PMC11040402 DOI: 10.7759/cureus.56883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/26/2024] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare vasculitis that can pose a significant mortality risk given its multiorgan involvement and is the most common of the three anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. Cardinal pathological features include necrotizing granulomas of the respiratory tract, small and medium vessel vasculitis, and glomerulonephritis. Early treatment is imperative to reduce permanent organ damage such as end-stage kidney disease. We describe the first case of GPA relapse 38 years after the initial pulmonary presentation. The patient previously had isolated lung involvement with preserved renal function, but presented with an acute kidney injury, uremia, and several constitutional symptoms. The patient was treated with corticosteroids and intermittent hemodialysis and initiated on immunosuppressants; the clinical course is highlighted by eventual renal recovery. Our purpose is to highlight the importance of treating patients to complete immunological recovery, particularly in GPA vasculitis, to prevent unnecessary relapse and further loss of renal function.
Collapse
Affiliation(s)
- Zeyad J Rifai
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Akshay Kohli
- Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Samie Gilani
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | - Xueguang Chen
- Department of Internal Medicine, Division of Nephrology, Southern Illinois University School of Medicine, Springfield, USA
| |
Collapse
|
17
|
Muhammad A, Xiao Z, Lin W, Zhang Y, Meng T, Ning J, Xu H, Tang R, Xiao X. Acute interstitial nephritis caused by ANCA-associated vasculitis: a case based review. Clin Rheumatol 2024; 43:1227-1244. [PMID: 37932622 DOI: 10.1007/s10067-023-06798-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023]
Abstract
Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) typically manifests as rapidly progressive glomerulonephritis with crescent formation. In this report, we present a local case of myeloperoxidase (MPO)-AAV-associated acute interstitial nephritis (AIN), showing slight pauci-immune glomerulonephritis and positive MPO-ANCA. This case is characterized by foot process effacement of podocytes in the glomerulus, a favorable prognosis, and an absence of crescentic formation. To further understand this condition, we conducted a comprehensive literature search on Google Scholar and PubMed, employing both free text words and MeSH terms related to "AAV and AIN." This search yielded 24 cases, which we analyzed for their clinical features, laboratory findings, renal pathological characteristics, and therapeutic outcomes. AAV-associated interstitial nephritis predominantly affects elderly patients and is often associated with anemia, proteinuria, hematuria, and nonspecific manifestations, including fever, anorexia, fatigue, edema, and weight loss. Most of the cases in our review were MPO-ANCA-positive and exhibited isolated interstitial inflammation. These patients typically presented with relatively lower levels of serum creatinine, 24-h urine protein levels, and MPO-ANCA titers. All patients in our study received immunosuppressive therapy, including glucocorticoids, immunosuppressants, and rituximab, with the majority achieving clinical remission. Isolated AIN in the context of AAV is a rare occurrence, but it displays distinct clinical, laboratory, and pathological features. Patients with this presentation show a positive response to immunosuppressive treatment. Nevertheless, the establishment of definitive therapy guidelines for AAV-associated AIN remains uncertain and necessitates further investigation to develop comprehensive treatment guidelines. AIN, particularly when lacking typical glomerulus lesions, may represent a novel subgroup within MPO-AAV warranting additional research and clinical attention. Key Points • This study contributes valuable scientific insights by highlighting that MPO-AAV-associated interstitial nephritis, even without crescentic formation, can exhibit podocyte foot process effacement and respond well to treatment. • The presence of AIN, independent of crescentic glomerulonephritis, suggests the potential emergence of a new subclass within MPA-AAV. • Notably, some cases of MPO-AAV-associated AIN may present with normal levels of Scr (Table 5, cases 5, 6, and 17). • This observation highlights the importance of considering renal biopsy, diagnosis, and therapy in a timely manner to prevent the development of chronic kidney disease (CKD).
Collapse
Affiliation(s)
- Amir Muhammad
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Zhou Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Wei Lin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Yingli Zhang
- Department of Nephrology, Third Hospital of Changsha, Changsha, 410015, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Jianping Ning
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Hui Xu
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Rong Tang
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| |
Collapse
|
18
|
Shukla S, Sekar A, Naik S, Rathi M, Sharma A, Nada R, Kohli HS, Ramachandran R. ANCA-Associated Vasculitis with Systemic Thrombotic Microangiopathy: A Review of Literature. Indian J Nephrol 2024; 34:155-161. [PMID: 38681020 PMCID: PMC11044693 DOI: 10.4103/ijn.ijn_376_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/01/2023] [Indexed: 05/01/2024] Open
Abstract
Introduction Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) rarely coexist with systemic thrombotic microangiopathy (TMA).The TMA can be in the form of either hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). This review explores the clinical characteristics, histopathological findings, treatment options, and outcomes in patients presenting as AAV with coexisting HUS/TTP. Methods We conducted a search on the PubMed database and additional searches from January 1998 to September 2022 using the following terms: "ANCA", "Antineutrophil cytoplasmic antibody", "thrombotic thrombocytopenic purpura", "TTP", "thrombotic microangiopathy", "haemolytic uremic syndrome", and "HUS". We excluded articles that described renal-limited TMA. Two authors independently reviewed the full texts and extracted all critical data from the included case reports. Finally, we included 15 cases for this review. Hematological remission and kidney recovery in the form of independence from dialysis was assessed. Results The median age of the patients was 61 years and a majority of them were females (66.7%). Myeloperoxidase (MPO)-ANCA positivity (66.67%) was more common than proteinase 3 (PR3)-ANCA positivity (33.33%). All patients had laboratory parameters consistent with systemic TMA (HUS or TTP), and only six (out of 11) cases showed histological features of renal TMA. Ten had crescentic glomerulonephritis, and two had advanced degrees of chronicity in histology. Eighty-six percent of cases had hematological remission, and sixty percent of cases became dialysis-independent after treatment. Conclusion In conclusion, kidney outcome was worse in patients who manifested both AAV and systemic TMA. A paucity of literature regarding this diagnostic quandary calls for avid reporting of such cases.
Collapse
Affiliation(s)
- Shubham Shukla
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sachin Naik
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir S. Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
19
|
Hara A, Sada KE, Wada T, Amano K, Dobashi H, Atsumi T, Sugihara T, Hirayama K, Banno S, Murakawa Y, Hasegawa M, Yamagata K, Arimura Y, Makino H, Harigai M. Predictors of damage accrual in patients with antineutrophil cytoplasmic antibody-associated vasculitis: A nationwide prospective study. Mod Rheumatol 2024; 34:382-390. [PMID: 36988333 DOI: 10.1093/mr/road029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES This study elucidated the prognosis and risk factors associated with damage accrual during long-term remission maintenance therapy for patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS We obtained data from 120 patients registered in a nationwide prospective cohort study on remission induction therapy in Japanese patients with AAV and rapidly progressive glomerulonephritis (RemIT-JAV-RPGN), who achieved remission at 24 months after treatment initiation and were followed up for additional 24 months. The primary outcome was the vasculitis damage index (VDI) score at Month 48, and the secondary outcome included risk factors associated with increased total VDI at Month 48. RESULTS The understudied patients comprised 52 men and 68 women aged 68 ± 13 years. Between Months 25 and 48, the patients' survival rate was 95% (114/120). End-stage renal disease developed in seven patients by Month 48, and 64 cases had increased VDI. The multivariable analysis results revealed that oral prednisolone (PSL) doses at Month 24 were associated with damage accrual between Months 24 and 48. CONCLUSIONS VDI accrual was observed in more than half of patients with AAV during maintenance therapy, and increased VDI scores were associated with oral PSL doses 24 months after initiating remission induction therapy in Japan.
Collapse
Affiliation(s)
- Akinori Hara
- Department of Hygiene and Public Health, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takahiko Sugihara
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Kouichi Hirayama
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Midori Hasegawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
- Kichijoji Asahi Hospital, Tokyo, Japan
| | | | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| |
Collapse
|
20
|
Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 119] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
Collapse
Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
21
|
Furuta S, Nakagomi D, Kobayashi Y, Hiraguri M, Sugiyama T, Amano K, Umibe T, Kono H, Kurasawa K, Kita Y, Matsumura R, Kaneko Y, Ninagawa K, Hiromura K, Kagami SI, Inaba Y, Hanaoka H, Ikeda K, Nakajima H. Reduced-dose versus high-dose glucocorticoids added to rituximab on remission induction in ANCA-associated vasculitis: predefined 2-year follow-up study. Ann Rheum Dis 2024; 83:96-102. [PMID: 37734880 DOI: 10.1136/ard-2023-224343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES The LoVAS trial reported non-inferiority in remission induction rates between the reduced-dose and conventional high-dose glucocorticoid regimens plus rituximab for antineutrophil cytoplasm antibody (ANCA)-associated vasculitis at 6 months; however, maintenance glucocorticoid requirements and long-term outcomes are unknown. METHODS A total of 140 patients with new-onset ANCA-associated vasculitis without severe glomerulonephritis or alveolar haemorrhage were randomised to receive reduced-dose prednisolone (0.5 mg/kg/day) plus rituximab (375 mg/m2/week×4) or high-dose prednisolone (1 mg/kg/day) plus rituximab. After achieving remission, patients received the rituximab maintenance therapy (1 g/6 months). RESULTS A total of 134 patients were analysed. Among patients who achieved remission with the protocolised treatments, the majority of patients in the reduced-dose group (89.7%) and 15.5% in the high-dose group discontinued prednisolone (median time to withdrawal, 150 and 375 days, respectively). During 24-month trial period, two patients in the reduced-dose group (2.8%) died, while five patients in the high-dose group (7.6%) died (p=0.225). Relapse occurred in nine patients in the reduced-dose group (13.0%) (two major and seven minor) and five in the high-dose group (7.6%) (two major and three minor) (p=0.311). Serious adverse events (SAEs) were less frequent in the reduced-dose group (36 events in 19 patients, 27.5%) than in the high-dose group (54 events in 30 patients, 46.2%) (p=0.025). CONCLUSION At 24 months, frequencies of relapse did not differ between the groups, and SAEs were less frequent in the reduced-dose group due to the lower event rate in the 6-month induction phase. The bias to myeloperoxidase-ANCA positivity (85.8%) in the trial population should be noted. TRIAL REGISTRATION NUMBER NCT02198248.
