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Tsutsumi K, Iwamura N, Eguchi K, Takatani A, Koga T, Araki T, Aramaki T, Terada K, Ueki Y. Comparative analysis of renal decline rates in microscopic polyangiitis: unveiling the slowly progressive phenotype. Immunol Med 2024:1-10. [PMID: 38907617 DOI: 10.1080/25785826.2024.2366313] [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: 04/21/2024] [Accepted: 06/06/2024] [Indexed: 06/24/2024] Open
Abstract
Although rapidly progressive glomerulonephritis (RPGN) is the main renal phenotype of microscopic polyangiitis (MPA), we aim to clarify the clinical features of slowly progressive MPA. This retrospective observational study included 12 patients diagnosed with MPA in our hospital between January 2012 and February 2022. We investigated the differences in surrogate markers, rate of decline of estimated glomerular filtration rate (eGFR) between the slowly progressive and rapidly progressive MPA groups. Of the 12 patients with MPA, 3 (25.0%) had slowly progressive MPA: MPA within 30% decrease in eGFR 3 months pretreatment, all of whom developed RPGN during the course. Patients with slowly progressive MPA had lower levels of C-reactive protein, myeloperoxidase anti-neutrophil cytoplasmic antibodies, and interleukin-6; higher levels of sialylated carbohydrate antigen KL-6. Slowly progressive MPA is not uncommon in our hospital. A linear relationship was found between slower rate of eGFR decline and lower surrogate markers of disease activity. Some MPA cases have slowly progressive glomerulonephritis leading to RPGN, which may be clinically characterized by low disease activity. It may be useful to measure myeloperoxidase anti-neutrophil cytoplasmic antibody in chronic kidney disease with concomitant urinary abnormalities to diagnose MPA with slowly progressive glomerulonephritis.
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Affiliation(s)
- Kanako Tsutsumi
- Department of Internal Medicine, Sasebo Chuo Hospital, Sasebo, Japan
| | - Narumichi Iwamura
- Department of Internal Medicine, Sasebo Chuo Hospital, Sasebo, Japan
| | - Katsumi Eguchi
- Department of Rheumatology, Sasebo Chuo Hospital, Sasebo, Japan
| | - Ayuko Takatani
- Department of Rheumatology, Sasebo Chuo Hospital, Sasebo, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takeshi Araki
- Department of Rheumatology, Sasebo Chuo Hospital, Sasebo, Japan
| | | | - Kaoru Terada
- Department of Rheumatology, Sasebo Chuo Hospital, Sasebo, Japan
| | - Yukitaka Ueki
- Department of Rheumatology, Sasebo Chuo Hospital, Sasebo, Japan
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2
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Iwamura N, Tsutsumi K, Ueno Y, Tamura Y, Nakano T. Very Slowly Progressive Microscopic Polyangiitis: Comparative Analysis with Rapidly Progressive Forms. Cureus 2024; 16:e62282. [PMID: 38873394 PMCID: PMC11170224 DOI: 10.7759/cureus.62282] [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: 06/12/2024] [Indexed: 06/15/2024] Open
Abstract
Microscopic polyangiitis (MPA) is predominantly characterized by rapidly progressive glomerulonephritis (RPGN) associated with myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA). Nonetheless, up to 30% of cases of ANCA-associated vasculitis (AAV) may exhibit a more indolent progression toward renal failure, an aspect less frequently discussed and understood in medical literature. This study seeks to clarify the clinical and pathological distinctions between the slowly and rapidly progressive forms of MPA, thereby enhancing understanding of their distinct pathogeneses and treatment responses. We conducted a comparative analysis of two patients diagnosed with MPA under the 2022 American College of Rheumatology/the European Alliance of Associations for Rheumatology (ACR/EULAR) classification. Evaluations included laboratory tests such as serum creatinine levels, serology for MPO-ANCA, and renal biopsies. Patient 1 exhibited a mere 1.07% decrease in estimated glomerular filtration rate (eGFR) over 6 months, significantly below the RPGN threshold, and demonstrated sclerotic glomerular pathology without active inflammation. This patient also showed lower levels of MPO-ANCA, Birmingham Vasculitis Activity Score (BVAS), and C-reactive protein. Conversely, Patient 2 experienced an 89.9% reduction in eGFR over the same timeframe, accompanied by acute systemic inflammation. The comparative clinical analysis of these cases illuminates clear differences in disease activity. Slowly progressive MPA is marked by lesser disease activity that fosters chronic inflammation, leading to a more gradual decline in renal function. Early diagnosis, facilitated by initial measurements of MPO-ANCA, can enhance disease management and improve patient outcomes.
