Liver involvement in ANCA-associated vasculitis

Effect of Mild or Moderate Hepatic Impairment on the Pharmacokinetics of Avacopan, a Small-Molecule Complement C5a Receptor Antagonist, for the Treatment of Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis

Avacopan is currently approved in several regions of the world as an oral treatment in combination with standard therapy, including glucocorticoids, for adult patients with severe active antineutrophil cytoplasmic autoantibody-associated vasculitis. In vitro and clinical studies have established that avacopan is primarily eliminated through cytochrome P450 3A4 metabolism. This Phase 1, open-label, single-dose study (ClinicalTrials.gov identifier: NCT06004934) was conducted to evaluate the effect of mild (n = 8) or moderate (n = 8) hepatic impairment compared with normal hepatic function (n = 8) on the pharmacokinetics, safety, and tolerability of a single oral dose of 30 mg of avacopan in patients without active antineutrophil cytoplasmic autoantibody-associated vasculitis. Relative to participants with normal hepatic function, in participants with mild or moderate hepatic impairment, the avacopan area under the plasma concentration-time curve from time 0 to infinity geometric mean ratios (90% confidence intervals) were 1.3 (0.9-2.0) and 1.1 (0.6-2.0), respectively, and the avacopan maximum plasma concentration geometric mean ratios (90% CIs) were 1.0 (0.8-1.3) and 0.8 (0.6-1.1), respectively. The geometric mean ratios of metabolite M1 also revealed no pharmacokinetically relevant increase in the peak exposure of M1 in participants with mild or moderate hepatic impairment. Thus, no avacopan dosage adjustment is necessary for patients with mild or moderate hepatic impairment.

Case Report: Case report: An unusual presentation of granulomatosis with polyangiitis

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Hepatic steatosis index at diagnosis has the potential for forecasting end-stage kidney disease in patients with antineutrophil cytoplasmic antibody-associated vasculitis

Objective

This study evaluated whether the hepatic steatosis index (HSI) at antineutrophil cytoplasmic antibody-associated vasculitis (AAV) diagnosis could forecast poor outcomes during the disease course in AAV patients.

Methods

This study included 260 AAV patients. The equation for HSI is as follows HSI=8×(alanine aminotransferase/aspartate aminotransferase)+body mass index+(2, diabetes mellitus)+(2, female). The cut-off of HSI was obtained using the receiver operating characteristic curve.

Results

The median age of the 260 patients was 59.5 years, and 65.0% were female. Among the continuous variables excluding the parameters composing the equation for HSI, HSI was significantly correlated with Birmingham vasculitis activity score, five-factor score, haemoglobin, blood urea nitrogen, serum creatinine, and total cholesterol. Among poor outcomes, the area under the curve of HSI for end-stage renal disease (ESRD) was significant, and the cut-off of HSI for ESRD was set at ≤30.82. AAV patients with HSI ≤30.82 exhibited a significantly higher risk of ESRD (relative risk 3.489) and a significantly lower cumulative ESRD-free survival rate than those with HSI >30.82.

Conclusion

This study is the first to demonstrate that HSI at AAV diagnosis could forecast ESRD during the disease course in AAV patients.

ANCA-associated refractory vasculitis with multiple systemic involvement: A rare case report

We report the case of a 65 year old female patient, presenting with a combination of bilateral hearing loss, otalgia, and hyperacusis. Pure tone audiometry revealed mixed bilateral hearing loss. Conventional cranial imaging tests failed to show a significant brain pathology, but fat-suppressed T1-weighted gadolinium-enhanced magnetic resonance imaging scan displayed a diffuse infiltrative skull base process, extending from the nasopharynx to the jugular fossa, and encasing the internal carotid artery. The latter findings, besides elevated inflammatory markers and a positive perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) led to the diagnosis of ANCA-associated vasculitis. Additional disease manifestations sequentially appeared, including a right peripheral nerve palsy, aortitis, hepatitis, peripheral neuropathy, and uveitis. Therapy with corticosteroids, azathioprine, and then cyclophosphamide brought no evident benefit, but rituximab led to impressive clinical and radiologic improvement.

