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Martin F, Leandro A, Giuliana V. Diagnostic challenge of hemoptysis in a hemodialysis patient. Eur J Intern Med 2024:S0953-6205(24)00319-4. [PMID: 39048337 DOI: 10.1016/j.ejim.2024.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Fullana Martin
- Pulmonology Department, Dr. Marcial Vicente Quiroga Hospital, Argentina.
| | - Aliaga Leandro
- Internal Medicine Department, Dr. Marcial Vicente Quiroga Hospital, Argentina
| | - Verni Giuliana
- Internal Medicine Department, Dr. Marcial Vicente Quiroga Hospital, Argentina
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Fussner LA, Flores-Suárez LF, Cartin-Ceba R, Specks U, Cox PG, Jayne DRW, Merkel PA, Walsh M. Alveolar Hemorrhage in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results of an International Randomized Controlled Trial (PEXIVAS). Am J Respir Crit Care Med 2024; 209:1141-1151. [PMID: 38346237 PMCID: PMC11092964 DOI: 10.1164/rccm.202308-1426oc] [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: 08/15/2023] [Accepted: 02/12/2024] [Indexed: 05/02/2024] Open
Abstract
Rationale: Diffuse alveolar hemorrhage (DAH) is a life-threatening manifestation of antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The PEXIVAS (Plasma Exchange and Glucocorticoids in Severe Antineutrophil Cytoplasmic Antibody-Associated Vasculitis) (NCT00987389) trial was the largest in AAV and the first to enroll participants with DAH requiring mechanical ventilation. Objectives: Evaluate characteristics, treatment effects, and outcomes for patients with AAV with and without DAH. Methods: PEXIVAS randomized 704 participants to plasma exchange (PLEX) or no-PLEX and reduced or standard-dose glucocorticoids (GC). DAH status was defined at enrollment as no-DAH, nonsevere, or severe (room air oxygen saturation of ⩽ 85% as measured by pulse oximetry, or use of mechanical ventilation). Measurements and Main Results: At enrollment, 191 (27.1%) participants had DAH (61 severe, including 29 ventilated) and were younger, more frequently relapsing, PR3 (proteinase 3)-ANCA positive, and had lower serum creatinine but were more frequently dialyzed than participants without DAH (n = 513; 72.9%). Among those with DAH, 8/95 (8.4%) receiving PLEX died within 1 year versus 15/96 (15.6%) with no-PLEX (hazard ratio, 0.52; confidence interval [CI], 0.21-1.24), whereas 13/96 (13.5%) receiving reduced GC died versus 10/95 (10.5%) with standard GC (hazard ratio, 1.33; CI, 0.57-3.13). When ventilated, ventilator-free days were similar with PLEX versus no-PLEX (medians, 25; interquartile range [IQR], 22-26 vs. 22-27) and fewer with reduced GC (median, 23; IQR, 20-25) versus standard GC (median, 26; IQR, 25-28). Treatment effects on mortality did not vary by presence or severity of DAH. Overall, 23/191 (12.0%) with DAH died within 1 year versus 34/513 (6.6%) without DAH. End-stage kidney disease and serious infections did not differ by DAH status or treatments. Conclusions: Patients with AAV and DAH differ from those without DAH in multiple ways. Further data are required to confirm or refute a benefit of PLEX or GC dosing on mortality. Original clinical trial registered with www.clinicaltrials.gov (NCT00987389).
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Affiliation(s)
- Lynn A. Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Luis Felipe Flores-Suárez
- La Clínica de Vasculitis Sistémicas Primarias, Instituto Nacional de Enfermedades Respiratorias, Tlalpan, Ciudad de México, Mexico
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - David R. W. Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Peter A. Merkel
- Division of Rheumatology, Department of Medicine, and
- Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Walsh
- Division of Nephrology, Department of Medicine
- Department of Health Research Methods, Evidence, and Impact, and
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Qi F, Hao J, Wei W. Impact of different ANCA serotypes on the long-term outcome of ANCA-associated vasculitis patients. Ann Med 2023; 55:2289614. [PMID: 38056010 PMCID: PMC10836254 DOI: 10.1080/07853890.2023.2289614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES To investigate the clinical features and long-term outcomes of Chinese anti-neutrophil cytoplasmic antibodies (ANCAs)-associated vasculitis (AAV) patients with different ANCA serotypes. METHODS Two hundred and twenty-four AAV patients from January 2010 to June 2021 were divided into myeloperoxidase (MPO)-ANCA and proteinase 3 (PR3)-ANCA groups. Clinical and long-term outcomes were compared. RESULTS In this study, the average follow-up was 46.4 months (range 0.3-188.4 months). One hundred and seventy-seven (79.0%) patients were MPO-ANCA-positive and 47 were PR3-ANCA-positive; the mean age of MPO-ANCA positive patients at diagnosis was elder than that of PR3-ANCA positive patients (67.0 vs. 60.0 years, p = .004). Among PR3-ANCA-positive patients, ear, nose and throat symptoms were more common (p = .014). Between two ANCA serotypes, there were no differences in complement 3 (C3), Birmingham vasculitis activity score (BVAS), five-factor score (FFS) or other organ involvements. For all AAV patients, the overall survival rates at one, three and five years were 80.0%, 67.0% and 56.4%, respectively. The cumulative relapse-free rates of one, three and five years were 89.5%, 76.4% and 68.4%, respectively. The survival of AAV patients was unaffected by the ANCA serotype (p = .23). The ANCA serotype also had no effect on either disease relapse (p = .20) or remission rates (p = .10). In our study, PR3-ANCA patients showed a better long-term survival, as the 5-year survival rate and the 5-year relapse-free survival rate of PR3-ANCA patients were 60.7% and 76.9%, while that of MPO-ANCA patients were 55.2% and 65.8%, respectively. Rather than ANCA serotype, younger patients with milder kidney involvement and lower disease assessment scores (BVAS and FFS) might be more relevant to better prognosis. CONCLUSIONS The likelihood of induced remission, patient survival or disease recurrence is all unaffected by ANCA serotypes. A better prognosis is seen in younger patients with milder kidney involvement and lower BVAS/FFS scores.
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Affiliation(s)
- Fumin Qi
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jian Hao
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, China
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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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Kambhatla S, Vipparthy S, Manadan AM. Rheumatic diseases associated with alveolar hemorrhage: analysis of the national inpatient sample. Clin Rheumatol 2023; 42:1177-1183. [PMID: 36396790 PMCID: PMC9672553 DOI: 10.1007/s10067-022-06449-9] [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: 07/11/2022] [Revised: 11/06/2022] [Accepted: 11/10/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Diffuse alveolar hemorrhage (DAH) is a severe pulmonary complication of numerous diseases, including rheumatic conditions. We have conducted an observational study using inpatient data from the National Inpatient Sample to study the relationship of DAH with rheumatic conditions along with their descriptive characteristics. METHODS An observational study was conducted on hospitalizations in 2016-2018 with a principal diagnosis of DAH from the United States National Inpatient Sample database. A multivariate logistic regression analysis was performed to calculate adjusted odds ratios (ORadj) for risk factors of DAH. RESULTS A total of 5420 DAH hospitalizations were identified among 90 million hospitalizations. Mortality in this group was found to be 24.3%. Majority of patients admitted with DAH were white and male, with a mean age of 61.8 years and a mean LOS of 10.6 days. Multivariate analysis showed that multiple rheumatic diseases were associated with DAH, including anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) (ORadj 72.56) (95% C.I. 50.607-104.043), antiphospholipid antibody syndrome (APLS) (ORadj 6.51) (95% C.I. 3.734-11.366), eosinophilic granulomatosis with polyangiitis (EGPA) (ORadj 7.13) (95% C.I. 1.886-26.926), Goodpasture's (ORadj 30.58) (95% C.I. 16.360-57.176), rheumatoid arthritis (RA) (ORadj 1.60) (95% C.I. 1.158-2.212), sarcoidosis (ORadj 3.99) (95% C.I. 2.300-6.926), and systemic lupus (SLE) (ORadj 5.82) (95% C.I. 3.993-8.481). CONCLUSION Although DAH is a relatively rare entity, it carries a very high mortality. Multiple rheumatic diseases were associated with DAH hospitalizations including AAV, APLS, EGPA, Goodpasture's, RA, sarcoidosis, and SLE. Key points • It is known that DAH carries a high morbidity and mortality based on prior literature. However, large datasets on the association of rheumatic diseases with DAH are lacking • This study identifies the descriptive characteristics of patients admitted to the hospital with DAH • This study also identifies the strength of association of rheumatic diseases with DAH.