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Affiliation(s)
- Narumichi Iwamura
- Department of Nephrology, Japan Community Health Care Organization Kyushu Hospital, Kitakyushu, JPN
| | - Kanako Tsutsumi
- Department of Nephrology, Steel Memorial Yahata Hospital, Kitakyushu, JPN
| | - Yuki Ueno
- Department of Nephrology, Japan Community Health Care Organization Kyushu Hospital, Kitakyushu, JPN
| | - Yasuhisa Tamura
- Department of Nephrology, Japan Community Health Care Organization Kyushu Hospital, Kitakyushu, JPN
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, JPN
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3
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Salvati L, Palterer B, Lazzeri E, Vivarelli E, Amendola M, Allinovi M, Caroti L, Mazzoni A, Lasagni L, Emmi G, Cavigli E, Del Carria M, Di Pietro L, Scavone M, Cammelli D, Lavorini F, Tomassetti S, Rosi E, Parronchi P. Presentation and progression of MPO-ANCA interstitial lung disease. J Transl Autoimmun 2024; 8:100235. [PMID: 38445024 PMCID: PMC10912625 DOI: 10.1016/j.jtauto.2024.100235] [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] [Received: 01/03/2024] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024] Open
Abstract
The association between MPO-ANCA-associated vasculitis (AAV) and interstitial lung disease (ILD) has been well established. Pulmonary fibrosis may coexist with, follow, or even precede the diagnosis of AAV, and its presence adversely affects the prognosis. The optimal approach to investigating ANCA in patients with ILD remains a subject of ongoing debate. Here we aim to describe presentation and progression of MPO-ANCA ILD. We conducted a retrospective evaluation of a cohort of individuals diagnosed with MPO-ANCA ILD, with or without accompanying renal impairment, at the Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy, between June 2016 and June 2022. Clinical records, imaging studies, pathologic examinations, and laboratory test results were collected. Among the 14 patients identified with MPO-ANCA ILD, we observed a significant association between MPO-ANCA titers assessed at the time of ILD diagnosis and renal involvement. Renal impairment in these cases often manifested as subclinical or slowly progressive kidney damage. Interestingly, complement C3 deposits were consistently found in all renal biopsy specimens, thereby suggesting the potential for novel therapeutic targets in managing renal complications associated with MPO-ANCA ILD. The presentation of MPO-ANCA vasculitis as ILD can be the first and only clinical manifestation. MPO-ANCA levels at ILD diagnosis could warn on the progression to renal involvement in patients with MPO-ANCA ILD, hence caution is needed because renal disease can be subclinical or smoldering.
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Affiliation(s)
- Lorenzo Salvati
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Boaz Palterer
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Lazzeri
- Department of Clinical and Experimental Biomedical Sciences, Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Emanuele Vivarelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marina Amendola
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Marco Allinovi
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Leonardo Caroti
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Flow Cytometry Diagnostic Center and Immunotherapy, Careggi University Hospital, Florence, Italy
| | - Laura Lasagni
- Department of Clinical and Experimental Biomedical Sciences, Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Edoardo Cavigli
- Department of Emergency Radiology, Careggi University Hospital, Florence, Italy
| | - Marco Del Carria
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Linda Di Pietro
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mariangela Scavone
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Daniele Cammelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Interventional Pulmonology Unit, Careggi University Hospital, Florence, Italy
| | - Elisabetta Rosi
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy
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4
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Arnold S, Kitching AR, Witko-Sarsat V, Wiech T, Specks U, Klapa S, Comdühr S, Stähle A, Müller A, Lamprecht P. Myeloperoxidase-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e300-e313. [PMID: 38574743 DOI: 10.1016/s2665-9913(24)00025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 04/06/2024]
Abstract
Myeloperoxidase (MPO)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (MPO-ANCA-associated vasculitis) is one of two major ANCA-associated vasculitis variants characterised by systemic necrotising vasculitis with few or no immune deposits. MPO-ANCA-associated vasculitis predominantly affects small blood vessels and, in contrast to its counterpart proteinase 3-ANCA-associated vasculitis, is generally not associated with granulomatous inflammation. The kidneys and lungs are the most commonly affected organs. The pathogenesis of MPO-ANCA-associated vasculitis is characterised by loss of tolerance to the neutrophil enzyme MPO. This loss of tolerance leads to a chronic immunopathological response where neutrophils become both the target and effector of autoimmunity. MPO-ANCA drives neutrophil activation, leading in turn to tissue and organ damage. Clinical trials have improved the therapeutic approach to MPO-ANCA-associated vasculitis. However, there remains substantial unmet need regarding relapse frequency, toxicity of current treatment, and long-term morbidity. In this Series paper, we present the current state of research regarding pathogenesis, diagnosis, and treatment of MPO-ANCA-associated vasculitis.