Collapse
Affiliation(s)
- Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi, Chuo, Japan
| | - Yoshihisa Kobayashi
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Masaki Hiraguri
- Allergy and Clinical Immunology Center, Japanese Red Cross Narita Hospital, Narita, Japan
| | - Takao Sugiyama
- Department of Rheumatology, Shimoshizu Hospital, National Hospital Organization, Yotsukaido, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Centre, Saitama Medical University, Kawagoe, Japan
| | - Takeshi Umibe
- Department of Rheumatology, Matsudo City General Hospital, Matsudo, Japan
| | - Hajime Kono
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Tochigi, Japan
| | - Yasuhiko Kita
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohoma, Japan
| | - Ryutaro Matsumura
- Department of Rheumatology, National Hospital Organization Chiba-East Hospital, Chiba, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keita Ninagawa
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shin-Ichiro Kagami
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, Asahi, Japan
| | - Yosuke Inaba
- Clinical Research Centre, Chiba University Hospital, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Centre, Chiba University Hospital, Chiba, Japan
- Chiba University Synergy Institute for Futuristic Mucosal Vaccine Research and Development (cSIMVa), Chiba University, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Department of Rheumatology, Dokkyo Medical University, Tochigi, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Chiba University Synergy Institute for Futuristic Mucosal Vaccine Research and Development (cSIMVa), Chiba University, Chiba, Japan
| |
Collapse
|
22
|
Durak Ediboğlu E, Karasu Ş, Ekici T, Gerçik Ö, Gümüş C, Akar S. Which is important in thoracic CT findings: Antineutrophil cytoplasmic antibody (ANCA) subtype or subgroups of ANCA-associated vasculitis? Int J Rheum Dis 2024; 27:e14891. [PMID: 37638741 DOI: 10.1111/1756-185x.14891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/29/2023]
Affiliation(s)
| | - Şebnem Karasu
- Department of Radiology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Tugce Ekici
- Department of Radiology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Önay Gerçik
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Izmir Demokrasi University, Izmir, Turkey
| | - Cesur Gümüş
- Department of Radiology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Servet Akar
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| |
Collapse
|
23
|
Tan C, Perara J, Kumar P. A unique case of indolent microscopic polyangiitis in an elderly gentleman: a case report and brief review. Arch Clin Cases 2023; 10:205-209. [PMID: 38155998 PMCID: PMC10754038 DOI: 10.22551/2023.41.1004.10276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
Antineutrophil cytoplasmic autoantibody associated vasculitides has 3 different types: Granulomatosis with polyangiitis, eosinophilic granulomatosis and polyangiitis and microscopic polyangiitis. These vasculitides manifest differently based on which area of small and medium size vessels in our bodies that it affects. In this case report, we discuss a unique case of microscopic polyangiitis diagnosed in a 75-year-old male who was relatively asymptomatic i.e. indolent, apart from nodules present in the lung with the use of the diagnostic criteria outlined by 2022 American College of Rheumatology and European Alliance of Associations for Rheumatology. In addition, we reviewed briefly about vasculitis, its epidemiology and the workup of microscopic polyangiitis.
Collapse
Affiliation(s)
- Clement Tan
- Department of General Medicine/Respiratory Medicine, Mackay Base Hospital, Mackay, Queensland, Australia
| | - Jithmy Perara
- Department of General Medicine/Respiratory Medicine, Mackay Base Hospital, Mackay, Queensland, Australia
| | - Pranav Kumar
- Department of General Medicine/Respiratory Medicine, Mackay Base Hospital, Mackay, Queensland, Australia
| |
Collapse
|
24
|
Qi F, Hao J, Wei W. Impact of different ANCA serotypes on the long-term outcome of ANCA-associated vasculitis patients. Ann Med 2023; 55:2289614. [PMID: 38056010 PMCID: PMC10836254 DOI: 10.1080/07853890.2023.2289614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES To investigate the clinical features and long-term outcomes of Chinese anti-neutrophil cytoplasmic antibodies (ANCAs)-associated vasculitis (AAV) patients with different ANCA serotypes. METHODS Two hundred and twenty-four AAV patients from January 2010 to June 2021 were divided into myeloperoxidase (MPO)-ANCA and proteinase 3 (PR3)-ANCA groups. Clinical and long-term outcomes were compared. RESULTS In this study, the average follow-up was 46.4 months (range 0.3-188.4 months). One hundred and seventy-seven (79.0%) patients were MPO-ANCA-positive and 47 were PR3-ANCA-positive; the mean age of MPO-ANCA positive patients at diagnosis was elder than that of PR3-ANCA positive patients (67.0 vs. 60.0 years, p = .004). Among PR3-ANCA-positive patients, ear, nose and throat symptoms were more common (p = .014). Between two ANCA serotypes, there were no differences in complement 3 (C3), Birmingham vasculitis activity score (BVAS), five-factor score (FFS) or other organ involvements. For all AAV patients, the overall survival rates at one, three and five years were 80.0%, 67.0% and 56.4%, respectively. The cumulative relapse-free rates of one, three and five years were 89.5%, 76.4% and 68.4%, respectively. The survival of AAV patients was unaffected by the ANCA serotype (p = .23). The ANCA serotype also had no effect on either disease relapse (p = .20) or remission rates (p = .10). In our study, PR3-ANCA patients showed a better long-term survival, as the 5-year survival rate and the 5-year relapse-free survival rate of PR3-ANCA patients were 60.7% and 76.9%, while that of MPO-ANCA patients were 55.2% and 65.8%, respectively. Rather than ANCA serotype, younger patients with milder kidney involvement and lower disease assessment scores (BVAS and FFS) might be more relevant to better prognosis. CONCLUSIONS The likelihood of induced remission, patient survival or disease recurrence is all unaffected by ANCA serotypes. A better prognosis is seen in younger patients with milder kidney involvement and lower BVAS/FFS scores.
Collapse
Affiliation(s)
- Fumin Qi
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jian Hao
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, China
| |
Collapse
|
25
|
Hsieh TY, Chen MH, Wu CC, Hong WJ, Lu CH, Lu CC, Lu LY, Hsieh SC, Tsai CY, Wu CS. Rituximab induction and reinduction in granulomatosis with polyangiitis and microscopic polyangiitis: A retrospective multicenter study in Taiwan. Int J Rheum Dis 2023; 26:2441-2449. [PMID: 37784228 DOI: 10.1111/1756-185x.14929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVES This study aimed to investigate the clinical outcomes of granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) under rituximab induction and reinduction therapy in Taiwan. METHODS We performed a retrospective study in patients with GPA or MPA receiving rituximab therapy from August 2008 to July 2020 in seven medical centers in Taiwan. The clinical characteristics and outcomes of these patients were analyzed. RESULTS In total, 53 patients (18 with GPA and 35 with MPA) were included. Kidney involvement (82.9% vs. 22.2%, p < .001) and initial creatinine (3.25 ± 2.37 vs. 1.07 ± 0.82, p < .001) were significantly higher in MPA. Within 24 weeks after the first course of rituximab, there were seven deaths (five due to infection and two due to active disease) in patients with MPA (7/35, 20%) compared to 0 in patients with GPA. Of 33 patients receiving rituximab for kidney involvement, 23 survived and were free from renal replacement therapy at 24 weeks. Their chronic kidney disease (CKD) stages improved in 2 but progressed in 7, while 24 had stable CKD stages. Death or end-stage renal disease (ESRD) was associated with infection and higher initial creatinine. Reinduction therapy for relapse was required in 18 (39.1%) of 46 survivors, which was associated with anti-proteinase 3 (PR3) positive (odds ratio 3.667, p = .049) and younger age with a cutoff of 49.4 (AUC = 0.679, p = .030, sensitivity = 66.67%, specificity = 75%). CONCLUSION Significant mortality occurred after rituximab induction, especially in patients with MPA. In survivors, age younger than 50 and anti-PR3 positive were associated with the risk of relapse requiring reinduction.
