Long-term follow-up of microscopic polyangiitis, 17-year experience at a single center

Risk prediction model for mortality in microscopic polyangiitis: multicentre REVEAL cohort study

BACKGROUND

To establish refined risk prediction models for mortality in patients with microscopic polyangiitis (MPA) by using comprehensive clinical characteristics.

METHODS

Data from the multicentre Japanese registry of patients with vasculitis (REVEAL cohort) were used in our analysis. In total, 194 patients with newly diagnosed MPA were included, and baseline demographic, clinical, laboratory, and treatment details were collected. Univariate and multivariate analyses were conducted to identify the significant risk factors predictive of mortality.

RESULTS

Over a median follow-up of 202.5 (84-352) weeks, 60 (30.9%) of 194 patients died. The causes of death included MPA-related vasculitis (18.3%), infection (50.0%), and others (31.7%). Deceased patients were older (median age 76.2 years) than survivors (72.3 years) (P < 0.0001). The death group had shorter observation periods (median 128.5 [35.3-248] weeks) than the survivor group (229 [112-392] weeks). Compared to survivors, the death group exhibited a higher smoking index, lower serum albumin levels, higher serum C-reactive protein levels, higher Birmingham Vasculitis Activity Score (BVAS), higher Five-Factor Score, and a more severe European Vasculitis Study Group (EUVAS) categorization system. Multivariate analysis revealed that higher BVAS and severe EUVAS independently predicted mortality. Kaplan-Meier survival curves demonstrated lower survival rates for BVAS ≥20 and severe EUVAS, and a risk prediction model (RPM) based on these stratified patients into low, moderate, and high-risk mortality groups.

CONCLUSIONS

The developed RPM is promising to predict mortality in patients with MPA and provides clinicians with a valuable tool for risk assessment and informed clinical decision-making.

Outcomes in ANCA-associated vasculitis patients with end-stage kidney disease on renal replacement therapy-A meta-analysis

BACKGROUND

End-stage kidney disease (ESKD) is associated with poor prognosis in patients with anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This study summarizes the existing evidence regarding outcomes in AAV patients with ESKD on renal replacement therapy.

METHODS

Searches of the MEDLINE and Embase databases were performed from inception until December 2021. Any study reporting outcomes after ESKD in patients with AAV on haemodialysis or peritoneal dialysis was included. The mortality rate per 100 person-years (100 py) calculated with a random-effects meta-analysis model was the primary outcome. Rates of infections and relapses were secondary outcomes.

RESULTS

2470 citations were found; 22 studies of 952 adult patients with over 3600 person-years of follow-up were included. The pooled mortality rate was 10.90 per 100 py (95% CI: 7.11 - 14.68, I² = 90.8%). The pooled 1-year survival was 80.9% (95% CI: 75.6 - 86.1%, I² = 86.1%) while the pooled 5-year survival was 61.0% (95% CI: 46.0 - 76.0%, I² = 0.0%). The pooled severe infection rate was 66.57 per 100 py (95% CI: 13.64 - 119.50, I² = 99.6%). The pooled relapse rate was 6.22 per 100 py (95% CI: 4.64 - 7.80, I² = 46.6%). Only 1 paediatric study met the inclusion criteria and reported a mortality rate of 11.7 ± 1.9 deaths per 100 py (95% CI: 0.23 - 23.20) amongst 9 patients.

CONCLUSIONS

Patients with AAV and ESKD have a lower risk of relapse, but higher infection and mortality rates. More prospective research exploring the role of immunosuppression after ESKD is needed.

Clinical Characteristics and Prognostic Analysis of Microscopic Polyangiitis With Diffuse Alveolar Hemorrhage

OBJECTIVE

To analyze the clinical features and prognostic factors of microscopic polyangiitis (MPA) with diffuse alveolar hemorrhage (DAH).

METHODS

We conducted a retrospective study of 92 patients diagnosed with MPA with DAH at the First Affiliated Hospital of Chongqing Medical University between March 1, 2012, and March 12, 2018. The cumulative survival rate was analyzed by the Kaplan-Meier method, and survival curves were drawn. A Cox hazard model was used to determine the prognostic factors for survival by univariate and multivariate analysis.