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Affiliation(s)
- Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia; Departments of Nephrology and Pediatric Nephrology, Monash Health, Clayton, VIC, Australia
| | - Veronique Witko-Sarsat
- INSERM U1016, Institut Cochin, CNRS UMR8104, Université Paris Cité et Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Thorsten Wiech
- Section of Nephropathology, Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sebastian Klapa
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Sara Comdühr
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Anja Stähle
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Antje Müller
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany.
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5
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Anzai H, Suzuki Y, Ueno M, Asakawa S, Nagura M, Arai S, Yamazaki O, Tamura Y, Ohashi R, Shibata S, Fujigaki Y. Slowly Progressive ANCA-associated Glomerulonephritis with Strong Mesangial MPO Deposits Following a Diagnosis of Interstitial Lung Disease. Intern Med 2024; 63:1253-1260. [PMID: 37722892 PMCID: PMC11116029 DOI: 10.2169/internalmedicine.2512-23] [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: 06/25/2023] [Accepted: 08/04/2023] [Indexed: 09/20/2023] Open
Abstract
An elderly woman showed positive conversion of myeloperoxidase (MPO)-antineutrophil cytoplasmic antibodies (ANCAs) following the diagnosis of interstitial lung disease (ILD) and glomerular hematuria and subsequently experienced slowly progressive glomerulonephritis. A kidney biopsy revealed chronic damage and necrotizing crescentic glomerulonephritis with mesangial MPO deposits. After corticosteroid treatment, the patient's urinalysis results and MPO-ANCA titers almost normalized and her renal function stabilized. This case is similar to recently reported cases of slowly progressive ANCA-associated glomerulonephritis. ILD likely triggered the production of MPO-ANCAs, and the accumulation of MPO deposits in the glomeruli may have contributed to the progression of her renal disease.
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Affiliation(s)
- Hitoshi Anzai
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yuki Suzuki
- Division of Respiratory Medicine and Allergology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Masaki Ueno
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Michito Nagura
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeyuki Arai
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Japan
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
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6
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Kronbichler A, Bajema IM, Bruchfeld A, Mastroianni Kirsztajn G, Stone JH. Diagnosis and management of ANCA-associated vasculitis. Lancet 2024; 403:683-698. [PMID: 38368016 DOI: 10.1016/s0140-6736(23)01736-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/05/2023] [Accepted: 08/17/2023] [Indexed: 02/19/2024]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis consists of two main diseases, granulomatosis with polyangiitis and microscopic polyangiitis, and remains among the most devastating and potentially lethal forms of autoimmune inflammatory disease. Granulomatosis with polyangiitis and microscopic polyangiitis are characterised by a necrotising vasculitis that can involve almost any organ, and have generally been studied together. The diseases commonly affect the kidneys, lungs, upper respiratory tract, skin, eyes, and peripheral nerves. Granulomatous inflammation and multinucleated giant cells are key pathological hallmarks of granulomatosis with polyangiitis, but are absent in microscopic polyangiitis. Many immune system events are essential to disease aetiopathogenesis, such as activation of the alternative complement pathway, neutrophil activation via complement receptors, and the influx of inflammatory cells, including monocytes and macrophages. These cells perpetuate inflammation and lead to organ damage. During the 21st century, the management of ANCA-associated vasculitis has moved away from reliance on cytotoxic medications and towards targeted biological medications for both the induction and maintenance of disease remission. Earlier diagnosis, partly the result of more reliable ANCA testing, has led to improved patient outcomes and better survival. Reductions in acute disease-related mortality have now shifted focus to long-term morbidities related to ANCA-associated vasculitis and their treatments, such as chronic kidney disease and cardiovascular disease. Therapeutic approaches in both clinical trials and clinical practice still remain too reliant on glucocorticoids, and continued efforts to reduce toxicity from glucocorticoids remain a priority in the development of new treatment strategies.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, UK.