Collapse
Affiliation(s)
- Tsu-Yi Hsieh
- Division of Allergy, Immunology, and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Han Chen
- Division of Allergy, Immunology, and Rheumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chen-Ching Wu
- Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Jhe Hong
- Division of Rheumatology and Immunology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Hsun Lu
- Division of Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Chi Lu
- Division of Rheumatology, Immunology, and Allergy, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Taiwan
| | - Ling-Ying Lu
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Song-Chou Hsieh
- Division of Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Youh Tsai
- Division of Immunology and Rheumatology, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chien-Sheng Wu
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
- Division of Allergy, Immunology, and Rheumatology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| |
Collapse
|
26
|
Romand X, Paclet MH, Chuong MV, Gaudin P, Pagnoux C, Guillevin L, Terrier B, Baillet A. Serum calprotectin and renal function decline in ANCA-associated vasculitides: a post hoc analysis of MAINRITSAN trial. RMD Open 2023; 9:e003477. [PMID: 37903568 PMCID: PMC10619089 DOI: 10.1136/rmdopen-2023-003477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/02/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVE Serum calprotectin appears to be an interesting biomarker associated with renal vascular disease activity in antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). The aim of this study was to assess whether serum calprotectin levels can predict decline in renal function in AAV patients receiving maintenance therapy. METHODS Serum calprotectin levels were assessed at inclusion and month 6 in AAV patients, in complete remission after induction therapy, randomly assigned to rituximab or azathioprine. Renal function decline was defined as a 25% decrease in estimated glomerular filtration rate (eGFR) and a change in the eGFR category, or a decrease of 15 mL/min/1.73 m2. Relapse was defined as a Birmingham Vasculitis Activity Score >0 attributable to active vasculitis. RESULTS Seventy-six AAV were included. Serum calprotectin increased from baseline to month 6 in patients with renal function decline (7940 (-226.0, 28 691) ng/ml vs -4800 (-18 777, 3708) ng/ml; p<0.001). An increase of calprotectin level was associated with a higher risk of subsequent renal function decline even after adjustment (OR 6.50 (95% CI 1.7 to 24.9) p=0.006). A significantly higher risk of relapse was observed in proteinase 3- AAV patients with an increase of serum calprotectin levels (OR 5.6 (95% CI 1.0 to 31.2), p=0.03). CONCLUSION An increase in serum calprotectin by month 6 compared with inclusion during remission-maintenance therapy in AAV was associated with a higher risk of renal function decline in the following 12 months. TRIAL REGISTRATION NUMBER NCT00748644.
Collapse
Affiliation(s)
- Xavier Romand
- CNRS, UMR 5525, T-RAIG, TIMC, CHU Grenoble Alpes, Universite Grenoble Alpes, Grenoble, France
| | - Marie Hélène Paclet
- CNRS, UMR 5525, T-RAIG, TIMC, CHU Grenoble Alpes, Universite Grenoble Alpes, Grenoble, France
| | - Minh Vu Chuong
- CNRS, UMR 5525, T-RAIG, TIMC, CHU Grenoble Alpes, Universite Grenoble Alpes, Grenoble, France
| | - Philippe Gaudin
- CNRS, UMR 5525, T-RAIG, TIMC, CHU Grenoble Alpes, Universite Grenoble Alpes, Grenoble, France
| | | | - Loïc Guillevin
- Université de Paris, Paris, France
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hopital Cochin APHP-Centre Université Paris (CUP), Paris, France
| | - Benjamin Terrier
- Université de Paris, Paris, France
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hopital Cochin APHP-Centre Université Paris (CUP), Paris, France
| | - Athan Baillet
- CNRS, UMR 5525, T-RAIG, TIMC, CHU Grenoble Alpes, Universite Grenoble Alpes, Grenoble, France
| |
Collapse
|
27
|
Wojcik I, Wuhrer M, Heeringa P, Stegeman CA, Rutgers A, Falck D. Specific IgG glycosylation differences precede relapse in PR3-ANCA associated vasculitis patients with and without ANCA rise. Front Immunol 2023; 14:1214945. [PMID: 37841251 PMCID: PMC10570725 DOI: 10.3389/fimmu.2023.1214945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Immunoglobulin G (IgG) contains a conserved N-glycan in the fragment crystallizable (Fc), modulating its structure and effector functions. In anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) alterations of IgG Fc-glycosylation have been observed to correlate with the disease course. Here, we examined longitudinal changes in N-linked Fc glycans of IgG in an AAV patient cohort and their relationship with disease flares. Methods Using liquid chromatography coupled with mass spectrometry, we analysed IgG Fc-glycosylation in 410 longitudinal samples from 96 individuals with AAV. Results Analysis of the cross-sectional differences as well as longitudinal changes demonstrated that IgGs of relapsing PR3-ANCA patients have higher ΔFc-bisection at diagnosis (P = 0.004) and exhibit a decrease in Fc-sialylation prior to the relapse (P = 0.0004), discriminating them from non-relapsing patients. Most importantly, PR3-ANCA patients who experienced an ANCA rise and relapsed shortly thereafter, exhibit lower IgG Fc-fucosylation levels compared to non-relapsing patients already 9 months before relapse (P = 0.02). Discussion Our data indicate that IgG Fc-bisection correlates with long-term treatment outcome, while lower IgG Fc-fucosylation and sialylation associate with impending relapse. Overall, our study replicated the previously published reduction in total IgG Fc-sialylation at the time of relapse, but showed additionally that its onset precedes relapse. Furthermore, our findings on IgG fucosylation and bisection are entirely new. All these IgG Fc-glycosylation features may have the potential to predict a relapse either independently or in combination with known risk factors, such as a rise in ANCA titre.
Collapse
Affiliation(s)
- Iwona Wojcik
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, Netherlands
- Glycoscience Research Laboratory, Genos Ltd., Zagreb, Croatia
| | - Manfred Wuhrer
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Peter Heeringa
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Coen A. Stegeman
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, Netherlands
| | - David Falck
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
28
|
Ghorishi A, Alayon A, Ghaddar T, Kandah M, Amundson PK. MR and CT angiography in the diagnosis of vasculitides. BJR Open 2023; 5:20220020. [PMID: 37953869 PMCID: PMC10636354 DOI: 10.1259/bjro.20220020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 11/14/2023] Open
Abstract
Vasculitides represent the wide-ranging series of complex inflammatory diseases that involve inflammation of blood vessel walls. These conditions are characterized according to the caliber of the predominantly involved vessels. The work-up of vasculitides often includes imaging to narrow a differential diagnosis and guide management. Findings from CT and MR angiography in conjunction with a thorough history and physical exam are of utmost importance in making an accurate diagnosis. Further, imaging can be used for follow-up, in order to monitor disease progression and response to treatment. This wide-ranging literature review serves as the primary resource for clinicians looking to diagnose and monitor the progression of rare vascular inflammatory conditions. This article provides a comprehensive summary of the main findings on imaging related to each of these vasculitides. For each of the named vasculitis conditions, a thorough overview of the diagnostic modalities and their respective findings is described. Many specific hallmarks of pathology are included in this review article.
Collapse
Affiliation(s)
- Alex Ghorishi
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Amaris Alayon
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Tarek Ghaddar
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Maya Kandah
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Per K Amundson
- School of Medicine, Indiana University, Indianapolis, United States
| |
Collapse
|
29
|
Wallace ZS, Stone JH, Fu X, Merkel PA, Miloslavsky EM, Zhang Y, Choi HK, Hyle EP. Development and Validation of a Simulation Model for Treatment to Maintain Remission in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2023; 75:1976-1985. [PMID: 36645017 PMCID: PMC10349892 DOI: 10.1002/acr.25088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 12/08/2022] [Accepted: 01/10/2023] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Fixed and tailored rituximab retreatment strategies to maintain remission in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are associated with tradeoffs. The current study was undertaken to develop a simulation model (AAV-Sim) to project clinical outcomes with these strategies. METHODS We developed the AAV-Sim, a microsimulation model of clinical events among individuals with AAV initiating treatment to maintain remission. Individuals transition between health states of remission or relapse and are at risk for severe infection, end-stage renal disease, or death. We estimated transition rates from published literature, stratified by individual-level characteristics. We performed validation using the mean average percent error (MAPE) and the coefficient of variation of root mean square error (CV-RMSE). In internal validation, we compared model-projected outcomes over 28 months with outcomes observed in the Rituximab versus Azathioprine in ANCA-Associated Vasculitis 2 (MAINRITSAN2) trial, which compared fixed versus tailored retreatment. In external validation, we compared outcomes with fixed rituximab retreatment from the AAV-Sim to outcomes from the MAINRITSAN1 trial and an observational study. RESULTS The AAV-Sim projected outcomes similar to those in the MAINRITSAN2 trial, including minor (AAV-Sim 6.0% fixed versus 7.3% tailored; MAINRITSAN2 6.2% versus 8.6%; MAPE 3% and 15%) and major relapse (AAV-Sim 3.5% versus 5.5%; MAINRITSAN2 3.7% versus 7.4%; MAPE 5% and 26%), severe infection (AAV-Sim 19.4% versus 11.1%; MAINRITSAN2 19.8% versus 10.2%; MAPE 2% and 9%), and relapse-free survival (AAV-Sim 84.8% versus 82.3%; MAINRITSAN2 86% versus 84%; CV-RMSE 2.3% and 2.5%). Similar performance was observed in external validation. CONCLUSION The AAV-Sim projected a range of clinical outcomes for different treatment approaches that were validated against published data. The AAV-Sim has the potential to inform management guidelines and research priorities.
