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Leacy EJ, Teh JW, O’Rourke AM, Brady G, Gargan S, Conlon N, Scott J, Dunne J, Phelan T, Griffin MD, Power J, Mooney A, Naughton A, Kiersey R, Gardiner M, O’Brien C, Mullan R, Flood R, Clarkson M, Townsend L, O’Shaughnessy M, Dyer AH, Moran B, Fletcher JM, Zgaga L, Little MA. Effect of Immunosuppression on the Immune Response to SARS-CoV-2 Infection and Vaccination. Int J Mol Sci 2024; 25:5239. [PMID: 38791279 PMCID: PMC11120762 DOI: 10.3390/ijms25105239] [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: 04/03/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Immunosuppressive treatment in patients with rheumatic diseases can maintain disease remission but also increase risk of infection. Their response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination is frequently blunted. In this study we evaluated the effect of immunosuppression exposure on humoral and T cell immune responses to SARS-CoV-2 infection and vaccination in two distinct cohorts of patients; one during acute SARS-CoV-2 infection and 3 months later during convalescence, and another prior to SARS-CoV-2 vaccination, with follow up sampling 6 weeks after vaccination. Results were compared between rituximab-exposed (in previous 6 months), immunosuppression-exposed (in previous 3 months), and non-immunosuppressed groups. The immune cell phenotype was defined by flow cytometry and ELISA. Antigen specific T cell responses were estimated using a whole blood stimulation interferon-γ release assay. A focused post-vaccine assessment of rituximab-treated patients using high dimensional spectral cytometry was conducted. Acute SARS-CoV-2 infection was characterised by T cell lymphopenia, and a reduction in NK cells and naïve CD4 and CD8 cells, without any significant differences between immunosuppressed and non-immunosuppressed patient groups. Conversely, activated CD4 and CD8 cell counts increased in non-immunosuppressed patients with acute SARS-CoV-2 infection but this response was blunted in the presence of immunosuppression. In rituximab-treated patients, antigen-specific T cell responses were preserved in SARS-CoV-2 vaccination, but patients were unable to mount an appropriate humoral response.
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Affiliation(s)
- Emma J. Leacy
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland (G.B.)
| | - Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Aoife M. O’Rourke
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, D02 R590 Dublin, Ireland; (A.M.O.)
| | - Gareth Brady
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland (G.B.)
| | - Siobhan Gargan
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, D08 W9RT Dublin, Ireland
| | - Niall Conlon
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Jennifer Scott
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland (G.B.)
| | - Jean Dunne
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Thomas Phelan
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland (G.B.)
| | - Matthew D. Griffin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM SFI Research Centre for Medical Devices, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Julie Power
- Vasculitis Ireland Awareness, Belfast & Dublin, Ireland
| | - Aoife Mooney
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Aifric Naughton
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Rachel Kiersey
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Mary Gardiner
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Caroline O’Brien
- Department of Immunology, St. James’s Hospital, D08 NHY1 Dublin, Ireland (J.D.)
| | - Ronan Mullan
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, D08 W9RT Dublin, Ireland
- Department of Rheumatology, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Rachael Flood
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, D08 W9RT Dublin, Ireland
- Department of Rheumatology, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Michael Clarkson
- Department of Nephrology, Cork University Hospital, T12 DC4A Cork, Ireland
| | - Liam Townsend
- Department of Infectious Diseases, St. James’s Hospital, D08 NHY1 Dublin, Ireland
| | - Michelle O’Shaughnessy
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- Department of Nephrology, Cork University Hospital, T12 DC4A Cork, Ireland
| | - Adam H. Dyer
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland
| | - Barry Moran
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, D02 R590 Dublin, Ireland; (A.M.O.)
| | - Jean M. Fletcher
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, D02 R590 Dublin, Ireland; (A.M.O.)
| | - Lina Zgaga
- Department of Public Health and Primary Care, Institute of Population Health, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Mark A. Little
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland (G.B.)
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Pena C, Costi AC, García L, García M. Severe infections in systemic necrotizing vasculitis. REUMATOLOGIA CLINICA 2024; 20:237-242. [PMID: 38821740 DOI: 10.1016/j.reumae.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/18/2024] [Indexed: 06/02/2024]
Abstract
Infections in patients with systemic vasculitis represent one of the main causes of mortality. Corticosteroid use, immunosuppressive therapy, age, associated organic involvement and dialysis dependence are risk factors of infection. OBJECTIVES To determine the prevalence of severe infection and associated factors in patients diagnosed with ANCA-associated vasculitis (AAV) and Polyarteritis Nodosa (PAN). METHODS retrospective study was conduced in a single rheumatology center (2000-2018). We included patients diagnosed with AAV (Granulomatosis with Polyangiitis (GPA), Eosinophilic Granulomatosis with Polyangiitis (EGPA) and Microscopic Polyangiitis (PAM) and Polyarteritis nodosa (PAN). Serious infectious events requiring hospitalisation or prolonged antibiotic/antiviral treatment, recurrent infection of Herpes Zoster Virus or opportunistic infections were evaluated. Sites of infection, isolated microorganisms and mortality related were analyzed. RESULTS 105 patients were analyzed, follow-up time median 18 m, 58.7% were women and median age was 52 years. Types of vasculitis: 41.9% PAM, 16.2% EPGA, 40% GPA, 1.9% PAN. Constitutional, pulmonary, renal and otorhinolaryngology manifestations were the most frequent. PREVALENCE OF INFECTION 34.2%, with a median of 3 months from diagnosis of vasculitis to the infectious event. Low respiratory tract (42.8%), sepsis (31.4%), and urinary tract (14.3%) were the most common sites of infections. Bacterial aetiology was the most prevalent (67.7%). Mortality at the first event was 14.3% and a 72.2% of patients were in the induction phase of treatment. Infectious events were significantly associated with age > 65 years (p = 0.030), presence of lung (p = 0.016) and renal involvement (p = 0.001), BVASv3 > 15, mortality (p = 0.0002). CONCLUSIONS The prevalence of infection was 34.2%. Lower airway infections, septicemia and urinary tract infections were the most prevalent. Infections were associated with renal and pulmonary involvement, age older than 65 years and score BVAS > 15. Severe infections were associated with mortality, especially in elderly patients.
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Affiliation(s)
- Claudia Pena
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina.
| | - Ana Carolina Costi
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina
| | - Lucila García
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina
| | - Mercedes García
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina
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Baliga S, Yadav S, Sagdeo P, Balakrishnan C. Invasive fungal infection in ANCA-associated vasculitis: Between the Devil and Deep blue sea. Case series and review of the literature. Clin Rheumatol 2024; 43:785-797. [PMID: 37798405 DOI: 10.1007/s10067-023-06785-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/16/2023] [Accepted: 09/23/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are susceptible to opportunistic infections, including invasive fungal infections (IFI). This is due to many factors, including prolonged immunosuppressive therapy. The treatment of AAV with such IFIs is challenging. METHODS A descriptive analysis of 5 patients with AAV complicated by concomitant invasive fungal infections was performed. We also have done a comprehensive literature review of IFIs in AAV using PubMed and Google Scholar databases. RESULTS All 5 patients initially received immunosuppressive medication but subsequently acquired IFI. One patient had sphenoid sinus involvement, and four had lung parenchymal involvement. Aspergillus infection was diagnosed in three patients, Cryptococcus infection in one patient and mixed infection with Aspergillus and Mucor infection in one patient. All our patients were on low doses of corticosteroids for several months to years or had received high-dose pulse steroids with cyclophosphamide in the last few weeks before being diagnosed with IFI. It was difficult to distinguish disease activity from IFI in all the cases. Two of the five patients died despite antifungal therapy. The literature review revealed a prevalence of IFIs ranging from 1 to 9.6% (excluding pneumocystis pneumonia). Aspergillosis was the predominant type of IFI, affecting 46 of 86 patients. Most of these patients (40/46) had pulmonary involvement. The prognosis for patients with IFI was consistently poor, as evidenced by 19 deaths out of 29 reported outcomes. CONCLUSION Overall, IFIs have a poor prognosis in patients with AAV. Differentiating disease activity from IFI is difficult because of similar organ distribution, imaging lesions, and histopathological characteristics. A high suspicion index and good-quality microbiology are needed for early treatment and prevention of mortality.
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Affiliation(s)
- Sahana Baliga
- Department of Rheumatology, PD Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, 400016, India.
| | - Sandeep Yadav
- Department of Rheumatology, PD Hinduja National Hospital and Medical Research Centre, Room No. 1107, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, 400016, India
| | - Parikshit Sagdeo
- Medicure Multispeciality Clinic, Ramdas Peth, Nagpur, Maharashtra, 440012, India
| | - Canchi Balakrishnan
- Department of Rheumatology, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Room no. 2414, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, 400016, India
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Alchi MB, Lever R, Flossmann O, Jayne D. Efficacy and safety of low- versus high-dose glucocorticoid regimens for induction of remission of anti-neutrophil cytoplasm antibody-associated vasculitis: a systematic review and meta-analysis. Scand J Rheumatol 2023; 52:564-573. [PMID: 37339385 DOI: 10.1080/03009742.2023.2211387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/04/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Glucocorticoids (GCs) remain a cornerstone of the initial management of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV), but have several dose-dependent side effects, in particular infections. The optimal dosing and tapering of oral GCs for remission induction are unknown. A systematic review and meta-analysis was undertaken to determine the efficacy and safety of low- versus high-dose GC regimens. METHOD A systematic search of MEDLINE, Embase, and PubMed databases was conducted. Clinical studies using a GC-based induction protocol were selected. A daily dose of 0.5 mg/kg or < 30 mg/day oral prednisolone equivalent by the start of week 4 of the induction tapering schedule marked the threshold between high- and low-dose GCs. Risk ratios (RRs) were calculated by the random effects model for outcomes of remission and infection. Relapse events were summarized using risk differences with 95% confidence intervals (CIs). RESULTS In total, 1145 participants were included in three randomized controlled trials and two observational studies, of whom 543 were assigned to the low-dose GC group and 602 to the high-dose GC group. A low-dose GC regimen was non-inferior to high-dose GCs with respect to outcomes of remission (RR 0.98, 95% CI 0.95-1.02, p = 0.37; I2 = 0%) and relapse (risk difference 0.03, 95% CI -0.01 to 0.06, p = 0.15; I2 = 12%), while significantly reducing the incidence of infection (RR 0.60, 95% CI 0.39-0.91, p = 0.02; I2 = 65%). CONCLUSION Studies with low-dose GC regimens in AAV are associated with fewer infections while obtaining equivalent efficacy.
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Affiliation(s)
- M B Alchi
- School of Pharmacy, University College London, London, UK
| | - R Lever
- School of Pharmacy, University College London, London, UK
| | - O Flossmann
- Berkshire Kidney Unit, Royal Berkshire Hospital, Reading, UK
| | - D Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Yamaguchi M, Sugiyama H, Nobata H, Kinashi H, Asai A, Kitamura F, Katsuno T, Ando M, Kubo Y, Banno S, Ito Y, Ishimoto T. Lymphopenia is a risk factor for severe infections in older patients with microscopic polyangiitis: a retrospective cohort study in Japan. Rheumatol Adv Pract 2023; 7:rkad073. [PMID: 37692053 PMCID: PMC10483030 DOI: 10.1093/rap/rkad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/17/2023] [Indexed: 09/12/2023] Open
Abstract
Objective Previous studies have identified the predictors of severe infections in ANCA-associated vasculitis. However, lymphopenia has not been fully evaluated as a predictor of subsequent severe infections in patients with microscopic polyangiitis (MPA). The aim of this study was to assess the association between lymphopenia and severe infections requiring hospitalization after receiving immunosuppressive therapy for MPA. Methods This single-centre retrospective cohort study included 130 consecutive patients with newly diagnosed MPA from Aichi Medical University Hospital, Japan, who received immunosuppressive therapy between March 2004 and December 2020. The relationship between lymphopenia and subsequent severe infections was assessed using time-dependent multivariate Cox proportional hazard models adjusted for clinically relevant factors. Results During the follow-up period (median: 38 months; interquartile range: 15-63 months), 56 severe infectious episodes occurred in 51 patients (39.2%). Time-dependent multivariate Cox proportional hazard analyses identified older age [adjusted hazard ratio (HR) = 1.74 per 10 years, 95% CI: 1.13, 2.67], methylprednisolone pulse therapy (adjusted HR = 2.04, 95% CI: 1.03, 4.02), moderate lymphopenia (vs normal, adjusted HR = 7.17, 95% CI: 3.10, 16.6) and severe lymphopenia (vs normal, adjusted HR = 36.1, 95% CI: 11.8, 110.9) as significant predictors of severe infection. Conclusion Lymphopenia is a predictor of subsequent severe infections in patients with MPA who receive immunosuppressive therapy. These results suggest the importance of sustained infection surveillance, particularly in older patients who develop lymphopenia during strong immunosuppressive therapy.