| | - Ingeborg M Bajema
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | | | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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7
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Uzzo M, Maggiore U, Sala F, Reggiani F, L'Imperio V, Deliso F, Calatroni M, Moroni G, Sinico RA. Changing Phenotypes and Clinical Outcomes Over Time in Microscopic Polyangiitis. Kidney Int Rep 2023; 8:2107-2116. [PMID: 37850011 PMCID: PMC10577323 DOI: 10.1016/j.ekir.2023.07.008] [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: 03/21/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Diagnosis and management of microscopic polyangiitis (MPA) have evolved considerably over the past decades, but it is unknown whether clinical and histological presentation and patient and renal outcomes have changed accordingly. Methods We compared clinical and histopathological characteristic at diagnosis, risk of death, end-stage kidney disease (ESKD), and relapse rate in patients diagnosed with MPA between 1980 and 2022, after grouping them in 2 periods (p): p1980-2001 and p2002-2022. We compared the mortality rate between the 2 periods using Kaplan-Meier estimator and Cox-regression, and competing risks of ESKD and death using the Aalen-Johansen estimator, Fine-Gray multiple regression, and multistate models. Results Out of 187 patients, 77 were in p1980-2001 and 110 in p2002 to 2022. Patients in p2002 to 2022 were older (66.2 ± 14.0 SD vs. 57.7 ± 15.8; P < 0.001), had a better kidney function (estimated glomerular filtration rate [eGFR] 25.9 ± 24.8 vs. 21.5 ± 28.2 ml/min per 1.73 m2; P = 0.011) and a lower prevalence of the Berden sclerotic class (5.9 vs. 20.9%; P = 0.011). Despite a similar crude and adjusted patient survival, the risk of ESKD decreased during p2002 to 2022 (subdistribution hazard ratio [HR] 0.30, 95% confidence interval [CI]: 0.16-0.57; P < 0.001). The results remained significant after accounting for death after ESKD and after adjusting for potential confounders (HR 0.33 [95% CI: 0.18-0.63; P < 0.001]). The risk of relapse was numerically higher during p2002 to 2022 (subdistribution-HR 1.64 [95% CI: 0.95-2.83; P = 0.075]). Conclusion MPA kidney involvement has become less severe over the past decades, leading to a reduced risk of ESKD and a higher relapse rate, despite a comparable risk of death.
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Affiliation(s)
- Martina Uzzo
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Filippo Sala
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Nephrology and Dialysis Unit, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Francesco Reggiani
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Federica Deliso
- Clinical Pathology Unit, IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marta Calatroni
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Gabriella Moroni
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Renato A. Sinico
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
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McGovern DP, Lees JS, Traynor JP, Mackinnon B, Bell S, Hunter RW, Dhaun N, Metcalfe W, Kidder D, Lim M, Joss N, Kelly M, Taylor A, Cousland Z, Dey V, Buck K, Brix S, Geddes CC, McQuarrie EP, Stevens KI. Outcomes in ANCA-Associated Vasculitis in Scotland: Validation of the Renal Risk Score in a Complete National Cohort. Kidney Int Rep 2023; 8:1648-1656. [PMID: 37547534 PMCID: PMC10403670 DOI: 10.1016/j.ekir.2023.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) causes autoimmune-mediated inflammation of small blood vessels in multiple organs, including the kidneys. The ability to accurately predict kidney outcomes would enable a more personalized therapeutic approach. Methods We used our national renal biopsy registry to validate the ability of ANCA Renal Risk Score (ARRS) to predict end-stage kidney disease (ESKD) for individual patients. This score uses histopathological and biochemical data to stratify patients as high, medium, or low risk for developing ESKD. Results A total of 288 patients were eligible for inclusion in the study (low risk n = 144, medium risk n = 122, high risk n = 12). Using adjusted Cox proportional hazard models with the low-risk group as reference, we show that outcome differs between the categories: high-risk hazard ratio (HR) 16.69 (2.91-95.81, P = 0.002); medium risk HR 4.14 (1.07-16.01, P = 0.039). Incremental multivariable-adjusted Cox proportional hazards models demonstrated that adding ARRS to a model adjusted for multiple clinical parameters enhanced predictive discrimination (basic model C-statistic 0.864 [95% CI 0.813-0.914], basic model plus ARRS C-statistic 0.877 [95% CI 0.823-0.931]; P <0.01). Conclusion The ARRS better discriminates risk of ESKD in AAV and offers clinicians more prognostic information than the use of standard biochemical and clinical measures alone. This is the first time the ARRS has been validated in a national cohort. The proportion of patients with high-risk scores is lower in our cohort compared to others and should be noted as a limitation of this study.