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Affiliation(s)
- Soumyasri Kambhatla
- Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA.
| | - Sharath Vipparthy
- Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
| | - Augustine M Manadan
- Rheumatology Program Director, Cook County Hospital, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
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Jayne D, Walsh M, Merkel PA, Peh CA, Szpirt W, Puéchal X, Fujimoto S, Hawley C, Khalidi N, Jones R, Flossmann O, Wald R, Girard L, Levin A, Gregorini G, Harper L, Clark W, Pagnoux C, Specks U, Smyth L, Ito-Ihara T, de Zoysa J, Brezina B, Mazzetti A, McAlear CA, Reidlinger D, Mehta S, Ives N, Brettell EA, Jarrett H, Wheatley K, Broadhurst E, Casian A, Pusey CD. Plasma exchange and glucocorticoids to delay death or end-stage renal disease in anti-neutrophil cytoplasm antibody-associated vasculitis: PEXIVAS non-inferiority factorial RCT. Health Technol Assess 2022; 26:1-60. [PMID: 36155131 DOI: 10.3310/pnxb5040] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasm antibody-associated vasculitis is a multisystem, autoimmune disease that causes organ failure and death. Physical removal of pathogenic autoantibodies by plasma exchange is recommended for severe presentations, along with high-dose glucocorticoids, but glucocorticoid toxicity contributes to morbidity and mortality. The lack of a robust evidence base to guide the use of plasma exchange and glucocorticoid dosing contributes to variation in practice and suboptimal outcomes. OBJECTIVES We aimed to determine the clinical efficacy of plasma exchange in addition to immunosuppressive therapy and glucocorticoids with respect to death and end-stage renal disease in patients with severe anti-neutrophil cytoplasm antibody-associated vasculitis. We also aimed to determine whether or not a reduced-dose glucocorticoid regimen was non-inferior to a standard-dose regimen with respect to death and end-stage renal disease. DESIGN This was an international, multicentre, open-label, randomised controlled trial. Patients were randomised in a two-by-two factorial design to receive either adjunctive plasma exchange or no plasma exchange, and either a reduced or a standard glucocorticoid dosing regimen. All patients received immunosuppressive induction therapy with cyclophosphamide or rituximab. SETTING Ninety-five hospitals in Europe, North America, Australia/New Zealand and Japan participated. PARTICIPANTS Participants were aged ≥ 16 years with a diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis, and either proteinase 3 anti-neutrophil cytoplasm antibody or myeloperoxidase anti-neutrophil cytoplasm antibody positivity, and a glomerular filtration rate of < 50 ml/minute/1.73 m2 or diffuse alveolar haemorrhage attributable to active anti-neutrophil cytoplasm antibody-associated vasculitis. INTERVENTIONS Participants received seven sessions of plasma exchange within 14 days or no plasma exchange. Oral glucocorticoids commenced with prednisolone 1 mg/kg/day and were reduced over different lengths of time to 5 mg/kg/day, such that cumulative oral glucocorticoid exposure in the first 6 months was 50% lower in patients allocated to the reduced-dose regimen than in those allocated to the standard-dose regimen. All patients received the same glucocorticoid dosing from 6 to 12 months. Subsequent dosing was at the discretion of the treating physician. PRIMARY OUTCOME The primary outcome was a composite of all-cause mortality and end-stage renal disease at a common close-out when the last patient had completed 10 months in the trial. RESULTS The study recruited 704 patients from June 2010 to September 2016. Ninety-nine patients died and 138 developed end-stage renal disease, with the primary end point occurring in 209 out of 704 (29.7%) patients: 100 out of 352 (28%) in the plasma exchange group and 109 out of 352 (31%) in the no plasma exchange group (adjusted hazard ratio 0.86, 95% confidence interval 0.65 to 1.13; p = 0.3). In the per-protocol analysis for the non-inferiority glucocorticoid comparison, the primary end point occurred in 92 out of 330 (28%) patients in the reduced-dose group and 83 out of 325 (26%) patients in the standard-dose group (partial-adjusted risk difference 0.023, 95% confidence interval 0.034 to 0.08; p = 0.5), thus meeting our non-inferiority hypothesis. Serious infections in the first year occurred in 96 out of 353 (27%) patients in the reduced-dose group and in 116 out of 351 (33%) patients in the standard-dose group. The rate of serious infections at 1 year was lower in the reduced-dose group than in the standard-dose group (incidence rate ratio 0.69, 95% confidence interval 0.52 to 0.93; p = 0.016). CONCLUSIONS Plasma exchange did not prolong the time to death and/or end-stage renal disease in patients with anti-neutrophil cytoplasm antibody-associated vasculitis with severe renal or pulmonary involvement. A reduced-dose glucocorticoid regimen was non-inferior to a standard-dose regimen and was associated with fewer serious infections. FUTURE WORK A meta-analysis examining the effects of plasma exchange on kidney outcomes in anti-neutrophil cytoplasm antibody-associated vasculitis is planned. A health-economic analysis of data collected in this study to examine the impact of both plasma exchange and reduced glucocorticoid dosing is planned to address the utility of plasma exchange for reducing early end-stage renal disease rates. Blood and tissue samples collected in the study will be examined to identify predictors of response to plasma exchange in anti-neutrophil cytoplasm in antibody-associated vasculitis. The benefits associated with reduced glucocorticoid dosing will inform future studies of newer therapies to permit further reduction in glucocorticoid exposure. Data from this study will contribute to updated management recommendations for anti-neutrophil cytoplasm antibody-associated vasculitis. LIMITATIONS This study had an open-label design which may have permitted observer bias; however, the nature of the end points, end-stage renal disease and death, would have minimised this risk. Despite being, to our knowledge, the largest ever trial in anti-neutrophil cytoplasm antibody-associated vasculitis, there was an insufficient sample size to assess clinically useful benefits on the separate components of the primary end-point: end-stage renal disease and death. Use of a fixed-dose plasma exchange regimen determined by consensus rather than data-driven dose ranging meant that some patients may have been underdosed, thus reducing the therapeutic impact. In particular, no biomarkers have been identified to help determine dosing in a particular patient, although this is one of the goals of the biomarker plan of this study. TRIAL REGISTRATION This trial is registered as ISRCTN07757494, EudraCT 2009-013220-24 and Clinicaltrials.gov NCT00987389. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael Walsh
- Department of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Peter A Merkel
- Department of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Chen Au Peh
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | - Xavier Puéchal
- National Referral Centre for Rare Systemic Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Carmel Hawley
- Department of Nephrology, The University of Queensland, Brisbane, QLD, Australia
| | - Nader Khalidi
- Department of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Rachel Jones
- Renal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Ron Wald
- Department of Rheumatology, St Michael's Hospital, Toronto, ON, Canada
| | - Louis Girard
- Department of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Adeera Levin
- Department of Nephrology, St Paul's Hospital, Vancouver, BC, Canada
| | - Gina Gregorini
- Department of Nephrology, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Lorraine Harper
- Department of Nephrology, University of Birmingham, Birmingham, UK
| | - William Clark
- Department of Nephrology, University of Western Ontario, London, ON, Canada
| | - Christian Pagnoux
- Department of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ulrich Specks
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lucy Smyth
- Department of Nephrology, The Royal Devon and Exeter Hospital, Exeter, UK
| | - Toshiko Ito-Ihara
- Clinical and Translational Research Centre, Kyoto Prefecture University of Medicine, Kyoto, Japan
| | - Janak de Zoysa
- Department of Nephrology, North Shore Hospital, Auckland, New Zealand
| | - Biljana Brezina
- Renal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrea Mazzetti
- The Research Institute, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Carol A McAlear
- Department of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Reidlinger
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, QLD, Australia
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Hugh Jarrett
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Alina Casian
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Charles D Pusey
- Department of Nephrology, Imperial College London, London, UK
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Molnár A, Studinger P, Ledó N. Diagnostic and Therapeutic Approach in ANCA-Associated Glomerulonephritis: A Review on Management Strategies. Front Med (Lausanne) 2022; 9:884188. [PMID: 35721093 PMCID: PMC9205443 DOI: 10.3389/fmed.2022.884188] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is a destructive small vessel vasculitis affecting multiple organs. Renal involvement often leads to end-stage renal disease and increases mortality. Prompt diagnosis and initiation of adequate immunosuppressive therapy are critical for the best patient and kidney outcomes. However, considerable heterogeneity in symptoms and severity across the patients frequently hinder the diagnosis and management. The objective of this review is to emphasize the heterogeneity of the ANCA-associated vasculitis, facilitate the recognition and give guidance to the therapeutical possibilities. We present epidemiologic and risk factors, pathogenesis, and provide comprehensive clinical features of the disease. This article also focuses on the currently available therapeutic options and emerging cellular and molecular targets for the management of systemic and especially renal disease. We conducted extensive literature research published on PubMed and Google Scholar. We systematically reviewed, analyzed, and assembled databases, covering a broad spectrum of aspects of the disease. We compared and summarized the recommendations of two recent guidelines on ANCA-associated vasculitis. The incidence of ANCA-associated vasculitis, hence glomerulonephritis shows a steady increase. Familiarity with the presenting symptoms and laboratory abnormalities are necessary for rapid diagnosis. Early initiation of treatment is the key aspect for favorable patient and renal outcomes. A better understanding of the pathogenesis constantly leads to more targeted and therefore more efficient and less toxic treatment.
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Affiliation(s)
| | | | - Nóra Ledó
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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Saha BK, Bonnier A, Chenna P, Milman NT. Prevalence of autoantibodies in pediatric patients with idiopathic pulmonary hemosiderosis: a scoping review of the literature in the period 1980-2021. Clin Rheumatol 2022; 41:977-990. [PMID: 35067768 DOI: 10.1007/s10067-021-06029-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/04/2021] [Accepted: 12/18/2021] [Indexed: 11/03/2022]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology. Due to the frequent findings of autoimmune antibodies - autoantibodies, immunologic causation of the diffuse alveolar hemorrhage in IPH has been proposed, to assess the prevalence/frequency and type of autoantibodies in pediatric patients with IPH. In addition, the patient demographics, diagnostic modalities used to diagnose IPH, treatment, and outcomes were also evaluated. Scoping review: The PubMed, Medline, and Embase databases were searched with appropriate MeSH terms to identify relevant papers consistent with the defined inclusion criteria. Thirteen observational studies comprising a total of 352 pediatric patients were included in this review. The majority of subjects were girls 217 out of 352 (61.6%). The mean and median ages of patients ranged from 3.1-6.5 years to 2.3-7 years, respectively. In the 10 studies that specified the number of patients in their cohorts with either at least one positive autoantibody or no antibody, the overall prevalence of autoantibodies was 76 out of 288 patients (26.4%). The prevalence of specific antibodies was as follows: ANA, 20.3%; ANCA, 17%; anti-dsDNA, 9.1%; RF, 12%; anti-SMA, 23.2%; and celiac antibodies, 25.9%. Cow's milk protein allergy was present in 16.2% of the children. The significance of an association between IPH and the presence of autoantibodies has not been clarified. The autoantibodies could be suggestive of an overall immune dysregulation rather than causation. However, limited evidence based on a single study suggests that the presence of ANA may be associated with a higher risk of recurrence and worse outcomes. Further research, including prospective studies, will be crucial to explore a possible genetic linkage between vasculitides, systemic rheumatologic diseases, and IPH.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, 1100 Kentucky Avenue, West Plains, MO, 65775, USA.