Collapse
Affiliation(s)
- Zachary S. Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - John H. Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Peter A. Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Eli M. Miloslavsky
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - Hyon K. Choi
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - Emily P. Hyle
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA
| |
Collapse
|
30
|
Acharya I, Weisman DS, Smith LW, Arend LJ. Diagnostic dilemma: drug-induced vasculitis versus systemic vasculitis. BMJ Case Rep 2023; 16:e254736. [PMID: 37429646 PMCID: PMC10335510 DOI: 10.1136/bcr-2023-254736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
Drug-induced vasculitis can rarely cause inflammation and necrosis of blood vessel walls of both kidney and lung tissue. Diagnosis is challenging because of the lack of difference between systemic and drug-induced vasculitis in clinical presentation, immunological workup and pathological findings. Tissue biopsy guides diagnosis and treatment. Pathological findings must be correlated with clinical information to arrive at a presumed diagnosis of drug-induced vasculitis. We present a patient with hydralazine-induced antineutrophil cytoplasmic antibodies-positive vasculitis with a pulmonary-renal syndrome manifesting as pauci-immune glomerulonephritis and alveolar haemorrhage.
Collapse
Affiliation(s)
- Indira Acharya
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - David S Weisman
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Lanaya Williams Smith
- Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA
| | - Lois Johanna Arend
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
31
|
Vegting Y, Penne EL, Hilhorst ML, Hoekstra T, Bemelman FJ, Vogt L, Voskuyl AE, Pagnoux C, Houben E. Traditional and disease-related cardiovascular risk factors in ANCA-associated vasculitis: A prospective, two-centre cohort study. Joint Bone Spine 2023; 90:105540. [PMID: 36758893 DOI: 10.1016/j.jbspin.2023.105540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/27/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) has been associated with increased risk of cardiovascular (CV) events. The aim was to assess traditional and disease-related CV risk determinants in a two-centre prospective cohort of AAV patients. METHODS Patients were recruited from centres in the Netherlands and Canada. A comprehensive CV risk assessment was performed at inclusion. Subjects were followed up yearly for 3-5 years until the first CV event, death or end of follow-up. Cox proportional hazards analyses were performed to relate baseline characteristics to the first CV event. RESULTS A total of 144 patients were included (mean age 62 years, female sex 44%, median Framingham risk score 14.3%). Insulin resistance was present in 73% of patients tested at inclusion, independent of concurrent prednisone therapy. After a median follow-up of 2.90 years, 16 patients (11%) experienced a CV event (14 non-fatal and 2 fatal). The incidence of CV events was 5.45 per 100 patient-years. Age, Framingham risk score, HbA1c level, Diabetes Mellitus (DM), and previous CV event were significantly associated with CV events. Other factors, such as sex, impaired renal function, dyslipidemia, hypertension, smoking history and microalbuminuria, or disease-specific variables, like ANCA serotype or disease activity, were not significantly related to CV events in univariable or age-adjusted cox regression analysis. CONCLUSIONS Determinants of an increased CV risk were identified. Disease-related factors and treatments can further modify individual risk factors, such as for steroids causing chronic insulin resistance and DM. Treatment of risk factors is essential to optimize long-term outcomes in AAV patients.
Collapse
Affiliation(s)
- Yosta Vegting
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands; Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands; Amsterdam institute for Infection and Immunity, Inflammatory diseases, Amsterdam, The Netherlands.
| | - Erik L Penne
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Marc L Hilhorst
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands
| | - Tiny Hoekstra
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederike J Bemelman
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Christian Pagnoux
- Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada
| | - Eline Houben
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands; Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
32
|
Merindol J, Levraut M, Seitz-Polski B, Morand L, Martis N. Diagnostic significance of antineutrophil cytoplasmic antibody (ANCA) titres: a retrospective case-control study. RMD Open 2023; 9:rmdopen-2023-003113. [PMID: 37055171 PMCID: PMC10106044 DOI: 10.1136/rmdopen-2023-003113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES To investigate the reliability of elevated titres of antineutrophil cytoplasmic antibody (ANCA) and to identify a cut-off titre in discriminating between ANCA-associated vasculitides (AAV) and its mimickers. METHODS This retrospective observational single-centre study included patients over 18 years with positive myeloperoxidase (MPO)-ANCA and/or proteinase 3 (PR3)-ANCA immunoassays over an 8-year period (January 2010 to December 2018), via their electronic medical files. Patients were classified according to the 2022 ACR/EULAR criteria and alternative diagnoses categorised either as non-AAV autoimmune disorders (ANCA-AI) or disorders without autoimmune features (ANCA-O). Findings from the AAV group were compared with those of ANCA-AI and ANCA-O groups and followed by a multivariate logistic stepwise regression analysis of features associated with AAV. RESULTS 288 ANCA-positive patients of which 49 had AAV were altogether included. There was no difference between patients between the ANCA-AI (n=99) and the ANCA-O (n=140) groups. The AUC for titres discriminating AAV from mimickers was 0.83 (95% CI, 0.79 to 0.87). The best threshold titre, irrespective of PR3-ANCA or MPO-ANCA, was 65 U/mL with a negative predictive value of 0.98 (95% CI, 0.95 to 1.00). On multivariate analysis, an ANCA titre ≥65 U/mL was independently associated with AAV with an OR of 34.21 (95% CI 9.08 to 129.81; p<0.001). Other risk factors were: pulmonary fibrosis (OR, 11.55 (95% CI, 3.87 to 34.47, p<0.001)), typical ear nose and throat involvement (OR, 5.67 (95% CI, 1.64 to 19.67); p=0.006) and proteinuria (OR, 6.56 (95% CI, 2.56 to 16.81; p<0.001)). CONCLUSION High PR3/MPO-ANCA titres can help to discriminate between AAV and their mimickers in patients presenting with small-calibre vasculitides, with a threshold titre of 65 U/mL and above.
Collapse
Affiliation(s)
- Julie Merindol
- Internal Medicine Department, University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
| | - Michael Levraut
- Internal Medicine Department, University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
- URRIS, Unité de Recherche Clinique Côte d'Azur (UR2CA), University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
| | - Barbara Seitz-Polski
- Biological Immunology Department, University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
- ImmunoPredict, Unité de Recherche Clinique Côte d'Azur (UR2CA), University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
| | - Lucas Morand
- Medical Intensive Care Unit, University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
| | - Nihal Martis
- Internal Medicine Department, University Hospital of Nice, Côte d'Azur University, Nice, Provence-Alpes-Côte d'Azur, France
- INSERM U1065 - Control of gene expression (COdEX), Mediterranean Centre for Molecular Medicine, Nice, Provence-Alpes-Côte d'Azur, France
| |
Collapse
|
33
|
Casal Moura M, Deng Z, Brooks SR, Tew W, Fervenza FC, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Prunotto M, Grayson PC, Specks U. Risk of relapse of ANCA-associated vasculitis among patients homozygous for the proteinase 3 gene Val119Ile polymorphism. RMD Open 2023; 9:e002935. [PMID: 36990659 PMCID: PMC10069578 DOI: 10.1136/rmdopen-2022-002935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The frequency of proteinase 3 gene (PRTN3) polymorphisms in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is not fully characterised. We hypothesise that the presence of a PRTN3 gene polymorphism (single nucleotide polymorphism (SNP) rs351111) is relevant for clinical outcomes. METHODS DNA variant calling for SNP rs351111 (chr.19:844020, c.355G>A) in PRTN3 gene assessed the allelic frequency in patients with PR3-AAV included in the Rituximab in ANCA-Associated Vasculitis trial. This was followed by RNA-seq variant calling to characterise the mRNA expression. We compared clinical outcomes between patients homozygous for PRTN3-Ile119 or PRTN3-Val119. RESULTS Whole blood samples for DNA calling were available in 188 patients. 75 patients with PR3-AAV had the allelic variant: 62 heterozygous PRTN3-Val119Ile and 13 homozygous for PRTN3-Ile119. RNA-seq was available for 89 patients and mRNA corresponding to the allelic variant was found in 32 patients with PR3-AAV: 25 heterozygous PRTN3-Val119Ile and 7 homozygous for PRTN3-Ile119. The agreement between the DNA calling results and mRNA expression of the 86 patients analysed by both methods was 100%. We compared the clinical outcomes of 64 patients with PR3-AAV: 51 homozygous for PRTN3-Val119 and 13 homozygous for PRTN3-Ile119. The frequency of severe flares at 18 months in homozygous PRTN3-Ile119 was significantly higher when compared with homozygous PRTN3-Val119 (46.2% vs 19.6%, p=0.048). Multivariate analysis identified homozygous PR3-Ile119 as main predictor of severe relapse (HR 4.67, 95% CI 1.16 to 18.86, p=0.030). CONCLUSION In patients with PR3-AAV, homozygosity for PRTN3-Val119Ile polymorphism appears associated with higher frequency of severe relapse. Further studies are necessary to better understand the association of this observation with the risk of severe relapse.
