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Aqeel F, Geetha D. Kidney Failure in Pauci-immune Crescentic Glomerulonephritis: Rationale for Immunosuppression to Improve Kidney Outcome. Curr Rheumatol Rep 2024; 26:290-301. [PMID: 38709420 DOI: 10.1007/s11926-024-01150-z] [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] [Accepted: 04/26/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE OF REVIEW Pauci-immune crescentic glomerulonephritis is the hallmark finding in ANCA-associated vasculitis (AAV) when the kidneys are affected. The rationale for immunosuppression in AAV is based on the underlying autoimmune nature of the disease. Overall remission rates, kidney outcomes, and the burden of disease have greatly improved since the discovery of various immunosuppressive therapies, but relapses remain common, and a significant proportion of patients continue to progress to end-stage kidney disease. Here, we review the role of immunosuppressive therapies for the treatment of pauci-immune crescentic glomerulonephritis. RECENT FINDINGS Besides the recognized role of B and T cells in the pathogenies of AAV, the focus on the contribution of inflammatory cytokines, neutrophil extracellular traps (NETs), and the complement system allowed the discovery of new therapies. Specifically, the C5a receptor blocker (avacopan) has been approved as a glucocorticoid-sparing agent. Additionally, based on observational data, more clinicians are now using combination therapies during the induction phase. There is also an evolving understanding of the role of plasma exchange in removing ANCA antibodies. Furthermore, the recent development of risk score systems provides physicians with valuable prognostic information that can influence decisions on immunosuppression, although future validation from larger cohorts is needed. The over-activation of various immune pathways plays a significant role in the pathogenesis of pauci-immune crescentic glomerulonephritis in AAV. Immunosuppression is, therefore, an important strategy to halt disease progression and improve overall outcomes. Relapse prevention while minimizing adverse events of immunosuppression is a major long-term goal in AAV management.
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Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Baltimore, MD, USA.
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2
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Zhu K, Lv F, Hou X, Wang F, Pang L, Zhong M. Thrombosis in vasculitis: An updated review of etiology, pathophysiology, and treatment. Heliyon 2024; 10:e30615. [PMID: 38975109 PMCID: PMC11225688 DOI: 10.1016/j.heliyon.2024.e30615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction Thromboembolic disease is a complication of many vasculitides. A common observation is that thromboembolic events coincide with the period of vasculitic disease, but the mechanism by which this occurs remains unclear. Inflammatory thrombosis is now recognized as a symptom of arteritis rheumatic, and vasculitides such as Behçet's syndrome (BS), and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) or giant cell arteritis (GCA). This systematic review aimed to explain recent findings related to etiology, pathophysiology, and treatment methods for BS, AAV, and medium/large-vessel vasculitis. Methods A comprehensive literature search on English sources from PubMed, Scopus, MEDLINE, Science Direct, ProQuest, AIM, CINAHIL, and ELDIS databases was used to find the relevant articles and reports. The relevant papers (having full text) were obtained until June 2023. Two independent reviewers screened the titles and abstracts of the obtained articles, and a third arbitrator resolved disputes between the reviewers. Results and conclusion It is becoming increasingly clear that certain systemic inflammatory diseases, like vasculitis, are linked to a higher risk of both venous and arterial thrombosis. An increased incidence of thromboembolic disease in AAV has been noted, particularly during times of active disease. Growing evidence supports the use of immunosuppression in the management of venous thrombosis in vasculitis. These patients also have a higher risk of developing ischemic disease.
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Affiliation(s)
- Kai Zhu
- Department of Vascular Surgery, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou City, 2530000, China
| | - Feng Lv
- Department of Vascular Surgery, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou City, 2530000, China
| | - Xiangqian Hou
- Department of Vascular Surgery, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou City, 2530000, China
| | - Feng Wang
- Department of Vascular Surgery, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou City, 2530000, China
| | - Linbin Pang
- Department of Vascular Surgery, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou City, 2530000, China
| | - Miqian Zhong
- Department of Hematopathology, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, 2530000, China
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3
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Rachid C, Ijim M, Fikri O, Amro L. Pulmonary Manifestation of Granulomatosis With Polyangiitis: A Challenging Case Presentation. Cureus 2024; 16:e57515. [PMID: 38707101 PMCID: PMC11067564 DOI: 10.7759/cureus.57515] [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: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a rare and potentially life-threatening autoimmune disease characterized by antineutrophil cytoplasmic antibody (ANCA)-associated vasculature inflammation. It presents as a systemic autoimmune disease with necrotizing granulomatous inflammation and pauci-immune small vessel vasculitis. This case initially posed a diagnostic challenge due to its atypical presentation and was misdiagnosed as hypersensitivity pneumonitis. The avian precipitin screening assay was positive in our patient, which may be consistent with bird breeder's lung disease or a non-specific reactivity of the chicken antigen test. However, the presence of positive c-ANCA was pivotal for the GPA diagnosis. Here, we describe in detail the clinical manifestations, diagnostic approach, and treatment of GPA in a 54-year-old female who presented with alveolar hemorrhage, but no renal involvement. Treatment involved the use of high-dose corticosteroids to suppress the autoimmune response. Finally, we discuss the striking response of this unique form of granulomatosis with polyangiitis to corticosteroid treatment and emphasize the importance of early initiation of treatment.
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Affiliation(s)
- Chaynez Rachid
- Pulmonology Department, Laboratoire de Recherche Morpho Sciences, Faculté de Médecine et de Pharmacie de Marrakech, Université Cadi Ayyad, Centre Hospitalier Universitaire (CHU) Mohammed VI, Hôpital Arrazi, Marrakech, MAR
| | - Mohamed Ijim
- Pulmonology Department, Laboratoire de Recherche Morpho Sciences, Faculté de Médecine et de Pharmacie de Marrakech, Université Cadi Ayyad, Centre Hospitalier Universitaire (CHU) Mohammed VI, Hôpital Arrazi, Marrakech, MAR
| | - Oussama Fikri
- Pulmonology Department, Laboratoire de Recherche Morpho Sciences, Faculté de Médecine et de Pharmacie de Marrakech, Université Cadi Ayyad, Centre Hospitalier Universitaire (CHU) Mohammed VI, Hôpital Arrazi, Marrakech, MAR
| | - Lamyae Amro
- Pulmonology Department, Laboratoire de Recherche Morpho Sciences, Faculté de Médecine et de Pharmacie de Marrakech, Université Cadi Ayyad, Centre Hospitalier Universitaire (CHU) Mohammed VI, Hôpital Arrazi, Marrakech, MAR
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4
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Long X, Yang X, Yao S, Wu J. Outcomes of Renal Transplantation in ANCA-Associated Vasculitis. Ann Transplant 2024; 29:e943433. [PMID: 38528671 PMCID: PMC10981353 DOI: 10.12659/aot.943433] [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: 12/08/2023] [Accepted: 02/06/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody-associated vasculitis is characterized by small-vessel inflammation and ANCA-positive serology that often lead to end-stage kidney disease. This study investigated the outcomes of renal transplantation in patients with antineutrophil cytoplasmic antibody-associated vasculitis. MATERIAL AND METHODS A comprehensive search of PubMed, Scopus, and Embase databases was done to retrieve studies that reported on the outcomes of renal transplantation in these patients. Data on mortality, survival, infection, and relapse rates were analyzed. The quality of the included studies was evaluated using the Newcastle-Ottawa Scale for cohort studies. RESULTS Twenty-three retrospective cohort studies were included in this review. Antineutrophil cytoplasmic antibody-associated vasculitis was associated with high post-transplantation mortality rates, with a pooled rate ratio of 11.99 per 100 patient-years, but relatively favorable survival rate (hazard rate of 0.80). After renal transplantation, these patients had elevated infection rates (pooled rate ratio of 52.70 per 100 patient-years), and high risk of relapse (pooled rate ratio of 6.96), emphasizing the importance of vigilant post-transplantation monitoring. CONCLUSIONS End-stage kidney disease patients with vasculitis, undergoing renal transplantation, are at elevated risk of mortality and postoperative infection compared to patients without antineutrophil cytoplasmic antibody-associated vasculitis. The risk of relapse is also high in these patients. However, renal transplantation offers a survival advantage for vasculitis patients who survive the early post-transplantation period.
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Affiliation(s)
- Xiaoqin Long
- Rheumatism Immunity Branch, Huzhou Third Municipal Hospital, The Affiliated Hospital of Huzhou University, Huzhou, Zhejiang, PR Chna
| | - Xiaobing Yang
- Rheumatism Immunity Branch, Huzhou Third Municipal Hospital, The Affiliated Hospital of Huzhou University, Huzhou, Zhejiang, PR Chna
| | - Shudong Yao
- Department of Nephrology, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou, Zhejiang, PR Chna
| | - Jia Wu
- Department of Nephrology, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou, Zhejiang, PR Chna
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Floege J, Jayne DR, Sanders JSF, Tesar V, Rovin BH. KDIGO 2024 Clinical Practice Guideline for the Management of Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. Kidney Int 2024; 105:S71-S116. [PMID: 38388102 DOI: 10.1016/j.kint.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/20/2023] [Indexed: 02/24/2024]
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Koubar SH, Garcia-Rivera A, Mohamed MMB, Hall JE, Hall ME, Hassanein M. Underlying Mechanisms and Treatment of Hypertension in Glomerular Diseases. Curr Hypertens Rep 2024; 26:119-130. [PMID: 37982994 DOI: 10.1007/s11906-023-01287-9] [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] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the underlying mechanisms that lead to hypertension in glomerular diseases and the advancements in treatment strategies and to provide clinicians with valuable insights into the pathophysiological mechanisms and evidence-based therapeutic approaches for managing hypertension in patients with glomerular diseases. RECENT FINDINGS In recent years, there have been remarkable advancements in our understanding of the immune and non-immune mechanisms that are involved in the pathogenesis of hypertension in glomerular diseases. Furthermore, this review will encompass the latest data on management strategies, including RAAS inhibition, endothelin receptor blockers, SGLT2 inhibitors, and immune-based therapies. Hypertension (HTN) and cardiovascular diseases are leading causes of mortality in glomerular diseases. The latter are intricately related with hypertension and share common pathophysiological mechanisms. Hypertension in glomerular disease represents a complex and multifaceted interplay between kidney dysfunction, immune-mediated, and non-immune-mediated pathology. Understanding the complex mechanisms involved in this relationship has evolved significantly over the years, shedding light on the pathophysiological processes underlying the development and progression of glomerular disease-associated HTN, and is crucial for developing effective therapeutic strategies and improving patients' outcomes.
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Affiliation(s)
- Sahar H Koubar
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alejandro Garcia-Rivera
- Department of Nephrology. Hospital General Regional 46, Instituto Mexicano del Seguro Social, Guadalajara, Mexico
| | - Muner M B Mohamed
- Department of Nephrology, Ochsner Health System, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - John E Hall
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
- Mississippi Center for Obesity Research, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael E Hall
- Division of Cardiovascular Disease, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohamed Hassanein
- Division of Nephrology and Hypertension, Department of Medicine, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, USA.
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7
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Hara A, Sada KE, Wada T, Amano K, Dobashi H, Atsumi T, Sugihara T, Hirayama K, Banno S, Murakawa Y, Hasegawa M, Yamagata K, Arimura Y, Makino H, Harigai M. Predictors of damage accrual in patients with antineutrophil cytoplasmic antibody-associated vasculitis: A nationwide prospective study. Mod Rheumatol 2024; 34:382-390. [PMID: 36988333 DOI: 10.1093/mr/road029] [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: 09/22/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES This study elucidated the prognosis and risk factors associated with damage accrual during long-term remission maintenance therapy for patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS We obtained data from 120 patients registered in a nationwide prospective cohort study on remission induction therapy in Japanese patients with AAV and rapidly progressive glomerulonephritis (RemIT-JAV-RPGN), who achieved remission at 24 months after treatment initiation and were followed up for additional 24 months. The primary outcome was the vasculitis damage index (VDI) score at Month 48, and the secondary outcome included risk factors associated with increased total VDI at Month 48. RESULTS The understudied patients comprised 52 men and 68 women aged 68 ± 13 years. Between Months 25 and 48, the patients' survival rate was 95% (114/120). End-stage renal disease developed in seven patients by Month 48, and 64 cases had increased VDI. The multivariable analysis results revealed that oral prednisolone (PSL) doses at Month 24 were associated with damage accrual between Months 24 and 48. CONCLUSIONS VDI accrual was observed in more than half of patients with AAV during maintenance therapy, and increased VDI scores were associated with oral PSL doses 24 months after initiating remission induction therapy in Japan.
