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Sachez-Alamo B, Moi L, Bajema I, Berden A, Flossmann O, Hruskova Z, Jayne D, Wester-Trejo M, Wallquist C, Westman K. Long-term outcome of kidney function in patients with ANCA-associated vasculitis. Nephrol Dial Transplant 2024; 39:1483-1493. [PMID: 38268409 PMCID: PMC11361807 DOI: 10.1093/ndt/gfae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Kidney involvement is common in anti-neutrophil cytoplasm antibody-associated vasculitis (AAV) and the prognosis is determined by the severity of kidney damage. This study focused on long-term kidney outcomes, defining possible risk factors and comparing the performance of three different histological classifications to predict outcomes for patients with AAV. METHODS The dataset included 848 patients with newly diagnosed AAV who participated in seven randomized controlled trials (RCTs) (1995-2012). Follow-up information was obtained from questionnaires sent to the principal investigators of the original RCTs. RESULTS The cumulative incidence of end-stage kidney disease (ESKD) at 5 and 10 years was 17% and 22%, respectively. Patients who developed ESKD had reduced patient survival compared with those with preserved kidney function (hazard ratio 2.8, P < .001). Comparing patients with AAV and kidney involvement with a matched general population, patients with AAV had poor survival outcomes, even in early stages of chronic kidney disease. The main cause of death was infection followed by cardiovascular disease in patients developing ESKD and malignancy in those who did not. Some 34% of patients with initial need for dialysis recovered kidney function after treatment. Thirty-five out of 175 in need of kidney replacement therapy (KRT) during follow-up received a kidney transplant with good outcome; there was 86% patient survival at 10 years.In the subcohort of 214 patients with available kidney biopsies, three scoring systems were tested: the Berden classification, the Renal Risk Score and the Mayo Clinic Score. The scores highlighted the importance of normal glomeruli and severe glomerulosclerosis on kidney survival (P < .001 and P = .001, respectively). The Renal Risk Score demonstrated a moderate prediction of kidney survival (area under the curve 0.79; standard error 0.03, 95% confidence interval 0.71-0.83). CONCLUSIONS Early diagnosis of AAV is extremely important. Even milder forms of kidney involvement have an impact on the prognosis. Patients in need of KRT had the lowest survival rates, but kidney transplantation has shown favorable outcomes for eligible AAV patients. The three histologic scoring systems were all identified as independent prognostic factors for kidney outcome.
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Affiliation(s)
- Beatriz Sachez-Alamo
- Department of Clinical Sciences Lund, Division of Nephrology, Lund University, Sweden
- Department Nephrology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
| | - Laura Moi
- Division of Immunology and Allergy Department of Medicine, University Hospital of Lausanne, Lausanne University, Lausanne, Switzerland
| | | | - Annelies Berden
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Zdenka Hruskova
- Department of Nephrology, General Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Maria Wester-Trejo
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Carin Wallquist
- Department of Nephrology, Skane Univ. Hospital Malmö, Malmö, Sweden
| | - Kerstin Westman
- Department of Clinical Sciences Lund, Division of Nephrology, Lund University, Lund, Sweden
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2
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Cody E, Hooper DK. Kidney transplantation in pediatric patients with rheumatologic disorders. Curr Opin Pediatr 2022; 34:234-240. [PMID: 34954727 DOI: 10.1097/mop.0000000000001100] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Providers caring for children with end-stage kidney disease from rheumatologic conditions face questions such as when to proceed with kidney transplantation, how common is disease recurrence posttransplant, how does recurrent disease impact patient and allograft outcomes, and what approaches are available to prevent and treat recurrent disease. We discuss recent developments and relevant literature that address these questions for the most common rheumatologic disorders that lead to end-stage kidney disease in childhood namely, systemic lupus erythematosus, IgA nephropathy, IgA Vasculitis/Henoch Schoenlein Purpura, and Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis. RECENT FINDINGS Recent data suggest that children with IgA nephropathy, IgA vasculitis, and ANCA-associated vasculitis have similar patient and allograft survival to other conditions despite the risk of recurrent disease, yet those with lupus have worse posttransplant patient and allograft outcomes. A period of disease quiescence may be prudent prior to transplantation to decrease the risk of recurrence, which is associated with decreased allograft survival. Data on preventive strategies and treatment options are limited. SUMMARY It is recommended that patients with systemic rheumatologic conditions not be excluded from kidney transplantation but that patients be counseled on the risk of potential recurrent disease with its impact on transplant outcomes.