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Affiliation(s)
- Dominic P. McGovern
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jennifer S. Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jamie P. Traynor
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- Department of Nephrology and Transplantation, John Hunter Hospital, New South Wales, Australia
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Robert W. Hunter
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michelle Lim
- Renal Unit, Ninewells Hospital and Medical School, Dundee, UK
| | - Nicola Joss
- Renal Unit, Raigmore Hospital, Inverness, UK
| | - Michael Kelly
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | | | | | - Vishal Dey
- Renal Unit, University Hospital Crosshouse, Kilmarnock, UK
| | - Kate Buck
- Renal Unit, Queen Margaret Hospital, Fife Acute Hospitals Trust, Kirkcaldy, Fife, UK
| | - Silke Brix
- Renal, Urology and Transplantation Unit, Manchester University Hospitals, Manchester, UK
- Cardiovascular Science, University of Manchester, Manchester, UK
| | - Colin C. Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily P. McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kathryn I. Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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9
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Odler B, Bruchfeld A, Scott J, Geetha D, Little MA, Jayne DRW, Kronbichler A. Challenges of defining renal response in ANCA-associated vasculitis: call to action? Clin Kidney J 2023; 16:965-975. [PMID: 37261001 PMCID: PMC10229283 DOI: 10.1093/ckj/sfad009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Indexed: 12/06/2023] Open
Abstract
Avoiding end-stage kidney disease in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) has a high therapeutic priority. Although renal response is a crucial measure to capture clinically relevant changes, clinal trials have used various definitions and no well-studied key surrogate markers to predict renal outcome in AAV exist. Differences in clinical features and histopathologic and therapeutic approaches will influence the course of kidney function. Its assessment through traditional surrogates (i.e. serum creatinine, glomerular filtration rate, proteinuria, hematuria and disease activity scores) has limitations. Refinement of these markers and the incorporation of novel approaches such as the assessment of histopathological changes using cutting-edge molecular and machine learning mechanisms or new biomarkers could significantly improve prognostication. The timing is favourable since large datasets of trials conducted in AAV are available and provide a valuable resource to establish renal surrogate markers and, likely, aim to investigate optimized and tailored treatment approaches according to a renal response score. In this review we discuss important points missed in the assessment of kidney function in patients with AAV and point towards the importance of defining renal response and clinically important short- and long-term predictors of renal outcome.
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Affiliation(s)
- Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Annette Bruchfeld
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine Karolinska Institutet, Stockholm, Sweden
- Department of Health, Medicine and Caring Sciences, Linköpings Universitet, Linköping, Sweden
| | - Jennifer Scott
- Trinity Health Kidney Center, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark A Little
- Trinity Health Kidney Center, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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10
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Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
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Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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11
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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.
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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.
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12
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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.
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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
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13
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Iwafuchi Y, Morioka T, Oyama Y, Narita I. A case of smoldering antineutrophil cytoplasmic antibody-associated vasculitis development during the course of primary Sjögren's syndrome. CEN Case Rep 2022; 11:247-253. [PMID: 34787826 PMCID: PMC9061905 DOI: 10.1007/s13730-021-00663-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022] Open
Abstract
Various forms of glomerular lesions have been described in primary Sjögren's syndrome (pSjS); however, myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is rarely reported, and the disease onset and clinical course of ANCA-associated vasculitis (AAV) complicated by pSjS are not well understood. A 51-year-old woman was referred to our hospital because of mild proteinuria and microscopic hematuria. She fulfilled the classification criteria for pSjS. We performed a kidney biopsy; however, it revealed no characteristic findings for pSjS, vasculitis, or other autoimmune diseases, including systemic lupus erythematosus. After 9 months, urinalysis abnormalities worsened and renal function was slowly declining, and ANCA was found to be positive. A second kidney biopsy was performed, revealing MPO-ANCA-associated pauci-immune segmental necrotizing glomerulonephritis with crescent formation. Even though immunofluorescence microscopy did not reveal any positive findings, additional electron microscopy demonstrated the presence of mesangial electron-dense deposits in both kidney biopsies. Based on kidney biopsy results and sequential serum ANCA measurements, we considered that smoldering ANCA-associated vasculitis had developed in this patient as this can develop during the clinical course of pSjS. She responded well to steroid therapy. Serum measurement, especially perinuclear, ANCA levels can be useful in patients with pSjS to detect the onset of ANCA-associated vasculitis, even in the absence of acute renal deterioration or severe urinary abnormalities.