| | - Alyssa Bonnier
- Goldfarb School of Nursing at Barnes-Jewish College, Saint Louis, MO, USA
| | - Praveen Chenna
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nils T Milman
- Department of Clinical Biochemistry, Næstved Hospital, University College Zealand, 4700, Næstved, Denmark
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Zhang Y, Guo J, Zhang P, Zhang L, Duan X, Shi X, Guo N, Liu S. Predictors of Mortality in Critically Ill Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Front Med (Lausanne) 2021; 8:762004. [PMID: 34760903 PMCID: PMC8573203 DOI: 10.3389/fmed.2021.762004] [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] [Received: 08/20/2021] [Accepted: 09/28/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) may require intensive care unit (ICU) admission due to different reasons, and the in-ICU mortality is high among AAV patients. The aim of this study was to explore the clinical features and risk factors of mortality of patients with AAV in the ICU. Methods: A retrospective study was conducted based on 83 AAV patients admitted to the ICU in a tertiary medical institution in China. Data on clinical characteristics, laboratory tests, treatment in ICU and outcomes were collected. The data were analyzed using univariate and multivariate logistic regression analysis to explore the variables that were independently related to mortality. Kaplan–Meier method was used to assess the long-term survival. Results: Among the 83 patients, 41 (49.4%) were female. The mean age of patients was 66 ± 13 years. Forty-four patients deceased, with the in-ICU mortality of 53%. The most common cause for ICU admission was active vasculitis (40/83, 48.2%). The main cause of death was infection (27/44, 61.4%) followed by active vasculitis (15/44, 34.1%). A multivariate analysis revealed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) at ICU admission (OR = 1.333, 95% CI: 1.031–1.722) and respiratory failure (OR = 620.452, 95% CI: 11.495–33490.306) were independent risk factors of in-ICU death. However, hemoglobin (OR = 0.919, 95% CI: 0.849–0.995) was an independent protective factor. The nomogram established in this study was practical in predicting the risk of in-ICU mortality for AAV patients. Moreover, for 39 patients survived to the ICU stay, the cumulative survival rates at 0.5, 1, and 5 years were 58.3%, 54.2%, and 33.9%, respectively, and the median survival time was 14 months. Conclusion: In our study, active vasculitis was the most frequent reason for ICU admission, and the main cause of death was infection. APACHE II and respiratory failure were independent risk factors while hemoglobin was an independent protective factor of in-ICU mortality for AAV patients admitted to the ICU. The risk prediction model developed in this study may be a useful tool for clinicians in early recognition of high-risk patients and applying appropriate management.
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Affiliation(s)
- Yuqi Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinyan Guo
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Panpan Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoguang Duan
- Department of Intensive Care Unit, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofei Shi
- Department of Rheumatology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Nailiang Guo
- Department of Rheumatology and Immunology, Xinyang Central Hospital, Xinyang, China
| | - Shengyun Liu
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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10
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Sayad E, Vogel TP, Guillerman RP, Spielberg D, McNeill DM, De Guzman M, Orman G, Silva-Carmona M. Pulmonary manifestations and outcomes in paediatric ANCA-associated vasculitis: a single-centre experience. Rheumatology (Oxford) 2021; 60:3199-3208. [PMID: 33355338 DOI: 10.1093/rheumatology/keaa769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/12/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) usually involves the renal and respiratory systems, but the paediatric literature on pulmonary manifestations and outcomes is limited. We aimed to describe pulmonary manifestations and outcomes after therapy in a cohort of paediatric AAV (pAAV) patients. METHODS A retrospective chart review of all patients <19 years presenting to our institution with AAV between 1/2008 and 2/2018 was conducted. Patient demographics, clinical presentation, diagnostic testing, therapy and pulmonary outcomes over the first 3 years after presentation were evaluated. RESULTS A total of 38 patients were included; all had ANCA positivity by immunofluorescence. A total of 23 had microscopic polyangiitis (MPA), 13 had granulomatosis with polyangiitis and 2 had eosinophilic granulomatosis with polyangiitis. A total of 30 (79%) had pulmonary manifestations, with cough (73%) and pulmonary haemorrhage (67%) being the most common. Abnormalities were noted in 82% of chest CT scans reviewed, with nodules and ground-glass opacities being the most common. At 6, 12 and 36 months follow-up, respectively, 61.8%, 39.4% and 29% of patients continued to show pulmonary manifestations. Five MPA patients with re-haemorrhage are described in detail. CONCLUSION MPA was more common than granulomatosis with polyangiitis, with pulmonary involvement being common in both. MPA patients had more severe pulmonary manifestations. Chest CT revealed abnormal findings in a majority of cases. A subgroup of young MPA patients experienced repeat pulmonary haemorrhage. Treatment modality and response were comparable in different subtypes of AAV, except for this young MPA group. Additional prospective studies are needed to better understand the different phenotypes of pAAV.
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Affiliation(s)
- Edouard Sayad
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
| | - Tiphanie P Vogel
- Texas Children's Hospital.,Division of Rheumatology, Department of Pediatrics
| | - R Paul Guillerman
- Texas Children's Hospital.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - David Spielberg
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
| | - David Moreno McNeill
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
| | - Marietta De Guzman
- Texas Children's Hospital.,Division of Rheumatology, Department of Pediatrics
| | - Gunes Orman
- Texas Children's Hospital.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Manuel Silva-Carmona
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
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11
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Specks U, Fussner LA, Cartin-Ceba R, Casal Moura M, Zand L, Fervenza FC. Plasma exchange for the management of ANCA-associated vasculitis: the con position. Nephrol Dial Transplant 2021; 36:231-236. [PMID: 33374017 DOI: 10.1093/ndt/gfaa312] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023] Open
Abstract
Advances in the diagnosis and treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis have led to continued improvement in survival and prognosis over the course of the last 4 decades. Nevertheless, the most acute and severe disease manifestations, including severe kidney disease and alveolar hemorrhage, continue to be associated with increased early mortality from disease activity or treatment complications as well as risk for the development of end-stage kidney disease (ESKD), which in turn directly affects the overall prognosis of ANCA-associated vasculitis. Plasma exchange (PLEX) has long been proposed and used for these most severe disease manifestations under the assumption that its effects are swift and supported by our understanding of the pathogenic role of ANCA. Yet convincing evidence of a beneficial effect of PLEX in ANCA-associated vasculitis has been lacking, as early studies and small trials have generated conflicting results. The controversy regarding PLEX has been accentuated recently as the largest randomized controlled trial ever conducted in ANCA-associated vasculitis, the Plasma Exchange and Glucocorticoids in Severe ANCA-associated Vasculitis trial, which was specifically designed to evaluate the efficacy of PLEX in patients with severe renal disease or alveolar hemorrhage, failed to show a difference in the combined primary outcome measure of death or ESKD in patients who received PLEX versus those who did not. In light of these disappointing results, we herein review the currently available data on PLEX for ANCA-associated vasculitis and explain why we believe that these data no longer support the use of PLEX in ANCA-associated vasculitis.
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Affiliation(s)
- Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary and Critical Care Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Department of Critical Care, Mayo Clinic, Scottsdale, AZ, USA
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ladan Zand
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, USA
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12
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Berti A, Specks U. The Survival of Patients With Alveolar Hemorrhage Secondary to Antineutrophil Cytoplasmic Antibody-associated Vasculitis. J Rheumatol 2021; 48:314-317. [PMID: 34237000 DOI: 10.3899/jrheum.201297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Alvise Berti
- A. Berti, MD, Rheumatology Department, Santa Chiara Hospital and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy, and Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA;
| | - Ulrich Specks
- U. Specks, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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13
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Jebali H, Khadhar M, Mami I, Beji S, Sellami M, Hassen M, Hmida FB, Chermiti M, Ghabi H, Salem TB, Houman H, Raies L, Zouaghi MK. Predictors of renal outcomes in anti-neutrophil cytoplasmic antibody glomerulonephritis. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:182-190. [PMID: 32129212 DOI: 10.4103/1319-2442.279939] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Glomerulonephritis associated with anti-neutrophil cytoplasmic antibody (ANCA) vasculitis still has a high prevalence of end-stage renal disease (ESRD), particularly in patients with advanced renal failure at presentation. This study aims to evaluate the clinical and histo- pathological features of renal involvement and investigate factors associated with ESRD. Patients with renal biopsy-proven ANCA-associated glomerulonephritis were included retrospectively over a period of nine years (June 2007 to March 2016). The renal survival, defined as time to reach ESRD, was evaluated based on clinical parameters, histopathological classification, and renal risk score. A total of 37 patients with crescentic glomerulonephritis were included in the study. The average age was 54 ± 16 years (range: 17-80) and 51.3% were female. Twenty-two patients were diagnosed with microscopic polyangiitis and 15 had granulomatosis with polyangiitis. The median glomerular filtration rate at presentation was 16.73 mL/min/1.73 m2. Thirty-five patients (94.5%) had renal failure at presentation and 23 patients (62.1%) required initial hemodialysis (HD) therapy. The pattern of glomerular injury was categorized as sclerotic in 48.6% of cases, crescentic in 24.3%, mixed in 24.3%, and focal class in 2.7%. Regarding renal risk score, we had five patients with low risk, 17 with intermediate risk and 15 with high risk. ESRD occurred in 47% of intermediate-risk group and 66% of the high risk group. During follow-up, 17 patients (45.9%) developed ESRD. Tobacco addiction (P = 0.02), alveolar hemorrhage (P = 0.04), hypertension (P = 0.04), initial HD (P = 0.04), and sclerotic class (P = 0.004) were associated with ESRD. In our patients, a sclerotic class was associated with a higher risk of ESRD, suggesting that histo- pathological classification is potentially an important parameter to predict outcomes in renal disease secondary to ANCA-associated vasculitis.