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Affiliation(s)
- Ellen Cody
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center
| | - David K Hooper
- Division of Nephrology and Hypertension, Department of Pediatrics, Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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3
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Binda V, Favi E, Calatroni M, Moroni G. Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis in Kidney Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1325. [PMID: 34946270 PMCID: PMC8708576 DOI: 10.3390/medicina57121325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 01/30/2023]
Abstract
Due to complex comorbidity, high infectious complication rates, an elevated risk of relapsing for primary renal disease, as well as inferior recipient and allograft survivals, individuals with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAVs) are often considered as poor transplant candidates. Although several aspects of recurrent and de novo AAVs remain unclear, recent evidence suggests that kidney transplantation (KT) represents the best option, which is also the case for this particular subgroup of patients. Special counselling and individualized approaches are strongly recommended at the time of enlistment and during the entire post-transplant follow-up. Current strategies include avoiding transplantation within one year of complete clinical remission and thoroughly assessing the recipient for early signs of renal or systemic vasculitis. The main clinical manifestations of allograft AAV are impaired kidney function, proteinuria, and hematuria with ANCA positivity in most cases. Mixed results have been obtained using high-dose steroids, mycophenolate mofetil, or cyclophosphamide. The aim of the present review was to summarize the available literature on AAVs in KT, particularly focusing on de novo pauci-immune glomerulonephritis.
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Affiliation(s)
- Valentina Binda
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Evaldo Favi
- Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy; (M.C.); (G.M.)
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy; (M.C.); (G.M.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
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4
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De Souza LM, Ghahramani N, Abendroth C, Kaur G. Evaluating a Living Donor With Rheumatoid Arthritis for a Recipient With End-Stage Renal Disease From Antineutrophil Cytoplasmic Antibodies Associated Vasculitis. Cureus 2021; 13:e18117. [PMID: 34692328 PMCID: PMC8527875 DOI: 10.7759/cureus.18117] [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] [Accepted: 09/17/2021] [Indexed: 11/30/2022] Open
Abstract
A 60-year-old Caucasian female with sero-positive rheumatoid arthritis (RA) was evaluated as a potential kidney donor for her brother-in-law with end-stage kidney disease (ESKD) secondary to c-antineutrophil cytoplasmic antibody (c-ANCA) associated vasculitis (AAV) and membranous nephropathy (MN). With little to no data supporting or contradicting this unique scenario, in addition to the varying viewpoints expressed by the different specialists, our multidisciplinary transplant committee encountered a difficult decision of whether to approve a candidate with RA for a living kidney donation or not. As a result, we carried out a careful literature review addressing aspects of recipients' outcomes following kidney transplants from a living donor with RA, especially when the recipient has AAV, living donor's short- and long-term outcomes post kidney donation, renal disease in AAV and RA, and maintenance of disease remission.