Collapse
Affiliation(s)
- Marta Casal Moura
- Pulmonary and Critical Care Medicine, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
- Biomedicina, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Zuoming Deng
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Stephen R Brooks
- Office of Science and Technology, Biodata Mining and Discovery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Wei Tew
- ITGR Diagnostics Discovery, Genentech Inc, South San Francisco, California, USA
| | - Fernando C Fervenza
- Nephrology and Hypertension, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
| | - Cees G M Kallenberg
- Rheumatology and Clinical Immunology, University of Groningen, Groningen, The Netherlands
| | - Carol A Langford
- Rheumatic and Immunologic Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul A Monach
- Department of Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Philip Seo
- Rheumatology, Johns Hopkins, Baltimore, Maryland, USA
| | - Robert F Spiera
- Department of Medicine, Hospital for Special Surgery, New York, New York, USA
| | | | - John H Stone
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marco Prunotto
- School of Pharmaceutical Sciences, University of Geneva, Geneve, Switzerland
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Ulrich Specks
- Pulmonary and Critical Care Medicine, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
| |
Collapse
|
34
|
Wang RX, Wang JW, Li ZY, Chen SF, Yu XJ, Wang SX, Zhang F, Xiong ZY, Bi SH, Wang Y, Zhao MH, Chen M. A modified renal risk score for Chinese patients with antineutrophil cytoplasmic antibody-associated vasculitis. BMC Med 2023; 21:45. [PMID: 36755282 PMCID: PMC9909876 DOI: 10.1186/s12916-023-02755-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/26/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The renal risk score (RRS) is a useful tool to predict end-stage renal disease (ESRD) in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The current study aimed to validate the predictive performance of RRS and to further modify this model in Chinese AAV patients. METHODS Two hundred and seventy-two patients diagnosed with AAV confirmed by renal biopsies were retrospectively enrolled from a single center. The RRS was calculated based on 3 categorical variables, i.e., the proportion of normal glomeruli, the proportion of interstitial fibrosis and tubular atrophy (IF/TA), and eGFR at biopsy, classifying these patients into low-, medium-, and high-risk groups. In addition, a modified model was developed based on the RRS and was further validated in another independent cohort of 117 AAV patients. The predictive performance of each model was evaluated according to discrimination and calibration. RESULTS Patients were classified by the RRS into low- (26.5%), medium- (46.7%), and high-risk (26.8%) groups, with 120-month renal survival rates of 93.3%, 57.2%, and 18.4%, respectively (P < 0.001). The RRS showed good discrimination but less satisfactory calibration. Therefore, a modified model with improved discrimination and calibration was developed in Chinese AAV patients, with eGFR, proportion of normal glomeruli (both as continuous variables), and IF/TA (< 25%, 25-50%, > 50%) included. Internal and external validation of the modified model were performed. Finally, an online risk prediction tool was developed based on the modified model. CONCLUSIONS The RRS was an independent predictor of ESRD of AAV patients. The modified model could predict the probability of ESRD for AAV patients with improved performance in Chinese AAV patients.
Collapse
Affiliation(s)
- Rui-Xue Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Jin-Wei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Zhi-Ying Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China.
| | - Su-Fang Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, 100034, China
| | - Fan Zhang
- Renal Division, Department of Medicine, Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Zu-Ying Xiong
- Renal Division, Department of Medicine, Peking University Shenzhen Hospital, Shenzhen, 518036, China.,Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, 518036, China
| | - Shu-Hong Bi
- Division of Nephrology, Peking University Third Hospital, Beijing, 100191, China
| | - Yue Wang
- Division of Nephrology, Peking University Third Hospital, Beijing, 100191, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100034, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| |
Collapse
|
35
|
Acharya P, Sharma D, Kamath S, Shenoy S, Magazine R. Microscopic polyangiitis with an atypical presentation. INDIAN JOURNAL OF RHEUMATOLOGY 2023. [DOI: 10.4103/injr.injr_169_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
|
36
|
Casal Moura M, Specks U, Tehranian S, Sethi S, Zubidat D, Nardelli L, dos Santos FG, Sousa C, León-Róman J, Bobart SA, Greene E, Zand L, Fervenza FC. Maintenance of Remission and Risk of Relapse in Myeloperoxidase-Positive ANCA-Associated Vasculitis with Kidney Involvement. Clin J Am Soc Nephrol 2023; 18:47-59. [PMID: 36526414 PMCID: PMC10101626 DOI: 10.2215/cjn.06460622] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The optimal strategy for remission-maintenance therapy in patients with myeloperoxidase-ANCA (MPO-ANCA)-associated vasculitis is not established. Defining parameters to guide maintenance therapy is required. METHODS This was a retrospective cohort study of all patients with MPO-ANCA-associated vasculitis (microscopic with polyangiitis and granulomatosis with polyangiitis) and GN followed at the Mayo Clinic between 1996 and 2015. Relapse rate, MPO-ANCA status, and remission-maintenance therapies were reviewed. Logistic regression models, Kaplan-Meier method, and Cox proportional hazards regression models were applied. RESULTS We analyzed 159 patients with active MPO-ANCA-associated vasculitis with GN. Sixty-six (42%) patients had at least one relapse, and 52 (33%) relapsed before 60 months. Patients with MPO-ANCA who became persistently negative did not relapse (hazard ratio [HR], 0.03; 95% confidence interval [95% CI], 0.002 to 0.431; P =0.01). The reappearance of MPO-ANCA was associated with a higher risk of relapse (HR, 1.91; 95% CI, 1.109 to 3.293; P =0.02). Immunosuppression was withdrawn in 80 (50%) patients, and this was less likely in those who received cyclophosphamide for remission induction or in patients with persistently positive MPO-ANCA (odds ratio [OR], 0.44; 95% CI, 0.228 to 0.861; P =0.02 and OR, 0.42; 95% CI, 0.213 to 0.820; P =0.01, respectively). Relapse frequency was not different between patients with persistently positive MPO-ANCA and patients with MPO-ANCA reappearance (44% versus 39%, P =0.49), irrespective of remission-maintenance treatment. Ear, nose, and throat involvement (OR, 6.10; 95% CI, 1.280 to 29.010; P =0.02) and MPO-ANCA reappearance (OR, 9.25; 95% CI, 3.126 to 27.361; P <0.001) were independently associated with relapse after treatment withdrawal. CONCLUSIONS Patients persistently MPO-ANCA negative are at low risk for relapse even without remission-maintenance therapy. Persistence or subsequent reappearance of MPO-ANCA is associated with a higher risk of relapse. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast.aspx?p=CJASN&e=2023_01_10_CJN06460622.mp3.
Collapse
Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Departamento de Biomedicina, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shahrzad Tehranian
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Dalia Zubidat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Luca Nardelli
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Fernanda G. dos Santos
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ciria Sousa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Juan León-Róman
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shane A. Bobart
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Nephrology and Hypertension, Cleveland Clinic Florida, Weston, Florida
| | - Eddie Greene
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| |
Collapse
|
37
|
Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
Collapse
Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
| |
Collapse
|
38
|
Alba MA, Jennette JC, Hu Y, Poulton CJ, Blazek L, Derebail VK, Falk RJ, Hogan SL. Relevance of Combined Clinicopathologic Phenotype and Antineutrophil Cytoplasmic Autoantibody Serotype in the Diagnosis of Antineutrophil Cytoplasmic Autoantibody Vasculitis. Kidney Int Rep 2022; 7:2676-2690. [PMID: 36506241 PMCID: PMC9727534 DOI: 10.1016/j.ekir.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), 2 major clinicopathologic variants of antineutrophil cytoplasmic autoantibody (ANCA) vasculitides, are mostly associated with proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, respectively. Less is known regarding the uncommon forms of ANCA vasculitis, PR3-ANCA MPA and MPO-ANCA GPA. Methods In this cohort study we detailed the clinical presentation and outcome of patients with PR3-ANCA MPA and MPO-ANCA GPA from the Glomerular Disease Collaborative Network (GDCN) inception cohort. Baseline clinical manifestations, relapses, end-stage kidney disease (ESKD), and survival were compared within MPA cases by PR3-ANCA (n = 116) versus MPO-ANCA (n = 173) and within GPA cases by PR3-ANCA (n = 108) versus MPO-ANCA (n = 43). Fisher's exact test and Wilcoxon two sample test were used for comparisons. Proportional hazards models were used to evaluate the development of relapses, ESKD, and death. Results Patients with PR3-ANCA MPA were younger (53 years vs. 62 years, P = 0.0007) and had increased prevalence of joint involvement (56% vs. 40%, P = 0.0115) and ear, nose, and throat (ENT) involvement (44% vs. 26%, P = 0.002) than MPO-ANCA MPA. Relapses, ESKD, and survival were similar between both MPA subsets. Within the GPA group, patients with MPO-ANCA GPA were older (61 years vs. 46 years, P = 0.0007) and more likely female (56% vs. 35%, P = 0.027) than PR3-ANCA GPA patients. MPO-ANCA GPA was also characterized by less prevalent ENT manifestations (58% vs. 77%, P = 0.028) and neurologic manifestations (5% vs. 25%, P = 0.0029), and increased ESKD and mortality. Conclusions PR3-ANCA MPA and MPO-ANCA GPA are clinicopathologically distinct subsets of ANCA vasculitis that differ from MPO-ANCA MPA and PR3-ANCA GPA. Although the impact of these differences on the clinical management and outcome warrants further evaluation, these results support the recommendation of including both the phenotypic diagnosis and ANCA serotype in the diagnosis of ANCA vasculitis.