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Affiliation(s)
- Hela Jebali
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Meriem Khadhar
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Ikram Mami
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Soumaya Beji
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Meriem Sellami
- Department of Immunology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Mohaned Hassen
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | - Fethi Ben Hmida
- Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital, Tunis, Tunisia
| | | | - Hiba Ghabi
- Department of Nephrology, Kef Hospital, Kef, Tunisia
| | | | - Hbib Houman
- Department of Internal Medicine, La Rabta Hospital, Tunis, Tunisia
| | - Lamia Raies
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Mohamed Karim Zouaghi
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
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14
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Bellos I, Michelakis I, Nikolopoulos D. The role of plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis: a meta-analysis. Clin Rheumatol 2020; 40:1447-1456. [PMID: 32935248 DOI: 10.1007/s10067-020-05390-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Plasma exchange (PLEX) in addition to standard immunosuppressive treatment in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AVV) remains controversial. The aim of this study is to evaluate the effect of PLEX on AVV outcomes. METHODS Literature search was performed using Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov databases, and Google Scholar. The statistical meta-analysis and leave-one-out analysis were conducted using the Review Manager 5.3 and Open Meta-Analyst software, respectively. RESULTS Ten studies were included in the meta-analysis comprising 1235 patients; 633 received conventional treatment and 602 were treated with PLEX in conjunction with induction therapy. PLEX was not associated with lower rates of either mortality at 3 (RR: 0.79, 95% CI: 0.19-3.25) and 12 months (RR: 0.73, 95% CI: 0.40-1.34) or ESRD at 3 (RR: 0.30, 95% CI: 0.30-2.42) and 12 months (RR: 1.32, 95% CI: 0.53-3.25). Similarly, no differences were captured concerning disease relapses (RR: 0.92, 95% CI: 0.62-1.36), the incidence of infections (RR: 1.05, 95% CI: 0.63-1.76), and severe adverse effects (RR: 1.04, 95% CI: 0.59-1.81). Time-to-event analysis revealed lower incidence of ESRD (HR: 0.71, 95% CI: 0.55-0.92) among patients who received PLEX, while the overall mortality was similar (HR: 0.96, 95% CI: 0.72-1.29) between the two groups. CONCLUSION The present meta-analysis does not support the wide use of PLEX for the management of AAV in routine clinical practice. Future well-designed randomized controlled trials focusing on specific disease-related manifestations are necessary to reach firm conclusions about the potential efficacy of PLEX. Key Points • PLEX is not widely recommended for the management of ANCA-associated vasculitis. • PLEX performance may reduce the overall incidence of ESRD in severe ANCA-associated vasculitis. • Well-designed randomized controlled trials focusing on specific disease-related manifestations are necessary to reach firm conclusions about the potential efficacy of PLEX on AAV-related outcome.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research NS Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Michelakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dionysis Nikolopoulos
- Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.
- 4th Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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15
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Prendecki M, McAdoo SP, Pusey CD. Is There a Role for Plasma Exchange in ANCA-Associated Vasculitis? CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00161-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of review
This review summarises the evidence for the use of therapeutic plasma exchange (TPE) in anti-neutrophil cytoplasm antibody (ANCA)–associated vasculitis. TPE is an extra-corporeal treatment which efficiently removes IgG and other pathogenic small molecules from the blood. There are several mechanistic reasons why this should be of benefit in AAV including the well-described pathogenicity of ANCA.
Recent findings
The recently published PEXIVAS trial is the largest study of TPE in AAV to date. It did not show a benefit for adjunctive TPE on a primary end point of ESRD or death. There was no difference in serious adverse events between those treated with TPE and those treated with immunosuppressive drugs alone.
Conclusions
Based on the results of PEXIVAS, most patients with AAV should not be treated with adjunctive TPE. However, there are subgroups of patients with AAV for whom TPE may still be of benefit, including those with double positivity for anti-GBM antibodies and ANCA.
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16
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Park PG, Yoo BW, Song JJ, Park YB, Lee SW. Clinical implication of plasma exchange on life-threatening antineutrophil cytoplasmic antibody-associated vasculitis. BMC Pulm Med 2020; 20:147. [PMID: 32466756 PMCID: PMC7257153 DOI: 10.1186/s12890-020-01181-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/11/2020] [Indexed: 11/12/2022] Open
Abstract
Background We assessed the rate of and predictors for all-cause mortality in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) receiving plasma exchange (PLEX) and evaluated the survival benefit of PLEX for diffuse alveolar haemorrhage (DAH) between AAV patients receiving PLEX and those not receiving PLEX. Methods We retrospectively reviewed the medical records of 212 patients with AAV. Demographic, clinical and laboratory data at the time of PLEX were collected from nine patients receiving PLEX, six of whom had DAH. The follow-up duration was defined as the period from the time of PLEX or DAH occurrence to death for the deceased patients and to the last visit for the survived patients. Results The median age of nine AAV patients receiving PLEX was 71.0 years, and five patients were men. Four of nine patients receiving PLEX died at a median follow-up duration of 92.0 days. Three patients died of sepsis and one died owing to a lack of response to PLEX. When patients with DAH receiving or not receiving PLEX were compared, there were no significant differences in variables between the two groups. The cumulative patients’ survival rate between patients with DAH receiving and not receiving PLEX were also compared using the Kaplan-Meier survival analysis; however, no survival-benefit of PLEX for DAH was observed. Conclusion The rate of all-cause mortality in nine AAV patients receiving PLEX was found to be 44.4% and the notion that PLEX is beneficial for the improvement in the prognosis of AAV-related DAH was deemed controversial.
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Affiliation(s)
- Pil Gyu Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung-Woo Yoo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.
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17
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Mirouse A, Parrot A, Audigier V, Demoule A, Mayaux J, Géri G, Mariotte E, Bréchot N, de Prost N, Vautier M, Neuville M, Bigé N, de Montmollin E, Cacoub P, Resche-Rigon M, Cadranel J, Saadoun D. Severe diffuse alveolar hemorrhage related to autoimmune disease: a multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:231. [PMID: 32423434 PMCID: PMC7236262 DOI: 10.1186/s13054-020-02936-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) occurs during the course of autoimmune disease and may be life threatening. The objective was to assess characteristics and prognosis factors of DAH who required intensive care unit (ICU) admission in patients with autoimmune diseases. METHODS French multicenter retrospective study including patients presenting DAH related to autoimmune diseases requiring ICU admission from 2000 to 2016. RESULTS One hundred four patients (54% of men) with median age of 56 [32-68] years were included with 79 (76%) systemic vasculitis and 25 (24%) connective tissue disorders. All patients received steroids, and 72 (69%), 12 (11.5%), and 57 (55%) patients had cyclophosphamide, rituximab, and plasma exchanges, respectively. During ICU stay, 52 (50%), 36 (35%), and 55 (53%) patients required mechanical ventilation, vasopressor use, and renal replacement therapy, respectively. Factors associated with mechanical ventilation weaning were age (HR [95%CI] 0.97 [0.96-0.99] per 10 years, p < 0.0001), vasculitis-related DAH (0.52 [0.27-0.98], p = 0.04), and time from dyspnea onset to ICU admission (0.99 [0.99-1] per day, p = 0.03). ICU mortality was 15%. Factors associated with alive status at ICU discharge were chronic cardiac failure (HR [95%CI] 0.37 [0.15-0.94], p = 0.04), antiphospholipid syndrome-related DAH (3.17 [1.89-5.32], p < 0.0001), SAPS II (0.98 [0.97-0.99], p = 0.007), and oxygen flow at ICU admission (0.95 [0.91-0.99] per liter/min, p = 0.04). CONCLUSION DAH in autoimmune diseases is a life-threatening complication which requires mechanical ventilation in half of the cases admitted to ICU.
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Affiliation(s)
- Adrien Mirouse
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (DHU i2B), UPMC Université Paris 06, UMR 7211, Sorbonne Universités, 75005, Paris, France.,INSERM, UMR_S 959, 75013, Paris, France.,CNRS, FRE3632, 75005, Paris, France.,Département de Médecine Interne et Immunologie Clinique, National Center for Autoimmune and Systemic Diseases and National Center for Autoinflammatory Diseases and Amyloidosis, APHP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
| | - Antoine Parrot
- Service de Pneumologie, Hôpital Tenon, APHP, Paris, France
| | - Vincent Audigier
- Département de Biostatistiques, Hôpital Saint-Louis, APHP, Paris, France
| | - Alexandre Demoule
- Service de Réanimation Médicale et Pneumologie, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Julien Mayaux
- Service de Réanimation Médicale et Pneumologie, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Guillaume Géri
- Service de Réanimation Médicale, Hôpital Cochin, APHP, Paris, France
| | - Eric Mariotte
- Service de Réanimation Médicale, Hôpital Saint-Louis, APHP, Paris, France
| | - Nicolas Bréchot
- Service de Réanimation Médicale, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Nicolas de Prost
- Service de Réanimation Médicale, Hôpital Henri Mondor, APHP, Créteil, France
| | | | - Mathilde Neuville
- Service de Réanimation Médicale, Hôpital Bichat, APHP, Paris, France
| | - Naïke Bigé
- Service de Réanimation Médicale, Hôpital Saint-Antoine, Paris, France
| | - Etienne de Montmollin
- Service de Réanimation Medico-chirurgicale, Hôpital Delafontaine, Saint-Denis, France
| | - Patrice Cacoub
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (DHU i2B), UPMC Université Paris 06, UMR 7211, Sorbonne Universités, 75005, Paris, France.,INSERM, UMR_S 959, 75013, Paris, France.,CNRS, FRE3632, 75005, Paris, France.,Département de Médecine Interne et Immunologie Clinique, National Center for Autoimmune and Systemic Diseases and National Center for Autoinflammatory Diseases and Amyloidosis, APHP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
| | | | | | - David Saadoun
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (DHU i2B), UPMC Université Paris 06, UMR 7211, Sorbonne Universités, 75005, Paris, France. .,INSERM, UMR_S 959, 75013, Paris, France. .,CNRS, FRE3632, 75005, Paris, France. .,Département de Médecine Interne et Immunologie Clinique, National Center for Autoimmune and Systemic Diseases and National Center for Autoinflammatory Diseases and Amyloidosis, APHP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France.