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Affiliation(s)
- Luisa M De Souza
- Medicine, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | | | | | - Gurwant Kaur
- Nephrology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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5
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Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a small to medium vessel vasculitis associated with excess morbidity and mortality. This review explores how management of AAV has evolved over the past two decades with pivotal randomized controlled trials shaping the management of induction and maintenance of remission. Contemporary AAV care is characterized by approaches that minimize the cumulative exposure to cyclophosphamide and glucocorticoids, increasingly use rituximab for remission induction and maintenance, and consider therapies with less toxicity (for example, methotrexate, mycophenolate mofetil) for manifestations of AAV that do not threaten organ function or survival. Simultaneously, improvements in outcomes, such as renal and overall survival, have been observed. Additional trials and observational studies evaluating the comparative effectiveness of agents for AAV in various patient subgroups are needed. Prospective studies are necessary to assess the effect of psychosocial interventions on patient reported outcomes in AAV. Despite the expanding array of treatments for AAV, little guidance on how to personalize AAV care is available to physicians.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eli M Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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6
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Kidney transplantation in ANCA-associated vasculitis. J Nephrol 2019; 32:919-926. [DOI: 10.1007/s40620-019-00642-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 08/14/2019] [Indexed: 02/04/2023]
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7
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Face Transplantation for Granulomatosis With Polyangiitis (Wegener Granulomatosis). Ann Plast Surg 2019; 82:320-329. [DOI: 10.1097/sap.0000000000001735] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Wallace ZS, Wallwork R, Zhang Y, Lu N, Cortazar F, Niles JL, Heher E, Stone JH, Choi HK. Improved survival with renal transplantation for end-stage renal disease due to granulomatosis with polyangiitis: data from the United States Renal Data System. Ann Rheum Dis 2018; 77:1333-1338. [PMID: 29760156 DOI: 10.1136/annrheumdis-2018-213452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/20/2018] [Accepted: 04/21/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Renal transplantation is the optimal treatment for selected patients with end-stage renal disease (ESRD). However, the survival benefit of renal transplantation among patients with ESRD attributed to granulomatosis with polyangiitis (GPA) is unknown. METHODS We identified patients from the United States Renal Data System with ESRD due to GPA (ESRD-GPA) between 1995 and 2014. We restricted our analysis to waitlisted subjects to evaluate the impact of transplantation on mortality. We followed patients until death or the end of follow-up. We compared the relative risk (RR) of all-cause and cause-specific mortality in patients who received a transplant versus non-transplanted patients using a pooled logistic regression model with transplantation as a time-varying exposure. RESULTS During the study period, 1525 patients were waitlisted and 946 received a renal transplant. Receiving a renal transplant was associated with a 70% reduction in the risk of all-cause mortality in multivariable-adjusted analyses (RR=0.30, 95% CI 0.25 to 0.37), largely attributed to a 90% reduction in the risk of death due to cardiovascular disease (CVD) (RR=0.10, 95% 0.06-0.16). DISCUSSION Renal transplantation is associated with a significant decrease in all-cause mortality among patients with ESRD attributed to GPA, largely due to a decrease in the risk of death to CVD. Prompt referral for transplantation is critical to optimise outcomes for this patient population.
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Affiliation(s)
- Zachary S Wallace
- Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel Wallwork
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Yuqing Zhang
- Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Na Lu
- Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Frank Cortazar
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Renal Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John L Niles
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Renal Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eliot Heher
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John H Stone
- Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hyon K Choi
- Rheumatology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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9
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Outcome of Patients With Small Vessel Vasculitis After Renal Transplantation: National Database Analysis. Transplant Direct 2018; 4:e350. [PMID: 29707620 PMCID: PMC5912015 DOI: 10.1097/txd.0000000000000769] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/22/2018] [Indexed: 12/01/2022] Open
Abstract
Background Small vessel vasculitis commonly affects the kidney and can progress to end-stage renal disease. The goal of this study is to compare outcomes of patients who received a renal transplant as a result of small vessel vasculitis (group A) with those who received kidney transplants because of other causes (group B). Methods This is a retrospective analysis of United Network for Organ Sharing registry data for adult primary kidney transplants from January 2000 to December 2014. Group A patients (N = 2196) were compared with a group B (N = 6588); groups were case matched for age, race, sex, donor type, and year of transplant in a 1:3 ratio. Results Renal and patient survivals were better in the group A (P < 0.001). New-onset diabetes after transplant developed in 8.3% of the group A and 11.3% of group B (P < 0.001). Seventeen (0.8%) patients in group A developed recurrent disease. Of these, 7 patients had graft failure, 3 of which were due to disease recurrence. Group A patients had significantly higher risk of developing posttransplant solid organ malignancies (11.3% vs 9.3%, P = 0.006) and lymphoproliferative disorder (1.3% vs 0.8%, P = 0.026). Independent predictors of graft failure and patient mortality were recipients' morbid obesity, diabetes, age, and dialysis duration (hazard ratio of 1.7, 1.4, 1.1/10 years, and 1.1/year for graft failure, and 1.7, 1.7, 1.6/10 years and 1.1/year for patient mortality, respectively). Conclusions Renal transplantation in patients with has favorable long-term graft and patient outcomes with a low disease recurrence rate. However, they may have a higher risk of developing posttransplant malignancies.