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Affiliation(s)
- Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hirokazu Sugiyama
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Akimasa Asai
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Fumiya Kitamura
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
- Department of Nephrology and Rheumatology, Aichi Medical University Medical Center, Okazaki, Aichi, Japan
| | - Masahiko Ando
- Data Coordinating Center, Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoko Kubo
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
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Odler B, Windpessl M, Eller K, Säemann MD, Lhotta K, Neumann I, Öberseder G, Duftner C, Dejaco C, Rudnicki M, Gauckler P, Hintenberger R, Zwerina J, Thiel J, Kronbichler A. [Diagnosis and therapy of granulomatosis with polyangiitis and microscopic polyangiitis-2023: consensus of the Austrian society of nephrology (ÖGN) and Austrian society of rheumatology (ÖGR)]. Wien Klin Wochenschr 2023; 135:656-674. [PMID: 37728651 PMCID: PMC10511611 DOI: 10.1007/s00508-023-02262-9] [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] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
ANCA-associated vasculitides (AAV) are rare, complex systemic diseases that are often difficult to diagnose, because of unspecific clinical symptoms at presentation. However, the clinical course may be very dramatic and even life-threatening, necessitating prompt diagnosis and treatment.Therefore, it is important to increase disease awareness among physicians and support colleagues who are not confronted with these rare diseases on a regular basis. Here, the Austrian Society of Nephrology (ÖGN) and the Austrian Society of Rheumatology (ÖGR) provide a joint consensus on how to best diagnose and manage patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA).
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Affiliation(s)
- Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | | | - Christina Duftner
- Department Innere Medizin II, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | | | - Michael Rudnicki
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Rainer Hintenberger
- Abteilung Innere Medizin 2 (Gastroenterologie und Hepatologie, Endokrinologie und Stoffwechsel, Nephrologie, Rheumatologie), JKU, Linz, Österreich
| | - Jochen Zwerina
- 1. Medizinische Abteilung, Hanusch Krankenhaus, Wien, Österreich
| | - Jens Thiel
- Klinische Abteilung für Rheumatologie und Immunologie, Bereich Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich.
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7
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Windpessl M, Gauckler P, Zitt E, Lhotta K, Ay C, Eller K, Odler B, Neumann I, Rudnicki M, Kronbichler A, Säemann MD. [General recommendations for the management of glomerular diseases-2023]. Wien Klin Wochenschr 2023; 135:696-704. [PMID: 37728654 PMCID: PMC10511582 DOI: 10.1007/s00508-023-02265-6] [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] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
Glomerular diseases are associated with extrarenal complications, such as thromboembolism, cardiovascular events and particularly infections. A thorough knowledge of the various immunosuppressants and their associated toxicity profile is therefore of great importance. While nephrologists usually have extensive experience with calcineurin inhibitors and antimetabolites, two other compounds (rituximab, in severe cases cyclophosphamide) are used comparatively infrequently and will be discussed in more detail. Moreover, practical recommendations for the prevention of thromboembolism in states of nephrosis and for the prophylaxis of Pneumcystic jirovecii pneumonia are provided.
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Affiliation(s)
- Martin Windpessl
- Medizinische Fakultät, JKU, Linz, Österreich
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Emanuel Zitt
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Cihan Ay
- Klinische Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | - Michael Rudnicki
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich.
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
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8
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Gérard M, de Boysson H, Morello R, Martin-Silva N, Leroux AC, Dumont A, Maigné G, Boutemy J, Khoy K, Mariotte D, Lobbedez T, Aouba A, Deshayes S. Early infectious risk in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis according to remission-induction therapy. Scand J Rheumatol 2023; 52:161-173. [PMID: 35048797 DOI: 10.1080/03009742.2021.2001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Few comparative data exist on early infections secondary to remission-induction therapy (RIT) with rituximab (RTX) versus cyclophosphamide (CYC) in newly diagnosed anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. We compared and analysed the rates and predictors of severe infection in such patients within the first 6 months following RIT. METHOD From the Caen University Hospital databases, we included all consecutive adults newly diagnosed with ANCA-positive granulomatosis with polyangiitis or microscopic polyangiitis between January 2006 and December 2019. We compared rates of survival without severe infection and survival without infections of any severity within 6 months of RIT and used a multivariate Cox analysis to identify predictors of infection. RESULTS We included 145 patients, 27 in the RTX and 118 in the CYC group. Patients in the RTX group more frequently had pneumococcal vaccination (p < 0.01) and creatinine < 150 µmol/L; other characteristics were comparable between the two groups. Overall, 37 severe infections and 65 infections of any severity were recorded. Rates of survival without severe infection were similar in both groups (p = 0.69), but survival without infections of any severity was lower in the RTX group (p = 0.005). In multivariate analysis, risk factors at diagnosis for severe infections included chronic urinary tract disease, dialysis, and absence of trimethoprim-sulfamethoxazole prophylaxis (p < 0.01 each). CONCLUSIONS Within 6 months of RIT, rates of survival without severe infection were similar in newly diagnosed ANCA-positive AAV patients treated with RTX or CYC, but survival rates without infections of any severity appeared to be lower with RTX treatment.
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Affiliation(s)
- M Gérard
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - H de Boysson
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - R Morello
- Functional Unit of Biostatistics and Clinical Research, CHU de Caen Normandie, Caen, France
| | - N Martin-Silva
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - A-C Leroux
- Department of Nephrology, Centre Hospitalier Mémorial, Saint-Lô, France
| | - A Dumont
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - G Maigné
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - J Boutemy
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - K Khoy
- Department of Immunology, CHU de Caen Normandie, Caen, France
| | - D Mariotte
- Department of Immunology, CHU de Caen Normandie, Caen, France
| | - T Lobbedez
- Department of Nephrology, CHU de Caen Normandie, Caen, France
| | - A Aouba
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - S Deshayes
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
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9
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Matsumoto K, Suzuki K, Yasuoka H, Hirahashi J, Yoshida H, Magi M, Noguchi-Sasaki M, Kaneko Y, Takeuchi T. Longitudinal monitoring of circulating immune cell phenotypes in anti-neutrophil cytoplasmic antibody-associated vasculitis. Autoimmun Rev 2023; 22:103271. [PMID: 36627064 DOI: 10.1016/j.autrev.2023.103271] [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: 12/10/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a necrotizing multiorgan autoimmune disease that affects small- to medium-sized blood vessels. Despite the improvements in treatments, half of the patients with AAV still experience disease relapses. In this review, we focus on peripheral leukocyte properties and phenotypes in patients with AAV. In particular, we explore longitudinal changes in circulating immune cell phenotypes during the active phase of the disease and treatment. The numbers and phenotypes of leukocytes in peripheral blood were differs between AAV and healthy controls, AAV in active versus inactive phase, AAV in treatment responders versus non-responders, and AAV with and without severe infection. Therefore, biomarkers detected in peripheral blood immune cells may be useful for longitudinal monitoring of disease activity in AAV.
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Affiliation(s)
- Kotaro Matsumoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Rheumatology, Department of Internal Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Junichi Hirahashi
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Mayu Magi
- Chugai Pharmaceutical Co. Ltd., Kanagawa, Japan
| | | | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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10
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Vassilopoulos A, Vassilopoulos S, Kalligeros M, Shehadeh F, Mylonakis E. Incidence of serious infections in patients with ANCA-associated vasculitis receiving immunosuppressive therapy: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1110548. [PMID: 36936221 PMCID: PMC10014619 DOI: 10.3389/fmed.2023.1110548] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 03/05/2023] Open
Abstract
Introduction Rituximab and azathioprine are used to induce or maintain remission in patients with ANCA-associated vasculitis (AAV). We evaluated the incidence of serious infections and infection-related deaths in patients with AAV treated with rituximab and azathioprine, during the maintenance of remission period. Methods We searched PubMed and EMBASE for randomized clinical trials (RCTs) and observational studies evaluating immunosuppressive agents in patients with AAV. We defined serious or severe infections according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The study was registered on PROSPERO (CRD42022366269). Results From 1,265 abstracts, we identified 21 studies (7 RCTs and 14 observational), with relevant data. We included data from 1,284 and 2,938 individuals for assessment in our primary and secondary outcomes, respectively. The overall cumulative incidence of serious infections was 15.99% (CI 95%: 6.95-27.53%) during the total follow-up period (induction and maintenance) and 7.62% (CI 95%: 4.43-11.43%) during the maintenance period. Additionally, we found a 0.49% overall case fatality rate (CI 95%: 0.02-1.37%) and a 0.09% infection-related mortality rate (CI 95%: 0.00-0.51%) during maintenance treatment. Notably, we found a 14.61% (CI 95%: 10.19-19.61%) cumulative incidence of serious infections among patients who received rituximab and a 5.93% (CI 95%: 1.19-13.26%) cumulative incidence of serious infections among patients who received azathioprine during maintenance. Moreover, the cumulative incidence of serious infections during the total follow-up period (induction and maintenance) was 20.81% (CI 95%:4.56-43.70%) for the combination of cyclophosphamide and azathioprine and 14.12% (CI 95%: 5.20-26.00%) for rituximab. Discussion The cumulative incidence of serious infections during total follow-up and maintenance was within expected limits, while fatal infections during maintenance treatment were uncommon. Additionally, treatment with rituximab for both induction and maintenance did not exceed the anticipated by previous studies incidence of serious infections. Clinical practice and long-term follow up data are needed to corroborate these findings. Systematic review registration Identifier: PROSPERO (CRD42022366269).
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Affiliation(s)
- Athanasios Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Stephanos Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Markos Kalligeros
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Fadi Shehadeh
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- *Correspondence: Eleftherios Mylonakis
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11
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Leong A, Fong W. Factors associated with cytomegalovirus infection in antineutrophil cytoplasmic antibody-associated vasculitis: A narrative review. Int J Rheum Dis 2022; 25:1357-1367. [PMID: 36135777 DOI: 10.1111/1756-185x.14444] [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: 05/27/2022] [Revised: 08/08/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022]
Abstract
Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are vulnerable to opportunistic infections, including cytomegalovirus (CMV) infection. This narrative review aims to identify factors associated with CMV infection in patients with AAV. The literature review was conducted on Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, PubMed, Scopus, and Web of Science. The start date of the literature search was unrestricted and the end date was February 2022. CMV infection was defined as (a) CMV pp65 antigenemia or positive CMV DNA viral load by polymerase chain reaction or CMV detection on histological specimens, with associated signs and symptoms compatible with CMV infection; (b) presence of CMV clinical syndrome (defined as presence of compatible symptoms and signs and documentation of CMV by biopsy by virus isolation, rapid culture, immunohistochemistry, or DNA in biopsy material as defined by the CMV Drug Development Forum); and (c) CMV infection as coded by the International Statistical Classification of Diseases and Related Health Problems, 10th revision with at least one prescription for CMV treatment. We identified 4505 articles, of which three (2327 patients with AAV) were included. All studies were retrospective and only one of the three studies included only patients with AAV. Low or decreasing lymphocyte counts and higher prednisolone usage were associated with CMV infection in patients with AAV. Patients with AAV with lymphopenia and on high doses of prednisolone should be monitored closely for signs and symptoms of CMV infection, and might benefit from CMV prophylaxis. Prospective studies are urgently needed to better identify causes of CMV infections in patients with AAV.
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Affiliation(s)
- Ashley Leong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore City, Singapore
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore City, Singapore.,Duke-NUS Medical School, Singapore City, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
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12
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Tsilingiris D, Nasiri-Ansari N, Spyrou N, Magkos F, Dalamaga M. Management of Hematologic Malignancies in the Era of COVID-19 Pandemic: Pathogenetic Mechanisms, Impact of Obesity, Perspectives, and Challenges. Cancers (Basel) 2022; 14:2494. [PMID: 35626099 PMCID: PMC9139192 DOI: 10.3390/cancers14102494] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
The COVID-19 pandemic brought about an unprecedented societal and healthcare system crisis, considerably affecting healthcare workers and patients, particularly those with chronic diseases. Patients with hematologic malignancies faced a variety of challenges, pertinent to the nature of an underlying hematologic disorder itself as well as its therapy as a risk factor for severe SARS-CoV-2 infection, suboptimal vaccine efficacy and the need for uninterrupted medical observation and continued therapy. Obesity constitutes another factor which was acknowledged since the early days of the pandemic that predisposed people to severe COVID-19, and shares a likely causal link with the pathogenesis of a broad spectrum of hematologic cancers. We review here the epidemiologic and pathogenetic features that obesity and hematologic malignancies share, as well as potential mutual pathophysiological links predisposing people to a more severe SARS-CoV-2 course. Additionally, we attempt to present the existing evidence on the multi-faceted crucial challenges that had to be overcome in this diverse patient group and discuss further unresolved questions and future challenges for the management of hematologic malignancies in the era of COVID-19.