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18
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Kronbichler A, Shin JI, Lee KH, Nakagomi D, Quintana LF, Busch M, Craven A, Luqmani RA, Merkel PA, Mayer G, Jayne DRW, Watts RA. Clinical associations of renal involvement in ANCA-associated vasculitis. Autoimmun Rev 2020; 19:102495. [PMID: 32068190 DOI: 10.1016/j.autrev.2020.102495] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/13/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Renal involvement in anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis is associated with significant morbidity and higher mortality rates. This study examined clinical manifestations associated with renal involvement in ANCA-associated vasculitis within a large, international cross-sectional cohort. METHODS Univariate and multivariate analyses were performed to identify clinical factors associated with renal disease, which was defined as i) a serum-creatinine >30% above normal and a fall in creatinine-clearance >25%; or ii) haematuria attributable to active vasculitis. RESULTS The study cohort include 1230 patients from 31 countries; 723 (58.8%) presented with renal involvement: microscopic polyangiitis (82.2%), granulomatosis with polyangiitis (58.6%), and eosinophilic granulomatosis with polyangiitis (26.4%). The following clinical and laboratory factors were more common among patients with renal disease: age (OR 1.01, 95% CI 1.01-1.02), fever (OR 1.97, 95% CI 1.35-2.88), fatigue (OR 1.55, 95% CI 1.14-2.10), weight loss (OR 1.62, 95% CI 1.23-2.12), polyarthritis (OR 1.39, 95% CI 1.02-1.89), petechiae/purpura (OR 1.47, 95% CI 1.06-2.05), pulmonary haemorrhage (OR 5.23, 95% CI 1.39-19.63), gastrointestinal symptoms (OR 2.19, 95% CI 1.34-3.58), seizures (OR 3.42, 95% CI 1.26-9.30), lower serum albumin (OR 2.42, 95% CI 1.64-3.57), higher CRP (OR 2.06, 95% CI 1.04-4.06), low serum C3 at baseline (OR 3.86, 95% CI 1.30-11.53), myeloperoxidase- (OR 7.97, 95% CI 2.74-23.20) and proteinase 3-ANCA (OR 3.40, 95% CI 1.22-9.50). The following clinical factors were less common among patients with renal disease: mononeuritis multiplex (OR 0.63, 95% CI 0.41-0.98), proptosis/exophthalmos (OR 0.19, 95% CI 0.06-0.59), nasal polyps (OR 0.32, 95% CI 0.19-0.55), septal defect/perforation (OR 0.29, 95% CI 0.14-0.60), respiratory distress/pulmonary fibrosis/asthma (OR 0.08, 95% CI 0.04-0.19), and wheeze/obstructive airway disease (OR 0.29, 95% CI 0.16-0.52). CONCLUSION In this large international study, several clinical and laboratory factors were identified as associated with renal involvement in ANCA-associated vasculitis.
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Affiliation(s)
- Andreas Kronbichler
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ Cambridge, United Kingdom; Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea; Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea; Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea
| | - Daiki Nakagomi
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ Cambridge, United Kingdom; Department of Third Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Luis F Quintana
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ Cambridge, United Kingdom; Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Martin Busch
- Department of Internal Medicine III, University Hospital Jena - Friedrich Schiller University, Erlanger Allee 101, Jena, Germany
| | - Anthea Craven
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ Cambridge, United Kingdom; Department of Medicine, University of Cambridge, CB2 0QQ Cambridge, United Kingdom
| | - Richard A Watts
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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19
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Quartuccio L, Bond M, Isola M, Monti S, Felicetti M, Furini F, Murgia S, Berti A, Silvestri E, Pazzola G, Bozzolo E, Leccese P, Raffeiner B, Parisi S, Leccese I, Cianci F, Bettio S, Sainaghi P, Ianniello A, Ravagnani V, Bellando Randone S, Faggioli P, Lomater C, Stobbione P, Ferro F, Colaci M, Alfieri G, Carubbi F, Erre GL, Giollo A, Franzolini N, Ditto MC, Balduzzi S, Padoan R, Bortolotti R, Bortoluzzi A, Cariddi A, Padula A, Di Scala G, Gremese E, Conti F, D'Angelo S, Matucci Cerinic M, Dagna L, Emmi G, Salvarani C, Paolazzi G, Roccatello D, Govoni M, Schiavon F, Caporali R, De Vita S. Alveolar haemorrhage in ANCA-associated vasculitis: Long-term outcome and mortality predictors. J Autoimmun 2020; 108:102397. [PMID: 31926833 DOI: 10.1016/j.jaut.2019.102397] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Alveolar haemorrhage (AH) is considered an important cause of morbidity and early mortality in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV). OBJECTIVES The aim of this study was to identify predictors of outcome in patients with AH-AAV and to evaluate outcome and causes of death in this subset. MATERIALS AND METHODS A multicenter retrospective study was conducted in 29 Italian Centers. Clinicians were asked to recruit all patients diagnosed with AAV-associated AH during the last 10 years, from 2007 to 2016. Univariate and multivariable analysis were performed. RESULTS One-hundred and six patients were included (median age at onset of 55 years [IQR 42-67]). The majority were ANCA-positive (PR3 57.1%, MPO 33.7%) and 72.6% had also renal involvement. At presentation, anaemia was shown in 97 (92.4%) patients, hemoptysis in 54 (51.9%), respiratory failure in 68 (66.7%), of whom 48 (70.6%), requiring respiratory support. At the end of the 37 months [IQR 13-77] follow-up, 19/106 (17.9%) patients were dead. The main causes of death were active disease and infections. By stepwise regression analysis, age >65 years (HR 3.66 [95% CI 1.4-9.51], p = 0.008) and the need for respiratory support (HR 4.58 [95% CI 1.51-13.87], p = 0.007) at AH onset were confirmed to be predictive of mortality. CONCLUSIONS Predictors of outcome in AAV-AH were determined. Factors related to the patient's performance status and the severity of the lung involvement strongly influenced the outcome. Balancing harms and benefits for the individual patient in induction and maintenance treatment strategies is crucial.
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Affiliation(s)
- Luca Quartuccio
- Rheumatology Clinic, Department of Medicine, Academic Hospital "Santa Maria della Misericordia", Udine, Italy.
| | - Milena Bond
- Rheumatology Clinic, Department of Medicine, Academic Hospital "Santa Maria della Misericordia", Udine, Italy
| | - Miriam Isola
- Institute of Statistics, Department of Medical Area, University of Udine, Udine, Italy
| | - Sara Monti
- Department of Rheumatology, IRCCS Policlinico S. Matteo Fondazione, Pavia, Italy; University of Pavia, PhD in Experimental Medicine, Pavia, Italy
| | - Mara Felicetti
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Italy
| | - Federica Furini
- Department of Medical Sciences, UOL Rheumatology, University of Ferrara, Ferrara, Italy
| | - Stefano Murgia
- CMID-Center of Research of Nephrology, Rheumatology, and Rare Diseases Interregional Coordinating Center of the Network of Rare Diseases of Piedmont and Aosta Valley, Nephrology and Dialysis Unit (ERK-net Member) G. Bosco Hospital, and University of Turin, Italy
| | - Alvise Berti
- Department of Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giulia Pazzola
- Azienda USL-IRCCS di Reggio Emilia and University of Modena and Reggio Emilia, Italy
| | - Enrica Bozzolo
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Pietro Leccese
- Rheumatology Department of Lucania - San Carlo Hospital, Potenza, Italy
| | - Bernd Raffeiner
- Rheumatology Unit, Department of Medicine, Centrale Hospital of Bolzano, Italy
| | - Simone Parisi
- S.C. Reumatologia, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ilaria Leccese
- Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Francesco Cianci
- Rheumatology Institute, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvano Bettio
- Rheumatology Unit, Internal Medicine Department, University Hospital of Cattinara, Trieste, Italy
| | - Pierpaolo Sainaghi
- Rheumatology Unit, CAAD and DiMet, University of Eastern Piedmont and AOU Maggiore della Carità, Novara, Italy
| | - Aurora Ianniello
- Day Hospital Multidisciplinare, Ospedale di Borgomanero, ASL-NO Novara, Novara, Italy
| | | | - Silvia Bellando Randone
- Department of Experimental and Clinical Medicine University of Florence and Division of Rheumatology AOUC, Florence, Italy
| | - Paola Faggioli
- ASST Ovest Milanese, UOC Internal Medicine, Legnano, Italy
| | | | | | | | - Michele Colaci
- Dept Clinical and Experimental Medicine University of Catania, Catania, Italy
| | | | | | | | - Alessandro Giollo
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | | | - Maria Chiara Ditto
- S.C. Reumatologia, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy; University of Padua, PhD Program in Clinical and Experimental Sciences, Padua, Italy
| | - Silvia Balduzzi
- Department of Rheumatology, IRCCS Policlinico S. Matteo Fondazione, Pavia, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Italy
| | | | - Alessandra Bortoluzzi
- Department of Medical Sciences, UOL Rheumatology, University of Ferrara, Ferrara, Italy
| | - Adriana Cariddi
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Angela Padula
- Rheumatology Department of Lucania - San Carlo Hospital, Potenza, Italy
| | - Gerardo Di Scala
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elisa Gremese
- Rheumatology Institute, Università Cattolica del Sacro Cuore, Rome, Italy; Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Fabrizio Conti
- Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | | | - Marco Matucci Cerinic
- Department of Experimental and Clinical Medicine University of Florence and Division of Rheumatology AOUC, Florence, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia and University of Modena and Reggio Emilia, Italy
| | | | - Dario Roccatello
- CMID-Center of Research of Nephrology, Rheumatology, and Rare Diseases Interregional Coordinating Center of the Network of Rare Diseases of Piedmont and Aosta Valley, Nephrology and Dialysis Unit (ERK-net Member) G. Bosco Hospital, and University of Turin, Italy
| | - Marcello Govoni
- Department of Medical Sciences, UOL Rheumatology, University of Ferrara, Ferrara, Italy
| | - Franco Schiavon
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Italy
| | - Roberto Caporali
- Department of Rheumatology, IRCCS Policlinico S. Matteo Fondazione, Pavia, Italy
| | - Salvatore De Vita
- Rheumatology Clinic, Department of Medicine, Academic Hospital "Santa Maria della Misericordia", Udine, Italy
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20
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Ford JA, Monach PA. Disease heterogeneity in antineutrophil cytoplasmic antibody-associated vasculitis: implications for therapeutic approaches. THE LANCET. RHEUMATOLOGY 2019; 1:e247-e256. [PMID: 38229381 DOI: 10.1016/s2665-9913(19)30077-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/20/2019] [Accepted: 10/02/2019] [Indexed: 01/18/2024]
Abstract
In recent decades, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis has transformed from an almost uniformly fatal disease to a treatable form of primary systemic vasculitis. Substantial disease heterogeneity exists within ANCA-associated vasculitis and the increasing understanding of this heterogeneity has implications for guiding treatment decisions. Approaches to induction and maintenance therapy vary depending on disease severity, clinical manifestations, and patient-specific factors. In this narrative Review, we examine how disease heterogeneity in ANCA-associated vasculitis, with respect to disease severity, clinical presentations, and ANCA specificity, influences therapeutic decision making. Many questions regarding therapeutic strategies in ANCA-associated vasculitis remain unanswered, and these should guide future research in this complex group of diseases.