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10
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Noone D, Yeung RSM, Hebert D. Outcome of kidney transplantation in pediatric patients with ANCA-associated glomerulonephritis: a single-center experience. Pediatr Nephrol 2017; 32:2343-2350. [PMID: 28766066 DOI: 10.1007/s00467-017-3749-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/30/2017] [Accepted: 06/26/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Data on kidney transplant outcomes for pediatric patients with end-stage renal disease (ESRD) secondary to anti-neutrophil cytoplasmic antibody glomerulonephritis (ANCA GN), particularly granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), is limited. We describe our experience of kidney transplantation in pediatric ANCA GN patients. METHODS We performed a retrospective review of patients with ANCA GN who developed ESRD and were transplanted at a single center between the years 2000 and 2014. RESULTS Since 2000, there were seven pediatric patients with ANCA GN (four MPA) transplanted. Mean age at ANCA GN diagnosis was 11.8 ± 2.8 (range, 7.2-15.4) years. All seven were ANCA (three anti-PR3/four anti-MPO) positive. Estimated glomerular filtration rate (eGFR) at diagnosis was 11.7 ± 6.3 ml/min/1.73 m2. All received steroids and cyclophosphamide and three (23.3%) received plasma exchange. Six were dialysis dependent by 6 months post diagnosis. Time from diagnosis to transplant was 30 ± 12 (range, 17-48) months. Six of the seven received a deceased donor transplant. All patients received induction therapy and standard maintenance immunosuppression post transplant. Median duration of follow-up post transplantation was 27 months (range, 13-88 months). Median eGFR at last follow-up was 77 ml/min/1.73 m2 (range, 7.9-83.5). One patient lost her transplant to acute cellular rejection following non-adherence to immunosuppression after 21 months of stable transplant function. No patient had recurrence of vasculitis, either renal or extra-renal. CONCLUSIONS Short-term patient and allograft survival in pediatric patients with ESRD secondary to ANCA GN seems excellent, with no recurrence of vasculitis post transplant in this small cohort.