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Affiliation(s)
- Dimitrios Tsilingiris
- First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 17 St Thomas Street, 11527 Athens, Greece
| | - Narjes Nasiri-Ansari
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece
| | - Nikolaos Spyrou
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Faidon Magkos
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, DK-2200 Frederiksberg, Denmark
| | - Maria Dalamaga
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece
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13
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Kauffmann M, Bobot M, Robert T, Burtey S, Couvrat-Desvergnes G, Lavainne F, Puéchal X, Terrier B, Quéméneur T, Faguer S, Karras A, Brunet P, Couchoud C, Jourde-Chiche N. Disease Activity and Adverse Events in Patients with ANCA-Associated Vasculitides Undergoing Long-Term Dialysis. Clin J Am Soc Nephrol 2021; 16:1665-1675. [PMID: 34750159 PMCID: PMC8729406 DOI: 10.2215/cjn.03190321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 09/08/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney impairment of ANCA-associated vasculitides can lead to kidney failure. Patients with kidney failure may suffer from vasculitis relapses but are also at high risk of infections and cardiovascular events, which questions the maintenance of immunosuppressive therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with ANCA-associated vasculitides initiating long-term dialysis between 2008 and 2012 in France registered in the national Renal Epidemiology and Information Network registry and paired with the National Health System database were included. We analyzed the proportion of patients in remission off immunosuppression over time and overall and event-free survival on dialysis (considering transplantation as a competing risk). We compared the incidence of vasculitis relapses, serious infections, cardiovascular events, and cancers before and after dialysis initiation. RESULTS In total, 229 patients were included: 142 with granulomatous polyangiitis and 87 with microscopic polyangiitis. Mean follow-up after dialysis initiation was 4.6±2.7 years; 82 patients received a kidney transplant. The proportion of patients in remission off immunosuppression increased from 23% at dialysis initiation to 62% after 5 years. Overall survival rates on dialysis were 86%, 69%, and 62% at 1, 3, and 5 years, respectively. Main causes of death were infections (35%) and cardiovascular events (26%) but not vasculitis flares (6%). The incidence of vasculitis relapses decreased from 57 to seven episodes per 100 person-years before and after dialysis initiation (P=0.05). Overall, during follow-up, 45% of patients experienced a serious infection and 45% had a cardiovascular event, whereas 13% experienced a vasculitis relapse. CONCLUSIONS The proportion of patients with ANCA-associated vasculitis in remission off immunosuppression increases with time spent on dialysis. In this cohort, patients were far less likely to relapse from their vasculitis than to display serious infectious or cardiovascular events. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_11_08_CJN03190321.mp3.
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Affiliation(s)
- Maëlis Kauffmann
- Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France
| | - Mickaël Bobot
- Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France,Aix-Marseille Univ, Center for Cardio-Vascular and Nutrition research, Institut National de la Santé et de la Recherche Médicale, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Marseille, France
| | - Thomas Robert
- Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France
| | - Stéphane Burtey
- Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France,Aix-Marseille Univ, Center for Cardio-Vascular and Nutrition research, Institut National de la Santé et de la Recherche Médicale, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Marseille, France
| | | | - Frédéric Lavainne
- University hospital de Nantes, Department of Nephrology and Clinical Immunology, Nantes, France
| | - Xavier Puéchal
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Department of Internal Medicine, Centre de Référence des Maladies Auto-immunes Systémiques Rares d'Ile-de-France, Paris, France
| | - Benjamin Terrier
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Department of Internal Medicine, Centre de Référence des Maladies Auto-immunes Systémiques Rares d'Ile-de-France, Paris, France
| | - Thomas Quéméneur
- Hospital de Valenciennes, Department of Internal Medicine, Valenciennes, France
| | - Stanislas Faguer
- University hospital de Toulouse, Hôpital Rangueil, Department of Nephrology and Organ Transplantation, Centre de référence des maladies rénales rares, Institut National de la Santé et de la Recherche Médicale, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France
| | - Alexandre Karras
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Nephrology, Paris, France
| | - Philippe Brunet
- Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France,Aix-Marseille Univ, Center for Cardio-Vascular and Nutrition research, Institut National de la Santé et de la Recherche Médicale, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Marseille, France
| | - Cécile Couchoud
- Agence de la Biomédecine, Registre Renal Epidemiology and Information Network, Saint-Denis, France
| | - Noémie Jourde-Chiche
- Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France,Aix-Marseille Univ, Center for Cardio-Vascular and Nutrition research, Institut National de la Santé et de la Recherche Médicale, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Marseille, France
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14
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Kant S, Kronbichler A, Sharma P, Geetha D. Advances in Understanding of Pathogenesis and Treatment of Immune-Mediated Kidney Disease: A Review. Am J Kidney Dis 2021; 79:582-600. [PMID: 34508831 DOI: 10.1053/j.ajkd.2021.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/25/2021] [Indexed: 12/21/2022]
Abstract
There continues to be rapid advancement in our understanding of the pathogenesis of immune-mediated kidney disease. This progress has culminated in the development of multiple therapeutic agents that have consistently improved renal and patient outcomes. The focus of this review is to discuss these recent advancements in immune-mediated kidney disease via the lens of direct and indirect immune-mediated mechanisms. In the direct immune-mediated disease, recently described antigens in anti-glomerular basement membrane (GBM) disease and membranous nephropathy are discussed, along with new therapeutic regimens in membranous nephropathy and focal segmental glomerulosclerosis. From an indirect immune-mediated disease standpoint, recent pivotal trials in antineutrophil cytoplasmic antibody vasculitis, lupus nephritis, and IgA nephropathy are examined from a real-world practice perspective. New molecular pathways in various disorders of alternate complement pathway are described, which in turn have led to development of various experimental therapies. In addition, pivotal and ongoing therapeutic trials in the aforementioned diseases are presented.
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Affiliation(s)
- Sam Kant
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine, Hofstra University/Northwell Health, Hempstead, New York
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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15
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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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16
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Koirala A, Jefferson JA. Steroid Minimization in Adults with Minimal Change Disease. GLOMERULAR DISEASES 2021; 1:237-249. [PMID: 36751385 PMCID: PMC9677715 DOI: 10.1159/000517626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/30/2021] [Indexed: 11/19/2022]
Abstract
Background Minimal change disease (MCD) causes approximately 10% of nephrotic syndrome in adults. While glucocorticoids (GCs) effectively induce remission in MCD, the disease has a high relapse rate (50-75%), and repeated exposure to GCs is often required. The adverse effects of GCs are well recognized and commonly encountered with the high doses and recurrent courses used in MCD. Summary In this review, we will discuss the standard therapy of MCD in adults and then describe new therapeutic options in induction therapy and treatment of relapses in MCD, minimizing the exposure to GCs. Key Messages Steroid minimization strategies may decrease adverse effects in the treatment of MCD.
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17
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Fonseca JA, Gameiro J, Duarte I, Jorge S, Lopes JA. The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity, severe infection and mortality in anca-associated vasculitis: A retrospective study. Nefrologia 2021; 41:321-328. [PMID: 36165341 DOI: 10.1016/j.nefroe.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/25/2020] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients. METHODS We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method. RESULTS We registered 45 cases of AVV. The mean age at diagnosis was 67.5±12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0±10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9±2.5mg/dL, erythrocyte sedimentation rate (ESR) was 76.9±33.8mm/h, hemoglobin was 9.5±1.7g/dL, C-reactive protein was 13.2±5.8mg/dL and NLR was 8.5±6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6±10.5 vs. 62.6±11.3, p=0.002, adjusted OR 1.08 [95% CI 1.01-1.16], p=0.035) and higher NLR (11.9±7.4 vs. 5.9±5.0, p=0.002, adjusted OR 1.14 [95% CI 1.01-1.29], p=0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647-0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12-34.32], p=0.037). CONCLUSIONS NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.
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Affiliation(s)
- José Agapito Fonseca
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.
| | - Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - Inês Duarte
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
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18
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Batten I, Robinson MW, White A, Walsh C, Fazekas B, Wyse J, Buettner A, D'Arcy S, Greenan E, Murphy CC, Wigston Z, Gabhann-Dromgoole JN, Vital EM, Little MA, Bourke NM. Investigation of type I interferon responses in ANCA-associated vasculitis. Sci Rep 2021; 11:8272. [PMID: 33859290 PMCID: PMC8050071 DOI: 10.1038/s41598-021-87760-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/13/2021] [Indexed: 12/23/2022] Open
Abstract
Type I interferon (IFN) dysregulation is a major contributory factor in the development of several autoimmune diseases, termed type I interferonopathies, and is thought to be the pathogenic link with chronic inflammation in these conditions. Anti-neutrophil cytoplasmic antibody (ANCA)-Associated Vasculitis (AAV) is an autoimmune disease characterised by necrotising inflammation of small blood vessels. The underlying biology of AAV is not well understood, however several studies have noted abnormalities in type I IFN responses. We hypothesised that type I IFN responses are systemically dysregulated in AAV, consistent with features of a type I interferonopathy. To investigate this, we measured the expression of seven interferon regulated genes (IRGs) (ISG15, SIGLEC1, STAT1, RSAD2, IFI27, IFI44L and IFIT1) in peripheral blood samples, as well as three type I IFN regulated proteins (CXCL10, MCP-1 and CCL19) in serum samples from AAV patients, healthy controls and disease controls. We found no difference in type I IFN regulated gene or protein expression between AAV patients and healthy controls. Furthermore, IRG and IFN regulated protein expression did not correlate with clinical measurements of disease activity in AAV patients. Thus, we conclude that systemic type I IFN responses are not key drivers of AAV pathogenesis and AAV should not be considered a type I interferonopathy.
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Affiliation(s)
- Isabella Batten
- Department of Medical Gerontology, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Mark W Robinson
- Department of Biology, Kathleen Lonsdale Institute for Human Health Research, Maynooth University, Kildare, Ireland
| | - Arthur White
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Cathal Walsh
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Barbara Fazekas
- Regenerative Medicine Institute (REMEDI), School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Jason Wyse
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Antonia Buettner
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Suzanne D'Arcy
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Emily Greenan
- Department of Ophthalmology, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin 2, Ireland
| | - Conor C Murphy
- Department of Ophthalmology, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin 2, Ireland
| | - Zoe Wigston
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joan Ní Gabhann-Dromgoole
- Department of Ophthalmology, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,School of Pharmacy and Biomolecular Sciences (PBS) and RSCI Research Institute, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Nollaig M Bourke
- Department of Medical Gerontology, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland.
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19
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Wacrenier S, Riou J, Jourdain P, Guibert F, Henry N, Djema A, Coindre JP, Crochette R, Cousin M, Croue A, Subra JF, Piccoli G, Augusto JF, Brilland B. Lymphopenia at diagnosis of ANCA-vasculitis with renal involvement is correlated with severity and renal prognosis. Nephrol Dial Transplant 2021; 37:1078-1087. [PMID: 33856482 DOI: 10.1093/ndt/gfab158] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lymphopenia is commonly observed in autoimmune diseases, where it has been associated with disease activity or prognosis. However, in ANCA-associated vasculitis (AAV) only few, small-scale studies have been targeted to this issue. Research has not yet focused on AAV with renal involvement (AAV-RI) patients. Thus, the aim of this study was to analyze the association between lymphocyte counts and outcomes in a large cohort of AAV-RI patients. METHODS We used the Maine-Anjou AAV registry that retrospectively gathers data on consecutive patients affected by AAV in four French Nephrology Centers, recorded since January 2000. We analyzed clinical, biological, and histological data at diagnosis of AAV-RI. Risk factors for end-stage kidney disease (ESKD) were analyzed. Event-free survival was also assessed. RESULTS Among the 145 patients included in the study, those with lymphopenia at diagnosis had a lower renal function at baseline (eGFR 13 mL/min vs 26 mL/min, p = 0.002) and were more likely to require kidney replacement therapy (51% vs 25%, p = 0.003). Lymphopenia was correlated with histological lesions and especially with the percentage of sclerotic glomeruli (p = 0.0027). ESKD-free survival was lower in lymphopenic patients (p < 0.0001). In multivariate Cox analysis, lymphopenia was an independent risk factor for ESKD (HR 4.47 (95% confidence interval: [2.06-9.72], p < 0.001). CONCLUSION Lymphopenia correlates with the severity of AAV glomerulonephritis at diagnosis and predicts poor renal outcome. In this view, lymphopenia could be used as a simple and cost-effective biomarker to assess renal prognosis at AAV-RI diagnosis.