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Affiliation(s)
- Yoichi Iwafuchi
- Department of Internal Medicine, Koseiren Sanjo General Hospital, 5-1-62 Tsukanome, Sanjo, 955-0055, Japan.
| | - Tetsuo Morioka
- Department of Internal Medicine, Kidney Center, Shinrakuen Hospital, 3-3-11 Shindoriminami Nishi-ku, Niigata, 950-2087, Japan
| | - Yuko Oyama
- Department of Internal Medicine, Koseiren Sanjo General Hospital, 5-1-62 Tsukanome, Sanjo, 955-0055, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-754 Asahimachi-Dori, Chuo-ku, Niigata, 951-8510, Japan
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14
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Ueno M, Kobayashi S, Asakawa S, Arai S, Nagura M, Yamazaki O, Tamura Y, Ohashi R, Shibata S, Fujigaki Y. Emergence of proteinase 3-antineutrophil cytoplasmic antibody-associated glomerulonephritis with mesangial immune deposition during the clinical course of IgG λ monoclonal gammopathy of uncertain significance. CEN Case Rep 2022; 11:463-470. [PMID: 35420387 DOI: 10.1007/s13730-022-00703-4] [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: 02/28/2022] [Accepted: 03/29/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with monoclonal gammopathy of uncertain significance (MGUS) is sometimes associated with renal diseases, usually due to the deposition of secreted monoclonal immunoglobulin or a fragment thereof, a condition which is defined as monoclonal gammopathy of renal significance. Patients with MGUS appear to be at increased risk for various autoimmune conditions. We report the case of a 68-year-old man developed nephritic syndrome and mild renal insufficiency during the course of IgG λ MGUS. Laboratory findings showed hypocomplementemia, cryoglobulinemia, proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA) positivity and monoclonal proteins (λ light chain and λ-Bence-Jones protein) in the urine. A kidney biopsy revealed crescentic glomerulonephritis with mesangial immune deposits without paraproteins. Treatment with prednisolone for ANCA-associated glomerulonephritis, normalized urinalysis and decreased PR3-ANCA but MGUS persisted. This is a rare case of PR3-ANCA-associated glomerulonephritis with comorbid IgG λ MGUS with various pathological paraproteins. We highlight it as a clinical example with diagnostic and therapeutic implications.
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Affiliation(s)
- Masaki Ueno
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Sawako Kobayashi
- Division of Nephrology, Tokyo-Kita Medical Center, Kita-ku, Tokyo, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan.
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15
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Nezam D, Porcher R, Grolleau F, Morel P, Titeca-Beauport D, Faguer S, Karras A, Solignac J, Jourde-Chiche N, Maurier F, Sakhi H, El Karoui K, Mesbah R, Carron PL, Audard V, Ducloux D, Paule R, Augusto JF, Aniort J, Tiple A, Rafat C, Beaudreuil S, Puéchal X, Gobert P, Massy Z, Hanrotel C, Bally S, Martis N, Durel CA, Desbuissons G, Godmer P, Hummel A, Perrin F, Néel A, De Moreuil C, Goulenok T, Guerrot D, Grange S, Foucher A, Deroux A, Cordonnier C, Guilbeau-Frugier C, Modesto-Segonds A, Nochy D, Daniel L, Moktefi A, Rabant M, Guillevin L, Régent A, Terrier B. Kidney Histopathology Can Predict Kidney Function in ANCA-Associated Vasculitides with Acute Kidney Injury Treated with Plasma Exchanges. J Am Soc Nephrol 2022; 33:628-637. [PMID: 35074934 PMCID: PMC8975074 DOI: 10.1681/asn.2021060771] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/24/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Data from the PEXIVAS trial challenged the role of plasma exchange (PLEX) in ANCA-associated vasculitides (AAV). We aimed to describe kidney biopsy from patients with AAV treated with PLEX, evaluate whether histopathologic findings could predict kidney function, and identify which patients would most benefit from PLEX. METHODS We performed a multicenter, retrospective study on 188 patients with AAV and AKI treated with PLEX and 237 not treated with PLEX. The primary outcome was mortality or KRT at 12 months (M12). RESULTS No significant benefit of PLEX for the primary outcome was found. To identify patients benefitting from PLEX, we developed a model predicting the average treatment effect of PLEX for an individual depending on covariables. Using the prediction model, 223 patients had a better predicted outcome with PLEX than without PLEX, and 177 of them had >5% increased predicted probability with PLEX compared with without PLEX of being alive and free from KRT at M12, which defined the PLEX-recommended group. Risk difference for death or KRT at M12 was significantly lower with PLEX in the PLEX-recommended group (-15.9%; 95% CI, -29.4 to -2.5) compared with the PLEX not recommended group (-4.8%; 95% CI, 14.9 to 5.3). Microscopic polyangiitis, MPO-ANCA, higher serum creatinine, crescentic and sclerotic classes, and higher Brix score were more frequent in the PLEX-recommended group. An easy to use score identified patients who would benefit from PLEX. The average treatment effect of PLEX for those with recommended treatment corresponded to an absolute risk reduction for death or KRT at M12 of 24.6%. CONCLUSIONS PLEX was not associated with a better primary outcome in the whole study population, but we identified a subset of patients who could benefit from PLEX. However, these findings must be validated before utilized in clinical decision making.