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Affiliation(s)
- Damien Noone
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
| | - Rae S M Yeung
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Diane Hebert
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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11
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O'Shaughnessy MM, Liu S, Montez-Rath ME, Lenihan CR, Lafayette RA, Winkelmayer WC. Kidney Transplantation Outcomes across GN Subtypes in the United States. J Am Soc Nephrol 2016; 28:632-644. [PMID: 27432742 DOI: 10.1681/asn.2016020126] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/28/2016] [Indexed: 12/28/2022] Open
Abstract
Differences in kidney transplantation outcomes across GN subtypes have rarely been studied. From the US Renal Data System, we identified all adult (≥18 years) first kidney transplant recipients (1996-2011) with ESRD attributed to one of six GN subtypes or two comparator kidney diseases. We computed hazard ratios (HRs) for death, all-cause allograft failure, and allograft failure excluding death as a cause (competing risks framework) using Cox proportional hazards regression. Among the 32,131 patients with GN studied, patients with IgA nephropathy (IgAN) had the lowest mortality rates and patients with IgAN or vasculitis had the lowest allograft failure rates. After adjusting for patient- and transplant-related factors, compared with IgAN (referent), FSGS, membranous nephropathy, membranoproliferative GN, lupus nephritis, and vasculitis associated with HRs (95% confidence intervals) for death of 1.57 (1.43 to 1.72), 1.52 (1.34 to 1.72), 1.76 (1.55 to 2.01), 1.82 (1.63 to 2.02), and 1.56 (1.34 to 1.81), respectively, and with HRs for allograft failure excluding death as a cause of 1.20 (1.12 to 1.28), 1.27 (1.14 to 1.41), 1.50 (1.36 to 1.66), 1.11 (1.02 to 1.20), and 0.94 (0.81 to 1.09), respectively. Considering external comparator groups, and comparing with IgAN, autosomal dominant polycystic kidney disease (ADPKD) and diabetic nephropathy associated with higher HRs for mortality [1.22 (1.12 to 1.34) and 2.57 (2.35 to 2.82), respectively], but ADPKD associated with a lower HR for allograft failure excluding death as a cause [0.85 (0.79 to 0.91)]. Reasons for differential outcomes by GN subtype and cause of ESRD should be examined in future research.
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Affiliation(s)
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Colin R Lenihan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
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12
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Hashem AM, Hoffman GS, Gastman B, Bernard S, Djohan R, Hendrickson M, Schwarz G, Doumit G, Gharb BB, Rampazzo A, Zins JE, Siemionow M, Papay F. Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis. Am J Transplant 2016; 16:2213-2223. [PMID: 26876068 DOI: 10.1111/ajt.13751] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/21/2016] [Accepted: 02/06/2016] [Indexed: 01/26/2023]
Abstract
Granulomatosis with polyangiitis (GPA; formerly Wegener's granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten-year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1-year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.
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Affiliation(s)
- A M Hashem
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH.,Department of Plastic Surgery, Cairo University, Cairo, Egypt
| | - G S Hoffman
- Department of Rheumatology, Cleveland Clinic, Cleveland, OH
| | - B Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - S Bernard
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - R Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - M Hendrickson
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - G Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - G Doumit
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - B B Gharb
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - A Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - J E Zins
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - M Siemionow
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - F Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
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14
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O'Shaughnessy MM, Montez-Rath ME, Lafayette RA, Winkelmayer WC. Differences in initial treatment modality for end-stage renal disease among glomerulonephritis subtypes in the USA. Nephrol Dial Transplant 2015; 31:290-8. [PMID: 26610594 DOI: 10.1093/ndt/gfv386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD), while peritoneal dialysis affords certain benefits over hemodialysis. Distributions and determinants of first ESRD treatment modality have not been compared across glomerulonephritis (GN) subtypes. METHODS We identified all adult (18-75 years) patients with ESRD attributed to any of six GN subtypes [focal segmental glomerulosclerosis (FSGS), IgA nephropathy (IgAN), membranous nephropathy (MN), membranoproliferative GN (MPGN), lupus nephritis (LN) and vasculitis] who were first registered in the US Renal Data System (USRDS) between 1996 and 2011. We used multinomial logistic regression--adjusting for temporal, geographic, demographic, socioeconomic and comorbid factors--to determine odds ratios (ORs) with 95% confidence intervals (CIs) for transplantation versus hemodialysis, and for peritoneal dialysis versus hemodialysis, comparing other GN subtypes to IgAN. RESULTS Among the 75 278 patients studied, patients with comparator GN subtypes were significantly less likely than those with IgAN to receive either transplantation or peritoneal dialysis. After adjusting for potentially confounding covariates, patients with comparator primary GN subtypes (FSGS, MN, MPGN) were at least as likely to receive transplantation [FSGS OR 0.98 (95% CI 0.93-1.15), MN OR 1.19 (95% CI 1.01-1.39), MPGN OR 1.08 (95% CI 0.93-1.26)] or peritoneal dialysis [FSGS OR 1.05 (95% CI 0.98-1.12), MN OR 1.30 (95% CI 1.18-1.43), MPGN OR 0.95 (95% CI 0.85-1.06)] as patients with IgAN. Conversely, patients with the secondary GN subtypes LN and vasculitis remained significantly less likely to receive either modality [transplantation OR 0.49 (95% CI 0.43-0.56) for LN and 0.27 (95% CI 0.22-0.34) for vasculitis, peritoneal dialysis OR 0.76 (95% CI 0.70-0.82) for LN and 0.54 (95% CI 0.48-0.60) for vasculitis]. CONCLUSIONS Significant differences in ESRD treatment practice patterns are apparent among GN subtypes. To ensure equitable care for all patients, regardless of GN subtype, reasons for observed disparities should be elucidated and-if appropriate-eliminated.