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Affiliation(s)
- Samuel Wacrenier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie, Centre Hospitalier du Mans, Le Mans, France
| | - Jérémie Riou
- Micro et Nanomédecines Translationnelles, MINT, Université d'Angers, UMR INSERM 6021, UMR CNRS 6021, Angers, France.,Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Pierre Jourdain
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Fanny Guibert
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie, Centre Hospitalier de Cholet, Cholet, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie, Centre Hospitalier de Laval, Laval, France
| | - Assia Djema
- Service de Néphrologie, Centre Hospitalier de Cholet, Cholet, France
| | | | - Romain Crochette
- Service de Néphrologie, Centre Hospitalier du Mans, Le Mans, France
| | - Maud Cousin
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Anne Croue
- Département de pathologie cellulaire et tissulaire, Université d'Angers, CHU Angers, Angers, France
| | - Jean-François Subra
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Giorgina Piccoli
- Service de Néphrologie, Centre Hospitalier du Mans, Le Mans, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
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20
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Oelzner P, Wolf G. Risikostratifizierung bei ANCA-assoziierten
Vaskulitiden. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1380-2984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungANCA-assoziierte Vaskulitiden (AAV) sind nekrotisierende Vaskulitiden der
kleinen bis mittelgroßen Gefäße, welche die
Granulomatose mit Polyangiitis (GPA), die mikroskopische Polyangiitis (MPA)
und die Eosinophile Granulomatose mit Polyangiitis (EGPA) umfassen. AAV
gehen häufig mit Organfunktion-bedrohenden Manifestationen und einer
entsprechend erhöhten Mortalität einher. Für die
Planung von Diagnostik, Therapie und Langzeitbetreuung ist daher eine
Risikostratifizierung im Hinblick auf Mortalität, Entwicklung
schwerer Organinsuffizienzen, insbesondere einer terminalen
Niereninsuffizienz, mögliche Therapieresistenz, Rezidive,
Infektionen und Malignome erforderlich. Wichtige Risikofaktoren für
erhöhte Mortalität und/oder terminale
Niereninsuffizienz sind neben der renalen Beteiligung per se eine bereits
zum Zeitpunkt der Diagnose deutlich eingeschränkte renale Funktion
einschliesslich initialer Dialysepflichtigkeit, eine hohe initiale
Aktivität der AAV gemessen am Birmingham Vaskulitis Activity Score,
aber auch kardiale und gastrointestinale Manifestationen, Infektionen,
Anämie sowie ein Alter von>65 Jahren. Histologisch ist der
Nachweis chronischer irreversibler glomerulärer und
tubulärer Läsionen in der Nierenbiopsie mit einer schlechten
Prognose im Hinblick auf die Nierenfunktion assoziiert. Basierend auf der
histopathologischen Klassifikation der ANCA-assoziierten Glomerulonephritis
(GN) ist der Befund einer sklerosierenden GN mit einer besonders
ungünstigen Prognose assoziiert, während die fokale GN sehr
selten zur terminalen Niereninsuffizienz führt. MPO-ANCA zeigen eine
Assoziation mit chronischen Läsionen in der Nierenbiopsie sowie
erhöhter Mortalität und erhöhtem Risiko für
terminale Niereninsuffizienz. Im Hinblick auf die pulmonale Beteiligung sind
alveoläre Hämorrhagie und interstitielle Lungenerkrankung
mit einer erhöhten Mortalität assoziiert. Bei EGPA wird die
Prognose entscheidend durch die Kardiomyopathie bestimmt. Risikofaktoren
für Rezidive weichen erheblich von denen für
Mortalität und terminale Niereninsuffizienz ab. Ein erhöhtes
Rezidivrisiko besteht bei Nachweis von PR3-ANCA, GPA und pulmonaler
Beteiligung. Auch bei granulomatösen Läsionen, Beteiligung
des oberen Respirationstraktes und kardiovaskulären Manifestationen
wird ein erhöhtes Rezidivrisiko beschrieben. Im Gegensatz zur
Assoziation einer initial schlechten Nierenfunktion mit Mortalität
und terminaler Niereninsuffizienz, wurde für Patienten mit initial
guter Nierenfunktion ein erhöhtes Rezidivrisiko gezeigt. Weitere
Risikofaktoren für Rezidive sind Staphylokokken-Besiedelung der
Nase, frühere Rezidive und ANCA-Positivität nach
Remissionsinduktion. Titeranstieg oder Wiederauftreten von ANCA zeigen nur
eine moderate Beziehung zum Rezidivrisiko. Der prädiktive Wert
für Rezidive ist offenbar bei bestimmten Subgruppen, wie bei
Patienten mit renaler Beteiligung und pulmonaler Hämorrhagie sowie
bei mit Rituximab-behandelten Patienten besser als bei Patienten mit
granulomatösen Manifestationen. Daher ist eine Therapieentscheidung
allein auf Basis der Entwicklung der ANCA-Titer nicht möglich.
Risikofaktoren für schwere Infektionen sind höher dosierte
und prolongierte Glukokortikoidtherapie, Leuko- und Lymphopenie,
höheres Lebenalter, Niereninsuffizienz und pulmonale Beteiligung.
Die Malignomrate insbesondere für Nicht-Melanom-Hauttumoren,
Harnblasenkarzinome und Leukämie ist bei AAV erhöht und
zeigt eine Assoziation mit hohen kumulativen Cyclophosphamiddosen. Da
insbesondere frühzeitige irreversible Organschäden die
Prognose bestimmen und Rezidive die Entwicklung irreversibler
Schäden treiben, sind frühestmögliche Diagnose und
Therapie sowie rasches Erkennen und Vermeiden von Rezidiven essentiell
für die Risikominimierung.
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Affiliation(s)
- Peter Oelzner
- Rheumatologie/Osteologie, Klinik für Innere Medizin
III, Universitätsklinikum Jena, Jena, Deutschland
| | - Gunter Wolf
- Nephrologie, Klinik für Innere Medizin III,
Universitätsklinikum Jena, Jena, Deutschland
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21
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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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22
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Segelmark L, Flores-Suárez LF, Mohammad AJ. Severe infections in patients with ANCA associated vasculitis treated with rituximab. Rheumatology (Oxford) 2021; 61:205-212. [PMID: 33757116 DOI: 10.1093/rheumatology/keab293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab (RTX) is an anti-CD20 antibody that selectively depletes B-cells and has emerged as a therapy for ANCA-associated vasculitis (AAV) during the past decade. This study sought to quantify, and determine potential risk factors for, severe infections in AAV patients treated with RTX at rheumatology clinics in Mexico City, Mexico and Lund, Sweden. METHODS The study consisted of a retrospective case-record review (2005-2015) with standardized data collection related to the occurrence of severe infection in 46 patients with AAV in Mexico City (n = 20) and Lund (n = 26) treated with RTX during their disease course. Median duration of follow-up from first RTX dose to death or end of study was 26 months. RESULTS Eleven (24%) patients suffered a total of 18 severe infections (infection rate of 11.5/100 patient-years). Thirteen of the 18 infections (72%) occurred within the first year of treatment. Risk factors for severe infection were older age at RTX initiation and absence of ENT-involvement at diagnosis. In multivariate analyses, age at RTX infusion was the only independent factor predicting severe infection. Four patients (9%) died during follow-up, all as a result of infection. CONCLUSIONS Severe infections are common following RTX treatment, and mortality due to infection is a major concern. Most severe infections occur within the first year of RTX treatment. The negative correlation of ENT involvement with severe infection might reflect GPA phenotype heterogeneity. Older age at time of RTX treatment independently predicts severe infections.
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Affiliation(s)
- Leo Segelmark
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - L F Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden.,Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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23
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Sugiyama H, Yamaguchi M, Katsuno T, Iwagaitsu S, Nobata H, Kinashi H, Banno S, Ando M, Kubo Y, Ishimoto T, Ito Y. Association between body mass index and severe infection in older adults with microscopic polyangiitis: a retrospective cohort in Japan. BMC Geriatr 2021; 21:171. [PMID: 33750328 PMCID: PMC7942001 DOI: 10.1186/s12877-021-02123-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although previous studies have evaluated risk factors for the incidence of severe infection in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV), the relationship between body mass index (BMI) and severe infection in AAV has not been elucidated. We hypothesized that older adults with AAV and a low BMI would be at a higher risk of infection. We therefore investigated the association between underweight status at AAV diagnosis and subsequent occurrence of severe infection in older adults with AAV. METHODS This single-center retrospective cohort study included 93 consecutive older adults with microscopic polyangiitis (MPA) treated at the Aichi Medical University Hospital in Japan between 2004 and 2018. The relationships between BMI at diagnosis and subsequent first severe infection were assessed using multivariate Cox proportional hazards models. The cumulative probability of the development of the first severe infection was calculated using the Kaplan-Meier method and the log-rank test. The level of statistical significance was set at P < 0.05. RESULTS During the median follow-up period of 19 (6-53) months, 29 (31.2%) patients developed at least one severe infection. Older age (adjusted hazard ratio [HR] = 2.02, 95% confidence interval [CI]: 1.14-3.52, per 10 years; P = 0.016), low BMI (< 18.5 kg/m2 compared with normal BMI [18.5-23.0 kg/m2], adjusted HR = 2.63, 95% CI: 1.11-6.19; P = 0.027), and use of methylprednisolone pulse therapy (adjusted HR = 2.48, 95% CI: 1.07-5.76; P = 0.034) were found to be significant predictors of severe infection. CONCLUSIONS Low BMI was associated with a higher risk of severe infection in older adults with MPA, suggesting that careful management may be required to prevent this complication in this vulnerable group. Further studies are needed to elucidate the optimal treatment strategy for these patients.
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Affiliation(s)
- Hirokazu Sugiyama
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Masahiko Ando
- Data Coordinating Center, Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoko Kubo
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan.
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24
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McClure ME, Zhu Y, Smith RM, Gopaluni S, Tieu J, Pope T, Kristensen KE, Jayne DRW, Barrett J, Jones RB. Long-term maintenance rituximab for ANCA-associated vasculitis: relapse and infection prediction models. Rheumatology (Oxford) 2021; 60:1491-1501. [PMID: 33141217 PMCID: PMC7937025 DOI: 10.1093/rheumatology/keaa541] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/14/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Following a maintenance course of rituximab (RTX) for ANCA-associated vasculitis (AAV), relapses occur on cessation of therapy, and further dosing is considered. This study aimed to develop relapse and infection risk prediction models to help guide decision making regarding extended RTX maintenance therapy. METHODS Patients with a diagnosis of AAV who received 4-8 grams of RTX as maintenance treatment between 2002 and 2018 were included. Both induction and maintenance doses were included; most patients received standard departmental protocol consisting of 2× 1000 mg 2 weeks apart, followed by 1000 mg every 6 months for 2 years. Patients who continued on repeat RTX dosing long-term were excluded. Separate risk prediction models were derived for the outcomes of relapse and infection. RESULTS A total of 147 patients were included in this study with a median follow-up of 63 months [interquartile range (IQR): 34-93]. Relapse: At time of last RTX, the model comprised seven predictors, with a corresponding C-index of 0.54. Discrimination between individuals using this model was not possible; however, discrimination could be achieved by grouping patients into low- and high-risk groups. When the model was applied 12 months post last RTX, the ability to discriminate relapse risk between individuals improved (C-index 0.65), and once again, clear discrimination was observed between patients from low- and high-risk groups. Infection: At time of last RTX, five predictors were retained in the model. The C-index was 0.64 allowing discrimination between low and high risk of infection groups. At 12 months post RTX, the C-index for the model was 0.63. Again, clear separation of patients from two risk groups was observed. CONCLUSION While our models had insufficient power to discriminate risk between individual patients they were able to assign patients into risk groups for both relapse and infection. The ability to identify risk groups may help in decisions regarding the potential benefit of ongoing RTX treatment. However, we caution the use of these prediction models until prospective multi-centre validation studies have been performed.
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Affiliation(s)
- Mark E McClure
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Yajing Zhu
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rona M Smith
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Seerapani Gopaluni
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Joanna Tieu
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Tasneem Pope
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Karl Emil Kristensen
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jessica Barrett
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK
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25
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Abstract
BACKGROUND The C5a receptor inhibitor avacopan is being studied for the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. METHODS In this randomized, controlled trial, we assigned patients with ANCA-associated vasculitis in a 1:1 ratio to receive oral avacopan at a dose of 30 mg twice daily or oral prednisone on a tapering schedule. All the patients received either cyclophosphamide (followed by azathioprine) or rituximab. The first primary end point was remission, defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 (on a scale from 0 to 63, with higher scores indicating greater disease activity) at week 26 and no glucocorticoid use in the previous 4 weeks. The second primary end point was sustained remission, defined as remission at both weeks 26 and 52. Both end points were tested for noninferiority (by a margin of 20 percentage points) and for superiority. RESULTS A total of 331 patients underwent randomization; 166 were assigned to receive avacopan, and 165 were assigned to receive prednisone. The mean BVAS at baseline was 16 in both groups. Remission at week 26 (the first primary end point) was observed in 120 of 166 patients (72.3%) receiving avacopan and in 115 of 164 patients (70.1%) receiving prednisone (estimated common difference, 3.4 percentage points; 95% confidence interval [CI], -6.0 to 12.8; P<0.001 for noninferiority; P = 0.24 for superiority). Sustained remission at week 52 (the second primary end point) was observed in 109 of 166 patients (65.7%) receiving avacopan and in 90 of 164 patients (54.9%) receiving prednisone (estimated common difference, 12.5 percentage points; 95% CI, 2.6 to 22.3; P<0.001 for noninferiority; P = 0.007 for superiority). Serious adverse events (excluding worsening vasculitis) occurred in 37.3% of the patients receiving avacopan and in 39.0% of those receiving prednisone. CONCLUSIONS In this trial involving patients with ANCA-associated vasculitis, avacopan was noninferior but not superior to prednisone taper with respect to remission at week 26 and was superior to prednisone taper with respect to sustained remission at week 52. All the patients received cyclophosphamide or rituximab. The safety and clinical effects of avacopan beyond 52 weeks were not addressed in the trial. (Funded by ChemoCentryx; ADVOCATE ClinicalTrials.gov number, NCT02994927.).