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Affiliation(s)
- Akinori Hara
- Department of Hygiene and Public Health, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takahiko Sugihara
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Kouichi Hirayama
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Midori Hasegawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
- Kichijoji Asahi Hospital, Tokyo, Japan
| | | | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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8
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Gisslander K, Rutherford M, Aslett L, Basu N, Dradin F, Hederman L, Hruskova Z, Kardaoui H, Lamprecht P, Lichołai S, Musial J, O'Sullivan D, Puechal X, Scott J, Segelmark M, Straka R, Terrier B, Tesar V, Tesi M, Vaglio A, Wandrei D, White A, Wójcik K, Yaman B, Little MA, Mohammad AJ. Data quality and patient characteristics in European ANCA-associated vasculitis registries: data retrieval by federated querying. Ann Rheum Dis 2024; 83:112-120. [PMID: 37907255 PMCID: PMC10804071 DOI: 10.1136/ard-2023-224571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/16/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES This study aims to describe the data structure and harmonisation process, explore data quality and define characteristics, treatment, and outcomes of patients across six federated antineutrophil cytoplasmic antibody-associated vasculitis (AAV) registries. METHODS Through creation of the vasculitis-specific Findable, Accessible, Interoperable, Reusable, VASCulitis ontology, we harmonised the registries and enabled semantic interoperability. We assessed data quality across the domains of uniqueness, consistency, completeness and correctness. Aggregated data were retrieved using the semantic query language SPARQL Protocol and Resource Description Framework Query Language (SPARQL) and outcome rates were assessed through random effects meta-analysis. RESULTS A total of 5282 cases of AAV were identified. Uniqueness and data-type consistency were 100% across all assessed variables. Completeness and correctness varied from 49%-100% to 60%-100%, respectively. There were 2754 (52.1%) cases classified as granulomatosis with polyangiitis (GPA), 1580 (29.9%) as microscopic polyangiitis and 937 (17.7%) as eosinophilic GPA. The pattern of organ involvement included: lung in 3281 (65.1%), ear-nose-throat in 2860 (56.7%) and kidney in 2534 (50.2%). Intravenous cyclophosphamide was used as remission induction therapy in 982 (50.7%), rituximab in 505 (17.7%) and pulsed intravenous glucocorticoid use was highly variable (11%-91%). Overall mortality and incidence rates of end-stage kidney disease were 28.8 (95% CI 19.7 to 42.2) and 24.8 (95% CI 19.7 to 31.1) per 1000 patient-years, respectively. CONCLUSIONS In the largest reported AAV cohort-study, we federated patient registries using semantic web technologies and highlighted concerns about data quality. The comparison of patient characteristics, treatment and outcomes was hampered by heterogeneous recruitment settings.
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Affiliation(s)
- Karl Gisslander
- Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
| | | | - Louis Aslett
- Department of Mathematical Science, University of Durham, Durham, UK
| | - Neil Basu
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | | | - Lucy Hederman
- ADAPT SFI Centre, School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Zdenka Hruskova
- Department of Nephrology, General University Hospital, Prague, Czech Republic
- First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hicham Kardaoui
- National Referral Center for Rare Systemic Autoimmune Diseases, Hospital Cochin, Paris, France
- Université Paris Cité, Paris, France
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, Universitat zu Lubeck, Lubeck, Germany
| | - Sabina Lichołai
- Division of Molecular Biology and Clinical Genetics, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Declan O'Sullivan
- ADAPT SFI Centre, School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Xavier Puechal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hospital Cochin, Paris, France
- French Vasculitis Study Group, Paris, France
| | - Jennifer Scott
- ADAPT SFI Centre, School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
- Trinity Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Endocrinology, Nephrology and Rheumatology, Skåne University Hospital, Lund, Sweden
| | - Richard Straka
- General University Hospital in Prague, Praha, Czech Republic
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hospital Cochin, Paris, France
- French Vasculitis Study Group, Paris, France
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital, Prague, Czech Republic
- First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Firenze, Italy
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Firenze, Italy
| | - Dagmar Wandrei
- Clinical Trials Unit, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Arthur White
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Krzysztof Wójcik
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Beyza Yaman
- ADAPT SFI Centre, School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Mark A Little
- ADAPT SFI Centre, School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
- Trinity Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Aladdin J Mohammad
- Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
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Russwurm M, Kortus-Goetze B, Maier-Giebing T, Groene HJ, Hoyer J. General prognostic models may neglect vulnerable subgroups in ANCA-associated vasculitis. J Nephrol 2023; 36:2269-2280. [PMID: 37768548 PMCID: PMC10638135 DOI: 10.1007/s40620-023-01726-5] [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: 02/02/2023] [Accepted: 06/30/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND ANCA-associated vasculitis is an organ and life-threatening disease with the highest incidence in elderly patients. However, few studies have focussed on characteristics and treatment outcomes in a direct comparison of elderly and younger patients. METHODS In a retrospective, single-centre, renal biopsy-cohort, patients were dichotomized by age ≥ 65 years to analyse baseline clinical, histological, laboratory and immunological characteristics and outcome differences in elderly and younger patients as regard to mortality, renal recovery from dialysis and eGFR after two years. RESULTS In the biopsy registry, n = 774 patients were identified, of whom 268 were ≥ 65 years old. Among them, ANCA-associated vasculitis was the most prevalent kidney disease (n = 54 ≈ 20%). After a follow-up of 2 years, overall mortality was 13.4%, with 19% and 4% in patients ≥ and < 65 years of age, respectively. While 41% of elderly and 25% of younger patients were dialysis-dependent at the time of biopsy, renal recovery was achieved in 41% and 57% of patients, respectively. The accuracy of prediction differed significantly between the whole cohort and elderly patients as regard to mortality (sensitivity 46% vs. 90%, respectively) and between younger and elderly patients as regard to eGFR (r2 = 0.7 vs. 0.46, respectively). Age-group-wise analysis revealed patients above 80 years of age to have particularly dismal renal outcome and survival. CONCLUSION In our cohort, ANCA-associated vasculitis is the single most frequent histopathological diagnosis among the elderly patients in our cohort. Elderly and younger patients have comparable chances of recovering from dialysis-dependent renal failure, with comparable residual independent kidney function after two years. This study suggests (1) relevant predictors differ between age groups and hence (2) models involving all patients with ANCA-associated vasculitis neglect important features of vulnerable subgroups, i.e., patients above 80 years old.
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Affiliation(s)
- Martin Russwurm
- Centre for Internal Medicine, Renal Division, University Hospital Marburg, Marburg, Germany.
- Institute of Pharmacology, Philipps-University, Marburg, Germany.
| | - Birgit Kortus-Goetze
- Centre for Internal Medicine, Renal Division, University Hospital Marburg, Marburg, Germany
| | - Tanja Maier-Giebing
- Centre for Internal Medicine, Renal Division, University Hospital Marburg, Marburg, Germany
| | - Hermann-Josef Groene
- Institute of Pharmacology, Philipps-University, Marburg, Germany
- Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Joachim Hoyer
- Centre for Internal Medicine, Renal Division, University Hospital Marburg, Marburg, Germany
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10
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Zhang S, Chen X, Hou Z, Xia P, Shi X, Wu H, Wen Y, Qin Y, Tian X, Chen L. Renal Outcomes in Older Adults with Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis: A New Prediction Model. Am J Nephrol 2023; 54:399-407. [PMID: 37708862 DOI: 10.1159/000533512] [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: 04/05/2023] [Accepted: 08/07/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Older patients with antineutrophil cytoplasmic autoantibody-associated vasculitis (AAV) commonly experience renal impairment and poor prognoses. This study aimed to establish a risk-scoring system for predicting composite renal outcomes in older patients with AAV. METHODS This retrospective observational study included all patients with AAV hospitalized in a single-center tertiary hospital in China between January 2013 and April 2022. Patients aged ≥65 years were defined as older adults and short-term composite renal outcomes included a ≥25% reduction in estimated glomerular filtration rate (eGFR) (for AKI), renal replacement therapy, provision of renal replacement therapy (long-term dialysis, kidney transplant, or sustained eGFR <15 mL/min/1.73 m), or all-cause mortality. Patients were randomly divided into development and validation cohorts (2:1). Logistic regression analysis was performed in the development cohort to analyze risk factors. The scoring system was established accordingly and further validated in the validation cohort. RESULTS 1,203 patients were enrolled in the study, among whom the older adult group accounted for 36% with a mean age of 71. The older adult group had a worse prognosis, a higher mortality rate, a higher rate of end-stage renal disease, and worsening renal function. Logistic regression showed that age >75 years, chronic heart disease, and elevated serum creatinine and D-dimer values were risk factors for poor prognosis in patients with AAV. The development and validation cohorts in patients with AAV produced area under the curve values of 0.82 (0.78-0.86) and 0.83 (0.77-0.89), respectively. CONCLUSION We established a risk-scoring system based on baseline clinical characteristics to predict composite renal outcomes in patients with AAV. Our results suggest that more attention should be paid to older patients with severe renal impairment and active inflammation.
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Affiliation(s)
- Shuo Zhang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xin Chen
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China,
| | - Zuoxian Hou
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Peng Xia
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaoxiao Shi
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haiting Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yubing Wen
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yan Qin
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Limeng Chen
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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11
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Aqeel F, Xu L, Salas A, Wen Y, Eid SM, Geetha D. Outcomes of remission induction therapy for ANCA-associated vasculitis in the elderly. Clin Rheumatol 2023; 42:2427-2435. [PMID: 37225927 PMCID: PMC11128295 DOI: 10.1007/s10067-023-06644-2] [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: 01/25/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Treatment regimens combining glucocorticoids with cyclophosphamide or rituximab or both are used to induce remission in ANCA-associated glomerulonephritis (ANCA-GN). There is a paucity of data on the efficacy and safety of these regimens in elderly patients with ANCA-GN. This study aimed to examine outcomes and adverse events in elderly AAV patients with three induction regimens: cyclophosphamide (CYC), cyclophosphamide and rituximab (CYC + RTX), and rituximab (RTX). METHODS This single-center retrospective cohort study included patients 60 years and older diagnosed with ANCA-GN. Baseline characteristics and outcomes across several clinical parameters were recorded and compared for significance using Kruskal-Wallis test, Chi-squared test, Fisher exact test, univariate, and multivariate logistic regression as appropriate. Cox proportional hazard regression model was used for survival analysis. RESULTS Seventy-five patients were included. The mean (SD) age at diagnosis was 70 (± 6) years. The mean (SD) follow-up duration was 5.17 (± 3.47) years. Remission induction therapy with glucocorticoids plus CYC was used in 25 patients, glucocorticoids plus CYC and RTX in 12 patients, and glucocorticoids plus RTX in 38 patients. RTX-treated patients had a higher baseline estimated glomerular filtration ratio (eGFR) (p = 0.00009). High remission rates were achieved in all groups (100% vs. 100% vs. 94.6% respectively, p = 0.368). The incidence of end-stage renal disease (ESRD) at one year was 8% among all groups (p = 0.999). There was no difference in the number of infections requiring hospitalization (p = 0.822), but a statistical difference in leukopenia was noted (32% vs. 25% vs. 3% respectively, p = 0.005). The use of RTX only was associated with reduced leukopenia (aOR = 0.1, 95% CI = 0.005-0.8) after adjusting for other variables. CONCLUSIONS CYC, CYC + RTX, and RTX are equally effective for remission induction in elderly patients with ANCA-GN. Induction therapy with RTX only was associated with a lower risk of leukopenia compared to CYC-containing regimens. Infections requiring hospitalization were similar among all groups. End-stage kidney disease at one year was comparable among the 3 groups. Key Points • Cyclophosphamide, Rituximab, and Cyclophosphamide+Rituximab are equally effective in remission induction in elderly patients with ANCA glomerulonephritis. • The use of Rituximab only was associated with a lower risk of bone marrow suppression compared to Cyclophosphamide only. • More information is needed on the comparative safety of induction therapy strategies in elderly ANCA glomerulonephritis patients.