Collapse
Affiliation(s)
- Marco A. Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Blazek
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
39
|
McDermott G, Fu X, Cook C, Ahola C, Doliner B, Hanberg J, Stone JH, Choi HK, Zhang Y, Wallace ZS. The effect of achieving serological remission on subsequent risk of relapse, end-stage renal disease and mortality in ANCA-associated vasculitis: a target trial emulation study. Ann Rheum Dis 2022; 81:1438-1444. [PMID: 35697489 PMCID: PMC9474699 DOI: 10.1136/annrheumdis-2022-222439] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the effect of achieving a negative postinduction antineutrophil cytoplasmic antibody ANCA) assay on the risk of relapse, end-stage renal disease (ESRD) and death in ANCA-associated vasculitis (AAV). METHODS We emulated a target trial using observational data from the Mass General Brigham AAV cohort comparing patients who achieved versus did not achieve serological remission (negative ANCA assay) within 180 days of induction. Outcomes were relapse, ESRD or death within 5 years, obtained from medical records, the US Renal Data System and the National Death Index. We placed a 'clone' of each patient in both trial arms, censored those deviating from their assigned protocol and weighted each by the inverse probability of censoring. Outcomes were assessed by pooled logistic regression. RESULTS The study included 506 patients with AAV. The mean age was 61 years (SD 18) and the majority were women (58%), white (87%), myeloperoxidase-ANCA+ (72%) and had renal involvement (68%). Rituximab (59%) or cyclophosphamide (33%) was most often used for induction treatment. Within 5 years, 81 (16%) died, 51 (10%) had ESRD and 64 (13%) had relapse. Patients treated to a negative ANCA assay within 180 days had HR 0.55 (95% CI 0.38 to 0.81) for relapse and HR 0.87 (95% CI 0.61 to 1.25) for the composite of ESRD or death within 5 years. CONCLUSIONS In this emulated target trial from a large AAV cohort, achieving serological remission within 180 days of induction was associated with lower risk of relapse, but no statistically significant difference in ESRD or mortality outcomes.
Collapse
Affiliation(s)
- Gregory McDermott
- Department of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Claire Cook
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catherine Ahola
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brett Doliner
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer Hanberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hyon K Choi
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuqing Zhang
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
40
|
Trivioli G, Marquez A, Martorana D, Tesi M, Kronbichler A, Lyons PA, Vaglio A. Genetics of ANCA-associated vasculitis: role in pathogenesis, classification and management. Nat Rev Rheumatol 2022; 18:559-574. [PMID: 36109667 DOI: 10.1038/s41584-022-00819-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 12/15/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) comprises granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), that share features of pauci-immune small-vessel vasculitis and the positivity of ANCA targeting proteinase-3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). AAV syndromes are rare, complex diseases and their aetio-pathogenesis is mainly driven by the interaction between environmental and genetic factors. In patients with GPA and MPA, the genetic associations are stronger with ANCA specificity (PR3- versus MPO-ANCA) than with the clinical diagnosis, which, in keeping with the known clinical and prognostic differences between PR3-ANCA-positive and MPO-ANCA-positive patients, supports an ANCA-based re-classification of these disorders. EGPA is also made up of genetically distinct subsets, which can be stratified on ANCA-status (MPO ANCA-positive versus ANCA-negative); these subsets differ in clinical phenotype and possibly in their response to treatment. Interestingly, MPO-ANCA-positive patients with either MPA or EGPA have overlapping genetic determinants, thus strengthening the concept that this EGPA subset is closely related to the other AAV syndromes. The genetics of AAV provides us with essential information to understand its varied phenotype. This Review discusses the main findings of genetic association studies in AAV, their pathogenic implications and their potential effect on classification, management and prognosis.
Collapse
Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Ana Marquez
- Institute of Parasitology and Biomedicine "López-Neyra", CSIC, Granada, Spain
| | - Davide Martorana
- Medical Genetics Unit, Department of Diagnostics, University Hospital of Parma, Parma, Italy
- CoreLab Unit, Research Center, University Hospital of Parma, Parma, Italy
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Vasculitis and Lupus Service, Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.
| |
Collapse
|
41
|
Association between renal-limited vasculitis and relapse of antineutrophil cytoplasmic antibody-associated vasculitis: A single-center retrospective cohort study in Japan. PLoS One 2022; 17:e0274483. [PMID: 36174007 PMCID: PMC9522015 DOI: 10.1371/journal.pone.0274483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background Several previous studies have evaluated the predictors of relapse in antineutrophil cytoplasmic antibody-associated vasculitis. Nonetheless, the association between renal-limited vasculitis and relapse has not been evaluated. Objective To assess the association between renal-limited vasculitis and the incidence of relapse in Japan among patients with microscopic polyangiitis/renal-limited vasculitis. Methods This retrospective cohort study included consecutive patients in remission at 6 months, with renal-limited vasculitis (n = 24, renal-limited vasculitis group) and microscopic polyangiitis with renal and extra-renal involvement (n = 56, non-renal-limited vasculitis group) between 2004 and 2020. Results During the median follow-up period of 35 (range, 15‒57) months, 28 (35.0%) patients had a relapse. Multivariable Cox proportional hazards models revealed that the lower estimated glomerular filtration rate (per -10 mL/min/1.73 m2; adjusted hazard ratio = 0.87, 95% confidence interval: 0.76–0.99; P = 0.043), renal-limited vasculitis (adjusted hazard ratio = 0.23, 95% confidence interval: 0.08–0.68; P = 0.008), and glucocorticoid combined with intravenous cyclophosphamide or rituximab (adjusted HR = 0.32, 95% CI: 0.11–0.96; P = 0.042) were associated with a decreased risk of relapse. Glucocorticoid dose during the observation period was lower in the renal-limited vasculitis group than in the non-renal-limited vasculitis group. Conclusions Renal-limited vasculitis was associated with a lower risk of relapse than non-renal-limited vasculitis. Our data may contribute to the development of optimal management for renal-limited vasculitis, which may assist in minimizing the adverse effects of immunosuppressive therapy.
Collapse
|
42
|
Samoreau C, Piccoli GB, Martin C, Gatault P, Vinatier E, Bridoux F, Riou J, Desouche A, Jourdain P, Coindre JP, Wacrenier S, Guibert F, Henry N, Blanchet O, Croué A, Djema A, Pouteau LM, Copin MC, Beauvillain C, Subra JF, Augusto JF, Brilland B. Association between kinetic of Anti-Neutrophil Cytoplasmic Antibody (ANCA), renal survival and relapse risk in ANCA-glomerulonephritis. Nephrol Dial Transplant 2022; 38:1192-1203. [PMID: 36043422 DOI: 10.1093/ndt/gfac240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasmic antibody (ANCA) kinetic in ANCA-associated vasculitis with glomerulonephritis (AAV-GN) has been suggested to be associated with AAV relapse. Few studies focused on its association with renal prognosis. Thus, we aimed to investigate the relationship between i) ANCA specificity and evolutive profile, and ii) renal outcomes. METHODS This multicentric retrospective study included patients diagnosed with ANCA-GN since 01/01/2000. Patients without ANCA at diagnosis and with fewer than 3 ANCA determinations during follow-up were excluded. We analyzed eGFR variation, renal-free and relapse-free survival according to three ANCA profiles (negative, recurrent, persistent) and to ANCA specificity (MPO or PR3). RESULTS Over a follow-up of 56 [34-101] months, a median of 19 [13-25] ANCA determinations were performed for the 134 included patients. Patients with a recurrent/persistent ANCA profile had a lower relapse-free (p = 0.019) survival and tended to have a lower renal survival (p = 0.053) compared to those with negative ANCA profile. Patients with a recurrent/persistent MPO-ANCA profile had the shortest renal survival (p = 0.015) and those with recurrent/persistent PR3-ANCA profile had the worst relapse-free survival (p = 0.013) compared to other profiles. The negative ANCA profile was associated with a greater eGFR recovery. In multivariate regression analysis, it was an independent predictor of a two-fold increase of eGFR at 2-year (OR = 6.79, 95% CI [1.78, 31.4], p = 0.008). CONCLUSION ANCA kinetic after ANCA-GN diagnosis is associated with outcomes. MPO-ANCA recurrence/persistence identifies patients with a lower potential of renal recovery and a higher risk of kidney failure, while PR3-ANCA recurrence/persistence identifies patients with a greater relapse risk. Thus, ANCA kinetic may help identify patients with a smoldering disease.