Long-Term Prognostic Factors in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A 15-Year Multicenter Retrospective Study

Background

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a multisystem autoimmune disease with small-vessel involvement. In AAV, microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are major clinicopathologic variants. In addition, myeloperoxidase (MPO) and proteinase 3 (PR3) are major target antigens. The objective of the study was to explore the predictive factors for long-term survival in AAV patients.

Materials and Methods

A multicenter retrospective study was carried out on 407 patients between 2005 and 2020. Clinical parameters were obtained from laboratory tests including the ANCA types, antinuclear antibody (ANA), extractable nuclear antigen (ENA), anti-streptolysin O (ASO), glomerular filtration rate (GFR), and the laboratory examinations for the blood routine, liver function, renal function, and immunity, etc. The data for clinical parameters were collected from electronic medical records (EMRs), and the data for patient survival were acquired through regular follow-up. The association of clinical parameters with overall survival (OS) along with 3-year and 5-year survival rates was analyzed, and the nomogram as a predictive model was established according to the analysis results.

Results

In the present study, 336 (82.6%) patients and 46 (11.3%) patients were diagnosed with MPA and GPA, respectively. The mean and median OS for all the patients were 2,285 and 2,290 days, respectively. The 1-year, 3-year, 5-year, and 10-year cumulative survival rates for all the patients were 84.2%, 76.3%, 57.2%, and 32.4%, respectively. Univariate and multivariate survival analyses indicated that the independent prognostic factors included age, pathological categories (MPA, GPA, and other types), serum ANCA types (negative or positive for MPO and/or PR3), ANA, ASO, GFR, lymphocyte, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP), and these clinical parameters except for ASO were used to construct a nomogram. The nomogram for 3-year and 5-year survival rates had a C-index of 0.721 (95% CI 0.676–0.766). The calibration curves showed that the predicted values of the nomogram for 3-year and 5-year survival rates were generally consistent with practical observed values, and decision curve analysis (DCA) further demonstrated the practicability and accuracy of the predictive model.

Conclusion

Laboratory tests at diagnosis have great significance in the prediction of long-term survival in AAV patients.

Fatty Liver Index Independently Predicts All-Cause Mortality in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis but No Substantial Liver Disease

Background

This study investigated whether the fatty liver index (FLI) could predict all-cause mortality and cerebrovascular accident (CVA) during follow-up in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) without substantial liver disease.

Methods

The medical records of 75 AAV patients with AAV were retrospectively reviewed. An equation for the FLI is as follows: FLI = (e0.953×loge(triglycerides)+0.139×BMI+0.718×loge(GGT)+0.053×waistcircumference–15.745)/(1 + e0.953×loge(triglycerides)+0.139×BMI+0.718×loge(GGT)+0.053×waistcircumference–15.745) × 100. The cut-offs of the FLI were obtained using the receiver operator characteristic (ROC) curve analysis.

Results

The mean age at AAV diagnosis was 59.1 years and 42.7% were male. Eight patients (10.7%) died and 8 patients had CVA during follow-up. When the cut-offs of the FLI for all-cause mortality and CVA were set as the FLI ≥ 33.59 and the FLI ≥ 32.31, AAV patients with the FLI over each cut-off exhibited a higher risk for all-cause mortality or CVA than those without (RR 8.633 and 8.129), respectively. In addition, AAV patients with the FLI over each cut-off exhibited a significantly lower cumulative patients’ survival rate or CVA-free survival rate than those without, respectively. In the multivariable Cox analysis, only the FLI ≥ 33.59 at AAV diagnosis was an independent predictor of all-cause mortality during follow-up in AAV patients (HR 10.448).

Conclusion

The FLI at AAV diagnosis can be a potential independent predictor of all-cause mortality and CVA during follow-up in AAV patients. We suggest that physicians measure the FLI at AAV diagnosis and pay more attention to those with a high FLI value for prevention of future mortality and CVA.