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Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Lillian Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio Salas
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yumeng Wen
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaker M Eid
- Department of Internal Medicine, Division of Hospitalist Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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12
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Baqir M, Singam NS, DuBrock H. Pulmonary hypertension in ANCA-associated vasculitis: a retrospective analysis. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2023; 40:e2023020. [PMID: 37382075 PMCID: PMC10494752 DOI: 10.36141/svdld.v40i2.13631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 05/27/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Little is known about pulmonary hypertension (PH) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). OBJECTIVES The aims of this retrospective study, in which echocardiography was used for detection of PH, were to identify the potential causes of PH in AAV and to analyze the risk factors for mortality. METHODS We performed a retrospective descriptive review of 97 patients who had AAV with PH at our institution from January 1, 1997, through December 31, 2015. These patients with PH were compared with 558 patients who had AAV without PH. Demographic and clinical data were abstracted from electronic health records. RESULTS Among the patients who had PH, 61% were men; mean (SD) age was 70.5 (14.1) years at the time of PH diagnosis. The majority of patients with PH (73.2%) had more than 1 potential cause of PH, with left heart disease and chronic lung disease being the most common causes. Older age, male sex, smoking history, and kidney involvement were associated with the presence of PH. PH was associated with an increased risk of death (hazard ratio, 3.15; 95% CI, 2.37-4.18). On multivariate analysis, PH, age, smoking status, and kidney involvement were independent risk factors for death. Median survival after the diagnosis of PH was 25.9 months (95% CI, 12.2-49.9). CONCLUSIONS PH in AAV is often multifactorial, is commonly associated with left heart disease, and is associated with a poor prognosis.
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Affiliation(s)
- Misbah Baqir
- Pulmonary Medicine Department, Mayo Clinic Rochester MN USA.
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13
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Outcomes in ANCA-associated vasculitis patients with end-stage kidney disease on renal replacement therapy-A meta-analysis. Semin Arthritis Rheum 2023; 60:152189. [PMID: 36931168 DOI: 10.1016/j.semarthrit.2023.152189] [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: 11/26/2022] [Revised: 02/11/2023] [Accepted: 02/27/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND End-stage kidney disease (ESKD) is associated with poor prognosis in patients with anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This study summarizes the existing evidence regarding outcomes in AAV patients with ESKD on renal replacement therapy. METHODS Searches of the MEDLINE and Embase databases were performed from inception until December 2021. Any study reporting outcomes after ESKD in patients with AAV on haemodialysis or peritoneal dialysis was included. The mortality rate per 100 person-years (100 py) calculated with a random-effects meta-analysis model was the primary outcome. Rates of infections and relapses were secondary outcomes. RESULTS 2470 citations were found; 22 studies of 952 adult patients with over 3600 person-years of follow-up were included. The pooled mortality rate was 10.90 per 100 py (95% CI: 7.11 - 14.68, I2 = 90.8%). The pooled 1-year survival was 80.9% (95% CI: 75.6 - 86.1%, I2 = 86.1%) while the pooled 5-year survival was 61.0% (95% CI: 46.0 - 76.0%, I2 = 0.0%). The pooled severe infection rate was 66.57 per 100 py (95% CI: 13.64 - 119.50, I2 = 99.6%). The pooled relapse rate was 6.22 per 100 py (95% CI: 4.64 - 7.80, I2 = 46.6%). Only 1 paediatric study met the inclusion criteria and reported a mortality rate of 11.7 ± 1.9 deaths per 100 py (95% CI: 0.23 - 23.20) amongst 9 patients. CONCLUSIONS Patients with AAV and ESKD have a lower risk of relapse, but higher infection and mortality rates. More prospective research exploring the role of immunosuppression after ESKD is needed.
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14
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Barroso Hernández S, Rodríguez Sabillón JA, Álvarez López Á, García de Vinuesa Calvo E, Calvo Cano A, Robles Pérez-Monteoliva NR. [Cytomegalovirus disease in immunosuppressed patients with necrotizing pauci-immune glomerulonephritis]. Med Clin (Barc) 2023; 160:199-202. [PMID: 36031453 DOI: 10.1016/j.medcli.2022.07.009] [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: 02/23/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Renal involvement due to necrotizing pauci-immune glomerulonephritis (PIGN) associated with small vessel vasculitis requires the use of immunosuppressive. Associated side effects include an increased risk of infectious processes, such as cytomegalovirus (CMV) disease; therefore, there are no recommendations on its management in the various clinical practice guidelines (CPG). OBJECTIVE To study the incidence of CMV disease and its determinants. PATIENTS AND METHODS Patients with histological diagnosis of necrotizing pauci-immune glomerulonephritis in the last 10 years, who were determined the viral load of CMV, analyzing the determinants of its occurrence. RESULTS Forty-four biopsies were performed during the study period. Eleven patients (25%) developed CMV disease; all had received immunosuppressive treatment. Four (30.8%) died during admission. The determinants of CMV disease were age (for every 10 years OR: 3.0, 95% CI: 1.0-8.9, p = 0.012), and plasma albumin (for each g/L OR: 0.8, 95% CI: 0.6-1.0, p = 0.012). CONCLUSIONS The incidence of CMV disease in immunocompromised patients due to PIGN is high, with high mortality. It would be necessary to include strategies in the CPGs to prevent it.
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Affiliation(s)
| | | | | | | | - Antonia Calvo Cano
- Unidad de Patología Infecciosa, Hospital Universitario de Badajoz, Badajoz, España
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15
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Thietart S, Beinse G, Smets P, Karras A, Philipponnet C, Augusto JF, El Karoui K, Mesbah R, Titeca-Beauport D, Hamidou M, Carron PL, Maurier F, Sacre K, Cohen P, Liozon E, Blanchard-Delaunay C, Kostianovsky A, Pagnoux C, Mouthon L, Guillevin L, Terrier B, Puéchal X. Patients of 75 years and over with ANCA-associated vasculitis have a lower relapse risk than younger patients: A multicentre cohort study. J Intern Med 2022; 291:350-363. [PMID: 34755398 DOI: 10.1111/joim.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) in older patients. We aim to study relapse risk of granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) in patients diagnosed after 75 years and compare it with those of patients aged 65-75 years. METHODS Data from AAV patients aged ≥65 years were extracted from the French Vasculitis Study Group (FVSG) database and from a call for observation to FVSG members. Cox and Fine-Gray models were used to assess relapse risk, taking death into account either as a censoring or a competing event, respectively. RESULTS The analysis included 219 patients aged ≥75 years (median 79) and 80 patients aged 65-75 years (median 70), of those 155 had GPA (52%), 136 MPA (45%), with 95 (32%) anti-proteinase 3 positivity and 179 (61%) anti-myeloperoxidase. Patients aged ≥75 years had a lower relapse risk in multivariate analysis (cause-specific hazards ratio [CSHR] 0.54, 95% CI [0.33-0.89], p = 0.016, Cox model; subdistribution hazard ratio [SHR] 0.46, 95% CI [0.29-0.74], p = 0.001, Fine-Gray model) after taking into account vasculitis type. Patients aged ≥75 years had a lower probability of being treated for remission maintenance with a combination of glucocorticoids and immunosuppressants (vs. glucocorticoids alone, HR 0.28, 95% CI [0.11-0.68], p = 0.005) after adjusting to Five Factor Score, although relapse-free survival was significantly longer when receiving such combination (CSHR 0.40, 95% [CI 0.24-0.67], p < 0.001). CONCLUSIONS AAV patients ≥75 years have a lower relapse risk than patients aged 65-75 years despite a lower probability of having received maintenance therapy with a combination of glucocorticoids and immunosuppressants, but they still benefit from such treatment regimen.
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Affiliation(s)
- Sara Thietart
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Guillaume Beinse
- Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université INSERM, Team Personalized Medicine, Pharmacogenomics and Therapeutic Optimization (MEPPOT), Paris, France
| | - Perrine Smets
- Department of Internal Medicine, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Carole Philipponnet
- Department of Nephrology, Centre Hospitalier Universitaire, Clermont-Ferrand, France
| | - Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, Centre Hospitalier Universitaire, Angers, France
| | - Khalil El Karoui
- Department of Nephrology and Renal transplantation, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Rafik Mesbah
- Department of Nephrology, Centre Hospitalier, Boulogne-sur-Mer, France
| | | | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | - Pierre-Louis Carron
- Department of Nephrology-Dialysis-Transplantation, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France
| | - François Maurier
- Department of Internal Medicine and Immunology, Groupe Hospitalier UNEOS, Metz-Vantoux, France
| | - Karim Sacre
- Department of Internal Medicine, Hôpital Bichat, Université de Paris, Assistance Publique Hôpitaux de Paris, INSERM U1149, Paris, France
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Eric Liozon
- Department of Internal Medicine and Clinical Immunology, Dupuytren University Hospital, Limoges, France
| | | | - Alex Kostianovsky
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,APHP-CUP, Hôpital Cochin, Université de Paris, Paris, France
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- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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16
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Native kidney biopsies in older adults: disease spectrum, long-term kidney and patient survival and safety. Int Urol Nephrol 2022; 54:2365-2373. [DOI: 10.1007/s11255-022-03143-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
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17
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Wu X, Zhong Y, Meng T, Ooi JD, Eggenhuizen PJ, Tang R, Nie W, Xiao X, Sun J, Ao X, Zhang H. Patient Survival Between Hemodialysis and Peritoneal Dialysis Among End-Stage Renal Disease Patients Secondary to Myeloperoxidase-ANCA-Associated Vasculitis. Front Med (Lausanne) 2022; 8:775586. [PMID: 35118086 PMCID: PMC8804699 DOI: 10.3389/fmed.2021.775586] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/16/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A significant proportion of anti-neutrophil cytoplasmic antibody (ANCA) associated glomerulonephritis eventually progresses to end-stage renal disease (ESRD) thus requiring long-term dialysis. There is no consensus about which dialysis modality is more recommended for those patients with associated vasculitis (AAV-ESRD). The primary objective of this study was to compare patient survival in patients with AAV-ESRD treated with hemodialysis (HD) or peritoneal dialysis (PD). METHODS This double-center retrospective cohort study included dialysis-dependent patients who were treated with HD or PD. Clinical data were collected under standard format. The Birmingham vasculitis activity score (BVAS) was used to evaluate disease activity at diagnosis and organ damage was assessed using the vasculitis damage index (VDI) at dialysis initiation. RESULTS In total, 85 patients were included: 64 with hemodialysis and 21 with peritoneal dialysis. The patients with AAV-PD were much younger than the AAV-HD patients (48 vs. 62, P < 0.01) and more were female (76.2 vs. 51.6%, P = 0.05). The laboratory data were almost similar. The comorbidities, VDI score, and immuno-suppressive therapy at dialysis initiation were almost no statistical difference. Patient survival rates between HD and PD at 1 year were 65.3 vs. 90% (P = 0.062), 3 year were 59.6 vs. 90% (P < 0.001), and 5 years were 59.6 vs. 67.5% (P = 0.569). The overall survival was no significant difference between the two groups (P = 0.086) and the dialysis modality (HD or PD) was not shown to be an independent predictor for all-cause death (hazard ratio (HR) 0.73; 95% confidence interval (CI) 0.31-1.7; P = 0.473). Cardio-cerebrovascular events were the main cause of death among AAV-HD patients while infection in patients with AAV-PD. CONCLUSION These results provide real-world data that the use of either hemodialysis or peritoneal dialysis modality does not affect patient survival for patients with AAV-ESRD who need long-term dialysis.