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Affiliation(s)
- Julia A Ford
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Paul A Monach
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Veterans Affairs Boston Healthcare System, Boston, MA, USA
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21
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 775] [Impact Index Per Article: 155.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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22
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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23
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Abe Y, Yamaji K, Endo Y, Kusaoi M, Nakano S, Yang KS, Tada K, Tsuda H, Tamura N. Plasma Exchange Therapy to Reduce Mortality in Japanese Patients With Diffuse Alveolar Hemorrhage and Microscopic Polyangiitis. Ther Apher Dial 2019; 24:208-214. [PMID: 31233282 DOI: 10.1111/1744-9987.12939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/19/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is well known as a serious complication of microscopic polyangiitis (MPA). We examined the effectiveness of plasma exchange (PLEX) therapy to reduce mortality in Japanese DAH patients with MPA. This retrospective, double-center, observational cohort study included 20 DAH patients with MPA who were admitted to Juntendo University Hospital or Juntendo Koto Geriatric Medical Center between April 1998 and March 2018. The primary outcome was non-disease-specific mortality. The 1-year survival rate of patients with PLEX therapy (N = 4) was higher than that of patients with conventional therapy (N = 16, 75% and 13%, respectively, P = 0.037). Higher values of the 1996 Five-Factor Score (FFS) and 2009 FFS were associated with increased mortality, with hazard ratios of 2.29 (P = 0.040) and 2.41 (P = 0.043), respectively, by Cox univariate analysis. We investigated PLEX therapy for reducing mortality in DAH patients with MPA, and the 1996 FFS and 2009 FFS were both independent prognostic factors.
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Affiliation(s)
- Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yukari Endo
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Internal Medicine and Rheumatology, Juntendo Koto Geriatric Medical Center, Tokyo, Japan
| | - Makio Kusaoi
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Soichiro Nakano
- Department of Internal Medicine and Rheumatology, Juntendo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kwang-Seok Yang
- Department of Internal Medicine and Rheumatology, Juntendo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kurisu Tada
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Tsuda
- Department of Internal Medicine and Rheumatology, Juntendo Koto Geriatric Medical Center, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
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Kida T, Tanaka T, Yokota I, Tamagaki K, Sagawa T, Kadoya M, Yamada T, Fujioka K, Wada M, Kohno M, Hiraoka N, Omoto A, Fukuda W, Kawahito Y. Association between preexisting lung involvements and the risk of diffuse alveolar hemorrhage in patients with microscopic polyangiitis: A multi-center retrospective cohort study. Mod Rheumatol 2019; 30:338-344. [DOI: 10.1080/14397595.2019.1601855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Takashi Kida
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tadashi Tanaka
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Hokkaido, Japan
| | - Keiichi Tamagaki
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoya Sagawa
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | | | | | - Kazuki Fujioka
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Makoto Wada
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masataka Kohno
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Atsushi Omoto
- Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Wataru Fukuda
- Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yutaka Kawahito
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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25
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Kimmoun A, Levy B. Vascularites à anticorps anticytoplasme des polynucléaires neutrophiles et réanimation : quel pronostic en 2018 ? MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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26
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Uechi E, Okada M, Fushimi K. Effect of plasma exchange on in-hospital mortality in patients with pulmonary hemorrhage secondary to antineutrophil cytoplasmic antibody-associated vasculitis: A propensity-matched analysis using a nationwide administrative database. PLoS One 2018; 13:e0196009. [PMID: 29684034 PMCID: PMC5912736 DOI: 10.1371/journal.pone.0196009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/04/2018] [Indexed: 11/28/2022] Open
Abstract
Background Secondary pulmonary hemorrhage increases the risk of mortality in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV); plasma exchange therapy may improve outcomes in these patients. We conducted a retrospective cohort study to investigate the effect of plasma exchange therapy on short-term prognoses in patients with pulmonary hemorrhage secondary to AAV. Methods This study utilized the Diagnosis Procedure Combination database, which is a nationwide inpatient database in Japan. We checked the abstract data and medical actions and identified the patients with pulmonary hemorrhage secondary to AAV who required proactive treatment between 2009 and 2014. To compare the in-hospital mortality, we performed propensity score matching between the plasma exchange and non-plasma exchange groups at a ratio of 1:1. Results Of the 52,932 patients with AAV, 940 developed pulmonary hemorrhage as a complication. A total of 249 patients from 194 hospitals were eligible for the study. Propensity score matching at a ratio of 1:1 was performed, and 59 pairs were formed (plasma exchange group, n = 59; non-plasma exchange group, n = 59). A statistically significant difference was found in the all-cause in-hospital mortality between the plasma exchange and non-plasma exchange groups (35.6% vs. 54.2%; p = 0041; risk difference, −18.6; 95% confidence interval (CI), −35.4% to −0.67%). Conclusion Thus, plasma exchange therapy was associated with improved in-hospital mortality in patients with pulmonary hemorrhage secondary to AAV.
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Affiliation(s)
- Eishi Uechi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Yushima, Bunkyo-ku, Tokyo, Japan
- Division of Rheumatology, Tomishiro Central Hospital, Ueta, Tomigusuku-shi, Okinawa, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Akashi-cho Chuo-Ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Yushima, Bunkyo-ku, Tokyo, Japan
- * E-mail:
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Yoo J, Kim HJ, Jung SM, Song JJ, Park YB, Lee SW. Birmingham vasculitis activity score of more than 9.5 at diagnosis is an independent predictor of refractory disease in granulomatosis with polyangiitis. Int J Rheum Dis 2017; 20:1593-1605. [DOI: 10.1111/1756-185x.13144] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Juyoung Yoo
- Division of Rheumatology, Department of Internal Medicine; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Ho Jae Kim
- Division of Rheumatology, Department of Internal Medicine; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine; Yonsei University College of Medicine; Seoul Republic of Korea
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Heijl C, Mohammad AJ, Westman K, Höglund P. Long-term patient survival in a Swedish population-based cohort of patients with ANCA-associated vasculitis. RMD Open 2017; 3:e000435. [PMID: 28955485 PMCID: PMC5604606 DOI: 10.1136/rmdopen-2017-000435] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 05/03/2017] [Accepted: 05/05/2017] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Patients with antineutrophil cytoplasmatic antibodies-associated vasculitides (AAV) exhibit higher mortality than the general population. In the current study, we assessed whether cluster affiliation based on clinical presentation might predict mortality. METHODS With case record review, the outcomes for a population-based cohort of patients diagnosed with AAV in southern Sweden (catchment area of 0.7 million inhabitants) between 1997 and 2010 were assessed. Based on organ involvement at presentation, the cohort was stratified into the following clusters: gastrointestinal, cardiovascular, non-renal, renal with proteinase 3 (PR3) and renal without PR3. Cluster affiliation, demographics, clinical and laboratory values at entry were tested as prognostic factors for survival in multivariable models. RESULTS 195 patients (98 female) with a median age of 69 years (IQR 55-77) at diagnosis were included in the cohort. The median time of follow-up was 4 years for the 98 patients (50%) who died during follow-up and 11 years for those alive at end of follow-up. The 1-year, 2-year, 5-year and 10-year survival was 87%, 82%, 70% and 55%, respectively. Prognostic factors for survival were sex, age, renal function and cluster affiliation. The mortality of patients with AAV was significantly increased compared with the general population except in the non-renal cluster. The cardiovascular and gastrointestinal clusters showed the highest mortality. CONCLUSION Even though the mortality in patients with AAV is increased compared with the general population this does not apply to patients without gastrointestinal, cardiovascular or renal involvement at diagnosis. We suggest that the initial clinical presentation is an important predictor for survival.