Collapse
Affiliation(s)
- Clément Samoreau
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | | | - Cécile Martin
- Service de Néphrologie-Dialyse-Transplantation, CHU de Poitiers, Poitiers, France
| | - Philippe Gatault
- Service de Néphrologie-Dialyse-Transplantation, CHU de Tours, Tours, France
| | - Emeline Vinatier
- Laboratoire d'Immunologie et Allergologie, CHU Angers, Angers, France.,Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Frank Bridoux
- Service de Néphrologie-Dialyse-Transplantation, CHU de Poitiers, Poitiers, France
| | - Jérémie Riou
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, CHU Angers, Angers, France
| | - Alice Desouche
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Pierre Jourdain
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | | | - Samuel Wacrenier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, Centre Hospitalier du Mans, Le Mans, France
| | - Fanny Guibert
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, Centre Hospitalier de Cholet, Cholet, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, Centre Hospitalier de Laval, Laval, France
| | - Odile Blanchet
- Centre de Ressources Biologiques, BB-0033-00038, CHU Angers, Angers, France
| | - Anne Croué
- Département de pathologie cellulaire et tissulaire, Université d'Angers, CHU Angers, Angers, France
| | - Assia Djema
- Service de Néphrologie-Dialyse, Centre Hospitalier de Cholet, Cholet, France
| | - Lise-Marie Pouteau
- Service de Néphrologie-Dialyse, Centre Hospitalier de Cholet, Cholet, France
| | - Marie-Christine Copin
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France.,Département de pathologie cellulaire et tissulaire, Université d'Angers, CHU Angers, Angers, France
| | - Céline Beauvillain
- Laboratoire d'Immunologie et Allergologie, CHU Angers, Angers, France.,Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Jean-François Subra
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| |
Collapse
|
43
|
Thayakaran R, Goel R, Adderley NJ, Chandan JS, Zemedikun D, Nirantharakumar K, Harper L. Cluster analysis of patients with granulomatosis with polyangiitis (GPA) based on clinical presentation symptoms: a UK population-based cohort study. Arthritis Res Ther 2022; 24:201. [PMID: 35986399 PMCID: PMC9389785 DOI: 10.1186/s13075-022-02885-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 07/26/2022] [Indexed: 11/29/2022] Open
Abstract
Background Granulomatosis with polyangiitis (GPA) is small vessel vasculitis with heterogeneous clinical presentation. In the present population-based cohort study, we classified patients with GPA based on clinical features at presentation using an unsupervised clustering approach and compared their mortality, infections and frequency of comorbidities. Methods In this open cohort study, de-identified primary care data of patients with GPA included in the IQVIA Medical Research Data database between 1 January 1995 and 25 September 2019 was analysed retrospectively. Latent class analysis was performed to create symptom clusters of patients based on 16 categories of symptoms representing various organ involvement. All-cause mortality of resultant clusters was compared after adjusting for age, sex, Townsend deprivation quintile and smoking status at index date using extended Cox proportional hazards models. Prescription of antibiotics, considered as an indirect indicator of recurrent bacterial infection, was compared using a recurrent event model, after adjusting for quarterly use of steroid as a time-dependent covariate. Cumulative frequencies of common comorbidities were compared among the clusters at index visit, 1-year and 3-year follow-up. Results Altogether, 649 patients with GPA [median age 60.0 (IQR: 49.6–70.1)] were included. Three clusters were identified: patients with limited disease mainly with involvement of ENT and cough were classified into cluster 1 (n = 426); cluster 2 had generalised non-renal disease (n = 176); while patients in cluster 3 had renal-predominant disease (n = 47). Many patients in cluster 1 developed generalised disease at the end of 1 year. Mortality in clusters 2 and 3 was higher compared with cluster 1. Mortality in cluster 1 itself was 68% higher than the general population without GPA. The duration of antibiotics prescription and frequency of coexisting medical illnesses was also higher in clusters 2 and 3. Conclusions In a primary care setting, patients with GPA can be classified into three distinct clusters with different prognosis, susceptibility to recurrent infections and presence of comorbidities. The tendency of cluster 1 to evolve into a more generalised disease raises questions about current immunosuppressive treatment approaches in these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02885-9.
Collapse
|
44
|
He X, Wen Y, Hu R, Wu H, Ye W, Yue C, Qin Y, Xia P, Chen L. Interstitial nephritis without glomerulonephritis in ANCA-associated vasculitis: a case series and literature review. Clin Rheumatol 2022; 41:3551-3563. [PMID: 35759125 PMCID: PMC9568481 DOI: 10.1007/s10067-022-06264-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
The typical nephrological presentation of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is rapidly progressive glomerulonephritis. AAV-associated interstitial nephritis without apparent glomerular lesions was rare. We reported three local cases of AAV-associated interstitial nephritis without glomerulonephritis confirmed by renal biopsy. Then, a literature search was conducted in PubMed using free text words and MeSH terms related to "AAV and interstitial nephritis". Fifteen cases were included, and their demographics, clinical manifestations, laboratory data, renal pathological features, and treatment response were summarized. AAV-associated interstitial nephritis usually affects elderly patients. The common symptoms include fever, arthralgias, and edema. These patients were mostly MPO-ANCA positive. Pathological lesions in the kidney showed diffuse infiltration of inflammatory cells, edema, tubulitis, and fibrosis in the interstitial area. Various immunosuppressive treatments, including glucocorticoids, immunosuppressants, and rituximab, were used, and most of the patients achieved clinical remission. AAV-associated interstitial nephritis is rare but shows a characteristic clinical phenotype, serological results, and pathogenic lesions. Immunosuppressive therapy showed good efficacy in these patients.
Collapse
Affiliation(s)
- Xuxia He
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yubing Wen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Rongrong Hu
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Haiting Wu
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Wei Ye
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Cai Yue
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
45
|
Scott J, Havyarimana E, Navarro-Gallinad A, White A, Wyse J, van Geffen J, van Weele M, Buettner A, Wanigasekera T, Walsh C, Aslett L, Kelleher JD, Power J, Ng J, O'Sullivan D, Hederman L, Basu N, Little MA, Zgaga L. The association between ambient UVB dose and ANCA-associated vasculitis relapse and onset. Arthritis Res Ther 2022; 24:147. [PMID: 35717248 PMCID: PMC9206351 DOI: 10.1186/s13075-022-02834-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 06/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background The aetiology of ANCA-associated vasculitis (AAV) and triggers of relapse are poorly understood. Vitamin D (vitD) is an important immunomodulator, potentially responsible for the observed latitudinal differences between granulomatous and non-granulomatous AAV phenotypes. A narrow ultraviolet B spectrum induces vitD synthesis (vitD-UVB) via the skin. We hypothesised that prolonged periods of low ambient UVB (and by extension vitD deficiency) are associated with the granulomatous form of the disease and an increased risk of AAV relapse. Methods Patients with AAV recruited to the Irish Rare Kidney Disease (RKD) (n = 439) and UKIVAS (n = 1961) registries were studied. Exposure variables comprised latitude and measures of ambient vitD-UVB, including cumulative weighted UVB dose (CW-D-UVB), a well-validated vitD proxy. An n-of-1 study design was used to examine the relapse risk using only the RKD dataset. Multi-level models and logistic regression were used to examine the effect of predictors on AAV relapse risk, phenotype and serotype. Results Residential latitude was positively correlated (OR 1.41, 95% CI 1.14–1.74, p = 0.002) and average vitD-UVB negatively correlated (0.82, 0.70–0.99, p = 0.04) with relapse risk, with a stronger effect when restricting to winter measurements (0.71, 0.57–0.89, p = 0.002). However, these associations were not restricted to granulomatous phenotypes. We observed no clear relationship between latitude, vitD-UVB or CW-D-UVB and AAV phenotype or serotype. Conclusion Our findings suggest that low winter ambient UVB and prolonged vitD status contribute to AAV relapse risk across all phenotypes. However, the development of a granulomatous phenotype does not appear to be directly vitD-mediated. Further research is needed to determine whether sufficient vitD status would reduce relapse propensity in AAV. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02834-6.
Collapse
Affiliation(s)
- Jennifer Scott
- Trinity Health Kidney Centre, Trinity College Dublin, The University of Dublin, Trinity Translational Medicine Institute, St. James's Street, Dublin 8, Ireland
| | - Enock Havyarimana
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Arthur White
- Department of Statistics, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Jason Wyse
- Department of Statistics, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Jos van Geffen
- Royal Netherlands Meteorological Institute (KNMI), De Bilt, The Netherlands
| | - Michiel van Weele
- Royal Netherlands Meteorological Institute (KNMI), De Bilt, The Netherlands
| | - Antonia Buettner
- Trinity Health Kidney Centre, Trinity College Dublin, The University of Dublin, Trinity Translational Medicine Institute, St. James's Street, Dublin 8, Ireland
| | - Tamara Wanigasekera
- Trinity Health Kidney Centre, Trinity College Dublin, The University of Dublin, Trinity Translational Medicine Institute, St. James's Street, Dublin 8, Ireland
| | - Cathal Walsh
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Louis Aslett
- Department of Mathematical Science, University of Durham, Durham, UK
| | - John D Kelleher
- School of Computer Science, Technological University Dublin, Dublin, Ireland
| | - Julie Power
- Vasculitis Ireland Awareness, Galway, Ireland
| | - James Ng
- Department of Statistics, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Declan O'Sullivan
- ADAPT Centre for Digital Content, Trinity College Dublin, Dublin, Ireland
| | - Lucy Hederman
- ADAPT Centre for Digital Content, Trinity College Dublin, Dublin, Ireland
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, The University of Dublin, Trinity Translational Medicine Institute, St. James's Street, Dublin 8, Ireland. .,ADAPT Centre for Digital Content, Trinity College Dublin, Dublin, Ireland.