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Affiliation(s)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
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15
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Kadiyala A, Mathew AT, Sachdeva M, Sison CP, Shah HH, Fishbane S, Jhaveri KD. Outcomes following Kidney transplantation in IgA nephropathy: a UNOS/OPTN analysis. Clin Transplant 2015; 29:911-9. [PMID: 26190417 DOI: 10.1111/ctr.12594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2015] [Indexed: 01/20/2023]
Abstract
This study updates assessment of post-transplant outcomes in IgAN patients in the modern era of immunosuppression. Using UNOS/OPTN data, patients ≥18 yr of age with first kidney transplant (1/1/1999 to 12/31/2008) were analyzed. Multivariable Cox regression models and propensity score-based matching techniques were used to estimate hazard ratios (HRs) for death-censored allograft survival (DCGS) and patient survival in IgAN compared to non-IgAN. Results of multivariable regression were stratified by donor type (living vs. deceased). A total of 107, 747 recipients were included (4589 with IgAN and 103 158 with non-IgAN). Adjusted HR for DCGS showed no significant difference between IgAN and non-IgAN. IgAN had higher patient survival compared to non-IgAN (HR 0.54, 95% CI 0.47-0.62, p < 0.0001 for deceased donors; HR 0.42, 95% CI 0.33-0.54, p < 0.0001 for living donors). Propensity score-matched analysis was similar, with no significant difference in DCGS between matched groups and higher patient survival in IgAN patients compared to non-IgAN group (HR 0.54, 95% CI 0.47, 0.63; p-value <0.0001). IgAN patients with first kidney transplant have superior patient survival and similar graft survival compared to non-IgAN recipients. Results can be used in prognostication and informed decision-making about kidney transplantation in patients with IgAN.
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Affiliation(s)
- Aditya Kadiyala
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | - Anna T Mathew
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | - Mala Sachdeva
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | - Cristina P Sison
- Biostatistics Unit, Feinstein Institute for Medical Research, North Shore-Long Island Jewish Health System, Manhasset, NY, USA.,Department of Molecular Medicine and Department of Population Health, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | - Hitesh H Shah
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA
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16
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Hruskova Z, Geetha D, Tesar V. Renal transplantation in anti-neutrophil cytoplasmic antibody-associated vasculitis. Nephrol Dial Transplant 2014; 30 Suppl 1:i159-63. [PMID: 25324359 DOI: 10.1093/ndt/gfu328] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite major advances in the management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) achieved in the last decades, a large proportion of AAV patients still develop end-stage renal disease. The survival of AAV patients dependent on dialysis is significantly worse compared with dialysis-independent AAV patients, but is comparable to other non-diabetic patients requiring dialysis. Renal transplantation (RTx) is the method of choice among renal replacement therapies and there has been increasing evidence that it is a suitable method with favorable patient- and graft-survival also in AAV patients. It is recommended to perform RTx after ≥12 months of remission, and ANCA positivity at the time of RTx is generally not considered a contraindication. Even though the risk of relapse after RTx is relatively low with current post-transplant immunosuppressive regimens, disease recurrence may occur. Besides cyclophosphamide, rituximab might become a therapeutic alternative for post-transplant AAV recurrence in the near future but its efficacy and safety in this setting needs to be confirmed in larger studies.