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Affiliation(s)
- Xueqin Wu
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yong Zhong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Joshua Daniel Ooi
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China.,Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Peter J Eggenhuizen
- Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Rong Tang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Wannian Nie
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Sun
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Ao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Hao Zhang
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, China
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18
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Intapiboon P, Siripaitoon B. Thai Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Outcomes and Risk Factors for Mortality. J Clin Rheumatol 2021; 27:e378-e384. [PMID: 32568951 DOI: 10.1097/rhu.0000000000001456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) have an increased risk of premature death. Different subtypes, predictors, and ethnicities may affect the overall survival. However, the overall survival of Thai AAV patients has not been reported. We examined the mortality and prognosis of these patients. METHODS This medical record review study included adult AAV patients, admitted to Songklanagarind Hospital from 2007 to 2017. Antineutrophil cytoplasmic antibody-associated vasculitis was diagnosed according to the 1990 American College of Rheumatology criteria or 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Follow-up data were collected until June 2018. Prognostic factors and overall survival were analyzed. RESULTS Among 57 AAV patients, mean (SD) age was 49.3 (16.1) years. Microscopic polyangiitis was the predominant diagnosis (42%). Kidneys (67%) and lungs (65%) were the 2 most affected organs. Initial Birmingham Vasculitis Activity Score (BVAS) greater than 20 was found in 61% of patients. Corticosteroids were the main drugs, and 58% received cyclophosphamide during the induction phase. Overall mean survival time was 38.8 (42.2) months. Patient survival was 91% and 82% at 1 and 6 months, respectively. One-year and 5-year survival rates were 78% and 63%, respectively. Univariate analysis showed that initial BVAS of greater than 20, neutrophil-to-lymphocyte ratio greater than 5.8, and need for invasive ventilator were significant predictors of mortality. Initial BVAS of greater than 20 was the only predictor of death in multivariate analyses (odds ratio, 4.22; 95% confidence interval, 1.01-17.63; p = 0.048). CONCLUSIONS The mortality rate of Thai AAV patients is high and strongly related to high disease activity. An early recognition and referral system are warranted to improve outcomes.
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Affiliation(s)
- Porntip Intapiboon
- From the Allergy and Rheumatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
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19
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Kim HJ, Han M, Song SH, Seong EY. Clinical features and outcomes of elderly patients with antineutrophil cytoplasmic antibody-positive vasculitis: a single-center retrospective study. Kidney Res Clin Pract 2021; 41:209-218. [PMID: 34781636 PMCID: PMC8995490 DOI: 10.23876/j.krcp.21.008] [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: 01/04/2021] [Accepted: 08/07/2021] [Indexed: 11/22/2022] Open
Abstract
Background We aimed to investigate the clinical characteristics and outcomes of patients aged ≥65 years with antineutrophil cytoplasmic autoantibody (ANCA)-positive ANCA-associated vasculitis (AAV) in Korea. Methods Seventy patients diagnosed with ANCA-positive AAV from 2006 to 2019 at a single center were analyzed and categorized into younger (aged <65 years) or elderly (aged ≥65 years) groups. Initial induction treatments were investigated according to age group. All-cause mortality and kidney outcomes were evaluated. Results After categorization by age, 34 (48.6%) and 36 patients (51.4%) were in the younger and elderly groups, respectively. In the elderly group, more patients were treated with oral cyclophosphamide (CYC) (30.6%) than with intravenous CYC (19.4%). During a median follow-up of 14.6 months (range, 3.0–53.1 months), 13 patients died (elderly group: 11 patients, 84.6%). In the elderly group, older age (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.09–1.90; p = 0.01), lower hemoglobin (HR, 0.21; 95% CI, 0.08–0.60; p = 0.003), and higher serum creatinine level (HR 14.17; 95% CI, 1.29–155.84; p = 0.03) were significant risk factors for all-cause mortality after adjustment. Oral CYC + steroid treatment was associated with decreased all-cause mortality compared to untreated induction immunosuppressants (HR, 0.01; 95% CI, 0.001–0.47; p = 0.02). Kidney failure or kidney recovery outcomes were not significantly different between the younger and elderly groups. Conclusion Patients aged ≥65 years had higher mortality rates than younger patients, and mortality was associated with older age, lower hemoglobin, higher serum creatinine level, and nontreatment compared to oral CYC + steroids.
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Affiliation(s)
- Hyo Jin Kim
- Department of Internal Medicine, Pusan National School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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20
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 735] [Impact Index Per Article: 245.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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21
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Boesen EI, Kakalij RM. Autoimmune-mediated renal disease and hypertension. Clin Sci (Lond) 2021; 135:2165-2196. [PMID: 34533582 PMCID: PMC8477620 DOI: 10.1042/cs20200955] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 12/18/2022]
Abstract
Hypertension is a major risk factor for cardiovascular disease, chronic kidney disease (CKD), and mortality. Troublingly, hypertension is highly prevalent in patients with autoimmune renal disease and hastens renal functional decline. Although progress has been made over the past two decades in understanding the inflammatory contributions to essential hypertension more broadly, the mechanisms active in autoimmune-mediated renal diseases remain grossly understudied. This Review provides an overview of the pathogenesis of each of the major autoimmune diseases affecting the kidney that are associated with hypertension, and describes the current state of knowledge regarding hypertension in these diseases and their management. Specifically, discussion focuses on Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN), Immunoglobulin A (IgA) Nephropathy, Idiopathic Membranous Nephropathy (IMN), Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated glomerulonephritis, and Thrombotic Thrombocytopenic Purpura (TTP). A summary of disease-specific animal models found to exhibit hypertension is also included to highlight opportunities for much needed further investigation of underlying mechanisms and novel therapeutic approaches.
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Affiliation(s)
- Erika I Boesen
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
| | - Rahul M Kakalij
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
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Pimentel-Quiroz VR, Sánchez-Torres A, Acevedo-Vásquez E, Gamboa-Cárdenas RV, Reátegui-Sokolova C, Medina-Chinchón M, Zevallos F, Noriega-Zapata E, Alfaro-Lozano J, Cucho-Venegas JM, Sánchez-Schwartz C, Rodríguez-Bellido Z, Perich-Campos R, Pastor-Asurza CA, Alarcón GS, Ugarte-Gil MF. Survival in ANCA-Associated Vasculitides in a Peruvian Center: 28 Years of Experience. J Clin Rheumatol 2021; 27:S252-S258. [PMID: 32833916 DOI: 10.1097/rhu.0000000000001529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The aim of this study was to identify demographic and clinical risk factors for mortality in patients with antineutrophil cytoplasmic antibodies-associated vasculitides (AAVs) in a Peruvian tertiary referral hospital. METHODS Medical records of patients with AAV according to classification criteria or diagnosed by an experienced rheumatologist, covering the period between January 1990 and December 2018, were reviewed. Granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, and renal-limited vasculitis were included. Potential predictors of mortality were demographic factors, clinical manifestations, antineutrophil cytoplasmic antibodies status, diagnosis, disease categorization, the 2009 Five Factor Score (FFS), and treatment. Cox regression models were used to determine the risk factors for mortality. Univariable and multivariable analyses using a backward selection method were performed. RESULTS One hundred ninety-six patients were included; female-to-male ratio was 2:1. The median (interquartile range) age at diagnosis and follow-up were 60.0 (51.0-68.0) and 4.8 (1.3-11.6) years, respectively. One hundred forty-eight patients (75.5%) had microscopic polyangiitis, 37 (18.9%) granulomatosis with polyangiitis, 5 (2.6%) eosinophilic granulomatosis with polyangiitis, and 6 (3.0%) renal-limited vasculitis. Overall survival rates at 1, 5, and 10 years were 83.4%, 68.2%, and 51.7%, respectively. Ocular involvement was protective (hazards ratio [HR], 0.36; 95% confidence interval [CI], 0.17-0.74; p = 0.006), whereas renal (HR, 2.09; 95% CI, 1.33-3.28; p = 0.001) and lung involvement (HR, 2.07; 95% CI, 1.31-3.28; p = 0.002) and the 2009 FFSs were predictive of mortality (2009 FFS = 1: HR, 2.46; 95% CI, 1.50-4.04; p < 0.001; 2009 FFS = 2: HR, 3.07; 95% CI, 1.54-6.10; p = 0.001; 2009 FFS = 3: HR, 13.29; 95% CI, 3.69-47.88; p < 0.001). CONCLUSIONS Ocular involvement was protective, whereas 2009 FFS ≥ 1 and renal and lung involvement were predictive factors of mortality in Peruvian AAV patients.
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Affiliation(s)
| | - Alfredo Sánchez-Torres
- From the Department of Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud
| | | | | | | | | | - Francisco Zevallos
- From the Department of Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud
| | - Erika Noriega-Zapata
- From the Department of Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud
| | - José Alfaro-Lozano
- From the Department of Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud
| | - Jorge M Cucho-Venegas
- From the Department of Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud
| | - César Sánchez-Schwartz
- From the Department of Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud
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Rathmann J, Jayne D, Segelmark M, Jönsson G, Mohammad AJ. Incidence and predictors of severe infections in ANCA-associated vasculitis: a population-based cohort study. Rheumatology (Oxford) 2021; 60:2745-2754. [PMID: 33253372 DOI: 10.1093/rheumatology/keaa699] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/19/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine the incidence rate, predictors and outcome of severe infections in a population-based cohort of ANCA-associated vasculitis (AAV). METHODS The study included 325 cases of AAV (152 female) diagnosed from 1997 through 2016 from a defined geographic area in Sweden. All severe infection events (requiring hospitalization and treatment with intravenous antimicrobials) were identified. The Birmingham vasculitis activity score (BVAS) was used to evaluate disease activity, and organ damage was assessed using the vasculitis damage index (VDI). Patients were followed from time of AAV diagnosis to death or December 2017. RESULTS A total of 129 (40%) patients suffered at least one severe infection. In 2307 person-years (PY) of follow-up, 210 severe infections were diagnosed. The incidence rate of severe infections was 9.1/100 PY and was highest during the first year following AAV diagnosis at 22.1/100 PY (P < 0.001). Pneumonia, sepsis and urinary tract infection were the most common infections. Opportunistic infections constituted only 6% of all severe infections. In Cox regression analysis age and BVAS at diagnosis were the only factors independently predicting severe infection [hazard ratio: 1.54 (P < 0.001) and 1.27 (P = 0.001), respectively]. Severe infection was associated with poorer prognosis with respect to median VDI score 12 months post-AAV diagnosis, renal survival and mortality. Severe infections were the cause of death in 32 patients (22% of all deaths). CONCLUSION . Severe infection is a common problem in AAV, with the most important prognostic factors being older age and high disease activity at diagnosis. Severe infections are associated with permanent organ damage and high mortality.
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Affiliation(s)
- Jens Rathmann
- Division of Rheumatology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mårten Segelmark
- Division of Nephrology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Göran Jönsson
- Division of Infectious Diseases, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Aladdin J Mohammad
- Division of Rheumatology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
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Speer C, Altenmüller-Walther C, Splitthoff J, Nusshag C, Kälble F, Reichel P, Morath C, Zeier M, Bergner R, Schaier M. Cyclophosphamide induction dose and outcomes in ANCA-associated vasculitis with renal involvement: A comparative cohort study. Medicine (Baltimore) 2021; 100:e26733. [PMID: 34398050 PMCID: PMC8294897 DOI: 10.1097/md.0000000000026733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Treatment of ANCA-associated vasculitis (AAV) improved over the last decades but disease-unspecific agents such as cyclophosphamide are still associated with serious adverse events, including high rates of infectious complications and malignancy with increased mortality.In this comparative cohort study, we included 121 AAV patients with renal involvement from 2 German vasculitis centers. Patients were separated into subsequent groups: 2.5 to 3 g vs >3 g cumulative cyclophosphamide induction dose. We investigated if a cyclophosphamide induction dose of 2.5 to 3 g could maintain efficacy while minimizing adverse events in AAV patients with renal involvement.Patients with 2.5 to 3 g vs >3 g cumulative cyclophosphamide (median 3.0 g vs 5.5 g, P < .001) had a comparable time to remission (median 4.0 vs 3.8 months, log-rank P = .87) with 90.6% and 91.5% achieving remission after 12 months. Refractory disease was low in both groups (median 3.6% vs 6.2%, P = .68) and relapse rate did not differ (median 36% vs 42%, log-rank P = .51). Kidney function was comparable at disease onset in both groups (eGFR, mean ± SD 29 ± 20 mL/min/1.73 m2 vs 35 ± 26 mL/min/1.73 m2, P = .34) and improved after 2 years irrespective of the cyclophosphamide dose (ΔeGFR, mean ± SD +8.9 ± 1.4 mL/min/1.73 m2 vs +6.0 ± 1.1 mL/min/1.73 m2, P = .33). The 2.5-3 g group had a lower rate of leukopenia (HR = 2.73 [95% CI, 1.2-6.3], P = .014) and less infectious episodes per patient (median 1.2 vs 0.7, P = .012), especially urinary tract infections (HR = 2.15 [95% CI, 1.1-4.5], P = .032).A cyclophosphamide induction dose of 2.5 to 3 g was able to induce remission and prevent from relapses with fewer cases of leukopenia and less infectious episodes during follow-up. Especially elderly AAV patients who are particularly susceptible to infectious complications could benefit from minimizing dosing regimens with maintained efficacy to control disease activity.