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Affiliation(s)
- Dorian Nezam
- Service de Néphrologie, Dialyse et Transplantation, CHU de Rouen, France
| | - Raphaël Porcher
- Centre de Recherche Épidémiologie et Statistiques, Université de Paris, Paris, France
| | - François Grolleau
- Centre de Recherche Épidémiologie et Statistiques, Université de Paris, Paris, France
| | - Pauline Morel
- Service de dialyse et aphérèse, AURA Paris Plaisance, Paris, France
| | | | - Stanislas Faguer
- Département de Néphrologie et Transplantation d’organes, Hôpital Rangueil, Toulouse, France
| | - Alexandre Karras
- Service de Néphrologie, Hôpital Européen Georges Pompidou, Université de Paris, Paris, France
| | - Justine Solignac
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception (APHM), Marseille, France
| | - Noémie Jourde-Chiche
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception (APHM), Marseille, France
| | - François Maurier
- Hôpital Belle-Isle, Groupe Hospitalier Associatif UNEOS, Metz, France
| | - Hamza Sakhi
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Creteil, France,Institut National de la Santé et de la Recherche Médicale U955, Institut Mondor de Recherche Biomédicale, Creteil, France
| | - Khalil El Karoui
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Creteil, France,Institut National de la Santé et de la Recherche Médicale U955, Institut Mondor de Recherche Biomédicale, Creteil, France
| | - Rafik Mesbah
- Service de Néphrologie, Centre Hospitalier, Boulogne-sur-mer, France
| | | | - Vincent Audard
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Creteil, France,Institut National de la Santé et de la Recherche Médicale U955, Institut Mondor de Recherche Biomédicale, Creteil, France
| | - Didier Ducloux
- Service de Néphrologie, Dialyse et Transplantation, CHU Besançon, France
| | - Romain Paule
- Service de Médecine Interne, Hôpital Foch, Suresnes, France
| | | | - Julien Aniort
- Service de Néphrologie, Dialyse et Transplantation rénale, CHU Gabriel Montpied, Clermont-Ferrand, France
| | - Aurélien Tiple
- Service de Néphrologie, CHU Jacques Lacarin, Vichy, France
| | - Cédric Rafat
- Unité de Néphrologie, Transplantation Rénale, Hôpital Tenon (Assistance Publique des Hôpitaux de Paris), Paris, France
| | - Séverine Beaudreuil
- Service de Néphrologie, Dialyse et Transplantation rénale, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Xavier Puéchal
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Pierre Gobert
- Service de Médecine Interne et Immunologie clinique, Clinique Rhône Durance, Avignon, France
| | - Ziad Massy
- Département de Néphrologie, Hôpital Ambroise Paré, Boulogne Billancourt, France
| | - Catherine Hanrotel
- Service de Néphrologie, Dialyse et Transplantation rénale, Hôpital La Cavale Blanche, Brest, France
| | - Stéphane Bally
- Service de Néphrologie Dialyse, Centre Hospitalier Métropole Savoie, Chambery, France
| | | | - Cécile-Audrey Durel
- Service de Médecine, Interne Hôpital Edouard Herriot, Hospices civils de Lyon, France
| | | | - Pascal Godmer
- Service de Médecine Interne, CHBA site de Vannes, Vannes, France
| | - Aurélie Hummel
- Service de Néphrologie et Transplantation Rénale, Hôpital Necker-Enfants Malades (Assistance Publique des Hôpitaux de Paris), Paris, France
| | | | - Antoine Néel
- Service de Médecine Interne, CHU de Nantes, France
| | | | - Tiphaine Goulenok
- Service de Médecine Interne, Hôpital Bichat (Assistance Publique des Hôpitaux de Paris), Paris, France
| | - Dominique Guerrot
- Service de Néphrologie, Dialyse et Transplantation, CHU de Rouen, France
| | - Steven Grange
- Service de Réanimation médicale, CHU Charles Nicolle, Rouen, France
| | - Aurélie Foucher
- Service de Médecine Interne, CHU site Sud Saint-Pierre, Saint-Pierre, France
| | - Alban Deroux
- Service de Médecine Interne, CHU de Grenoble, France
| | - Carole Cordonnier
- Service d’anatomie et de cytologie pathologiques, Hôpital Nord, CHU d’Amiens, France
| | - Céline Guilbeau-Frugier
- Service d’anatomie pathologique et histologie-cytologie, Hôpital de Rangueil-Larrey, CHU Toulouse, Toulouse, France
| | - Anne Modesto-Segonds
- Service d’anatomie pathologique et histologie-cytologie, Hôpital de Rangueil-Larrey, CHU Toulouse, Toulouse, France
| | - Dominique Nochy
- Service d’Anatomie et Cytologie Pathologiques, Hôpital Européen Georges Pompidou (Assistance Publique des Hôpitaux de Paris), Paris, France
| | - Laurent Daniel
- Service d’Anatomie et cytologie pathologiques, Hôpital La Timone (APHM), Marseille, France