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Affiliation(s)
- David R W Jayne
- From Addenbrooke's Hospital, Cambridge, United Kingdom (D.R.W.J.); the University of Pennsylvania, Philadelphia (P.A.M.); and ChemoCentryx, Mountain View, CA (T.J.S., P.B.)
| | - Peter A Merkel
- From Addenbrooke's Hospital, Cambridge, United Kingdom (D.R.W.J.); the University of Pennsylvania, Philadelphia (P.A.M.); and ChemoCentryx, Mountain View, CA (T.J.S., P.B.)
| | - Thomas J Schall
- From Addenbrooke's Hospital, Cambridge, United Kingdom (D.R.W.J.); the University of Pennsylvania, Philadelphia (P.A.M.); and ChemoCentryx, Mountain View, CA (T.J.S., P.B.)
| | - Pirow Bekker
- From Addenbrooke's Hospital, Cambridge, United Kingdom (D.R.W.J.); the University of Pennsylvania, Philadelphia (P.A.M.); and ChemoCentryx, Mountain View, CA (T.J.S., P.B.)
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26
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Obrișcă B, Vornicu A, Jurubiță R, Achim C, Bobeică R, Andronesi A, Sorohan B, Herlea V, Procop A, Dina C, Ismail G. Corticosteroids are the major contributors to the risk for serious infections in autoimmune disorders with severe renal involvement. Clin Rheumatol 2021; 40:3285-3297. [PMID: 33595739 DOI: 10.1007/s10067-021-05646-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION We sought to investigate the infection profile and associated risk factors in a compiled cohort of patients with autoimmune disorders with severe renal involvement treated with aggressive immunosuppressive (IS) regimens. METHODS A total of 162 patients with aggressive glomerulonephritis [101 with lupus nephritis (LN), 24 with cryoglobulinemic vasculitis (CryoVasc), and 37 with ANCA-associated vasculitis (AAV)] were retrospectively reviewed for any infection occurrence. Infection incidence, type, site, and grade (1-5) were recorded. Multivariate Cox proportional hazard regression analysis was performed to identify independent risk factors for infections. RESULTS A total of 179 infection episodes occurred during a follow-up of 468 patient-years. Eighty-two patients (50.6%) had at least one infection. The incidence rates of infections and severe infections were 38.2 and 14.3 events per 100 patient-years. Patients with AAV had more infections than those with CryoVasc and LN (100.6, 47.5, and 26.6 infections per 100-patient-years, respectively; p = 0.002). Most patients developed infections early during the initial induction therapy (62.1% in the first 6 months of follow-up). In multivariate Cox regression analysis, high-dose oral corticosteroids (≥ 0.5 mg/kg/day in the first month of induction therapy) was an independent predictor of any infection (HR 2.66; 95% CI, 1.5-4.73), severe infections (HR 2.45; 95% CI, 1.03-5.82), and pulmonary infections (HR 2.91; 95% CI, 1.05-8.01). Pulmonary involvement increased the risk for pulmonary infections (HR 3.67; 95% CI, 1.32-10.1) and severe infections (HR 2.45; 95% CI, 1.01-5.92). CONCLUSION Infections occur frequently with current IS regimens in aggressive glomerulonephritis. Pulmonary involvement and high-dose corticosteroid regimen were the most significant risk factors for infections. Key Points • Infections occur frequently with current immunosuppressive regimens in autoimmune aggressive glomerulonephritis. • High-dose corticosteroids are the major contributors to the risk for serious infections.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania. .,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Procop
- Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Constantin Dina
- Department of Anatomy, Ovidius University, Constanța, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Yin P, Li J, Wen Q, Qiu Y, Liang W, Wang J, Yu J, Zhong Z, Yang X, Yu X, Ye Q, Huang F. Infection-related hospitalization after intensive immunosuppressive therapy among lupus nephritis and ANCA glomerulonephritis patients. Ren Fail 2021; 42:474-482. [PMID: 32406300 PMCID: PMC7269069 DOI: 10.1080/0886022x.2020.1763400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: This study aimed to investigate the clinical characteristics, risk factors, and outcomes of infection-related hospitalization (IRH) in patients with lupus nephritis (LN) and ANCA glomerulonephritis after intensive immunosuppressive therapy.Methods: Patients diagnosed with LN or ANCA glomerulonephritis who received intensive immunosuppressive therapy at the First Affiliated Hospital of Sun Yat-sen University from 2005 to 2014 were enrolled. Demographics, laboratory parameters, immunosuppressive agents, and IRH details were collected. Multivariable Cox regression was used, and hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.Results: Totally, 872 patients with 806 LN and 66 ANCA glomerulonephritis were enrolled, and 304 (34.9%) patients with 433 episodes of IRH were recorded. ANCA glomerulonephritis patients were more vulnerable to IRH than LN patients (53.0% vs. 33.4%, p = .001). Multivariable Cox regression analysis showed that ANCA glomerulonephritis (HR = 1.62, 95% CI: 1.06-2.49, p = .027), diabetes (HR = 1.82, 95% CI: 1.03-3.22, p = .039) and a higher initial dose of prednisone (HR = 1.01, 95% CI: 1.00-1.02, p = .013) were associated with a higher likelihood of IRH. Higher albumin (HR = 0.96, 95% CI: 0.94-0.98, p < .001), globulin (HR = 0.98, 95% CI: 0.96-0.99, p = .008), and eGFR (HR = 0.99, 95% CI: 0.99-1.00, p < .001), were associated with a lower likelihood of IRH. The rates of transfer to ICU and mortality for ANCA glomerulonephritis patients were higher than those for LN patients (22.9% vs. 1.9%, p < .001, and 20.0% vs. 0.7%, p < .001, respectively).Conclusions: ANCA glomerulonephritis patients had a higher risk of IRH and poorer outcome once infected after intensive immunosuppressive therapy than LN patients. More strict control for infection risks is required for ANCA glomerulonephritis patients who undergo intensive immunosuppressive therapy.
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Affiliation(s)
- Peihong Yin
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Nephrology, Zhongshan City People's Hospital, Zhongshan, China
| | - Jianbo Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiong Wen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yagui Qiu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenyi Liang
- Department of Nephrology, Zhongshan City People's Hospital, Zhongshan, China
| | - Junxian Wang
- Department of Nephrology, Zhongshan City People's Hospital, Zhongshan, China
| | - Jing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhong Zhong
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qing Ye
- Department of Nephrology, Zhongshan City People's Hospital, Zhongshan, China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Lafarge A, Joseph A, Pagnoux C, Puéchal X, Cohen P, Samson M, Hamidou M, Karras A, Quemeneur T, Ribi C, Groh M, Mouthon L, Guillevin L, Terrier B. Predictive factors of severe infections in patients with systemic necrotizing vasculitides: data from 733 patients enrolled in five randomized controlled trials of the French Vasculitis Study Group. Rheumatology (Oxford) 2021; 59:2250-2257. [PMID: 31782786 DOI: 10.1093/rheumatology/kez575] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 10/29/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Infections remain a major cause of morbidity and mortality in systemic necrotizing vasculitides (SNV). We aimed to identify factors predicting severe infections (SI) in SNV. METHODS Data from five randomized controlled trials (RCTs) enrolling 733 patients were pooled. The primary end point was the occurrence of SI, defined by the need of a hospitalization and/or intravenous anti-infectious treatment and/or leading to death. RESULTS After a median follow-up of 5.2 (interquartile range 3-9.7) years, 148 (20.2%) patients experienced 189 SI, and 98 (66.2%) presented their first SI within the first 2 years. Median interval from inclusion to SI was 14.9 (4.3-51.7) months. Age ≥65 years (hazard ratio (HR) 1.49 [1.07-2.07]; P=0.019), pulmonary involvement (HR 1.82 [1.26-2.62]; P=0.001) and Five Factor Score ≥1 (HR 1.21 [1.03-1.43]; P=0.019) were independent predictive factors of SI. Regarding induction therapy, the occurrence of SI was associated with the combination of GCs and CYC (HR 1.51 [1.03-2.22]; P = 0.036), while patients receiving only GCs were less likely to present SI (HR 0.69 [0.44-1.07]; P = 0.096). Finally, occurrence of SI had a significant negative impact on survival (P<0.001). CONCLUSION SI in SNV are frequent and impact mortality. Age, pulmonary involvement and Five Factor Score are baseline independent predictors of SI. No therapeutic regimen was significantly associated with SI but patients receiving glucocorticoids and CYC as induction tended to have more SI.
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Affiliation(s)
- Antoine Lafarge
- Department of Internal Medicine.,National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital
| | | | - Christian Pagnoux
- Department of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Xavier Puéchal
- Department of Internal Medicine.,National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital
| | - Pascal Cohen
- Department of Internal Medicine.,National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon
| | | | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris
| | - Thomas Quemeneur
- Department of Internal Medicine, Hôpital de Valenciennes, Valenciennes, France
| | - Camillo Ribi
- Department of Immunology, CHUV, Lausanne, Switzerland
| | | | - Luc Mouthon
- Department of Internal Medicine.,National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital.,Paris Descartes University, Paris 5, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine.,National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital.,Paris Descartes University, Paris 5, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine.,National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital.,Paris Descartes University, Paris 5, Paris, France
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Jourdain P, Brilland B, Medhioub O, Caron J, Samoreau C, Djema A, Gansey R, Coindre JP, Cousin M, Garnier AS, Henry N, Wacrenier S, Riou J, Piccoli GB, Augusto JF. Incidence and Temporal Trend in Risk Factors of Severe Infections in ANCA-Glomerulonephritis Patients. Kidney Int Rep 2021; 6:1161-1165. [PMID: 33912765 PMCID: PMC8071615 DOI: 10.1016/j.ekir.2020.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Pierre Jourdain
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,CRCINA, INSERM, Université de Nantes, Université d'Angers, Angers, France
| | - Ouassim Medhioub
- Micro et Nanomedecines Translationnelles, MINT, Université d'Angers, UMR INSERM 6021, UMR CNRS 6021, Angers, France
| | - Jeanne Caron
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Clément Samoreau
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Assia Djema
- Service de Néphrologie-Dialyse, CH de Cholet, Cholet, France
| | - Renaud Gansey
- Service de Néphrologie-Dialyse, CH de Laval, Laval, France
| | | | - Maud Cousin
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Anne Sophie Garnier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, CH de Laval, Laval, France
| | - Samuel Wacrenier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, CH du Mans, Le Mans, France
| | - Jeremy Riou
- CRCINA, INSERM, Université de Nantes, Université d'Angers, Angers, France.,Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, 49100 Angers, France
| | - Giorgina Barbara Piccoli
- Service de Néphrologie-Dialyse, CH de Laval, Laval, France.,Department of Clinical and Biological Sciences University of Torino, Italy
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,CRCINA, INSERM, Université de Nantes, Université d'Angers, Angers, France
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Fonseca JA, Gameiro J, Duarte I, Jorge S, Lopes JA. The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity, severe infection and mortality in anca-associated vasculitis: A retrospective study. Nefrologia 2020; 41:321-328. [PMID: 33309337 DOI: 10.1016/j.nefro.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/10/2020] [Accepted: 07/25/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients. METHODS We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method. RESULTS We registered 45 cases of AVV. The mean age at diagnosis was 67.5±12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0±10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9±2.5mg/dL, erythrocyte sedimentation rate (ESR) was 76.9±33.8mm/h, hemoglobin was 9.5±1.7g/dL, C-reactive protein was 13.2±5.8mg/dL and NLR was 8.5±6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6±10.5 vs. 62.6±11.3, p=0.002, adjusted OR 1.08 [95% CI 1.01-1.16], p=0.035) and higher NLR (11.9±7.4 vs. 5.9±5.0, p=0.002, adjusted OR 1.14 [95% CI 1.01-1.29], p=0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647-0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12-34.32], p=0.037). CONCLUSIONS NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.
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Affiliation(s)
- José Agapito Fonseca
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.
| | - Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - Inês Duarte
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine. Centro Hospitalar Universitário Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
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Sarica SH, Dhaun N, Sznajd J, Harvie J, McLaren J, McGeoch L, Kumar V, Amft N, Erwig L, Marks A, Black C, Basu N. Characterizing infection in anti-neutrophil cytoplasmic antibody-associated vasculitis: results from a longitudinal, matched-cohort data linkage study. Rheumatology (Oxford) 2020; 59:3014-3022. [PMID: 32159801 PMCID: PMC7516107 DOI: 10.1093/rheumatology/keaa070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/27/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Infection exerts a major burden in ANCA-associated vasculitis (AAV), however, its precise extent and nature remains unclear. In this national study we aimed to longitudinally quantify, characterize and contextualize infection risk in AAV. METHODS We conducted a multicentre matched cohort study of AAV. Complementary data on infections were retrieved via data linkage with the population-based Scottish microbiological laboratory, hospitalization and primary care prescribing registries. RESULTS A total of 379 AAV patients and 1859 controls were followed up for a median of 3.5 years (interquartile range 1.9-5.7). During follow-up, the proportions of AAV patients with at least one laboratory-confirmed infection, severe infection and primary care antibiotic prescription were 55.4%, 35.6% and 74.6%, respectively. The risk of infection was higher in AAV than in matched controls {laboratory-confirmed infections: incidence rate ratio [IRR] 7.3 [95% confidence interval (CI) 5.6, 9.6]; severe infections: IRR 4.4 [95% CI 3.3, 5.7]; antibiotic prescriptions: IRR 2.2 [95% CI 1.9, 2.6]}. Temporal trend analysis showed that AAV patients remained at a higher risk of infections throughout the follow-up period, especially year 1. Although the Escherichia genus was the most commonly identified pathogen (16.6% of AAV, 5.5% of controls; P < 0.0001), AAV patients had the highest risk for Herpes [IRR 12.5 (95% CI 3.7, 42.6)] and Candida [IRR 11.4 (95% CI 2.4, 55.4)]. CONCLUSION AAV patients have up to seven times higher risk of infection than the general population and the overall risk remains significant after 8 years of follow-up. The testing of enhanced short- to medium-term prophylactic antibiotic regimes should be considered.