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Affiliation(s)
- Claudius Speer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | | | - Jan Splitthoff
- Clinical Center Ludwigshafen, Department of Internal Medicine A, Ludwigshafen, Germany
| | - Christian Nusshag
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Paula Reichel
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Raoul Bergner
- Clinical Center Ludwigshafen, Department of Internal Medicine A, Ludwigshafen, Germany
| | - Matthias Schaier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
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25
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[ANCA-associated vasculitis in an older male patient]. Z Gerontol Geriatr 2021; 54:451-453. [PMID: 34115174 DOI: 10.1007/s00391-021-01913-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
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26
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Interstitial lung disease with myeloperoxidase-antineutrophil cytoplasmic antibody-associated vasculitis in elderly patients. Rheumatol Int 2021; 41:1641-1650. [PMID: 34056682 DOI: 10.1007/s00296-021-04891-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/14/2021] [Indexed: 11/27/2022]
Abstract
Anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) occurs in elderly people, and patients with anti-myeloperoxidase autoantibodies (MPO-ANCA)-positive AAV are often complicated with interstitial lung disease (ILD). This study aimed to evaluate the age-related clinical features of elderly patients with MPO-ANCA-positive AAV-ILD. This study retrospectively investigated 63 patients with MPO-ANCA-positive AAV-ILD, all of whom were 65 years or older at diagnosis. Clinical characteristics, causes of death and survival rates among three groups stratified by age (65-74 years, n = 29; 75-79 years, n = 18; over 80 years, n = 16) were compared. This study also examined the association with severe infections in these patients. Among the three age groups, there were significant differences in sex (P = 0.032), serum Krebs von den Lungen-6 (P < 0.01), and total ground-glass opacity score (P = 0.011). The causes of death were mainly severe infections and complications of ILD. Kaplan-Meier curve analysis showed a significantly lower 5-year survival rate in the oldest group (P < 0.01). Regarding severe infections in these patients, the 5-year cumulative incidence of severe infections was higher in the patients receiving steroid pulse therapy (P = 0.034). The clinical characteristics of MPO-ANCA-positive AAV-ILD differ with age in elderly patients, with age being an important poor prognostic factor in these patients. The administration of steroid pulse therapy is a significant risk factor of severe infection in MPO-ANCA-positive elderly patients with AAV-ILD.
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27
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Yoo BW, Song JJ, Park YB, Lee SW. Clinical features of Korean elderly patients with antineutrophil cytoplasmic antibody-associated vasculitis. Korean J Intern Med 2021; 36:731-741. [PMID: 32811130 PMCID: PMC8137396 DOI: 10.3904/kjim.2020.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/19/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS We compared the clinical and laboratory data between elderly and non-elderly patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) at diagnosis; further, we investigated the predictors at diagnosis for all-cause mortality and end-stage renal disease (ESRD) occurrence during follow-up in Korean elderly patients with AAV. METHODS We reviewed the medical records of 191 AAV patients regarding clinical manifestations and laboratory results at diagnosis and during follow-up. The follow-up duration was defined as the period from diagnosis to death for deceased patients or to the time of dialysis for ESRD patients, or to the last visit. Elderly (n = 67) and non-elderly (n = 124) patients were grouped based on an age threshold of 65 years. RESULTS At diagnosis, elderly patients exhibited higher median Birmingham Vasculitis Activity Score (BVAS) and higher frequencies of ANCA positivity and pulmonary manifestations than non-elderly patients. Furthermore, elderly patients exhibited increased median white blood cell count, blood urea nitrogen (BUN), alkaline phosphatase, erythrocyte sedimentation rate, and C-reactive protein and decreased median hemoglobin. However, there were no significant differences in all-cause mortality and ESRD occurrence between elderly and non-elderly patients. Meanwhile, elderly patients exhibited lower cumulative patients' and ESRD-free survival rates than non-elderly patients. In the multivariable Cox hazards model, BUN, creatinine and serum albumin at diagnosis were independent predictors for ESRD occurrence, whereas there were no independent predictors at diagnosis for all-cause mortality. CONCLUSION Elderly AAV patients exhibited substantially higher rates of all-cause mortality and ESRD occurrence during follow-up compared than non-elderly AAV patients.
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Affiliation(s)
- Byung-Woo Yoo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
- Correspondence to Sang-Won Lee, M.D. Division of Rheumatology, Department of Internal Medicine, Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1987 Fax: +82-2-393-6884 E-mail:
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28
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Haris Á, Polner K, Arányi J, Braunitzer H, Kaszás I. Incidence and clinical predictors of infections in patients treated with severe systemic ANCA-associated vasculitis. Physiol Int 2021. [PMID: 33769957 DOI: 10.1556/2060.2021.00006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Immunosuppressive therapy has improved the outcome of ANCA-associated vasculitis (AAV), but infectious morbidity and mortality remained high. Recognizing its risk factors seems crucial for prevention, aiming to increase survival of these patients. METHODS We investigated the incidence and types of infections and assessed predictive factors in 132 patients with severe systemic AAV. RESULTS Patients with lower than median incidence of total infections/patient-year during induction had lower baseline serum creatinine, dialysis requirement and Charlson comorbidity index (CCI), compared to those with higher than median incidence (P = 0.037; P = 0.024; P = 0.001; respectively). In subgroups with below and above than median number of severe infections/patient-year during induction, differences were found in baseline creatinine (P = 0.002) and dialysis requirement (P = 0.001); comparing the same cohorts during maintenance immunosuppression, baseline dialysis requirement, diabetes, CCI, and dose of cyclophosphamide (CYC) administered as induction therapy differed significantly (P = 0.019; P = 0.015; P = 0.001; P = 0.015, respectively). Severe infections were predicted by baseline serum creatinine (OR 1.002 [CI 1.001-1.003]) and pulmonary manifestation (OR 2.153 [CI 1.017-4.560]) during induction immunosuppression. In multivariable Cox regression model all-cause mortality was independently predicted by severe infection (HR 1.998 [CI 1.214-3.287]). Among the 168 positive cultures Gram-negative bacteria were responsible for blood stream infections in 33%, and respiratory tract infections in 72%. CONCLUSIONS Advanced renal failure, pulmonary involvement and high degree of comorbidities increase the risk of infection in AAV. Those who suffer infection during induction immunosuppression have worse long-term survival. Our findings indicate the need for high vigilance for infections and close follow-up of comorbidities when treating AAV.
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Affiliation(s)
- Á Haris
- 11st Department of Internal Medicine and Nephrology, Péterfy Hospital and Outpatient Clinic, Budapest, Hungary
| | - K Polner
- 2Nephrology Department, Szent Margit Hospital, Budapest, Hungary
| | - J Arányi
- 2Nephrology Department, Szent Margit Hospital, Budapest, Hungary
| | - H Braunitzer
- 2Nephrology Department, Szent Margit Hospital, Budapest, Hungary
| | - I Kaszás
- 3Pathology Department, Szent Margit Hospital, Budapest, Hungary
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The risk factors for early mortality and end-stage renal disease in anti-neutrophil cytoplasmic antibody-associated glomerulonephritis: experiences from a single center. Clin Exp Med 2021; 21:389-397. [PMID: 33768341 DOI: 10.1007/s10238-021-00690-3] [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: 09/28/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a common disease with high mortality. Kidney involvement in AAV commonly performances as ANCA-associated glomerulonephritis (AAGN). We aimed to identify the risk factors for mortality and end-stage renal disease(ESRD) within 6 months since diagnosis in AAGN patients. A total of 350 AAGN patients were enrolled in our center between 2004 and 2017 retrospectively. We analyzed the demographic, clinical and follow-up data. Factors for mortality and ESRD were investigated with univariate and multivariate Cox regression models. The median follow-up time was 60.8 (IQR 31.2, 84.5) months and 40 (11.4%) patients died within the first 6 months. In the multivariate analysis, age ≥ 65 years (HR = 2.245, 95%CI 1.085-4.645, P = 0.029), high leukocyte counts (HR = 1.089, 95%CI 1.015-1.168, P = 0.018), high Birmingham Vasculitis Activity Score (BVAS) (HR = 1.089, 95%CI 1.017-1.165, P = 0.014), infection (HR = 2.023, 95%CI 1.013-4.042, P = 0.046) and low serum albumin (HR = 0.916, 95%CI 0.845-0.992, P = 0.030) were independent risk factors for all-cause mortality in the first 6 months. A total of 95 patients reached ESRD within the first 6 months. The renal survival rate was 72.9% at 6 months. Multivariate analysis showed that high BVAS (HR = 1.198, 95%CI 1.043-1.376, P = 0.011), high daily urine protein (HR = 1.316, 95%CI 1.046-1.656, P = 0.019) and low eGFR (HR = 0.877, 95%CI 0.804-0.957, P = 0.003) were independent risk factors for ESRD. The mortality and ESRD rates were high in the first 6 months for AAGN patients. High disease activity evaluated by BVAS impacted both on patients' survival and renal survival, while over 65 years of age and infection were risk factors for mortality.
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Monti S, Craven A, Klersy C, Montecucco C, Caporali R, Watts R, Merkel PA, Luqmani R. Association between age at disease onset of anti-neutrophil cytoplasmic antibody-associated vasculitis and clinical presentation and short-term outcomes. Rheumatology (Oxford) 2021; 60:617-628. [PMID: 32447389 DOI: 10.1093/rheumatology/keaa215] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/17/2020] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) can affect all age groups. We aimed to show that differences in disease presentation and 6 month outcome between younger- and older-onset patients are still incompletely understood. METHODS We included patients enrolled in the Diagnostic and Classification Criteria for Primary Systemic Vasculitis (DCVAS) study between October 2010 and January 2017 with a diagnosis of AAV. We divided the population according to age at diagnosis: <65 years or ≥65 years. We adjusted associations for the type of AAV and the type of ANCA (anti-MPO, anti-PR3 or negative). RESULTS A total of 1338 patients with AAV were included: 66% had disease onset at <65 years of age [female 50%; mean age 48.4 years (s.d. 12.6)] and 34% had disease onset at ≥65 years [female 54%; mean age 73.6 years (s.d. 6)]. ANCA (MPO) positivity was more frequent in the older group (48% vs 27%; P = 0.001). Younger patients had higher rates of musculoskeletal, cutaneous and ENT manifestations compared with older patients. Systemic, neurologic,cardiovascular involvement and worsening renal function were more frequent in the older-onset group. Damage accrual, measured with the Vasculitis Damage Index (VDI), was significantly higher in older patients, 12% of whom had a 6 month VDI ≥5, compared with 7% of younger patients (P = 0.01). Older age was an independent risk factor for early death within 6 months from diagnosis [hazard ratio 2.06 (95% CI 1.07, 3.97); P = 0.03]. CONCLUSION Within 6 months of diagnosis of AAV, patients >65 years of age display a different pattern of organ involvement and an increased risk of significant damage and mortality compared with younger patients.