| | - Lina Zgaga
- Department of Public Health and Primary Care, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | | |
Collapse
|
46
|
Petrou D, Karagiannis M, Nikolopoulos P, Liapis G, Lionaki S. MPO-ANCA-Positive Granulomatosis with Polyangiitis with Rapidly Progressive Glomerulonephritis and Saddle-Nose Deformity: A Case Report. Antibodies (Basel) 2022; 11:33. [PMID: 35645206 PMCID: PMC9149920 DOI: 10.3390/antib11020033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/25/2022] [Accepted: 05/01/2022] [Indexed: 12/04/2022] Open
Abstract
Early diagnosis and initiation of appropriate immunosuppressive treatment remain the cornerstone of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis at the cost of significant toxicity. In this report, we present a case of a 69-year-old female who presented with advanced renal insufficiency and evidence of pulmonary hemorrhage and was MPO-ANCA-positive with a clinical phenotype of granulomatosis with polyangiitis. Organ involvement included rapidly progressive glomerulonephritis (GN), along with extrarenal manifestations (skin, upper and lower respiratory system involvement, and onset of saddle-nose deformity). Kidney biopsy established the diagnosis of pauci-immune crescentic, sclerotic GN. She received therapy with glucocorticoids and cyclophosphamide, mainly due to life-threatening extra-renal manifestations, such as pulmonary hemorrhage. She avoided vasculitis-related death but she developed severe therapy-related toxicity, resulting in the discontinuation of immunosuppressive therapy. Continuous re-evaluation of patients with ANCA-associated vasculitis in terms of response to immunosuppressive therapy and treatment-related toxicity is crucial for their management.
Collapse
Affiliation(s)
- Dimitra Petrou
- Department of Nephrology, National and Kapodistrian University of Athens, Attikon Hospital, 12462 Athens, Greece; (D.P.); (M.K.); (P.N.)
| | - Minas Karagiannis
- Department of Nephrology, National and Kapodistrian University of Athens, Attikon Hospital, 12462 Athens, Greece; (D.P.); (M.K.); (P.N.)
| | - Petros Nikolopoulos
- Department of Nephrology, National and Kapodistrian University of Athens, Attikon Hospital, 12462 Athens, Greece; (D.P.); (M.K.); (P.N.)
| | - George Liapis
- Department of Pathology, National and Kapodistrian University of Athens, Laiko Hospital, 11527 Athens, Greece;
| | - Sophia Lionaki
- Department of Nephrology, National and Kapodistrian University of Athens, Attikon Hospital, 12462 Athens, Greece; (D.P.); (M.K.); (P.N.)
| |
Collapse
|
47
|
Massicotte-Azarniouch D, Herrera CA, Jennette JC, Falk RJ, Free ME. Mechanisms of vascular damage in ANCA vasculitis. Semin Immunopathol 2022; 44:325-345. [PMID: 35254509 PMCID: PMC9064952 DOI: 10.1007/s00281-022-00920-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
The discovery of anti-neutrophil cytoplasmic antibodies (ANCA) and their antigenic targets, myeloperoxidase (MPO) and proteinase 3 (PR3), has led to further understanding as to the pathophysiologic processes that underlie vascular and tissue damage in ANCA vasculitis. ANCA trigger neutrophil activation leading to vascular damage in ANCA vasculitis. However, decades of study have determined that neutrophil activation alone is not sufficient to cause disease. Inflammatory stimuli are drivers of ANCA autoantigen expression and ANCA production. Certain infections or bacterial peptides may be crucial players in the initial steps of ANCA immunopathogenesis. Genetic and epigenetic alterations of gene encoding for MPO and PR3 provide additional disturbances to the immune homeostasis which provide a substrate for pathogenic ANCA formation from an adaptive immune system predisposed to autoreactivity. Promoted by inflammatory cytokines, ANCA binding leads to neutrophil activation, a process characterized by conformational changes, production and release of cytotoxic substances, and alternative complement pathway activation, thus creating an intense inflammatory milieu. This cascade of events perpetuates a vicious cycle of further inflammatory cell recruitment and activation, culminating in tissue necrosis. Our understanding of the pathogenic process in ANCA vasculitis paves the way for the development of therapies targeting crucial steps in this process. The greater appreciation of the role for complement, monocytes, and the adaptive immune system has already led to novel complement blockers and is poised to lead to further innovations which will allow for tailored antigen- or cell-specific immunotherapy targeting the autoimmune process without exposure to undue risks or toxicities.
Collapse
Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Carolina A Herrera
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Meghan E Free
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| |
Collapse
|
48
|
Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
Collapse
Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | |
Collapse
|
49
|
Tampe D, Hakroush S, Biggemann L, Winkler MS, Tampe B. Kinetics of human leukocyte antigen receptor HLA-DR + monocytes and T lymphocytes during remission induction therapy in ANCA-associated vasculitis. J Nephrol 2022; 35:1283-1287. [PMID: 35445945 PMCID: PMC9107415 DOI: 10.1007/s40620-022-01330-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/03/2022] [Indexed: 01/07/2023]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is characterized by small vessel inflammation and the presence of autoantibodies against cytoplasmic proteases, most often proteinase-3 and myeloperoxidase. Peripheral blood monocytes are an important source of local macrophage accumulation within parenchymal organs, as evidenced by their presence in early lesions in ANCA-associated glomerulonephritis. Major histocompatibility complex (MHC) II cell surface receptor human leukocyte antigen receptor (HLA-DR) allows antigen presentation to T cells and is crucial for the initiation of an immune response. We herein report HLA-DR abundance in AAV and the kinetics of HLA-DR+ monocytes and T lymphocytes during remission induction therapy in AAV. Life-threatening AAV with pulmonary hemorrhage and renal involvement was associated with the presence of HLA-DR in a considerable population of peripheral blood monocytes and T lymphocytes, and relapsing disease manifested despite persistent B cell depletion after remission induction with rituximab. Moreover, remission induction in AAV with steroids, plasma exchange and intravenous cyclophosphamide, and improvement of clinical symptoms were associated with a decrease in HLA-DR+ differing between monocytes and T lymphocytes. Particularly, persistent suppression of HLA-DR+ monocytes was observed during remission induction, while an initial decrease in HLA-DR+ T lymphocytes was followed by recovery of this population during the further course. Detailed insights into HLA-DR kinetics could pave the way towards an increased understanding of immunopathology and identify patients that could mostly benefit from distinct remission induction regimens.
Collapse
Affiliation(s)
- Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Samy Hakroush
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Lorenz Biggemann
- Institute of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Martin Sebastian Winkler
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany.
| |
Collapse
|
50
|
Walker BS, Peterson LK, Koening C, White SK, Schmidt RL, Tebo AE. Performance of MPO-ANCA and PR3-ANCA immunoassays for the stratification of specific ANCA-associated vasculitis: A systematic review and meta-analysis. Autoimmun Rev 2022; 21:103100. [PMID: 35452854 DOI: 10.1016/j.autrev.2022.103100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the impact of myeloperoxidase (MPO) and proteinase 3 (PR3) antigen-specific immunoassays in the stratification of patients at-risk for anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) at diagnosis. METHODS A Medline search was conducted to identify diagnostic accuracy studies using PR3-ANCA or MPO-ANCA for the evaluation of granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Studies estimates were pooled using the bivariate method. RESULTS Diagnostic accuracy varied by analyte and AAV subtype. PR3-ANCA had greater sensitivity than MPO-ANCA for GPA (74% vs 11%, p < 0.001) and MPO-ANCA greater sensitivity for MPA (73% vs 7%, p < 0.001). Specificities of both MPO-ANCA and PR3-ANCA were consistently high (mean 97%, range: 93-99%) for both AAV subtypes. There was insufficient data to perform meta-analysis for the diagnostic accuracy of EPGA. CONCLUSION These results validate the use of high quality MPO-ANCA and PR3-ANCA immunoassays to screen patients at-risk for AAV as well as to categorize disease as GPA or MPA subtype. However, caution must be exercised in doing so, since some assays may not have optimal performance. Each laboratory should validate appropriate algorithms based on the tests used and testing population.
Collapse
Affiliation(s)
| | - Lisa K Peterson
- ARUP Laboratories, Salt Lake City, UT, United States of America; Department of Pathology, University of Utah, Salt Lake City, UT, United States of America
| | - Curry Koening
- Department of Internal Medicine, Division of Rheumatology, University of Utah, Salt Lake City, UT, United States of America
| | - Sandra K White
- Department of Pathology, University of Utah, Salt Lake City, UT, United States of America
| | - Robert L Schmidt
- ARUP Laboratories, Salt Lake City, UT, United States of America; Department of Pathology, University of Utah, Salt Lake City, UT, United States of America
| | - Anne E Tebo
- ARUP Laboratories, Salt Lake City, UT, United States of America; Department of Pathology, University of Utah, Salt Lake City, UT, United States of America.
| |
Collapse
|