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Affiliation(s)
- Shifa H Sarica
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
| | - Neeraj Dhaun
- Queen’s Medical Research Institute, University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, UK
| | - Jan Sznajd
- Department of Rheumatology, Raigmore Hospital, Inverness, UK
| | - John Harvie
- Department of Rheumatology, Raigmore Hospital, Inverness, UK
| | - John McLaren
- Fife Rheumatic Diseases Unit, Whyteman’s Brae Hospital, Kirkcaldy, UK
| | - Lucy McGeoch
- Centre for Rheumatic Diseases, Glasgow Royal Infirmary, Glasgow, UK
| | - Vinod Kumar
- Rheumatology Department, Ninewells Hospital, Dundee, UK
| | - Nicole Amft
- GlaxoSmithKline, Medicines Research Centre, Stevenage, UK
| | - Lars Erwig
- GlaxoSmithKline, Medicines Research Centre, Stevenage, UK
| | - Angharad Marks
- Morriston Hospital Renal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Corri Black
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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Gapud EJ, Kronbichler A, Gauckler P, Geetha D. Immunotherapy for ANCA-associated vasculitis during the COVID-19 pandemic. Eur J Rheumatol 2020; 7:S121-S128. [PMID: 32716836 DOI: 10.5152/eurjrheum.2020.2067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/06/2020] [Indexed: 12/19/2022] Open
Abstract
Since the first description of infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in China in December 2019, it has evolved into a pandemic and emerged as an unprecedented worldwide crisis overwhelming healthcare systems globally. Analysis of the available literature to date suggests that, in addition to older age, patients with underlying co-morbidities including hypertension, diabetes, heart disease are at higher risk for severe disease with increased mortality. Practitioners around the world also have become increasingly concerned that immunosuppressed patients including those with autoimmune diseases may be at increased risk for developing Coronavirus Disease 2019 (COVID-19) with serious complications. Very little is known about how anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis modifies the susceptibility, clinical presentation and disease course of COVID-19. In this review, we discuss the mechanism of action and challenges of the current therapeutic armamentarium of ANCA-associated vasculitis and outline approaches to management of ANCA-associated vasculitis during the COVID-19 pandemic.
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Affiliation(s)
- Eric J Gapud
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Andreas Kronbichler
- Department of Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Philipp Gauckler
- Department of Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine
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Singh JA, Cleveland JD. Epidemiology, Time Trends, and Outcomes of Serious Infections in Patients With Vasculitis: A Nineteen-Year National Study. Arthritis Care Res (Hoboken) 2020; 73:1544-1551. [PMID: 32526087 DOI: 10.1002/acr.24348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/02/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To examine the epidemiology, time trends, and outcomes and types of serious infections in people with vasculitis in the US. METHODS We identified people with vasculitis who were hospitalized with a primary diagnosis of pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections, or opportunistic infections in the 1998-2016 US National Inpatient Sample. We used adjusted logistic regression to examine the predictors of a hospital stay >3 days, total hospital charges greater than the median, discharge to a non-home setting, and in-hospital mortality. RESULTS We noted 111,345 serious infections in patients with vasculitis (14% of all vasculitis hospitalizations). Among the patients, the mean age was 67.3 years, the Deyo-Charlson comorbidity index score was ≥2 in 54%, 37% were male, and 67% were White. The serious infection hospitalization rate per 100,000 US National Inpatient Sample claims in 1998-2000 versus 2015-2016 (and rates of increase) in patients with vasculitis was as follows: overall, 12.14 versus 25.15 (2.1-fold); opportunistic infections, 0.78 versus 0.83 (1.1-fold); skin and soft tissue infections, 1.38 versus 2.52 (1.8-fold); UTI, 0.35 versus 1.48 (4.2-fold); pneumonia, 7.10 versus 6.23 (0.9-fold); and sepsis, 2.53 versus 14.10 (5.6-fold). Pneumonia was the most common serious infection in 1998-2000 (58%) versus sepsis in 2015-2016 (56%). Sepsis, older age, Deyo-Charlson comorbidity index score of ≥2, urban hospital, or medium/large hospital (by number of beds) were associated with higher health care utilization and in-hospital mortality rates; Northeast region and Medicare and Medicaid payer type were associated with higher rates of health care utilization. CONCLUSION Serious infection hospitalization rates are increasing in patients with vasculitis except among those with pneumonia. Sepsis was the most common serious infection in 2015-2016. Several patient and hospital factors are associated with health care utilization and mortality in serious infection hospitalization in vasculitis.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical Center, Birmingham, Alabama and University of Alabama at Birmingham
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Merkel PA, Jayne DR, Wang C, Hillson J, Bekker P. Evaluation of the Safety and Efficacy of Avacopan, a C5a Receptor Inhibitor, in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Treated Concomitantly With Rituximab or Cyclophosphamide/Azathioprine: Protocol for a Randomized, Double-Blind, Active-Controlled, Phase 3 Trial. JMIR Res Protoc 2020; 9:e16664. [PMID: 32088663 PMCID: PMC7175182 DOI: 10.2196/16664] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis is a serious, often life-threatening disease. In new-onset disease or a relapse, the standard treatment is immunosuppressive therapy with glucocorticoids; these therapies are associated with substantial short- and long-term toxicity. Complement component 5a (C5a) binding to C5a receptor (C5aR) may play a central role in the pathogenesis of ANCA-associated vasculitis. Avacopan is a novel, orally bioavailable, and highly selective antagonist of human C5aR. Avacopan does not interfere with the production of C5b or the membrane attack complex (ie, terminal complement complex) and does not block C5a binding to a second receptor, C5L2 (also called C5aR2), shown to be protective in antimyeloperoxidase glomerulonephritis. This trial will evaluate if avacopan replaces the need for chronic glucocorticoids in the treatment of ANCA-associated vasculitis. Objective The aim of this study is to determine the proportions of patients in remission at week 26 and with sustained remission at week 52, defined as Birmingham Vasculitis Activity Score=0, and not taking glucocorticoids within the 4 weeks before week 26 and week 52, respectively. Methods The Avacopan Development in Vasculitis to Obtain Corticosteroid elimination and Therapeutic Efficacy study is a randomized, double-blind, active-comparator (prednisone), 2-arm study evaluating the safety and efficacy of avacopan versus prednisone, administered in combination with other immunosuppressive therapy. Eligible subjects will have active disease requiring induction of remission. Subjects are stratified based on the type of immunosuppressive therapy, ANCA subtype, and new or relapsing disease. Target sample size is 300 patients, enrolled at over 200 sites globally. All authors and local ethics committees approved the study design. All patients will provide informed consent. Results Enrollment of patients was completed in Q4 2018. Topline results are anticipated to be published by Q3 2020. Conclusions Results will be released irrespective of whether the findings are positive or negative. Trial Registration ClinicalTrials.gov NCT02994927; https://clinicaltrials.gov/ct2/show/NCT02994927 International Registered Report Identifier (IRRID) DERR1-10.2196/16664
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Affiliation(s)
- Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - David R Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Chao Wang
- Biostatistics, Pharma Data Associates, LLC, Piscataway, NJ, United States
| | - Jan Hillson
- Research and Development, ChemoCentryx, Inc, Mountain View, CA, United States
| | - Pirow Bekker
- Research and Development, ChemoCentryx, Inc, Mountain View, CA, United States
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Thery-Casari C, Euvrard R, Mainbourg S, Durupt S, Reynaud Q, Durieu I, Belot A, Lobbes H, Cabrera N, Lega JC. Severe infections in patients with anti-neutrophil cytoplasmic antibody-associated vasculitides receiving rituximab: A meta-analysis. Autoimmun Rev 2020; 19:102505. [PMID: 32173512 DOI: 10.1016/j.autrev.2020.102505] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 12/31/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The efficacy of rituximab (RTX) for remission induction and maintenance in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) is now established, but the safety, particularly concerning severe infection risk, is not well known. OBJECTIVE The purpose of this meta-analysis is to assess the prevalence and incidence of severe infections and the factors explaining heterogeneity in AAV patients treated with RTX. METHODS PubMed and Embase were searched up to December 2017. Prevalence and incidence was pooled using a random-effects model in case of significant heterogeneity (I2 > 50%). Severe infection was defined as severe when it led to hospitalization, intravenous antibiotics therapy, and/or death. The heterogeneity was explored by subgroup analyses and meta-regression. RESULTS The included studies encompassed 1434 patients with a median age of 51.9 years. The overall prevalence and incidence of severe infections was 15.4% (95% CI [8.9; 23.3], I2 = 90%, 33 studies) and 6.5 per 100 person-years (PY) (95% CI [2.9; 11.4], I2 = 76%, 18 studies), respectively. The most common infections were bacterial (9.4%, 95% CI [5.1; 14.8]). The prevalence of opportunistic infection was 1.5% (95% CI [0.5; 3.1], I2 = 58%) including pneumocytis jirovecii infections (0.2%, 95% CI [0.0; 0.6], I2 = 0), irrespective of prophylaxis administration. Mortality related to infection was estimated at 0.7% (95% CI [0.2; 1.2], I2 = 27%). The RTX cumulative dose was positively associated with prevalence of infections (13 studies, prevalence increase of 4% per 100 mg, p < .0001). The incidence of infection was negatively associated with duration of follow-up (8 studies, incidence decrease of 9% per year, p = .03). CONCLUSION Prevalence and incidence of severe infections, mainly bacterial ones, were high in AAV patients treated with RTX. This meta-analysis highlights the need for prospective studies to stratify infectious risk and validate cumulative RTX dose and duration of follow-up as modifying factors.
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Affiliation(s)
- Clémence Thery-Casari
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Romain Euvrard
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Sabine Mainbourg
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - Stéphane Durupt
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Quitterie Reynaud
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Univ Lyon, Health Services and Performance Research EA7425, Claude Bernard University Lyon, F-69003, France
| | - Isabelle Durieu
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Univ Lyon, Health Services and Performance Research EA7425, Claude Bernard University Lyon, F-69003, France
| | - Alexandre Belot
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; INSERM U1111, National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases (RAISE) and Department of Paediatric Rheumatology, Lyon University Hospital, University of Lyon, France
| | - Hervé Lobbes
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Internal Medicine Department, University Hospital Clermont-Ferrand, 1 place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - Natalia Cabrera
- Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - Jean-Christophe Lega
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France.
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Waki D, Nishimura K, Tokumasu H, Kadoba K, Mukoyama H, Saito R, Murabe H, Yokota T. Initial high-dose corticosteroids and renal impairment are risk factors for early severe infections in elderly patients with antineutrophil cytoplasmic autoantibody-associated vasculitis: A retrospective observational study. Medicine (Baltimore) 2020; 99:e19173. [PMID: 32080098 PMCID: PMC7034627 DOI: 10.1097/md.0000000000019173] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Recent large observational studies of antineutrophil cytoplasmic autoantibody-associated vasculitis (AAV) show that severe infection is a major cause of death and that the majority of infections occur during the early phase of initiating remission-induction therapy. Many risk factors for severe infection have been suggested, but these have been inconsistent. Nevertheless, infectious risk factors in elderly patients with AAV have not been adequately investigated in previous studies.In this retrospective observational study, we examined potential predictors of severe infection within 90 days (early severe infections) after remission-induction therapy in patients with AAV aged 65 years or older. We included 167 consecutive elderly patients with AAV admitted to our hospital. Data from medical history and remission-induction therapy were analyzed for predictive risk factors associated with early severe infections. The relationship between initial doses of corticosteroids and cumulative incidence of severe infections was also analyzed. A multivariate analysis of risk factors for early severe infections was performed using logistic regression analysis. The Kaplan-Meier method was used to estimate the overall survival, and the log-rank test was used to evaluate the differences between patients with and without early severe infections. Gray method was used to compare the cumulative incidence of severe infections in patients who did and did not receive initial high-dose corticosteroids.Logistic regression analysis showed that initial high-dose corticosteroid administration (prednisolone ≥0.8 mg/kg/d) (odds ratio [OR] 3.86, P = .030) and serum creatinine levels at diagnosis ≥1.5 mg/dL (OR 5.13, P = .003) were independent predictors of early severe infection although administration of cyclophosphamide or rituximab was not. The cumulative incidence of severe infections was also significantly higher in patients who received initial high-dose corticosteroids (P = .042), and patients with early severe infections exhibited a high mortality rate within 6 months (P < .001).Our findings suggest that initial high-dose corticosteroids and renal impairment at diagnosis are associated with a higher risk of early severe infections and early death in elderly patients with AAV.