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Affiliation(s)
- Caroline Heijl
- Department of Clinical Sciences Lund, Division of Nephrology, Lund University, Lund, Sweden
| | - Aladdin J Mohammad
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden and Department of Renal Medicine, Vasculitis and lupus Clinic, Addenbrooke’s Hospital, Cambridge, UK
| | - Kerstin Westman
- Department of Clinical Sciences Lund, Division of Nephrology, Lund University, Lund, Sweden
| | - Peter Höglund
- Department of Laboratory Medicine, Division of Clinical Chemistry and Pharmacology, Lund University, Lund, Sweden
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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30
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Frausová D, Hrušková Z, Lánská V, Lachmanová J, Tesař V. Long-term outcome of patients with ANCA-associated vasculitis treated with plasma exchange: a retrospective, single-centre study. Arthritis Res Ther 2016; 18:168. [PMID: 27412443 PMCID: PMC4944267 DOI: 10.1186/s13075-016-1055-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Plasma exchange (PLEX) has been used routinely for treatment of severe renal vasculitis and/or alveolar haemorrhage (AH) in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), but the long-term benefit of PLEX in AAV remains unclear. We aimed to describe the characteristics and outcomes of patients treated with PLEX in a single centre. METHODS Patients with AAV were identified by performing a case review of medical records of 705 patients who received PLEX in a single tertiary referral centre between 2000 and 2010. Patient characteristics and outcomes were recorded. The Kaplan-Meier method, log-rank tests and Cox regression analysis were used for survival analyses. RESULTS A total of 94 patients with AAV were identified (44 men, 50 women; median age 60 years, range 21-90 years; 52 proteinase 3-ANCA, 41 myeloperoxidase-ANCA and 1 ANCA-negative; 8 double-positive for ANCA and anti-glomerular basement membrane; 93 newly diagnosed/1 relapse; 55 [58.5 %] required dialysis). The reasons for initiating PLEX therapy were severe renal involvement alone in 52 %, AH in 10 %, both renal involvement and AH in 35 %, and "other" in 3 %. The patients had 3-27 (median 7) PLEX sessions. At 3 months, 81 (86 %) of 94 were alive and 62 (66 %) of 94 were alive and dialysis-independent. The median follow-up was 41 months (minimum-maximum 0.5-137 months), when 56 (59.6 %) of 94 patients were alive and 47 (50 %) were dialysis-independent. The estimated overall survival rates were 75.3 % at 1 year and 61.1 % at 5 years. Patient survival decreased with increasing age at presentation (5-year survival 85 % for age <50 years, 64.4 % for ages 50-65 years, and 41 % for >65 years; p < 0.01 for comparison between all groups). Estimated renal survival rates were 65.5 % at 1 year and 43 % at 5 years. Renal survival was worse in patients aged >65 years than in the younger patients (5-year survival 25.1 % in patients >65 years vs. 50.8 % for those ≤65 years, p < 0.01). The estimated renal survival was better in patients with higher Disease Extent Index (DEI) >6 than in patients with DEI ≤6 (5-year survival 52.1 % vs. 39.4 %, p = 0.04), even though this was not confirmed in multivariate analysis. CONCLUSIONS The mortality of patients presenting with severe manifestations of AAV remains high despite the use of PLEX. Older age at presentation is associated with worse overall and renal prognosis.
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Affiliation(s)
- Doubravka Frausová
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Zdenka Hrušková
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.,Institute of Immunology and Microbiology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Věra Lánská
- Statistical Unit, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Lachmanová
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
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31
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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32
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Cartin-Ceba R, Diaz-Caballero L, Al-Qadi MO, Tryfon S, Fervenza FC, Ytterberg SR, Specks U. Diffuse Alveolar Hemorrhage Secondary to Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Predictors of Respiratory Failure and Clinical Outcomes. Arthritis Rheumatol 2016; 68:1467-76. [DOI: 10.1002/art.39562] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/17/2015] [Indexed: 01/31/2023]
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33
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[Therapy of ANCA-associated vasculitis with severe renal manifestation under routine conditions]. Z Rheumatol 2016; 75:910-916. [PMID: 26951194 DOI: 10.1007/s00393-016-0067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In the MEPEX trial the poor prognosis of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis with severe renal manifestation (AAVr) could be significantly improved in the first year by plasmapheresis. How and to what extent is this knowledge of AAVr therapy implemented into routine practice and what effectiveness and adverse events resulted? METHODS This was a retrospective cohort study in which all patients who received remission induction therapy for AAVr under routine clinical conditions (RCC) in this hospital from 2009 to 2014 after publication of the MEPEX trial (n = 22) were compared with those in the plasmapheresis arm of the MEPEX trial (n = 70). Endpoints were dialysis-dependent chronic kidney disease and mortality after 3 and 12 months and severe life-threatening adverse events during the first 12 months. RESULTS All patients with AAVr were treated by plasmapheresis under RCC. The two groups showed no differences with respect to the rate of dialysis dependency (after 3 months RCC 14 % versus MEPEX 16 %, P = 1.00 and after 12 months RCC 23 % versus MEPEX 14 %, P = 0.55) or mortality (after 3 months RCC 18 % versus MEPEX 16 %, P = 0.75 and after 12 months RCC 18 % versus MEPEX 27 %, P = 0.57). The rate of severe life-threatening adverse events was similar under RCC and under controlled study conditions (64 % versus 69 %, P = 0.87). CONCLUSION Under RCC there is a high quality of medical treatment for AAVr. All patients received plasmapheresis for remission induction with comparable effectiveness and safety compared to controlled study conditions.
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Vymetal J, Skacelova M, Smrzova A, Klicova A, Schubertova M, Horak P, Zadrazil J. Emergency situations in rheumatology with a focus on systemic autoimmune diseases. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160:20-9. [PMID: 26868300 DOI: 10.5507/bp.2016.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 01/22/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND AIM Rheumatic diseases are commonly considered chronic conditions. However, acute manifestations can be very severe and represent a diagnostic problem. Examples are systemic lupus erythematosus with acute flare, glomerulonephritis, CNS disorders and catastrophic antiphospholipid syndrome, scleroderma with interstitial lung disease, pulmonary hypertension and renal crisis and polyangiitis with alveolar haemorhage and acute respiratory failure. This aim of this paper is to overview emergency situations which can be encountered in the care of patients with autoimmune systemic diseases and vasculitides. METHODS A Pubmed search for both original and review articles, recent textbooks and current guidelines related to rheumatic diseases with possible acute situations were included in this review article. Relevant image documentation was obtained at the site over the past several years of observation. CONCLUSIONS This paper provides an overview of facts and emergency situations which can be encountered in the care of patients with autoimmune systemic diseases and vasculitides. It is directed at clinicians working in intensive care. It provides a differential diagnostic overview and information which is rare and commonly underestimated.
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Affiliation(s)
- Jiri Vymetal
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Martina Skacelova
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Andrea Smrzova
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Anna Klicova
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Marketa Schubertova
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Pavel Horak
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Josef Zadrazil
- Intensive Care Unit of the Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
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Kimmoun A, Baux E, Das V, Terzi N, Talec P, Asfar P, Ehrmann S, Geri G, Grange S, Anguel N, Demoule A, Moreau AS, Azoulay E, Quenot JP, Boisramé-Helms J, Louis G, Sonneville R, Girerd N, Ducrocq N, Agrinier N, Wahl D, Puéchal X, Levy B. Outcomes of patients admitted to intensive care units for acute manifestation of small-vessel vasculitis: a multicenter, retrospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:27. [PMID: 26812945 PMCID: PMC4729170 DOI: 10.1186/s13054-016-1189-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/14/2016] [Indexed: 11/25/2022]
Abstract
Background The outcomes of patients admitted to the intensive care unit (ICU) for acute manifestation of small-vessel vasculitis are poorly reported. The aim of the present study was to determine the mortality rate and prognostic factors of patients admitted to the ICU for acute small-vessel vasculitis. Methods This retrospective, multicenter study was conducted from January 2001 to December 2014 in 20 ICUs in France. Patients were identified from computerized registers of each hospital using the International Classification of Diseases, Ninth Revision (ICD-9). Inclusion criteria were (1) known or highly suspected granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis (respectively, ICD-9 codes M31.3, M30.1, and M31.7), or anti–glomerular basement membrane antibody disease (ICD-9 codes N08.5X-005 or M31.0+); (2) admission to the ICU for the management of an acute manifestation of vasculitis; and (3) administration of a cyclophosphamide pulse in the ICU or within 48 h before admission to the ICU. The primary endpoint was assessment of mortality rate 90 days after admission to the ICU. Results Eighty-two patients at 20 centers were included, 94 % of whom had a recent (<6 months) diagnosis of small-vessel vasculitis. Forty-four patients (54 %) had granulomatosis with polyangiitis. The main reasons for admission were respiratory failure (34 %) and pulmonary-renal syndrome (33 %). Mechanical ventilation was required in 51 % of patients, catecholamines in 31 %, and renal replacement therapy in 71 %. Overall mortality at 90 days was 18 % and the mortality in ICU was 16 %. The main causes of death in the ICU were disease flare in 69 % and infection in 31 %. In univariable analysis, relevant factors associated with death in nonsurvivors compared with survivors were Simplified Acute Physiology Score II (median [interquartile range] 51 [38–82] vs. 36 [27–42], p = 0.005), age (67 years [62–74] vs. 58 years [40–68], p < 0.003), Sequential Organ Failure Assessment score on the day of cyclophosphamide administration (11 [6–12] vs. 6 [3–7], p = 0.0004), and delayed administration of cyclophosphamide (5 days [3–14] vs. 2 days [1–5], p = 0.0053). Conclusions Patients admitted to the ICU for management of acute small-vessel vasculitis benefit from early, aggressive intensive care treatment, associated with an 18 % death rate at 90 days. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1189-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antoine Kimmoun
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France
| | - Elisabeth Baux
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, Andre Gregoire District Hospital Center, Montreuil, F-93105, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, Caen University Hospital, Avenue de la Côte de Nacre, 14000, Caen, France
| | - Patrice Talec
- Medical Intensive Care Unit, Angers University Hospital, Angers, F-49933, France
| | - Pierre Asfar
- Medical Intensive Care Unit, Angers University Hospital, Angers, F-49933, France
| | - Stephan Ehrmann
- Medical Intensive Care Unit, Bretonneau University Hospital, Tours, F-37044, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin University Hospital, Paris, F-75014, France
| | - Steven Grange
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, 76031, France
| | - Nadia Anguel
- Medical Intensive Care Unit, Kremlin-Bicêtre University Hospital, Paris, F-94275, France
| | - Alexandre Demoule
- Medical Intensive Care Unit and Respiratory Division, Pitié-Salpêtrière University Hospital, Paris, 75013, France
| | - Anne Sophie Moreau
- Medical-Surgical Intensive Care Unit, Lille University Hospital, Lille, F-59000, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, Paris, 75010, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, Dijon University Hospital, Dijon, F-21079, France
| | - Julie Boisramé-Helms
- Medical Intensive Care Unit, NHC University Hospital, Strasbourg, F-67091, France
| | - Guillaume Louis
- Medical Intensive Care Unit, Mercy Regional Hospital, Ars-Laquenexy, 57530, France
| | - Romain Sonneville
- Medical Intensive Care Unit, Bichat - Claude-Bernard University Hospital, Paris, 75018, France
| | - Nicolas Girerd
- INSERM CIC1433, Nancy University Hospital, Nancy, 54000, France
| | - Nicolas Ducrocq
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France
| | - Nelly Agrinier
- INSERM CIC-EC, CIE6, Nancy University Hospital, Nancy, 54000, France
| | - Denis Wahl
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy University Hospital, Vandoeuvre-les Nancy, Nancy, 54511, France
| | - Xavier Puéchal
- National Referral Center for Necrotizing Vasculitides and Systemic Sclerosis, Cochin Hospital, University Paris Descartes, Paris, F-75014, France
| | - Bruno Levy
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France. .,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France.