| | - Anissa Moktefi
- Assistance Publique des Hôpitaux de Paris, Department of Pathology, Groupe Hospitalier Henri-Mondor 94010 Creteil, France
| | - Marion Rabant
- Department of Pathology, Necker Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Loïc Guillevin
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Alexis Régent
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
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16
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Windpessl M, Bettac EL, Gauckler P, Shin JI, Geetha D, Kronbichler A. ANCA Status or Clinical Phenotype - What Counts More? Curr Rheumatol Rep 2021; 23:37. [PMID: 33909191 PMCID: PMC8081707 DOI: 10.1007/s11926-021-01002-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW There is ongoing debate concerning the classification of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. That is, whether classification should be based on the serotype (proteinase 3 (PR3)- or myeloperoxidase (MPO)-ANCA) or on the clinical phenotype (granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)). To add clarity, this review focused on integration of the most recent literature. RECENT FINDINGS Large clinical trials have provided evidence that a serology-based risk assessment for relapses is more predictive than distinction based on the phenotype. Research conducted in the past decade indicated that a serology-based approach more closely resembles the genetic associations, the clinical presentation (i.e., lung involvement), biomarker biology, treatment response, and is also predicting comorbidities (such as cardiovascular death). Our review highlights that a serology-based approach could replace a phenotype-based approach to classify ANCA-associated vasculitides. In future, clinical trials and observational studies will presumably focus on this distinction and, as such, translate into a "personalized medicine."
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Affiliation(s)
- Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstrasse 42, 4600, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Erica L Bettac
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Avenue, Vancouver, WA, USA
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Avello A, Fernandez-Prado R, Santos-Sanchez-Rey B, Rojas-Rivera J, Ortiz A. Slo-Mo anti-neutrophil cytoplasmic antibody-associated renal vasculitis. Clin Kidney J 2021; 14:18-22. [PMID: 33564403 PMCID: PMC7857803 DOI: 10.1093/ckj/sfaa181] [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: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/14/2022] Open
Abstract
Nephrologists are familiar with severe cases of anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) presenting as rapidly progressive glomerulonephritis. However, less is known about AAV with slowly progressive renal involvement. While its existence is acknowledged in textbooks, much remains unknown regarding its relative frequency versus more aggressive cases as well as about the optimal therapeutic approach and response to therapy. Moreover, this uncommon presentation may be underdiagnosed, given the scarce familiarity of physicians. In this issue of Clinical Kidney Journal, Trivioli et al. report the largest series to date and first systematic assessment of patients with AAV and slowly progressive renal involvement, defined as a reduction in estimated glomerular filtration rate (eGFR) of 25-50% in the 6 months prior to diagnosis after excluding secondary causes. Key findings are that slowly progressive AAV may be less common than previously thought, although it still represents the second most common presentation of renal AAV, it usually has a microscopic polyangiitis, anti-myeloperoxidase, mainly renal phenotype in elderly individuals, diagnosis may be late (over one-third of patients had end-stage kidney disease at diagnosis), clearly identifying an unmet need for physician awareness about this presentation, but those not needing renal replacement therapy at diagnosis still responded to immunosuppression.
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Affiliation(s)
- Alejandro Avello
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Raul Fernandez-Prado
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Begoña Santos-Sanchez-Rey
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Jorge Rojas-Rivera
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Alberto Ortiz
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
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