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Chalkia A, Jayne D. ANCA-associated vasculitis-treatment standard. Nephrol Dial Transplant 2024; 39:944-955. [PMID: 37947275 DOI: 10.1093/ndt/gfad237] [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: 09/04/2023] [Indexed: 11/12/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are characterized by small-vessel necrotizing inflammation, and prior to the advent of immunosuppressive therapy frequently had a fatal outcome. Treatment has transformed AAV into a relapsing/remitting disease with increased drug-related toxicities and organ damage. The use of glucocorticoids, cyclophosphamide and immunosuppressives (including azathioprine, mycophenolate and methotrexate) was optimized through a sequence of clinical trials establishing a standard of care against which subsequent targeted therapies could be developed. Improved understanding of pathophysiology has supported the development of B-cell depletion and complement inhibition in granulomatosis with polyangiitis and microscopic polyangiitis, and interleukin 5 inhibition for eosinophilic granulomatosis with polyangiitis, leading to the approval of newer agents for these conditions. There has been an increased attention on minimizing the adverse effects of treatment and on understanding the epidemiology of comorbidities in AAV. This review will focus on recent evidence from clinical trials, especially with respect to glucocorticoids, avacopan, plasma exchange, rituximab and mepolizumab, and their interpretation in the 2022 management recommendations by the European League of Associations of Rheumatology.
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Affiliation(s)
- Aglaia Chalkia
- Department of Medicine, University of Cambridge, Cambridge, UK
- Nephrology Department, Hippokration General Hospital, Athens, Greece
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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2
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Brix SR. The Challenge of Assessing Remission and Relapse in ANCA Kidney Disease. J Am Soc Nephrol 2024; 35:395-397. [PMID: 38557787 PMCID: PMC11000735 DOI: 10.1681/asn.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Silke R Brix
- Renal, Transplantation and Urology Unit, Manchester University Hospitals NHS Foundation Trust, and Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, United Kingdom
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3
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Prskalo L, Skopnik CM, Goerlich N, Freund P, Wagner L, Grothgar E, Mirkheshti P, Klocke J, Sonnemann J, Metzke D, Schneider U, Hiepe F, Eckardt KU, Salama AD, Bieringer M, Schreiber A, Enghard P. Urinary CD4 + T Cells Predict Renal Relapse in ANCA-Associated Vasculitis. J Am Soc Nephrol 2024; 35:483-494. [PMID: 38231590 PMCID: PMC11000730 DOI: 10.1681/asn.0000000000000311] [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: 07/21/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024] Open
Abstract
SIGNIFICANCE STATEMENT Early identification of patients at risk of renal flares in ANCA vasculitis is crucial. However, current clinical parameters have limitations in predicting renal relapse accurately. This study investigated the use of urinary CD4 + T lymphocytes as a predictive biomarker for renal flares in ANCA vasculitis. This study, including urine samples from 102 patients, found that the presence of urinary CD4 + T cells was a robust predictor of renal relapse within a 6-month time frame, with a sensitivity of 60% and a specificity of 97.8%. The diagnostic accuracy of urinary CD4 + T cells exceeded that of ANCA titers, proteinuria, and hematuria. Monitoring urinary CD4 + T lymphocytes could help assess the risk of future renal relapse, enabling early preventive measures and tailored treatment strategies. BACKGROUND In ANCA-associated vasculitis, there is a lack of biomarkers for predicting renal relapse. Urinary T cells have been shown to differentiate active GN from remission in ANCA-associated vasculitis, but their predictive value for renal flares remains unknown. METHODS The PRE-FLARED study was a prospective multicenter biomarker study including 102 individuals with ANCA-associated vasculitis in remission aimed to predict renal relapse by quantifying urinary CD4 + T-cell subsets using flow cytometry at baseline and monitoring clinical outcomes over a 6-month follow-up. RESULTS Among the participants, ten experienced renal relapses, two had non-renal flares, and 90 remained in stable remission. The median baseline urinary CD4 + T-cell count was significantly higher in patients who relapsed compared with those in remission. Receiver operating characteristic curve analysis of urinary CD4 + T-cell counts showed an area under the curve value of 0.88 for predicting renal flares, outperforming ANCA titers, hematuria, and proteinuria. Using a cutoff of 490 CD4 + T cells per 100 ml urine, the sensitivity and specificity in identifying patients with future renal flares were 60% and 97.8%, respectively. In a post hoc analysis, combining urinary CD4 + T-cell counts with proteinase-3 ANCA levels suggested improved predictive performance in the PR3 + subgroup. In addition, the number of urinary CD4 + T cells showed a limited correlation with a decline in GFR and an increase in proteinuria over the follow-up period. CONCLUSIONS This study concluded that urinary CD4 + T-cell counts could identify patients with ANCA-associated vasculitis at a substantial risk of renal relapse within 6 months. Combining these counts with ANCA levels further improved the prediction of relapse. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Urinary T Lymphocytes Predict Renal Flares in Patients With Inactive ANCA-associated Glomerulonephritis (PRE-FLARED), NCT04428398 .