Long-term Risk of Heart Failure and Other Adverse Cardiovascular Outcomes in Granulomatosis With Polyangiitis: a Nationwide Cohort Study

OBJECTIVE

To examine the long-term rates of heart failure and other adverse cardiovascular outcomes in a nationwide cohort of patients diagnosed with granulomatosis with polyangiitis (GPA) compared with the background population.

METHODS

Using Danish nationwide registries, patients with first-time diagnosed GPA were identified and matched 1:4 by age, sex, and comorbidities with subjects from background population. Outcomes were compared using Cox regression. Due to violation of the proportional hazard assumption, landmark analyses for the first year and from one year were performed.

RESULTS

Of the 1,923 patients with GPA, 1,781 patients (median age 59 years, 47.9% men) were matched with 7,124 subjects from the background population. The median follow-up was 6.4 years. The absolute 10-year risk of HF was 6.8% (95%CI, 5.5-8.2%) for GPA patients and 5.9% (5.3-6.6%) for the background population. During the first year after diagnosis, GPA was associated with a significantly higher rate of HF (HR 3.60 [95%CI, 2.28-5.67]) and other adverse outcomes, including atrial fibrillation/flutter (HR 6.50 [4.43-9.55]) and ischemic stroke (HR 3.24 [1.92-5.48]), compared with the background population. After the first year, GPA was not associated with higher rates of HF or other cardiovascular outcomes than the background population, except atrial fibrillation/flutter (HR 1.38 [1.12-1.70]).

CONCLUSION

During the first year after diagnosis, the rates of HF and other cardiovascular outcomes were higher in patients with GPA compared with the background population. However, after the first year, the rates of HF and other cardiovascular outcomes, except atrial fibrillation/flutter, were similar to those in the background population.

The novel fibrosis index at diagnosis may predict all-cause mortality in patients with antineutrophil cytoplasmic antibody-associated vasculitis without substantial liver diseases

OBJECTIVES

Antineutrophil cyto plasmic antibody-associated vasculitis (AAV) is a fatal disease. Currently, predictors of mortality due to AAV are based on the distribution of organ involvement. The novel fibrosis index (NFI) is an index composed of laboratory results that reflect the degree of liver fibrosis. This study aimed to evaluate whether NFI can predict poor outcomes in patients with AAV without substantial liver disease.

METHODS

A total of 210 patients with immunosuppressive drug-naïve AAV were retrospectively reviewed. NFI was calculated as follows: NFI=(serum bilirubin × (alkaline phosphatase)2)/(platelet count×(serum albumin)2). NFI cut-off was set at 1.24 (the highest quartile). Poor outcomes were defined as all-cause mortality, relapse, and end-stage renal disease (ESRD).

RESULTS

During the median 34.5 months of follow-up, 21 patients (10%) died, 72 patients (34.3%) relapsed, and 38 patients (18.1%) had ESRD due to AAV progression. The median calculated NFI was 0.61, and it was higher in AAV patients with all-cause mortality than in those without mortality, but the difference was not statistically significant (1.26 vs. 0.59). AAV patients with NFI at diagnosis ≥1.24 exhibited a significantly lower cumulative patient survival rate than those with NFI at diagnosis <1.24 (p=0.002). Multivariate Cox hazard model analysis showed that NFI at diagnosis ≥1.24 was an independent predictor of all-cause mortality in AAV (hazard ratios [HR] 2.850, 95% confidence interval [CI] 1.026, 7.910).

CONCLUSIONS

NFI ≥1.24, which may be an independent predictive marker for all-cause mortality in AAV patients without substantial liver disease.

Gastrointestinal and Hepatic Disease in Vasculitis

Vasculitis is an inflammatory condition that targets the blood vessels, which may occur in isolation or as a component of a systemic inflammatory condition. Although many of the vasculitides can directly affect the organs of the gastrointestinal system, some types exhibit a proclivity for certain gastrointestinal and hepatic organs. Often a patient presents with nonspecific symptoms, delaying the diagnosis and treatment of the underlying vasculitis. Vasculitis can also present with severe manifestations, such as upper gastrointestinal bleeds and bowel perforation. It is important to identify the signs and symptoms of vasculitis in gastrointestinal system and institute appropriate treatment.