RESULTS

The mean age at the onset of MPA with DAH was 66.32 years. Among the 92 MPA with DAH patients with follow-up visits, 41 (44.57%) were critically ill and 79 (85.87%) had pulmonary and renal involvement. The cumulative survival rates of the 92 patients at 1, 3, and 5 years were 63.7%, 51.2%, and 47.3%, respectively, and the median survival time was 46 months. In the multivariate analysis, age > 65 years (HR 4.30, 95% CI 1.94-9.55), sCr > 500 μmol/L (HR 2.04, 95% CI 1.05-3.97), PaO₂/FiO₂ < 300 mmHg (HR 4.10, 95% CI 1.97-8.53), and lung involvement area ≥ 50% (HR 2.93, 95% CI 1.40-6.13) were independent prognostic factors (P < 0.05).

CONCLUSION

The incidence and mortality of DAH are high in MPA patients. Age > 65 years, sCr > 500 μmol/L, PaO₂/FiO₂ < 300 mmHg, and lung involvement area ≥ 50% are independent prognostic factors for MPA with DAH.

Clinical features and prognosis of microscopic polyangiitis with usual interstitial pneumonia compared with idiopathic pulmonary fibrosis

INTRODUCTION

Pulmonary involvement in microscopic polyangiitis (MPA) is common, little is known about the clinical features of MPA with interstitial pneumonia (MPA-IP).

OBJECTIVES

This study aimed to explore the prevalence of microscopic polyangiitis associated usual interstitial pneumonia (UIP)(MPA-UIP) and compare its clinical features and prognosis with those of MPA-non-UIP and idiopathic pulmonary fibrosis (IPF).

METHODS

A total of 73 patients with MPA-IP were identified and divided into MPA-UIP patients and MPA-non-UIP patients. The clinical characteristics and survival of MPA-UIP patients were analysed and compared with those of MPA-non-UIP patients and 68 patients with IPF.

RESULTS

The results showed that 34/73 (47%) MPA-IP patients were classified as MPA-UIP patients. Compared with MPA-non-UIP patients, MPA-UIP patients tend to have longer duration of symptoms prior to diagnosis and usually have pulmonary involvement as the initial presentation. However, they were less likely to have proteinuria and/or hematuria. Compared with IPF patients, MPA-UIP patients usually had multisystem damage, positive anti-neutrophil cytoplasmic autoantibodies and elevated levels of nonspecific inflammatory markers. MPA-UIP death was concentrated mainly in the first 3 months after diagnosis and resulted in a higher early mortality compared with IPF.

CONCLUSION

UIP is the most frequent type of MPA-IP. These patients tend to have longer duration of symptoms prior to diagnosis and usually have pulmonary involvement as the first presentation. However, they are less likely to have proteinuria and/or hematuria. MPA patients with UIP can be differentiated from IPF patients through comprehensive analysis of clinical and laboratory findings.

Clinical characteristics and outcome of Spanish patients with ANCA-associated vasculitides: Impact of the vasculitis type, ANCA specificity, and treatment on mortality and morbidity

The aim of this study was to describe the clinical characteristics of ANCA-associated vasculitides (AAV) at presentation, in a wide cohort of Spanish patients, and to analyze the impact of the vasculitis type, ANCA specificity, prognostic factors, and treatments administered at diagnosis, in the outcome.A total of 450 patients diagnosed between January 1990 and January 2014 in 20 Hospitals from Spain were included. Altogether, 40.9% had granulomatosis with polyangiitis (GPA), 37.1% microscopic polyangiitis (MPA), and 22% eosinophilic granulomatosis with polyangiitis (EGPA). The mean age at diagnosis was 55.6 ± 17.3 years, patients with MPA being significantly older (P < 0.001). Fever, arthralgia, weight loss, respiratory, and ear-nose-throat (ENT) symptoms, were the most common at disease onset. ANCAs tested positive in 86.4% of cases: 36.2% C-ANCA-PR3 and 50.2% P-ANCA-MPO. P-ANCA-MPO was significantly associated with an increased risk for renal disease (OR 2.6, P < 0.001) and alveolar hemorrhage (OR 2, P = 0.010), while C-ANCA-PR3 was significantly associated with an increased risk for ENT (OR 3.4, P < 0.001) and ocular involvement (OR 2.3, P = 0.002). All patients received corticosteroids (CS) and 74.9% cyclophosphamide (CYC). The median follow-up was 82 months (IQR 100.4). Over this period 39.9% of patients suffered bacterial infections and 14.6% opportunistic infections, both being most prevalent in patients with high-cumulated doses of CYC and CS (P < 0.001). Relapses were recorded in 36.4% of cases with a mean rate of 2.5 ± 2.3, and were more frequent in patients with C-ANCA-PR3 (P = 0.012). The initial disease severity was significantly associated with mortality but not with the occurrence of relapses. One hundred twenty-nine (28.7%) patients (74 MPA, 41 GPA, 14 EGPA) died. The mean survival was 58 months (IQR 105) and was significantly lower for patients with MPA (P < 0.001). Factors independently related to death were renal involvement (P = 0.010), cardiac failure (P = 0.029) and age over 65 years old (P < 0.001) at disease onset, and bacterial infections (P < 0.001). An improved outcome with significant decrease in mortality and treatment-related morbidity was observed in patients diagnosed after 2000, and was related to the implementation of less toxic regimens adapted to the disease activity and stage, and a drastic reduction in the cumulated CYC and CS dose.