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Affiliation(s)
- Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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17
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Beck L, Bomback AS, Choi MJ, Holzman LB, Langford C, Mariani LH, Somers MJ, Trachtman H, Waldman M. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis. Am J Kidney Dis 2013; 62:403-41. [PMID: 23871408 DOI: 10.1053/j.ajkd.2013.06.002] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 06/04/2013] [Indexed: 01/28/2023]
Abstract
Glomerulonephritis (GN) is an important cause of morbidity and mortality in patients of all ages throughout the world. Because these disorders are relatively rare, it is difficult to perform randomized clinical trials to define optimal treatment for many of the specific glomerulopathies. In the absence of high-grade evidence to guide the care of glomerular diseases, in June 2012, KDIGO (Kidney Disease: Improving Global Outcomes) published an international clinical guideline for GN. The Work Group report represents an important review of the literature in this area and offers valid and useful guidelines for the most common situations that arise in the management of patients with glomerular disease. This commentary, developed by a panel of clinical experts convened by the National Kidney Foundation, attempts to put the GN guideline into the context of the US health care system. Overall, we support the vast majority of the recommendations and highlight select areas in which epidemiological factors and medical practice patterns in this country justify modifications and adjustments in order to achieve favorable outcomes. There remain large gaps in our knowledge of the best approaches to treat glomerular disease and we strongly endorse an expanded clinical research effort to improve the health and long-term outcomes of children and adults with GN.
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Affiliation(s)
- Laurence Beck
- Boston University School of Medicine, Boston, MA, USA
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18
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Tang W, Bose B, McDonald SP, Hawley CM, Badve SV, Boudville N, Brown FG, Clayton PA, Campbell SB, Peh CA, Johnson DW. The outcomes of patients with ESRD and ANCA-associated vasculitis in Australia and New Zealand. Clin J Am Soc Nephrol 2013; 8:773-80. [PMID: 23349331 PMCID: PMC3641619 DOI: 10.2215/cjn.08770812] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 12/12/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES This study aimed to evaluate dialysis and transplant outcomes of patients with ESRD secondary to ANCA-associated vasculitis (AAV). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All ESRD patients who commenced renal replacement therapy in Australia and New Zealand between 1996 and 2010 were included. Outcomes were assessed by Kaplan-Meier, multivariable Cox regression, and competing-risks regression survival analyses. RESULTS Of 36,884 ESRD patients, 228 had microscopic polyangiitis (MPA) and 221 had granulomatosis with polyangiitis (GPA). Using competing-risks regression, compared with other causes of ESRD, MPA patients (hazard ratio [HR], 0.89; 95% confidence interval [95% CI], 0.73-1.08; P=0.24) and GPA patients (HR, 0.94; 95% CI, 0.74-1.19; P=0.62) experienced comparable survival on dialysis. Forty-six MPA patients (21%) and 47 GPA (20%) patients received 98 renal allografts. Respective 10-year first graft survival rates in MPA, GPA, and non-AAV patients were 50%, 62%, 70%, whereas patient survival rates were 68%, 85% and 83%, respectively. Compared with non-AAV patients, MPA transplant recipients had higher risks of graft failure (HR, 1.87; 95% CI, 1.07-3.25; P=0.03) and death (HR, 1.94; 95% CI, 1.02-3.69; P=0.04), whereas GPA transplant recipients experienced comparable renal allograft survival (HR, 0.91; 95% CI, 0.43-1.93; P=0.81) and patient survival (HR, 0.58; 95% CI, 0.23-2.27; P=0.58). AAV recurrence was observed in two renal allografts (2%). CONCLUSIONS Compared with ESRD patients without AAV, those with GPA have comparable renal replacement therapy outcomes, whereas MPA patients have comparable dialysis survival but poorer renal transplant allograft and patient survival rates.