Suspected Hepatically Localized Granulomatosis with Polyangiitis

The patient was a 72-year-old woman whose alkaline phosphatase levels had been elevated since she was 56 years old. Liver biopsies obtained when the patient was 64 and 66 years of age led to a suspicion of cholangitis caused by vasculitis. Furthermore, proteinase-3 anti-neutrophil cytoplasmic antibody positivity led to a suspicion of granulomatosis with polyangiitis, but subjective symptoms and disorders in other organs were absent, so this suspicion was not confirmed. Cholangitis caused by vasculitis rarely occurs without vasculitis in other organs. We herein report this case in which we obtained distinctive laparoscopic and imaging findings that raised suspicions of liver circulatory failure.

Granulomatosis with polyangiitis: an unusual cause of acute liver injury

Granulomatosis with polyangiitis (GPA) causing liver injury is rare. Where liver biopsies have been taken findings are not always typical and diagnosis can be challenging. Here, we present a case of a 58-year-old male who on admission to hospital was found to have acute liver injury. Diagnosis of liver involvement in GPA is supported by liver histology and the resolution of hepatitis after commencement of immunosuppressive treatment.

Systemic vasculitis and the gut

PURPOSE OF REVIEW

Gastrointestinal system can be involved in primary and secondary vasculitides. The recent data regarding the pathophysiology, clinical findings, diagnosis, management, and outcome of gastrointestinal involvement in different types of vasculitis are reviewed.

RECENT FINDINGS

Diagnosis of gastrointestinal vasculitis may be difficult and relies mostly on imaging, because biopsy samples are hard to obtain and superficial mucosal biopsies have a low yield. There are conflicting reports on the association of antineutrophilic cytoplasmic antibodies (ANCA) type with the frequency of gastrointestinal involvement in ANCA-associated vasculitis. Pancreatitis is a rare but serious complication of ANCA-associated vasculitis. Terminal ileitis may be observed in immunoglobulin A vasculitis and can be hard to distinguish from Crohn's disease. High fecal calprotectin levels can indicate active gastrointestinal involvement in both immunoglobulin A vasculitis and Behçet's syndrome. Refractory gastrointestinal involvement in Behçet's syndrome can be treated with thalidomide and/or TNF-α antagonists. The outcome of mesenteric vasculitis in systemic lupus erythematosus can be improved with high-dose glucocorticoids and cyclophosphamide or rituximab.

SUMMARY

Gastrointestinal system can be commonly involved in immunoglobulin A vasculitis, ANCA-associated vasculitis, polyarteritis nodosa, and Behçet's syndrome and can be an important cause of morbidity and mortality. Treatment depends on the type of vasculitis and is usually with high-dose corticosteroids and immunosuppressives.

Hepatic involvement in granulomatosis with polyangiitis - diagnostic difficulties

We report the case of a 57-year-old Caucasian man who presented with dry cough, haemoptysis, fever, lung nodules, erythrocyturia, and acute hepatitis. After a lung biopsy, the patient was diagnosed with granulomatosis with polyangiitis. The diagnosis was supported by the presence of anti-proteinase-3 anti-neutrophil cytoplasmic antibodies. The most common causes of liver damage are excluded. The patient was treated with prednisone and cyclophosphamide, which resulted in remission of chest CT findings and improvement in liver function tests. During the flare, new lung infiltrations as well as elevation of liver enzymes were present. Treatment with rituximab resulted in complete clinical and radiological remission and normalisation of liver function tests. What makes this case worth reporting is the rare liver involvement in the GPA. After exclusion of coexistence of autoimmune liver disease and drug-induced liver lesion, organ involvement was supported by the reversion of abnormal LFT after the immunosuppression of GPA.