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Affiliation(s)
- Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy
- Experimental Medicine, University of Pavia, Pavia, Italy
| | - Anthea Craven
- NDORMS, Rheumatology Department, University of Oxford, Oxford, UK
| | - Catherine Klersy
- Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | - Roberto Caporali
- Rheumatology, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy
| | - Richard Watts
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Raashid Luqmani
- NDORMS, Rheumatology Department, University of Oxford, Oxford, UK
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Berti A, Felicetti M, Monti S, Ortolan A, Padoan R, Brunori G, Bortolotti R, Caporali R, Montecucco C, Schiavon F, Paolazzi G. Disease and treatment-related morbidity in young and elderly patients with granulomatosis with polyangiitis and microscopic polyangiitis. Semin Arthritis Rheum 2020; 50:1441-1448. [DOI: 10.1016/j.semarthrit.2020.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/26/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
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Mercuzot C, Letertre S, Daien CI, Zerkowski L, Guilpain P, Terrier B, Fesler P, Roubille C. Comorbidities and health-related quality of life in Patients with Antineutrophil Cytoplasmic Antibody (ANCA) - associated vasculitis. Autoimmun Rev 2020; 20:102708. [PMID: 33212227 DOI: 10.1016/j.autrev.2020.102708] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 08/02/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES The optimization of immunosuppressive therapies has led to a marked improvement in the survival of ANCA-associated vasculitides (AAV). The main issue now appears to be the management of comorbidities and the improvement of quality of life. The objective of this review was to investigate the incidence and the impact of AAV-associated comorbidities, as well as the determinants of health-related quality of life (HRQoL). METHODS We performed a systematic literature review of articles published in Medline from 2001 to 04/28/2020. We selected relevant articles about AAV-associated comorbidities as well as HRQoL and fatigue. For each selected article, data on the incidence of comorbidity were extracted, and factors associated with the Mental component score (MCS) and the Physical component score (PCS) were identified. RESULTS Among the 10,993 references identified, 103 were retained for the final analysis. A significant increase in cardiovascular risk was evidenced, particularly for coronary artery disease and thromboembolic events, especially during the active phase of the disease. AAV was also associated with bronchiectasis, thyroid diseases and osteoporosis. A marked decrease in HRQoL and an increase in fatigue and anxiety were reported. Decrease in PCS and MCS was associated with fatigue, mood disorders, sleep disturbance, and/or unemployment. CONCLUSION The excess mortality of AAV is still a concern, partly in connection with cardiovascular and thromboembolic comorbidities. AAV patients also experiment a reduction in their HRQoL that requires integrated management. Patients with AAV need comorbidity management strategies to improve their quality of life and outcomes.
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Affiliation(s)
- Cédric Mercuzot
- Department of Internal medicine, Montpellier University Hospital, Montpellier, France
| | - Simon Letertre
- Department of Internal medicine, Montpellier University Hospital, Montpellier, France
| | - Claire I Daien
- Department of Rheumatology, Montpellier University Hospital, Montpellier, France
| | - Laetitia Zerkowski
- Department of Internal medicine, Montpellier University Hospital, Montpellier, France
| | - Philippe Guilpain
- Internal Medicine: Multi-Organic Diseases, Local Referral Center for Systemic Autoimmune Diseases, Montpellier University Hospital, Montpellier, France; INSERM U 1183, IRMB, Universite Montpellier, INSERM, Montpellier, France
| | - Benjamin Terrier
- Department of Internal Medicine, Cochin University Hospital, Paris, France; National Referral Centre for Systemic and Autoimmune Diseases, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Pierre Fesler
- Department of Internal medicine, Montpellier University Hospital, Montpellier, France; PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, Cedex 5, France
| | - Camille Roubille
- Department of Internal medicine, Montpellier University Hospital, Montpellier, France; PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, Cedex 5, France.
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Sada KE, Ohashi K, Asano Y, Hayashi K, Morishita M, Watanabe H, Matsumoto Y, Fujimoto S, Takasaki Y, Yamagata K, Banno S, Dobashi H, Amano K, Harigai M, Arimura Y, Makino H. Treatment-related damage in elderly-onset ANCA-associated vasculitis: safety outcome analysis of two nationwide prospective cohort studies. Arthritis Res Ther 2020; 22:236. [PMID: 33046139 PMCID: PMC7552473 DOI: 10.1186/s13075-020-02341-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/02/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND It is not elucidated that there is treatment-related damage in elderly patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS Elderly (≥ 75 years of age) patients were enrolled from two nationwide prospective inception cohort studies. The primary outcome was 12-month treatment-related Vasculitis Damage Index (VDI) score. Secondary outcomes included serious infections within 6 months, total VDI score, remission, and relapse. Patient characteristics and outcomes were compared across three different initial glucocorticoid (GC) dose groups: high-dose, prednisolone (PSL) ≥ 0.8 mg/kg/day; medium-dose, 0.6 ≤ PSL < 0.8 mg/kg/day; and low-dose, PSL < 0.6 mg/kg/day. RESULTS Of the 179 eligible patients, the mean age was 80.0 years; 111 (62%) were female. The mean Birmingham Vasculitis Activity Score was 16.1. Myeloperoxidase-ANCA findings were positive in 168 (94%) patients, while proteinase 3-ANCA findings were positive in 11 (6%). The low-dose group was older and had higher serum creatinine levels than the other groups. There were no statistically significant intergroup differences in remission or relapse, whereas serious infection developed more frequently in the high-dose (29 patients [43%]) than the low-dose (13 patients [22%]) or medium-dose (10 patients [19%]) groups (p = 0.0007). Frequent VDI items at 12 months included hypertension (19%), diabetes (13%), atrophy and weakness (13%), osteoporosis (8%), and cataracts (8%). Logistic regression analysis revealed that GC dose at 12 months (odds ratio, 1.14; 95% confidence interval, 1.00-1.35) was a predictor for diabetes. CONCLUSION A reduced initial GC dose with rapid reduction might be required to ensure the safe treatment of elderly AAV patients.
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Affiliation(s)
- Ken-Ei Sada
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan. .,Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Keiji Ohashi
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Yosuke Asano
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Keigo Hayashi
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Michiko Morishita
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Haruki Watanabe
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Yoshinori Matsumoto
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yoshinari Takasaki
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan.,Kichijoji Asahi Hospital, Tokyo, Japan
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McGovern D, Williams SP, Parsons K, Farrah TE, Gallacher PJ, Miller-Hodges E, Kluth DC, Hunter RW, Dhaun N. Long-term outcomes in elderly patients with ANCA-associated vasculitis. Rheumatology (Oxford) 2020; 59:1076-1083. [PMID: 31794032 PMCID: PMC7671635 DOI: 10.1093/rheumatology/kez388] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/01/2019] [Indexed: 01/18/2023] Open
Abstract
Objective ANCA-associated vasculitis (AAV) is a small vessel vasculitis that commonly presents in the elderly. However, there are few long-term outcome data for these patients. Here, we assessed long-term outcomes in a single-centre cohort of elderly patients with AAV. Additionally, we tested whether a pre-morbid frailty score could aid prognosis. Methods Using a prospectively-compiled dataset, we investigated patients over the age of 65 who presented with AAV between 2005 and 2017 to a regional vasculitis centre. We used a Cox model to determine the factors associated with mortality. We also compared outcomes in pre-specified subgroups stratified by baseline frailty score, ANCA serotype and induction immunosuppression (with cyclophosphamide, rituximab or mycophenolate mofetil used as the main glucocorticoid-sparing agent). Results 83 patients were included in the study and were followed for a median of 1203 days. Median age was 74 years (range 65–92). Two- and five-year survival in the overall cohort were 83% (95% CI 75, 92%) and 75% (95% CI 65, 86%), respectively. The median cumulative dose of oral prednisolone was 2030 mg during the first three months. Only one patient received intravenous glucocorticoids. Age, frailty score and CRP at presentation were independently associated with mortality; all deaths occurred in patients aged over 75 at presentation. Patients treated with a cyclophosphamide-based induction regimen tended to be younger than those treated with rituximab or mycophenolate mofetil. Survival was better in the cyclophosphamide-treated group. Conclusion In the contemporary era, the overall prognosis of AAV in elderly patients is good. Baseline frailty associates with disease outcomes including mortality. A low-dose glucocorticoid regimen (avoiding intravenous methylprednisolone) can be used to treat AAV effectively in elderly patients.
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Affiliation(s)
- Dominic McGovern
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh
| | - Sam P Williams
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh
| | - Katrina Parsons
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow
| | - Tariq E Farrah
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh.,University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Peter J Gallacher
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh.,University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Eve Miller-Hodges
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh.,University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - David C Kluth
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh
| | - Robert W Hunter
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh.,University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Neeraj Dhaun
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh.,University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
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Tran TTT, Hara A, Kitagawa K, Kitajima S, Toyama T, Iwata Y, Sakai N, Shimizu M, Kaneko S, Furuichi K, Wada T. Relationship between autoantibodies to erythropoietin receptor and renal outcome in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis. Biomarkers 2020; 25:194-200. [PMID: 32024392 DOI: 10.1080/1354750x.2020.1727014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: We examined the relationship between autoantibodies to erythropoietin receptor (EPOR) and renal outcome in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).Materials and methods: Sixty-three Japanese patients with AAV were enrolled and followed for a median of 31.4 months. Patients were screened for serum anti-EPOR antibodies using an enzyme-linked immunosorbent assay. Associations of anti-EPOR antibodies with clinical parameters were analyzed using logistic-regression models.Results: Anti-EPOR antibodies were detected in 7 (11%) of the 63 patients, and levels of the antibodies decreased with immunosuppressive therapy. The presence of anti-EPOR antibodies was associated with a higher Birmingham vasculitis activity score. In addition, anti-EPOR antibodies were more frequently observed in patients with renal outcomes, which was defined as a sustained 50% reduction in the estimated glomerular filtration rate from baseline, than in those without. Multiple logistic regression analysis revealed that presence of anti-EPOR antibodies, as well as age at disease onset, were as risk factors for the renal outcome.Conclusion: Anti-EPOR antibodies were associated with the progression of renal dysfunction in patients with AAV.
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Affiliation(s)
- Trang Thi Thu Tran
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Akinori Hara
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan.,Department of Environmental and Preventive Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kiyoki Kitagawa
- Division of Nephrology, National Hospital Organization Kanazawa Medical Center, Kanazawa, Japan
| | - Shinji Kitajima
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
| | - Tadashi Toyama
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
| | - Yasunori Iwata
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
| | - Norihiko Sakai
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
| | - Miho Shimizu
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
| | - Shuichi Kaneko
- Department of Disease Control and Homeostasis, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kengo Furuichi
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan.,Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
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Hamroun A, Frimat M, Beuscart JB, Buob D, Lionet A, Lebas C, Daroux M, Provôt F, Hazzan M, Boulanger É, Glowacki F. [Kidney disease care for the elderly]. Nephrol Ther 2019; 15:533-552. [PMID: 31711751 DOI: 10.1016/j.nephro.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.
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Affiliation(s)
- Aghilès Hamroun
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marie Frimat
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | | | - David Buob
- Service d'anatomopathologie, Centre de biologie-pathologie, CHRU de Lille, 59037 Lille, France
| | - Arnaud Lionet
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Céline Lebas
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Maïté Daroux
- Service de néphrologie, hôpital Duchenne, allée Jacques Monod, 62200 Boulogne-sur-Mer, France
| | - François Provôt
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marc Hazzan
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Éric Boulanger
- Service de gériatrie, CHRU de Lille, 59037 Lille, France
| | - François Glowacki
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France.
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Shi J, Shen Q, Chen XM, Du XG. Clinical characteristics and outcomes in microscopic polyangiitis patients with renal involvement: a study of 124 Chinese patients. BMC Nephrol 2019; 20:339. [PMID: 31477033 PMCID: PMC6719371 DOI: 10.1186/s12882-019-1535-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Microscopic polyangiitis (MPA) is a systemic autoimmune disease, and renal involvement is frequently present in MPA. MPA patients with renal involvement may have a worse prognosis. In this study, we aimed to evaluate the prognostic factors associated with all-cause death and renal survival in MPA patients with renal involvement. METHODS A retrospective observational cohort study was performed. One hundred twenty-four patients newly diagnosed with MPA with renal involvement excluding end-stage renal disease (ESRD) who were hospitalized at the First Affiliated Hospital of Chongqing Medical University from January 2012 to July 2017 were included. All the survivors were followed up with until July 2018. The clinical and laboratory data at the time of the initial MPA diagnosis were collected, and the predictive values of the variables for mortality and renal outcome were analysed. RESULTS Among the 124 patients, 52 were men (41.9%) and 72 were women (58.1%), and the age range was from 25 to 85 years (63.9±10.6 years). Seventy-six patients (61.3%) had pulmonary involvement. Multivariate Cox analysis revealed that age≥65 years (HR: 2.437; P=0.021), serum creatinine≥500 μmol/L (HR=2.207; P=0.009) and interstitial lung disease (ILD) (HR=2.366; P=0.013) were associated with mortality. Cox multivariate analysis identified that serum creatinine≥500 μmol/L (HR=8.236; P<0.001) and ILD (HR=2.649; P=0.001) were independent detrimental factors for renal survival, and immunosuppressive treatment was a protective factor for renal survival (HR=0.349; P=0.001). The area under the ROC curve (AUC) of the serum creatinine level at diagnosis was 0.705 for mortality and 0.870 for progression to ESRD or the doubling of serum creatinine. CONCLUSIONS Age, serum creatinine level at diagnosis and ILD were independent predictors of mortality in MPA patients with renal involvement. Serum creatinine level at diagnosis, ILD and immunosuppressive treatment were independently related to renal survival.