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Affiliation(s)
- Wen Tang
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Division of Nephrology, Peking University Third Hospital, Beijing, China
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| | - Bhadran Bose
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| | - Stephen P. McDonald
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology and Transplantation Services, University of Adelaide at Central Northern Adelaide Renal and Transplantation Services, Adelaide, Australia
| | - Carmel M. Hawley
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| | - Sunil V. Badve
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| | - Neil Boudville
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- School of Medicine and Pharmacology, Sir Charles Gairdner Hospital Unit, The University of Western Australia, Perth, Australia
| | - Fiona G. Brown
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Philip A. Clayton
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia; and
- School of Public Health, University of Sydney, Sydney, Australia
| | - Scott B. Campbell
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| | - Chen Au Peh
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology and Transplantation Services, University of Adelaide at Central Northern Adelaide Renal and Transplantation Services, Adelaide, Australia
| | - David W. Johnson
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
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19
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Marco H, Mirapeix E, Arcos E, Comas J, Ara J, Gil-Vernet S, Puig J, Vinyas O, Perello M, Oppenheimer F, Poveda R, Ibernón M, Díaz M, Ballarin J. Long-term outcome of antineutrophil cytoplasmic antibody-associated small vessel vasculitis after renal transplantation. Clin Transplant 2013; 27:338-47. [DOI: 10.1111/ctr.12084] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Helena Marco
- Department of Nephrology; Fundació Puigvert; Barcelona; Spain
| | | | - Emma Arcos
- Organització Catalana de Trasplantament; Barcelona; Spain
| | - Jordi Comas
- Organització Catalana de Trasplantament; Barcelona; Spain
| | - Jordi Ara
- Department of Nephrology; Hospital Germans Trias i Pujol; Barcelona; Spain
| | - Salvador Gil-Vernet
- Department of Nephrology; Hospital Universitari de Bellvitge; Barcelona; Spain
| | - Josep Puig
- Department of Nephrology; Hospital del Mar; Barcelona; Spain
| | - Odette Vinyas
- Department of Immunology; Hospital Clinic; Barcelona; Spain
| | - Manel Perello
- Department of Nephrology; Hospital Universitari Vall d'Hebró; Barcelona; Spain
| | | | - Rafael Poveda
- Department of Nephrology; Hospital Universitari de Bellvitge; Barcelona; Spain
| | - Meritxell Ibernón
- Department of Nephrology; Hospital Germans Trias i Pujol; Barcelona; Spain
| | - Montserrat Díaz
- Department of Nephrology; Fundació Puigvert; Barcelona; Spain
| | - Jose Ballarin
- Department of Nephrology; Fundació Puigvert; Barcelona; Spain
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20
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Almouhawis HA, Leao JC, Fedele S, Porter SR. Wegener's granulomatosis: a review of clinical features and an update in diagnosis and treatment. J Oral Pathol Med 2013; 42:507-16. [PMID: 23301777 DOI: 10.1111/jop.12030] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2012] [Indexed: 01/31/2023]
Abstract
Wegener's granulomatosis (WG) is an idiopathic, systemic inflammatory disease characterized by necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis of upper and lower respiratory tract and kidneys. The condition affects both genders equally, although some inconsistent gender differences have been observed. The aetiology of WG remains unknown although a number of exogenous factors have been suggested to be of aetiological relevance. Most clinical characteristics of this disease are non-specific, making clinical diagnosis challenging. Histopathological examination of lesional and peritoneal tissue is not pathognomonic, but is an essential investigation to confirm the presence of disease and exclude other disorders. At present, despite the increasingly wide range of potential therapies, cyclophosphamide plus corticosteroids remain the most recognized and effective means of inducing and sustaining remission of WG.
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Affiliation(s)
- Hanan A Almouhawis
- Oral Medicine unit, Department of Maxillofacial Medicine and Surgery, UCL Eastman Dental Institute, London, UK
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