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Gisslander K, White A, Aslett L, Hrušková Z, Lamprecht P, Musiał J, Nazeer J, Ng J, O'Sullivan D, Puéchal X, Rutherford M, Segelmark M, Terrier B, Tesař V, Tesi M, Vaglio A, Wójcik K, Little MA, Mohammad AJ. Data-driven subclassification of ANCA-associated vasculitis: model-based clustering of a federated international cohort. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00187-5. [PMID: 39182506 DOI: 10.1016/s2665-9913(24)00187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/19/2024] [Accepted: 06/19/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a heterogenous autoimmune disease. While traditionally stratified into two conditions, granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), the subclassification of ANCA-associated vasculitis is subject to continued debate. Here we aim to identify phenotypically distinct subgroups and develop a data-driven subclassification of ANCA-associated vasculitis, using a large real-world dataset. METHODS In the collaborative data reuse project FAIRVASC (Findable, Accessible, Interoperable, Reusable, Vasculitis), registry records of patients with ANCA-associated vasculitis were retrieved from six European vasculitis registries: the Czech Registry of ANCA-associated vasculitis (Czech Republic), the French Vasculitis Study Group Registry (FVSG; France), the Joint Vasculitis Registry in German-speaking Countries (GeVas; Germany), the Polish Vasculitis Registry (POLVAS; Poland), the Irish Rare Kidney Disease Registry (RKD; Ireland), and the Skåne Vasculitis Cohort (Sweden). We performed model-based clustering of 17 mixed-type clinical variables using a parsimonious mixture of two latent Gaussian variable models. Clinical validation of the optimal cluster solution was made through summary statistics of the clusters' demography, phenotypic and serological characteristics, and outcome. The predictive value of models featuring the cluster affiliations were compared with classifications based on clinical diagnosis and ANCA specificity. People with lived experience were involved throughout the FAIRVASVC project. FINDINGS A total of 3868 patients diagnosed with ANCA-associated vasculitis between Nov 1, 1966, and March 1, 2023, were included in the study across the six registries (Czech Registry n=371, FVSG n=1780, GeVas n=135, POLVAS n=792, RKD n=439, and Skåne Vasculitis Cohort n=351). There were 2434 (62·9%) patients with GPA and 1434 (37·1%) with MPA. Mean age at diagnosis was 57·2 years (SD 16·4); 2006 (51·9%) of 3867 patients were men and 1861 (48·1%) were women. We identified five clusters, with distinct phenotype, biochemical presentation, and disease outcome. Three clusters were characterised by kidney involvement: one severe kidney cluster (555 [14·3%] of 3868 patients) with high C-reactive protein (CRP) and serum creatinine concentrations, and variable ANCA specificity (SK cluster); one myeloperoxidase (MPO)-ANCA-positive kidney involvement cluster (782 [20·2%]) with limited extrarenal disease (MPO-K cluster); and one proteinase 3 (PR3)-ANCA-positive kidney involvement cluster (683 [17·7%]) with widespread extrarenal disease (PR3-K cluster). Two clusters were characterised by relative absence of kidney involvement: one was a predominantly PR3-ANCA-positive cluster (1202 [31·1%]) with inflammatory multisystem disease (IMS cluster), and one was a cluster (646 [16·7%]) with predominantly ear-nose-throat involvement and low CRP, with mainly younger patients (YR cluster). Compared with models fitted with clinical diagnosis or ANCA status, cluster-assigned models demonstrated improved predictive power with respect to both patient and kidney survival. INTERPRETATION Our study reinforces the view that ANCA-associated vasculitis is not merely a binary construct. Data-driven subclassification of ANCA-associated vasculitis exhibits higher predictive value than current approaches for key outcomes. FUNDING European Union's Horizon 2020 research and innovation programme under the European Joint Programme on Rare Diseases.
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Affiliation(s)
- Karl Gisslander
- Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden.
| | - Arthur White
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland; ADAPT Centre, Trinity College Dublin, Dublin, Ireland
| | - Louis Aslett
- Department of Mathematical Sciences, Durham University, Durham, UK
| | - Zdenka Hrušková
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Jacek Musiał
- II Chair of Internal Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - James Ng
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | | | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France; French Vasculitis Study Group, Paris, France
| | | | - Mårten Segelmark
- Department of Clinical Sciences, Lund University and Department of Endocrinology, Nephrology and Rheumatology, Skåne University Hospital, Lund, Sweden
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France; French Vasculitis Study Group, Paris, France
| | - Vladimir Tesař
- Department of Nephrology, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Azienda Ospedaliera Universitaria Meyer IRCCS, Florence, Italy
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Azienda Ospedaliera Universitaria Meyer IRCCS, Florence, Italy; Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Krzysztof Wójcik
- II Chair of Internal Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Mark A Little
- ADAPT Centre, Trinity College Dublin, Dublin, Ireland; Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Aladdin J Mohammad
- Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Medicine, University of Cambridge, Cambridge, UK
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Henes J, Richter JG, Thiele K, Kiltz U, Callhoff J, Albrecht K. Trends in health care of patients with vasculitides, including giant cell arteritis, Takayasu arteritis, ANCA-associated vasculitis and Behçet's disease: cross-sectional data of the German National Database 2007-2021. Rheumatol Int 2024; 44:497-507. [PMID: 38180499 PMCID: PMC10866751 DOI: 10.1007/s00296-023-05508-x] [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: 10/20/2023] [Accepted: 11/08/2023] [Indexed: 01/06/2024]
Abstract
The aim of this study is to present the current care situation of patients with giant cell arteritis (GCA), Takayasu arteritis (TAK), ANCA-associated vasculitis (AAV) and Behçet's disease (BD). Trends over the last 15 years will reflect improvements and remaining deficits in the management of vasculitides. Consecutive cross-sectional data from patients with vasculitides from the German National Database (NDB) of the Collaborative Arthritis Centres between 2007 and 2021 were included. Medication, physician- and patient-reported outcomes on disease activity and disease burden, inpatient stays and occupational participation are compared for different vasculitis entities and over time. Employment rates were compared to German population rates. Between 502 and 854 vasculitis patients were annually documented. GCA and AAV were the most common vasculitides. Median disease duration ranged from 2 to 16 years. Over the years, glucocorticoids decreased in proportion and dose, most markedly in GCA and TAK, while biologic therapies increased up to 27%. Physicians rated disease activity as low for the vast majority of patients, while patients-reported moderate outcomes in many dimensions. PROs remained largely unchanged. The proportion of employed patients (< 65 years) increased from 47 to 57%. In recent years, biologics are increasingly used in patients with vasculitides, while glucocorticoids decreased significantly. PRO's have not improved. Work participation increased but remains lower than that in the German population.
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Affiliation(s)
- Jörg Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoimmune Diseases and Internal Medicine II, University Hospital Tübingen, Tübingen, Germany
| | - Jutta G Richter
- Department of Rheumatology, Faculty of Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Faculty of Medicine, Hiller Research Centre Rheumatology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Katja Thiele
- Programme Area Epidemiology and Health Services Research, German Rheumatism Research Centre Berlin, Berlin, Germany
| | - Uta Kiltz
- Ruhr Universität Bochum, Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Johanna Callhoff
- Programme Area Epidemiology and Health Services Research, German Rheumatism Research Centre Berlin, Berlin, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Katinka Albrecht
- Programme Area Epidemiology and Health Services Research, German Rheumatism Research Centre Berlin, Berlin, Germany.
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