Pathological and high resolution CT findings in Churg-Strauss syndrome

OBJECTIVE

To investigate the Churg-Strauss syndrome (CSS) associated lung involvement, concentrating on clinical characteristics, pathological findings of lung involvements, response to treatment, and prognosis.

METHODS

We retrospectively analyzed the characters of the clinical manifestations, thin-section CT and pathological findings of CSS. The study involved 16 patients. Clinical data were obtained by chart review. All patients underwent transbronchial lung biopsy (TBLB). Six of them underwent surgical lung biopsy as well.

RESULTS

The patients included 7 men and 9 women, aged from 14 to 61 years (median, 47.5 years). Extrathoracic organs involved included nervous system (7/16) and skin (5/16). Respiratory symptoms included cough (12/16), exertional dyspnea (11/16), hemoptysis (4/16), and chest pain (3/16). CT findings included bilateral ground-glass opacities (12/16), bilateral patchy opacities (12/16), and centrilobular nodules (6/16). The pathological findings of TBLB demonstrated increased eosinophils (3/16), vasculitis (3/16), and interstitial pneumonia (16/16). The pathological findings of surgical lung biopsy of 6 cases showed necrotizing vasculitis in 4 cases, capillaries in 5, eosinophilic pneumonia in 3, granulomas in 2, and airway abnormalities in 3. All patients improved in symptoms after therapy during the study period (range, 3 to 51 months; median, 15 months).

CONCLUSIONS

Asthma may be present in CSS patient when there is bronchial involvement. Ground-glass opacities and consolidation seen on high-resolution CT reflect the presence of eosinophilic pneumonia, vasculitis, and pulmonary alveolar hemorrhage. TBLB has significant limitations for the diagnosis of CSS. Early diagnosis and therapy can result in satisfactory prognosis.

Overall survival, renal survival and relapse in patients with microscopic polyangiitis: a systematic review of current evidence

OBJECTIVE

There are limited data on the long-term prognosis of microscopic polyangiitis (MPA). A systematic review was performed to estimate the survival, renal survival and relapse rates in patients with MPA.

METHODS

Articles included in MEDLINE and EMBASE databases were reviewed. Randomized or non-randomized trials, cohort, case-control and cases-series studies of patients with MPA diagnosed according to Chapel Hill Consensus Conference definitions, a high rate of biopsy-confirmed diagnosis, follow-up >1 year and follow-up losses <10%. Two independent authors using a predefined questionnaire for evaluating the quality and risk of bias for each study extracted data.

RESULTS

Eighteen studies for MPA prognosis (n = 940) and six for MPA outcomes after transplantation (n = 65) were included. Survival rates were 77-100% at 1 year, 46-80% at 5 years and 60-80% at 10 years. Higher mortality density occurred within the first months after diagnosis. Vasculitis was the cause of death in 32-50% of patients. Relapses were detected in 19-39% of cases (median time to relapse 15-43 months). Renal graft survival was 85-94% at 1 year and 51-87% at 5 years. Age, renal involvement and immunosuppressive treatment were related to mortality. Lower relapse rate was achieved with 12 vs 6 CYC pulses.

CONCLUSION

Evidence regarding MPA prognosis is weak. MPA mortality is mainly concentrated in the first months after diagnosis. Fewer than 50% of deaths are related to MPA activity. MPA long-term prognosis is less severe, although relapses are frequent. End-stage renal failure is a frequent complication of MPA, and renal transplantation could be an effective therapy in these patients. Early diagnosis, early initiation of a tailored therapy according to risk factors and a longer follow-up of the patients are needed.