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Affiliation(s)
- Luka Prskalo
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christopher M. Skopnik
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nina Goerlich
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum, an Institute of the Leibniz Foundation, Berlin, Germany
| | - Paul Freund
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Wagner
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Emil Grothgar
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pouneh Mirkheshti
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan Klocke
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum, an Institute of the Leibniz Foundation, Berlin, Germany
| | - Janis Sonnemann
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Diana Metzke
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum, an Institute of the Leibniz Foundation, Berlin, Germany
| | - Udo Schneider
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Falk Hiepe
- Deutsches Rheuma-Forschungszentrum, an Institute of the Leibniz Foundation, Berlin, Germany
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alan D. Salama
- University College London Department of Renal Medicine, Royal Free Hospital, London, United Kingdom
| | - Markus Bieringer
- Department of Nephrology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Adrian Schreiber
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Taniguchi T, Hiwa R, Morinobu A. Pitfalls in evaluating the impact of persistent hematuria after induction therapy on kidney prognosis in anti-neutrophil cytoplasmic autoantibody-associated vasculitis. Kidney Int 2024; 105:391-392. [PMID: 38245220 DOI: 10.1016/j.kint.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/09/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Tomoki Taniguchi
- Department of Rheumatology and Clinical Immunology, Kyoto University, Kyoto, Japan.
| | - Ryosuke Hiwa
- Department of Rheumatology and Clinical Immunology, Kyoto University, Kyoto, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kyoto University, Kyoto, Japan
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Benichou N, Abouqateb M, Karras A. The authors reply. Kidney Int 2024; 105:392-393. [PMID: 38245221 DOI: 10.1016/j.kint.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/11/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Nicolas Benichou
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Department of Medicine, Université Paris Cité, Paris, France.
| | - Mouad Abouqateb
- INSERM (Institut National de la Santé et de la Recherche Médicale) U970, Integrative Epidemiology of Cardiovascular Disease Department, Université Paris Cité, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Department of Medicine, Université Paris Cité, Paris, France
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Boud'hors C, Riou J, Fage N, Samoreau C, Desouche A, Gatault P, Bridoux F, Martin C, Wacrenier S, Vinatier E, Djema A, Henry N, Croué A, Piccoli GB, Copin MC, Augusto JF, Brilland B. Adding 6-month parameters for the prediction of kidney prognosis in ANCA-associated glomerulonephritis. Clin Kidney J 2023; 16:2530-2541. [PMID: 38046032 PMCID: PMC10689158 DOI: 10.1093/ckj/sfad157] [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: 02/21/2023] [Indexed: 12/05/2023] Open
Abstract
Background Antineutrophil-cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with kidney involvement (AAV-GN) frequently evolves to end-stage kidney disease (ESKD) despite aggressive immunosuppressive treatment. Several risk scores have been used to assess renal prognosis. We aimed to determine whether kidney function and markers of AAV-GN activity after 6 months could improve the prediction of ESKD. Methods This retrospective and observational study included adult patients with AAV-GN recruited from six French nephrology centers (including from the Maine-Anjou AAV registry). The primary outcome was kidney survival. Analyses were conducted in the whole population and in a sub-population that did not develop ESKD early in the course of the disease. Results When considering the 102 patients with all data available at diagnosis, Berden classification and Renal Risk Score (RRS) were not found to be better than kidney function [estimated glomerular filtration rate (eGFR)] alone at predicting ESKD (C-index = 0.70, 0.79, 0.82, respectively). Multivariables models did not indicate an improved prognostic value when compared with eGFR alone.When considering the 93 patients with all data available at 6 months, eGFR outperformed Berden classification and RRS (C-index = 0.88, 0.62, 0.69, respectively) to predict ESKD. RRS performed better when it was updated with the eGFR at 6 months instead of the baseline eGFR. While 6-month proteinuria was associated with ESKD and improved ESKD prediction, hematuria and serological remission did not. Conclusion This work suggests the benefit of the reassessment of the kidney prognosis 6 months after AAV-GN diagnosis. Kidney function at this time remains the most reliable for predicting kidney outcome. Of the markers tested, persistent proteinuria at 6 months was the only one to slightly improve the prediction of ESKD.
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Affiliation(s)
- Charlotte Boud'hors
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Jérémie Riou
- Département de Méthodologie et Biostatistiques, Délégation pour la Recherche Clinique et l'Innovation, CHU d'Angers, Angers, France
| | - Nicolas Fage
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Clément Samoreau
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Alice Desouche
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Philippe Gatault
- Service de Néphrologie-Dialyse-Transplantation, CHU de Tours, Tours, France
| | - Frank Bridoux
- Service de Néphrologie-Dialyse-Transplantation, CHU de Poitiers, Poitiers, France
| | - Cécile Martin
- Service de Néphrologie-Dialyse-Transplantation, CHU de Poitiers, Poitiers, France
| | - Samuel Wacrenier
- Service de Néphrologie-Dialyse, Centre Hospitalier du Mans, Le Mans, France
| | - Emeline Vinatier
- Laboratoire d'Immunologie et Allergologie, CHU Angers, Angers, France
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Assia Djema
- Service de Néphrologie-Dialyse, Centre Hospitalier de Cholet, Cholet, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse, Centre Hospitalier de Laval, Laval, France
| | - Anne Croué
- Département de pathologie cellulaire et tissulaire, CHU d'Angers, Angers, France
| | | | - Marie-Christine Copin
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
- Département de pathologie cellulaire et tissulaire, CHU d'Angers, Angers, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Benoît Brilland
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
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Aqeel F, Xu L, Geetha D. Repeat Kidney Biopsies in Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis: Clinical and Histologic Progression. Kidney Int Rep 2023; 8:2146-2149. [PMID: 37850018 PMCID: PMC10577318 DOI: 10.1016/j.ekir.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lillian Xu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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