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Affiliation(s)
- Jia Shi
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Qing Shen
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Xue-Mei Chen
- Emergency Department, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China
| | - Xiao-Gang Du
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Chongqing, 400042, China.
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Navaratnarajah A, Sambasivan K, Cook TH, Pusey C, Roufosse C, Willicombe M. Predicting long-term renal and patient survival by clinicopathological features in elderly patients undergoing a renal biopsy in a UK cohort. Clin Kidney J 2019; 12:512-520. [PMID: 31384442 PMCID: PMC6672059 DOI: 10.1093/ckj/sfz006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Several publications have demonstrated the use of renal biopsy in elderly patients in establishing a diagnosis and enabling directed therapy. However, evidence on the long-term outcomes following biopsies is lacking. The aim of this study is to describe the renal and patient outcomes in elderly patients according to indication for biopsy, clinical parameters and the histological diagnosis. METHODS We performed a retrospective cohort study of 463 patients >70 years old who underwent a renal biopsy at our centre between 2006 and 2015. RESULTS The median age of the patients was 74.8 (range 70.0-89.6) years. The most frequent primary diagnoses were pauci-immune crescentic glomerulonephritis (GN; 12%), acute interstitial nephritis (10.8%) and membranous GN (7.1%). Death-censored renal survival at 1 and 5 years following the index biopsy was 85.2 and 75.9%, respectively, and patient survival at 1 and 5 years was 92.2 and 71.6%, respectively. Patients who progressed to end-stage renal disease (ESRD) were at higher risk of dying compared with patients who did not require dialysis [hazard ratio 2.41 (95% confidence interval 1.58-3.68; P < 0.001]. On multivariate analysis, factors associated with the risk of progression to ESRD were creatinine (P < 0.001), heavy proteinuria (P = 0.002) and a non-chronic kidney disease (CKD) biopsy indication (P = 0.006). A histological diagnosis of primary GN (P = 0.001) or tubulointerstitial nephritis (P = 0.008) was associated with a favourable renal outcome, while patients with vasculitis and paraprotein-related renal disease (PPRD) had the highest risk of requiring dialysis (P = 0.0002 and P = 0.003, respectively). PPRD was also an independent risk factor for death. CONCLUSIONS This study demonstrates that renal biopsies in the elderly not only enable directed therapy, but also provide prognostic information on renal and patient survival.
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Affiliation(s)
- Arunraj Navaratnarajah
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Khrishanthne Sambasivan
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Terry H Cook
- Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK
- Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Pusey
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK
| | - Candice Roufosse
- Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK
- Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK
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Weiner M, Goh SM, Mohammad AJ, Hrušková Z, Tanna A, Sharp P, Kang A, Bruchfeld A, Selga D, Chocová Z, Westman K, Eriksson P, Harper L, Pusey CD, Tesař V, Salama AD, Segelmark M. Effect of Treatment on Damage and Hospitalization in Elderly Patients with Microscopic Polyangiitis and Granulomatosis with Polyangiitis. J Rheumatol 2019; 47:580-588. [DOI: 10.3899/jrheum.190019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2019] [Indexed: 11/22/2022]
Abstract
Objective.Age is a risk factor for organ damage, adverse events, and mortality in microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). However, the relationship between treatment and damage, hospitalizations, and causes of death in elderly patients is largely unknown.Methods.Consecutive patients from Sweden, the United Kingdom, and the Czech Republic diagnosed between 1997 and 2013 were included. Inclusion criteria were a diagnosis of MPA or GPA and age 75 years or more at diagnosis. Treatment with cyclophosphamide (CYC), rituximab (RTX), and corticosteroids the first 3 months was registered. Outcomes up to 2 years from diagnosis included Vasculitis Damage Index (VDI), hospitalization, and cause of death.Results.Treatment data were available for 167 of 202 patients. At 2 years, 4% had no items of damage. There was a positive association between VDI score at 2 years and Birmingham Vasculitis Activity Score at onset, and a negative association with treatment using CYC or RTX. Intravenous methylprednisolone dose was associated with treatment-related damage. During the first year, 69% of patients were readmitted to hospital. Myeloperoxidase–antineutrophil cytoplasmic antibody positivity and lower creatinine levels decreased the odds of readmission. The most common cause of death was infection, and this was associated with cumulative oral prednisolone dose.Conclusion.Immunosuppressive treatment with CYC or RTX in elderly patients with MPA and GPA was associated with development of less permanent organ damage and was not associated with hospitalization. However, higher doses of corticosteroids during the first 3 months was associated with treatment-related damage and fatal infections.
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Panupattanapong S, Stwalley DL, White AJ, Olsen MA, French AR, Hartman ME. Epidemiology and Outcomes of Granulomatosis With Polyangiitis in Pediatric and Working-Age Adult Populations In the United States: Analysis of a Large National Claims Database. Arthritis Rheumatol 2018; 70:2067-2076. [PMID: 29806148 PMCID: PMC6258356 DOI: 10.1002/art.40577] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 05/24/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The incidence and prevalence of granulomatosis with polyangiitis (GPA) in the US is not well characterized. Owing to its rarity, outcomes data in pediatric-onset GPA are also lacking. The aims of this study were to describe the epidemiology of GPA and outcomes in GPA patients in the US, and to compare outcomes between pediatric and working-age adult patients. METHODS A retrospective cohort study using the 2006-2014 Truven Health Analytics MarketScan Commercial Claims and Encounters Database was conducted. The incidence and prevalence rates of pediatric and adult GPA (age <65 years) were calculated. Outcomes among the 2 age groups were analyzed. RESULTS A total of 5,562 cases of GPA were identified, of which 214 (3.8%) were pediatric onset and 5,348 (96.2%) were adult onset. The incidence rate of pediatric-onset GPA was 1.8 cases per 1 million person-years, compared to 12.8 cases per 1 million person-years in working-age adults. There was a slight female preponderance in both groups (63% and 53% among pediatric and adult GPA patients, respectively). Rates of hospitalization and severe infections were high in both children and working-age adults, but children had more frequent hospitalizations (rate ratio [RR] 1.3 [95% confidence interval (95% CI) 1.1-1.4]) and 2-3-times higher rates of leukopenia (RR 2.6 [95% CI 1.5-4.3]), neutropenia (RR 2.2 [95% CI 1.2-4.0]), and hypogammaglobulinemia (RR 3.7 [95% CI 2.0-6.4]). Time-to-event analyses showed no differences in the time to hospitalization, severe infection, major relapse, or end-stage renal disease. CONCLUSION This study represents the largest cohort of GPA reported to date. Pediatric GPA patients experienced more frequent hospitalizations and were more vulnerable to hematologic complications than non-elderly adult patients.
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Affiliation(s)
| | | | - Andrew J. White
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Margaret A. Olsen
- Division of Infectious Diseases, Department of Medicine
- Division of Public Health Sciences, Department of Surgery
| | | | - Mary E. Hartman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University, St. Louis, MO
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Aging in Primary Systemic Vasculitis: Implications for Diagnosis, Clinical Manifestations, and Management. Drugs Aging 2018; 36:53-63. [DOI: 10.1007/s40266-018-0617-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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42
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Titeca-Beauport D, Francois A, Lobbedez T, Guerrot D, Launay D, Vrigneaud L, Daroux M, Lebas C, Bienvenu B, Hachulla E, Diouf M, Choukroun G. Early predictors of one-year mortality in patients over 65 presenting with ANCA-associated renal vasculitis: a retrospective, multicentre study. BMC Nephrol 2018; 19:317. [PMID: 30413153 PMCID: PMC6234782 DOI: 10.1186/s12882-018-1102-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 10/12/2018] [Indexed: 11/25/2022] Open
Abstract
Background The risk of early death is particularly high in patients over the age of 65 presenting with antineutrophil cytoplasmic antibody (ANCA)-associated renal vasculitis. We hypothesized that by combining disease severity markers, a comorbidity index and serious adverse event reports, we would be able to identify early predictors of one-year mortality in this population. Methods We performed a multicentre, retrospective study in the nephrology and internal medicine departments of six tertiary hospitals in northern France. A total of 149 patients (median [interquartile range (IQR)] age: 72.7 [68.5–76.8] years) presenting with ANCA-associated vasculitis and renal involvement were included between January 2002 and June 2015. The primary endpoint was the one-year mortality rate. Results Renal function was severely impaired at presentation (median [IQR] peak serum creatinine (SCr): 337 [211–522] μmol/l), and 45 patients required dialysis. The Five-Factor Score (FFS, scored as + 1 point for each poor prognostic factor (age > 65 years, cardiac symptoms, gastrointestinal involvement, SCr ≥150 μmol/L, and the absence of ear, nose, and throat involvement)) was ≥3 in 120 cases. The one-year mortality rate was 19.5%. Most of the deaths occurred before month 6, and most of these were related to severe infections. In a univariate analysis, age, a high comorbidity index, a performance status of 3 or 4, a lack of co-trimoxazole prophylaxis, early severe infection, and disease activity parameters (such as the albumin level, haemoglobin level, peak SCr level, dialysis status, and high FFS) were significantly associated with one-year mortality. In a multivariable analysis, the best predictors were a high FFS (relative risk (RR) [95% confidence interval (CI)] = 2.57 [1.30–5.09]; p = 0.006) and the occurrence of a severe infection during the first month (RR [95%CI] = 2.74 [1.27–5.92]; p = 0.01). Conclusions When considering various disease severity markers in over-65 patients with ANCA-associated renal vasculitis, we found that an early, severe infection (which occurred in about a quarter of the patients) is a strong predictor of one-year mortality. A reduction in immunosuppression, the early detection of infections, and co-trimoxazole prophylaxis might help to reduce mortality in this population. Electronic supplementary material The online version of this article (10.1186/s12882-018-1102-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dimitri Titeca-Beauport
- Department of Nephrology, Dialysis and Transplantation, Amiens University Hospital, F-80054, Amiens, France.
| | - Alexis Francois
- Department of Nephrology, Dialysis and Transplantation, Amiens University Hospital, F-80054, Amiens, France
| | - Thierry Lobbedez
- Department of Nephrology, Caen University Hospital, Caen, France.,Registre de Dialyse Péritonéale de Langue Française, Pontoise, France
| | - Dominique Guerrot
- Department of Nephrology, Rouen University Hospital, Rouen, France.,INSERM, U1096, Rouen, France
| | - David Launay
- University of Lille, U995, Lille, France.,Lille Inflammation Research International Center (LIRIC), Lille, France.,Inserm, U995, Lille, France.,Département de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France.,Centre national de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), Lille, France
| | - Laurence Vrigneaud
- Department of Nephrology and Internal Medicine, Valenciennes General Hospital, Valenciennes, France
| | - Maité Daroux
- Department of Nephrology, Duchenne Hospital, Boulogne-sur-Mer, France
| | - Celine Lebas
- Department of Nephrology, Calmette Hospital, Lille University Hospital, Lille, France
| | - Boris Bienvenu
- Department of Internal Medicine, Caen, France.,Normandie Univ, UNICAEN, INSERM, COMETE, Caen, France
| | - Eric Hachulla
- University of Lille, U995, Lille, France.,Lille Inflammation Research International Center (LIRIC), Lille, France.,Inserm, U995, Lille, France.,Département de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France.,Centre national de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), Lille, France
| | - Momar Diouf
- Clinical Research and Innovation Directorate, Amiens University Hospital, Amiens, France
| | - Gabriel Choukroun
- Department of Nephrology, Dialysis and Transplantation, Amiens University Hospital, F-80054, Amiens, France
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ANCA-associated vasculitis (AAV) in the elderly: clinical presentation, treatment and outcomes. Eur Geriatr Med 2018; 9:725-728. [PMID: 34654225 DOI: 10.1007/s41999-018-0093-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To explore treatment and outcomes in older patients with AAV. METHODS Retrospective review (1 year) of patients > 75 years with positive MPO/PR3 antibodies. RESULTS Thirty-nine evaluable patients had new positive MPO/PR3 antibodies. Nine patients had AAV and two possible AAV (2M, 9F mean age 82 years). Nine patients had renal impairment and three died during their presenting admission, all having required dialysis ± plasma exchange. Non-survivors had higher average creatinine (442 vs 265 µmol/L) and more co-morbidities (2 or more co-morbidities vs 0 or 1). All patients deemed fit received treatment, one discontinued (infection). Survival in AAV was 46% at 1 year and 18% at 2 years. 1/3 of positive MPO/PR3 results were not acknowledged in case records by clinicians. CONCLUSIONS Renal involvement is common in elderly patients with AAV. High creatinine, co-morbidity and need for dialysis are associated with a poorer prognosis. Mortality is high but survivors tolerate treatments well.