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Affiliation(s)
| | | | - Hironobu Tokumasu
- Department of Management, Clinical Research Center, Kurashiki Central Hospital, Okayama, Japan
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Lao M, Huang M, Li C, Li H, Qiu Q, Zhan Z, Chen D. Infectious profile in inpatients with ANCA-associated vasculitis: a single-center retrospective study from Southern China. Clin Rheumatol 2019; 39:499-507. [DOI: 10.1007/s10067-019-04779-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/16/2019] [Accepted: 09/11/2019] [Indexed: 01/28/2023]
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Smoking Is a Risk Factor for Relapse of Antimyeloperoxidase Antibodies-Associated Vasculitis. J Clin Rheumatol 2019; 24:361-367. [PMID: 29667942 DOI: 10.1097/rhu.0000000000000737] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Several studies have identified predictors of relapse in antineutrophil cytoplasmic antibody-associated small-vessel vasculitis. However, the role of smoking as a risk factor of relapse has not been elucidated. Therefore, this study aimed to evaluate whether a history of smoking is a dose-dependent independent risk factor for antineutrophil cytoplasmic antibody-associated small-vessel vasculitis relapse. METHODS This multicenter retrospective cohort study included 122 patients with granulomatosis with polyangiitis and microscopic polyangiitis (MPA) from 9 nephrology centers in Japan. Dose-response relationships between cigarette smoking and outcomes were assessed using multivariate Cox proportional hazards models, adjusted for clinically relevant factors. The primary outcome was the time from remission to first relapse. RESULTS During the observation period (median, 41 months; interquartile range, 23-66 months), 118 (95.8%) and 34 (21.7%) patients experienced at least 1 remission and 1 relapse, respectively. A log-rank test showed that smoking was significantly associated with relapse (p = 0.003). Multivariate Cox proportional hazards models found current smoking to be associated with relapse (adjusted hazard ratio, 7.48; 95% confidence interval, 2.73-21.0). An association between the risk of relapse and cumulative pack-years of smoking was also noted (p = 0.004). Smoking, however, was not associated with remission. CONCLUSIONS Smoking is a significant and dose-dependent risk factor for relapse of MPA. All patients with MPA who smoke should be encouraged to quit.
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Sakai R, Tanaka E, Nishina H, Suzuki M, Yamanaka H, Harigai M. Risk of opportunistic infections in patients with antineutrophil cytoplasmic antibody‐associated vasculitis, using a Japanese health insurance database. Int J Rheum Dis 2019; 22:1978-1984. [DOI: 10.1111/1756-185x.13662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/10/2019] [Accepted: 06/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ryoko Sakai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases Department of Rheumatology, School of Medicine Tokyo Women's Medical University Tokyo Japan
- Department of Rheumatology School of Medicine Tokyo Women's Medical University Tokyo Japan
| | - Eiichi Tanaka
- Department of Rheumatology School of Medicine Tokyo Women's Medical University Tokyo Japan
| | - Hirokazu Nishina
- Department of Rheumatology School of Medicine Tokyo Women's Medical University Tokyo Japan
| | | | - Hisashi Yamanaka
- Department of Rheumatology School of Medicine Tokyo Women's Medical University Tokyo Japan
| | - Masayoshi Harigai
- Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases Department of Rheumatology, School of Medicine Tokyo Women's Medical University Tokyo Japan
- Department of Rheumatology School of Medicine Tokyo Women's Medical University Tokyo Japan
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Lepeytre F, Royal V, Lavoie PL, Bollée G, Gougeon F, Beauchemin S, Rhéaume M, Brachemi S, Laurin LP, Troyanov S. Estimating the Change in Renal Function During the First Year of Therapy in ANCA-Associated Vasculitis. Kidney Int Rep 2019; 4:594-602. [PMID: 30993234 PMCID: PMC6451086 DOI: 10.1016/j.ekir.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction Studies in antineutrophil cytoplasmic autoantibody (ANCA)–associated vasculitis (AAV) consistently show that the months following diagnosis have the greatest impact on the long-term renal function. Yet, it remains uncertain how much early gain should be expected with treatment. We sought to determine the factors associated with the change in glomerular filtration rate (GFR) throughout the first year. Methods We retrospectively reviewed patients from 3 university hospitals who received treatments. We assessed the proportions of glomeruli with crescents, with global sclerosis, the AAV glomerulonephritis classification, the severity of chronic vascular and tubulo-interstitial disease, and the presence of acute tubular injury (ATI). We used repeated-measures analyses of variance (ANOVAs) to determine factors associated with the change in GFR throughout the first year. Results There were 162 individuals with AAV identified, 96 with a valid renal biopsy and 82 with at least 12 months of follow-up. The initial GFR of 30 ± 25 ml/min per 1.73 m2 rose by 15 ± 20 during the first year. The severity of pathology findings, myeloperoxidase positivity, and those with kidney- and lung-limited disease presented with a lower GFR. Younger patients with a lower initial GFR and the presence of ATI correlated with a greater increase in GFR by 12 months. A higher proportion of crescents did not predict the change in GFR, contrary to global glomerulosclerosis, where each 10% increase added a loss of 2.7 ± 1.3 ml/min per 1.73 m2 per year (P = 0.03). These factors remained independent of each other. Conclusion Multiple factors influence renal recovery during the first year of therapy. Estimating the change in GFR early on will help identify and reassess outliers.
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Affiliation(s)
- Fanny Lepeytre
- Nephrology Division, Hôpital du Sacré-Coeur de Montréal, Québec, Canada
| | - Virginie Royal
- Pathology Department, Hôpital Maisonneuve-Rosemont, Québec, Canada
| | - Pierre-Luc Lavoie
- Nephrology Division, Hôpital du Sacré-Coeur de Montréal, Québec, Canada
| | - Guillaume Bollée
- Nephrology Division, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - François Gougeon
- Pathology Department, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | | | - Maxime Rhéaume
- Internal Medicine Division, Hôpital du Sacré-Coeur de Montréal, Québec, Canada
| | - Soumeya Brachemi
- Nephrology Division, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | | | - Stéphan Troyanov
- Nephrology Division, Hôpital du Sacré-Coeur de Montréal, Québec, Canada
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Lao M, Zhan Z, Su F, Li H, Yang Z, Chen H, Liang L, Chen D. Invasive mycoses in patients with connective tissue disease from Southern China: clinical features and associated factors. Arthritis Res Ther 2019; 21:71. [PMID: 30867045 PMCID: PMC6416859 DOI: 10.1186/s13075-019-1851-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/20/2019] [Indexed: 12/28/2022] Open
Abstract
Background A retrospective study was performed to investigate the clinical features and associated factors of invasive mycoses (IM) in patients with connective tissue disease (CTD) from Southern China. Methods Demographic and clinical data were recorded. Associated factors were analyzed by logistic regression analysis. Results A total of 6911 patients with CTD were included. IM was diagnosed in 32 patients (incidence, 0.5%). IM was predominant in patients with ANCA-associated vasculitis (AAV) (incidence, 1.5%, 7/480). Lung was commonly involved (30/32, 93.8%). Aspergillus spp. (81.3%) were the leading strain. The positive rate of fungi detection in sputum culture was 69.0%. Serum galactomannan (GM) test was positive in bronchoalveolar lavage fluid (BALF) from seven (7/10, 70.0%) patients. Ten patients died (31.3%), including three with AAV (42.9%) and seven with SLE (36.8%). Penicillium marneffei was the most fatal (mortality, 100%). Non-survivors had higher prevalence of leukopenia (30.0% vs 4.5%, P = 0.04), lymphopenia (100.0% vs 59.1%, P = 0.02), elevated serum creatinine (70.0% vs 27.3%, P = 0.02), and co-infection (70.0% vs 18.2%, P = 0.004) than survivors. Multivariate logistic regression analysis showed that lymphopenia [odds ratio (OR) = 3.28, 95% confidence interval (CI) 1.29–8.38, P = 0.01] and median-to-high dose of glucocorticoid (GC) [OR = 3.40, 95% CI 1.04–11.13, P = 0.04] were associated with IM in patients with CTD. Conclusions IM tended to develop in patients with AAV, resulting in high mortality. Sputum culture and GM test in BALF were effective methods to distinguish IM. Vigilance against lymphopenia, impaired kidney function, and co-infection improved the prognosis of IM. Electronic supplementary material The online version of this article (10.1186/s13075-019-1851-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Minxi Lao
- Department of Rheumatology & Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhongping Zhan
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Fan Su
- Department of Rheumatology & Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hao Li
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Zheng Yang
- Department of Pathology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Haihong Chen
- Department of Respirology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liuqin Liang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
| | - Dongying Chen
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
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Chanouzas D, McGregor JAG, Nightingale P, Salama AD, Szpirt WM, Basu N, Morgan MD, Poulton CJ, Draibe JB, Krarup E, Dospinescu P, Dale JA, Pendergraft WF, Lee K, Egfjord M, Hogan SL, Harper L. Intravenous pulse methylprednisolone for induction of remission in severe ANCA associated Vasculitis: a multi-center retrospective cohort study. BMC Nephrol 2019; 20:58. [PMID: 30777023 PMCID: PMC6378728 DOI: 10.1186/s12882-019-1226-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/23/2019] [Indexed: 11/12/2022] Open
Abstract
Background Intravenous pulse methylprednisolone (MP) is commonly included in the management of severe ANCA associated vasculitis (AAV) despite limited evidence of benefit. We aimed to evaluate outcomes in patients who had, or had not received MP, along with standard therapy for remission induction in severe AAV. Methods We retrospectively studied 114 consecutive patients from five centres in Europe and the United States with a new diagnosis of severe AAV (creatinine > 500 μmol/L or dialysis dependency) and that received standard therapy (plasma exchange, cyclophosphamide and high-dose oral corticosteroids) for remission induction with or without pulse MP between 2000 and 2013. We evaluated survival, renal recovery, relapses, and adverse events over the first 12 months. Results Fifty-two patients received pulse MP in addition to standard therapy compared to 62 patients that did not. There was no difference in survival, renal recovery or relapses. Treatment with MP associated with higher risk of infection during the first 3 months (hazard ratio (HR) 2.7, 95%CI [1.4–5.3], p = 0.004) and higher incidence of diabetes (HR 6.33 [1.94–20.63], p = 0.002), after adjustment for confounding factors. Conclusions The results of this study suggest that addition of pulse intravenous MP to standard therapy for remission induction in severe AAV may not confer clinical benefit and may be associated with more episodes of infection and higher incidence of diabetes. Electronic supplementary material The online version of this article (10.1186/s12882-019-1226-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dimitrios Chanouzas
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter Nightingale
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alan D Salama
- Centre for Nephrology, University College London, London, UK
| | | | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Matthew David Morgan
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Caroline J Poulton
- University of North Carolina Kidney Center, Chapel Hill, North Carolina, USA
| | | | | | - Paula Dospinescu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Jessica Anne Dale
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Keegan Lee
- Centre for Nephrology, University College London, London, UK
| | | | - Susan L Hogan
- University of North Carolina Kidney Center, Chapel Hill, North Carolina, USA
| | - Lorraine Harper
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK. .,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Li J, Cui Z, Long JY, Huang W, Wang JW, Wang H, Zhang L, Chen M, Zhao MH. The frequency of ANCA-associated vasculitis in a national database of hospitalized patients in China. Arthritis Res Ther 2018; 20:226. [PMID: 30286799 PMCID: PMC6235226 DOI: 10.1186/s13075-018-1708-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 08/27/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is a group of life-threatening autoimmune diseases. The epidemiological data on AAV in China are limited. The aim of the present study is to investigate the frequency, geographical distribution, and ethnic distribution of AAV in hospitalized patients in China, and its association with environmental pollution. METHODS We investigated the hospitalized patients in a national inpatient database covering 54.1% tertiary hospitals in China from 2010 to 2015. Diagnosis of AAV was extracted according to the definition of International Classification of Diseases (ICD)-10 codes and free text. Variables from the front page of inpatient records were collected and analyzed, including frequency, geographic distribution, demographic characteristics and seasonal variations of AAV. The association between various environmental pollutants and frequency of AAV was further analyzed. RESULTS Among 43.7 million inpatients included in the study period, 0.25‰ (10,943) were diagnosed as having AAV. The frequency of AAV was relatively stable during the study period (from 0.34‰ in 2010 to 0.27‰ in 2015). The proportion of AAV increased with latitude (0.44‰ in Northern China and 0.27‰ in Southern China in 2015). Hospitalizations were mostly observed in winter (30.2%). The Dong population, an ethnic minority of the Chinese population, had the highest frequency of patients with AAV (0.67‰). We also found a positive association between the exposure to carbon monoxide and the frequency of AAV (R2 = 0.172, p = 0.025). In Yunnan province, the frequency of AAV increased 1.37-fold after the Zhaotong earthquake, which took place in 2014. CONCLUSIONS Our present investigation of hospitalized patients provided epidemiological information on AAV in China for the first time. A spatial and ethnic clustering trend and an association between pollution and the frequency of AAV were observed.
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Affiliation(s)
- Jiannan Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Jian-Yan Long
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Huang
- Department of Occupational and Enviromental Health, Peking University School of Public Health, Beijing, China
| | - Jin-Wei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Haibo Wang
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,China Standard Medical Information Research Center, Shenzhen, Guangdong, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking University, Center for Data Science in Health and Medicine, Beijing, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China. .,Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China.
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Keller F, Hann A. Clinical Pharmacodynamics: Principles of Drug Response and Alterations in Kidney Disease. Clin J Am Soc Nephrol 2018; 13:1413-1420. [PMID: 29769182 PMCID: PMC6140566 DOI: 10.2215/cjn.10960917] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pharmacokinetics and pharmacodynamics follow the logic of cause and consequence. Receptor-mediated and reversible effects can be distinguished from direct and irreversible effects. Reversible effects are capacity-limited and saturable whereas irreversible effects are limited only by the number of viable targets. In the case of receptor-mediated and reversible effects a threshold and a ceiling concentration can be defined. Antimicrobial drugs with concentration-dependent action are distinguished from drugs with time-dependent action. Concentration-dependent effects are associated with a high ceiling concentration and the target is the high peak. Time-dependent effects are associated with a high threshold concentration and the target is the high trough. During kidney dysfunction, alterations of drug response are usually attributed to pharmacokinetic but rarely to pharmacodynamic changes. Dose adjustment calculations, therefore, tacitly presume that pharmacodynamic parameters remain unchanged while only pharmacokinetic parameters are altered in kidney failure. Kidney dysfunction influences the pharmacokinetic parameters of at least 50% of all essential drugs. Clinicians usually consider pharmacokinetics when kidney disease is found, but pharmacodynamics is as important. Alterations of pharmacodynamic parameters are conceivable but only rarely reported in kidney failure. Sometimes surprising dosing adjustments are needed when pharmacodynamic concepts are brought into the decision process of which dose to choose. Pharmacokinetics and pharmacodynamics should both be considered when any dosing regimen is determined.
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Affiliation(s)
- Frieder Keller
- Center for Internal Medicine, University Hospital, Ulm, Germany
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Pediatric Nephrology and Rheumatology Practice Patterns in Granulomatosis with Polyangiitis: A Midwest Pediatric Nephrology Consortium Study. Int J Nephrol 2018; 2018:8413096. [PMID: 30155302 PMCID: PMC6098870 DOI: 10.1155/2018/8413096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/07/2018] [Accepted: 06/26/2018] [Indexed: 02/06/2023] Open
Abstract
Objective To assess practice pattern similarities and differences amongst pediatric rheumatologists and nephrologists in the management of pediatric Granulomatosis with Polyangiitis (GPA). Methods A voluntary survey was distributed to the Midwest Pediatric Nephrology Consortium Group (MWPNC) and an international pediatric rheumatology email listserv in 2016-2017. Data were collected on general practice characteristics and preferences for induction management under three clinical scenarios (A-C): newly diagnosed GPA with glomerulonephritis, GPA with rapidly progressive glomerulonephritis, and GPA with pulmonary hemorrhage. In addition, individual preferences for GPA maintenance medications, disease monitoring, and management of GPA with end-stage renal disease were ascertained. Results There was a 68% response rate from the MWPNC membership and equal numbers of rheumatology respondents. Survey results revealed Rituximab plus Cyclophosphamide is a more common induction choice for rheumatologists than nephrologists in induction Scenarios A and B, whereas Cyclophosphamide is more commonly chosen by nephrologists in Scenario A. Plasmapheresis rates increased for Scenarios A, B, and C for both specialties, but were overall low. There was no clear consensus on the duration of maintenance therapy nor diagnostic work-up. Rheumatologists more frequently chose Rituximab for maintenance and induction compared to nephrologists. There was also a higher than expected proportion of Mycophenolate Mofetil use for both specialties. Conclusion This survey has revealed important differences in the way that rheumatologists and nephrologists manage this disease. It highlights the need for well-designed clinical trials in pediatric GPA patients and reveals that both specialties must be represented during consensus-building and clinical trial design efforts.
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Abstract
Despite the progress in the last years on the field of vasculitides, there are several unmet needs regarding classification, disease activity assessment, predictors of flares and complications, and type of treatment for the different forms. The 1990 American College of Rheumatology (ACR) classification criteria currently used to define giant cell arteritis and Takayasu arteritis were designed to discriminate between different types of vasculitides but not to differentiate vasculitis from other disorders. Recently, efforts have been made to overcome the shortcomings of the ACR criteria. The lack of an accepted definition of disease activity in large-vessel vasculitides presents a major challenge in creating useful and valid outcome tools for the assessment of disease course. Identification of predictors of flares can aid in optimizing therapeutic strategies, minimizing disease flares, and reducing treatment-related side effects. It is furthermore important to recognize and characterize the risk factor that might predict the manifestations associated with poor outcome and prognosis. Two RCTs have evidenced the efficacy of tocilizumab in addition to glucocorticoids (GCs) in the treatment of giant cell arteritis (GCA). However, the role of tocilizumab or other biological agents without GCs needs to be investigated. Recent observational studies have suggested that rituximab is also effective in patients with eosinophilic granulomatosis with polyangiitis and in antineutrophil cytoplasmic antibodies (ANCA)-negative patients with granulomatosis with polyangiitis and microscopic polyangiitis. Rituximab or anti-TNF alfa may represent a possible alternative therapy in case of refractory or difficult to treat polyarteritis nodosa (PAN) patients. The new International Criteria for Behçet's Disease have shown a better sensitivity and a better accuracy compared to the older International Study Group on Behçet's Disease criteria. The EULAR recommendations for the management of Behçet's disease (BD) have been recently updated. However, the treatment of refractory disease is still a real challenge.
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Abstract
Most glomerular diseases are immunologically mediated disorders of the kidney and are common causes of ESKD. In addition to supportive therapy, a wide range of immunosuppressive agents are used in the management of patients with these conditions. Immunosuppression requires a careful balance of risk and benefits, and many of these agents have a narrow therapeutic window and require close monitoring. This review describes the side effects of immunosuppressive agents used in recent randomized, controlled trials of glomerular disease, and highlights some of the key adverse events that determine the choice and prescription of these medications.
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Affiliation(s)
- J Ashley Jefferson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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Platelet to lymphocyte ratio is associated with the current activity of ANCA-associated vasculitis at diagnosis: a retrospective monocentric study. Rheumatol Int 2018; 38:1865-1871. [PMID: 30088046 DOI: 10.1007/s00296-018-4125-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/04/2018] [Indexed: 12/31/2022]
Abstract
Platelet to lymphocyte ratio (PLR) has been introduced as a useful index to estimate the current inflammatory burdens in various diseases. In this study, we investigate whether PLR is associated with the severity of ANCA-associated vasculitis (AAV). We retrospectively reviewed the medical records of 163 patients with AAV, collected clinical, laboratory and radiological data and calculated Birmingham vasculitis activity score (BVAS). We defined the lower limit of the highest tertile of BVAS as the cut-off for severe AAV (BVAS ≥ 16). The optimal cut-off of PLR for severe AAV was set as 272.0. The odds ratio (OR) of PLR for severe AAV was assessed using the univariable and multivariable logistic regression analyses. The median age at diagnosis was 58.0 years and 51 patients (31.3%) were men. Patients with severe AAV exhibited higher rate of ANCA positivity and higher blood urea nitrogen (BUN), creatinine (Cr), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) than those without. Patients with severe AAV exhibited significantly increased median PLR compared to those without (299.3 vs. 184.0). In the univariable binary logistic regression analysis, BUN ≥ 17.45 mg/dL (OR 3.730), Cr ≥ 1.12 mg/dL (OR 3.519), ESR ≥ 83.5 mm/h (OR 2.785), CRP ≥ 20.0 mg/L (OR 2.612), PLR ≥ 272.0 (OR 4.231) and ANCA positivity (OR 2.306) were associated with severe AAV. In the multivariable binary logistic regression analysis, only PLR ≥ 272.0 was an independent predictor of severe AAV at diagnosis (OR 2.734, 95% CI 1.247, 5.993). In conclusion, PLR at diagnosis is associated with the current activity of vasculitis in AAV patients.
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Garnier C, Ribes D, Chauveau D, Huart A, Pugnet G, Adoue D, Prevot G, Alric L, Delobel P, Derumeaux H, Mengelle C, Sailler L, Moulis G. Zoster after Cyclophosphamide for Systemic Lupus Erythematosus or Vasculitis: Incidence, Risk Factors, and Effect of Antiviral Prophylaxis. J Rheumatol 2018; 45:1541-1548. [DOI: 10.3899/jrheum.180310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 12/12/2022]
Abstract
Objective.To assess the incidence and the risk factors for zoster in patients exposed to intravenous cyclophosphamide (CYC) for systemic vasculitis or systemic lupus erythematosus (SLE), as well as the protective effect of prophylaxis by valacyclovir (VCV).Methods.This retrospective study included all adults treated by intravenous CYC for SLE or systemic vasculitis between 2011 and 2015 at Toulouse University Hospital, France. Zoster occurrence was recorded using medical chart review, laboratory data, and patient interviews. Univariate Cox models were computed to assess the risk factors for zoster and the protective effect of prophylaxis by VCV.Results.The cohort consisted of 110 patients (81 systemic vasculitis and 29 SLE). During a mean followup of 3.4 years after CYC initiation, 10 cases of zoster occurred, leading to an overall incidence of 27.9/1000 patient-years (95% CI 15.2–50.6); it was 59.4/1000 patients (95% CI 27.5–123.6) during the year after CYC initiation. Four patients experienced persistent postherpetic neuralgia. Probable risk factors were lymphopenia < 500/µl at CYC initiation (HR 5.11, 95% CI 0.94–27.93) and female sex (HR 4.36, 95% CI 0.51–37.31). The incidence was higher in patients with SLE (HR as compared with systemic vasculitis patients = 2.68, 95% CI 0.54–13.26). None of the 19 patients exposed to VCV during the followup developed zoster.Conclusion.The incidence of zoster is high in systemic vasculitis and in patients with SLE exposed to intravenous CYC. CYC may favor postherpetic neuralgia. Prophylaxis by VCV should be considered, particularly in cases of lymphopenia < 500/µl at CYC initiation and during the year after.
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Kronbichler A, Kerschbaum J, Gopaluni S, Tieu J, Alberici F, Jones RB, Smith RM, Jayne DRW. Trimethoprim-sulfamethoxazole prophylaxis prevents severe/life-threatening infections following rituximab in antineutrophil cytoplasm antibody-associated vasculitis. Ann Rheum Dis 2018; 77:1440-1447. [PMID: 29950327 PMCID: PMC6161662 DOI: 10.1136/annrheumdis-2017-212861] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 06/11/2018] [Indexed: 12/18/2022]
Abstract
Objective We aimed to assess risk factors for the development of severe infection in patients with antineutrophil cytoplasm antibody-associated vasculitis (AAV) receiving rituximab. Methods 192 patients with AAV were identified. Univariate and multivariate analyses were performed to identify risk factors for severe infection following rituximab. Severe infections were classified as grade ≥3 as proposed by the Common Terminology Criteria for Adverse Events V.4.0. Results 95 severe infections were recorded in 49 (25.52%) patients, corresponding to an event rate of 26.06 per 100 person-years. The prophylactic use of trimethoprim–sulfamethoxazole was associated with a lower frequency of severe infections (HR 0.30, 95% CI 0.13 to 0.69), while older age (HR 1.03, 95% CI 1.01 to 1.05), endobronchial involvement (HR 2.21, 95% CI 1.14 to 4.26), presence of chronic obstructive pulmonary disease (HR 6.30, 95% CI 1.08 to 36.75) and previous alemtuzumab use (HR 3.97, 95% CI 1.50 to 10.54) increased the risk. When analysis was restricted to respiratory tract infections (66.3% of all infections), endobronchial involvement (HR 4.27, 95% CI 1.81 to 10.06), severe bronchiectasis (HR 6.14, 95% CI 1.18 to 31.91), higher neutrophil count (HR 1.19, 95% CI 1.06 to 1.33) and major relapse (HR 3.07, 95% CI 1.30 to 7.23) as indication for rituximab use conferred a higher risk, while refractory disease (HR 0.25, 95% CI 0.07 to 0.90) as indication had a lower frequency of severe infections. Conclusions We found severe infections in one quarter of patients with AAV receiving rituximab. Trimethoprim–sulfamethoxazole prophylaxis reduced the risk, while especially bronchiectasis and endobronchial involvement are risk factors for severe respiratory infections.
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Affiliation(s)
- Andreas Kronbichler
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Department of Internal Medicine IV (Nephrology and Hypertension), Anichstraße, Innsbruck, Austria
| | - Julia Kerschbaum
- Department of Internal Medicine IV (Nephrology and Hypertension), Anichstraße, Innsbruck, Austria
| | | | - Joanna Tieu
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - Federico Alberici
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Renal Medicine and Vasculitis Clinic, San Carlo Borromeo Hospital, Milan, Italy
| | | | - Rona M Smith
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
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