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Basu N, Karabayas M, Pusey C. Prognosis and future developments in vasculitis. Best Pract Res Clin Rheumatol 2018; 32:148-165. [PMID: 30526894 DOI: 10.1016/j.berh.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/07/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022]
Abstract
The prognosis of ANCA-associated vasculitis has been transformed in recent years. Once it was a set of invariably acute and fatal conditions, but these disorders are currently considered to be chronic diseases. This change is largely attributable to earlier diagnosis and the careful application of immunotherapeutics. However, patients still experience premature mortality, relapse, comorbid ill health and poor quality of life. Mortality rates in large-vessel vasculitis are not comparable; however, morbidity and poor patient outcomes prevail. Toxicity secondary to glucocorticoids represents a common driver of poor outcomes across systemic vasculitis. The main thrust of future treatment strategies is to reduce if not eliminate exposure to these agents.
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Affiliation(s)
- N Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, United Kingdom.
| | - M Karabayas
- Department of Rheumatology, NHS Grampian, United Kingdom
| | - C Pusey
- Department of Medicine, Imperial College London, United Kingdom
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Whatmough S, Fernandez S, Sweeney N, Howell L, Dhaygude A. Comparing outcomes of biopsy-proven anti-neutrophil cytoplasmic autoantibody-associated glomerulonephritis patients treated with cyclophosphamide in the 20th and 21st centuries: a 23-year study. Clin Kidney J 2018; 12:42-48. [PMID: 30746129 PMCID: PMC6366142 DOI: 10.1093/ckj/sfy084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/31/2018] [Indexed: 11/17/2022] Open
Abstract
Background Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is a multisystem autoimmune disorder associated with significant morbidity and mortality. Approximately 80–90% of patients have circulating ANCAs. Long-term outcomes appear to be improving. This retrospective study analyses the incidence and patient outcomes over a period of 23 years at a single tertiary centre. Methods Outcomes of patients diagnosed with AAV between 1 January 1988 and 31 December 2010 were collected retrospectively. Data including patient demographics, age of diagnosis, dates of starting renal replacement therapy, death and biochemistry results were collected. Patients were divided into two cohorts (1988–99 and 2000–10) and analysed using Stata software (StataCorp, College Station, TX, USA). Results A complete dataset was obtained for 273 patients. Of these patients, 101 were diagnosed between 1988 and 1999 while 172 were diagnosed between 2000 and 2010. The number of patients diagnosed with AAV increased from 2.2/million in 1988 to 10.3/million in 2010. A higher proportion of patients (56.4%) in the earlier cohort presented with creatinine >500 μmol/L compared with the later cohort (30.2%; P < 0.001). Overall patient survival improved significantly between the two cohorts. Cohort 1 had a median survival of 59 months compared with 125 months for Cohort 2 (P = 0.003). Conclusions This study shows that AAV is being diagnosed at an earlier stage, resulting in improved outcomes. This may be because of improvements in the management of AAV and chronic kidney disease.
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Affiliation(s)
| | | | - Niamh Sweeney
- Renal Department, Royal Preston Hospital, Preston, UK
| | - Laura Howell
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Preston, UK
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46
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Sato S, Yashiro M, Matsuoka N, Asano T, Kobayashi H, Watanabe H, Migita K. Clinical features and outcomes in patients with elderly-onset anti-neutrophil cytoplasmic antibody-associated vasculitis. Geriatr Gerontol Int 2018; 18:1453-1457. [PMID: 30168252 DOI: 10.1111/ggi.13511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 07/01/2018] [Accepted: 07/14/2018] [Indexed: 11/28/2022]
Abstract
AIM Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is commonly seen in older patients. The present study intended to clarify whether elderly-onset AAV (at age ≥75 years) shows any specific clinical features and outcomes in Japanese patients. METHODS This study was a retrospective cohort study. A total of 36 AAV patients who were initially treated at the Department of Rheumatology, Fukushima Medical University Hospital (Fukushima, Japan) between 2004 and 2016 were included. AAV patients were divided into an elderly group (≥75 years) and a younger group (<75 years), and their clinical records were reviewed. RESULTS Elderly AAV patients showed similar clinical features to younger AAV patients, except that they were more often women, weighed less, had an increased frequency of kidney involvement and had lower serum ferritin levels. Kaplan-Meier analyses showed significantly lower 1-year survival in elderly AAV (P =0.008) as well as AAV patients enrolled not receiving additional immunosuppressive treatment (P =0.023). The cause of death was disease progression itself or infection. CONCLUSIONS The clinical features of AAV are similar between elderly and younger patients, except for increased kidney involvement and lower serum ferritin levels. Proper monitoring of the disease and adverse events, and providing conventional immunosuppressive therapy is suggested to avoid a poor outcome, especially in elderly AAV patients. Geriatr Gerontol Int 2018; 18: 1453-1457.
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Affiliation(s)
- Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Makiko Yashiro
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroko Kobayashi
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
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47
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Misra DP, Naidu GSRSNK, Agarwal V, Sharma A. Vasculitis research: Current trends and future perspectives. Int J Rheum Dis 2018; 22 Suppl 1:10-20. [PMID: 30168260 DOI: 10.1111/1756-185x.13370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/03/2018] [Accepted: 07/25/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Durga P. Misra
- Department of Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS); Lucknow India
| | - Godasi S. R. S. N. K. Naidu
- Department of Internal Medicine; Clinical Immunology and Rheumatology Services; Postgraduate Institute of Medical Education and Research (PGIMER); Chandigarh India
| | - Vikas Agarwal
- Department of Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS); Lucknow India
| | - Aman Sharma
- Department of Internal Medicine; Clinical Immunology and Rheumatology Services; Postgraduate Institute of Medical Education and Research (PGIMER); Chandigarh India
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48
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B cell therapy in ANCA-associated vasculitis: current and emerging treatment options. Nat Rev Rheumatol 2018; 14:580-591. [DOI: 10.1038/s41584-018-0065-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/10/2018] [Indexed: 12/19/2022]
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49
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Prognosis and Histological Classification in Elderly Patients with ANCA-Glomerulonephritis: A Registry-Based Cohort Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7581567. [PMID: 29955611 PMCID: PMC6000915 DOI: 10.1155/2018/7581567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/03/2018] [Accepted: 05/07/2018] [Indexed: 12/03/2022]
Abstract
Background The value of a histologic classification scheme to classify patients with anti-neutrophil cytoplasmic antibody-associated glomerulonephritis (ANCA-GN) into focal, mixed, crescentic, and sclerotic types for predicting risk of end-stage renal disease (ESRD) is well documented. However, the prognostic value of histological classification specifically in elderly patients (≥70 years) with ANCA-GN has not previously been investigated. Methods Patients with biopsy-verified pauci-immune necrotizing glomerulonephritis were identified from the Norwegian Kidney Biopsy Registry between 1991 and 2012 and those ≥70 years of age at the time of diagnosis and having positive anti-neutrophil cytoplasmic antibody serology were included in this study. The incidence rate of ESRD and/or death was determined by linking the study cohort to the Norwegian Renal Registry and the Population Registry of Norway. The ESRD-free survival and patient survival were compared between the 4 histological types. Results Of the 81 patients included, 20 progressed to ESRD and 34 died. The 1-year and 5-year ESRD-free survival varied between histological groups (p = 0.003) as follows: focal, 97% and 97%, respectively; mixed, 70% and 57%; crescentic, 76% and 63%; and sclerotic, 49% and 49%. Patient survival did not differ significantly between groups (p = 0.30). Conclusion Histological classification in elderly patients with ANCA-GN is useful for predicting ESRD but not survival.
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50
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Jardel S, Puéchal X, Le Quellec A, Pagnoux C, Hamidou M, Maurier F, Aumaitre O, Aouba A, Quemeneur T, Subra JF, Cottin V, Sibilia J, Godmer P, Cacoub P, Fauchais AL, Hachulla E, Maucort-Boulch D, Guillevin L, Lega JC. Mortality in systemic necrotizing vasculitides: A retrospective analysis of the French Vasculitis Study Group registry. Autoimmun Rev 2018; 17:653-659. [PMID: 29730524 DOI: 10.1016/j.autrev.2018.01.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/07/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of the study was to describe the evolution of mortality and cause-specific mortality over time in patients with systemic necrotizing vasculitides (SNV), including polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Patients with SNV from the French Vasculitis Study Group registry were divided into 5 groups according to the date of diagnosis: <1980, 1980-1989, 1990-1999, 2000-2010, and ≥ 2010. The causes of death were classified as vasculitis, infection, cardiovascular, malignancy, miscellaneous, or unknown. RESULTS Among the 2217 patients included (PAN 16.1%, GPA 41.7%, EGPA 22.6%, MPA 19.6%), overall incidence of death was 2.26 per 100 person-years. The overall survival improved during each period considered. The 5-year survival rate increased from 72.2% (95% confidence interval [CI] 59.7-87.2) for patients diagnosed before 1980 to 94.5% (95% CI 90.4-98.8) after 2010 (p < 0.001). Periods of diagnosis, age, and male gender were independently associated with a poor survival with a non-significant difference between vasculitis. The incidence of mortality between the 1980s and after 2010 significantly decreased for vasculitis-related (p = 0.03) and cardiovascular-related deaths (p = 0.04). Incidence of death by infection remained stable between the 1980s and the 2000s but no death by infection occurred after 2010. The incidence of death by malignancy remained stable over time. CONCLUSION Overall survival of SNV patients has improved since the 1980s with the decrease of vasculitis- and cardiovascular-related deaths, but cancer-related mortality remained stable. These results highlight malignancy as the current target to improve the overall prognosis.
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Affiliation(s)
- Sabine Jardel
- National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
| | - Xavier Puéchal
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Alain Le Quellec
- Department of Internal Medicine, Centre Hospitalier Régional Universitaire de Montpellier, Hôpital St. Eloi, Montpellier 1 University, Montpellier, France
| | - Christian Pagnoux
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | - François Maurier
- Department of Internal medicine and Clinical Immunology, Site Belle Isle, Metz, France
| | - Olivier Aumaitre
- Department of Internal Medicine, Centre Hospitalier Universitaire, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Achille Aouba
- Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Caen, France
| | - Thomas Quemeneur
- Department of Internal Medicine, Centre Hospitalier, Valenciennes, France
| | - Jean-François Subra
- Department of Internal Medicine, Centre Hospitalier Universitaire d' Angers, Angers, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Jean Sibilia
- Department of Rheumatology, National Reference Center for rare Systemic Autoimmune Diseases, Strasbourg University Hospital, Strasbourg University, Strasbourg, France
| | - Pascal Godmer
- Department of Internal Medicine, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France; INSERM, UMRS 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France
| | - Anne Laure Fauchais
- Department of Internal Medicine, Hôpital Dupuytren, Centre Hospitalier Universitaire de Limoges Limoges University, Limoges, France
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, University of Lille, Lille, France
| | - Delphine Maucort-Boulch
- Department of Biostatistics and bioinformatics, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon Claude Bernard University Lyon 1, Lyon, France
| | - Loïc Guillevin
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Jean-Christophe Lega
- National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France.
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