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Andreiana I, Stancu S, Avram A, Taran L, Mircescu G. ANCA positive crescentic glomerulonephritis outcome in a Central East European cohort: a retrospective study. BMC Nephrol 2015; 16:90. [PMID: 26123651 PMCID: PMC4486444 DOI: 10.1186/s12882-015-0091-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 06/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recently suggested distinct pathogenic pathways for myeloperoxidase (MPO) and proteinase 3 (PR3) anti-neutrophilic cytoplasmic antibodies (ANCA) associated vasculitis could result in different modes of presentation and outcome. Moreover, kidney outcome was related to a new histopathologic classification of pauci-immune glomerulonephritis. As reports were not always concordant, possible because differences in severity of organ lesions and ethnicity, we evaluated the outcome of a cohort of Central-East European patients with crescentic glomerulonephritis in relation with ANCA specificity and histopathological classification. METHODS Seventy-five patients were consecutively diagnosed by kidney biopsy (76 % MPO-ANCA specificity, 52 % crescentic) and followed for a median period of 3.2 years. Study end-points were response to therapy, end stage renal disease (ESRD) and death. RESULTS PR3-ANCA patients were younger, in higher proportion male and had higher Birmingham Vasculitis Activity Scores (BVAS). The kidney disease was severe at presentation (median creatinine 5 mg/dL; 27 % required temporary dialysis) and worst in PR3-ANCA positive patients (50 % patients needed temporary dialysis vs. 19 %). The lung was the second most affected organ (31 % severe lung hemorrhage). Lung and kidney damage were related; the odds of hemorrhagic alveolitis in patients needing dialysis at presentation were 4 (95 % CI 1-13; p = 0.006) times higher than in those who did not. The rate of response to therapy (without signs of active vasculitis and stable or declining serum creatinine) was 60 % and was associated with dialysis independency, older age and higher platelet number at presentation. The probabilities to survival 1 and 5 years for kidney and patient were 93 and 64 %, and respectively 88 and 67 %. Kidney survival was predicted by response to therapy and dialysis independency at presentation. Patients with BVAS < 15 and responding to induction therapy had better chances of survival. Neither response to therapy nor outcome was influenced by ANCA specificity or by the histopathological class. CONCLUSIONS When kidney damage is severe in ANCA vasculitis, the need of dialysis at presentation and the response to induction therapy overcome the prognostic utility of both ANCA specificity and histopathological class.
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Affiliation(s)
- Iuliana Andreiana
- Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, 4th Calea Grivitei Street, Bucharest, 010731, Romania. .,Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Simona Stancu
- Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, 4th Calea Grivitei Street, Bucharest, 010731, Romania. .,Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Andreea Avram
- Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, 4th Calea Grivitei Street, Bucharest, 010731, Romania.
| | - Ludmila Taran
- Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, 4th Calea Grivitei Street, Bucharest, 010731, Romania.
| | - Gabriel Mircescu
- Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, 4th Calea Grivitei Street, Bucharest, 010731, Romania. .,Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
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Jayne D, Rasmussen N. Twenty-five years of European Union collaboration in ANCA-associated vasculitis research. Nephrol Dial Transplant 2015; 30 Suppl 1:i1-7. [PMID: 25805742 DOI: 10.1093/ndt/gfv060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This special edition reviews the progress in understanding of systemic vasculitis associated with autoantibodies to neutrophil cytoplasmic antigens (ANCA). European research groups have contributed to this research including the original observations of the association between ANCA and vasculitis. Areas of interest include classification and epidemiology, genetics and pathogenesis, disease assessment, histology and long-term outcomes. Clinical trials conducted by the European Vasculitis Study group have helped to define the current standard of care for the treatment of patients with vasculitis and provided a platform for the investigation of newer therapies. The prognosis of patients with ANCA-associated vasculitis has improved over this period as a result of facilitated diagnosis and development of consensus, evidence-based, treatment recommendations. The ANCA story represents an example of the power of a biomarker in influencing a disease area, inspiring research and providing physicians with better tools to treat patients with these disorders.
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Affiliation(s)
- David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Niels Rasmussen
- Department of Otolaryngology, Rigshospitalet, Copenhagen, Denmark
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Hilhorst M, van Paassen P, Tervaert JWC. Proteinase 3-ANCA Vasculitis versus Myeloperoxidase-ANCA Vasculitis. J Am Soc Nephrol 2015; 26:2314-27. [PMID: 25956510 DOI: 10.1681/asn.2014090903] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In patients with GN or vasculitis, ANCAs are directed against proteinase 3 (PR3) or myeloperoxidase (MPO). The differences between PR3-ANCA-associated vasculitis (AAV) and MPO-AAV described in the past have been supplemented during the last decade. In this review, we discuss the differences between these two small-vessel vasculitides, focusing especially on possible etiologic and pathophysiologic differences. PR3-AAV is more common in northern parts of the world, whereas MPO-AAV is more common in southern regions of Europe, Asia, and the Pacific, with the exception of New Zealand and Australia. A genetic contribution has been extensively studied, and there is a high prevalence of the HLA-DPB1*04:01 allele in patients with PR3-AAV as opposed to patients with MPO-AAV and/or healthy controls. Histologically, MPO-AAV and PR3-AAV are similar but show qualitative differences when analyzed carefully. Clinically, both serotypes are difficult to distinguish, but quantitative differences are present. More organs are affected in PR3-AAV, whereas renal limited vasculitis occurs more often in patients with MPO-AAV. For future clinical trials, we advocate classifying patients by ANCA serotype as opposed to the traditional disease type classification.
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Affiliation(s)
- Marc Hilhorst
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Pieter van Paassen
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Jan Willem Cohen Tervaert
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands jw.cohentervaert@maastrichtuniversity
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Rowaiye OO, Kusztal M, Klinger M. The kidneys and ANCA-associated vasculitis: from pathogenesis to diagnosis. Clin Kidney J 2015; 8:343-50. [PMID: 26034600 PMCID: PMC4440467 DOI: 10.1093/ckj/sfv020] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 03/05/2015] [Indexed: 12/20/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are a group of pauci-immune small vessel vasculitides that often affect the kidneys manifesting as rapidly progressive glomerulonephritis. Although the exact pathogenesis of AAV is not fully known, evidence from in vitro, in vivo and clinical studies all point to the involvement of ANCA in the pathogenesis of AAV. In this review, we highlight the contributory roles played by various factors (e.g. genetics, environment, B and T-regulatory cells, toll-like receptors, etc.) in the pathogenesis of AAV. Furthermore, we discuss renal involvement in AAV in terms of clinical features and the various histopathological classification patterns, which are also known to be of prognostic importance. We also present information on useful imaging techniques for localizing kidney and other organ system involvement in AAV, and also on novel laboratory methods and assays useful for rapid and more specific determination of patients' ANCA status. Finally, we demonstrate evidence on novel serum biomarkers that have been shown to correlate with disease activity in AAV.
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Affiliation(s)
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine , Wroclaw Medical University , Wroclaw , Poland
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine , Wroclaw Medical University , Wroclaw , Poland
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Parrot A, Fartoukh M, Cadranel J. Hémorragie intra-alvéolaire. Rev Mal Respir 2015; 32:394-412. [DOI: 10.1016/j.rmr.2014.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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Szpirt WM. Plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis--a 25-year perspective. Nephrol Dial Transplant 2015; 30 Suppl 1:i146-9. [PMID: 25770166 DOI: 10.1093/ndt/gfv051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Demonstration of a pathogenic role for antineutrophil cytoplasmic antibodies (ANCA) underlies the scientific rationale for plasma exchange (PLEX) in the treatment of ANCA-associated vasculitis (AAV). Most clinical evidence of efficacy concerns the use of PLEX for the recovery of renal function in severe nephritis, when used in conjunction with immunosuppressive drug therapy. The development of PLEX for this indication, the strength of the clinical trial evidence supporting its use, its roles in other AAV indications and ongoing research are discussed.
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Affiliation(s)
- Wladimir M Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Cao Y, Tian Z, Li W, Yang Y, Wang G. Hemorrhagic complications associated with PR3-ANCA crescentic glomerulonephritis. Ren Fail 2015; 37:745-50. [PMID: 25697228 DOI: 10.3109/0886022x.2015.1014756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hemorrhagic complications of anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis are life-threatening conditions. Of these, alveolar hemorrhage is the most common and well-described hemorrhagic complication and is a prominent component of the pulmonary-renal syndrome. The clinical presentation of alveolar hemorrhage is highly variable ranging from mild to serious disease that may require respiratory support. Less attention has been directed at hemorrhagic complications that have been reported in other organs and which may be as severe or more severe with regard to morbidity and mortality. For example, among the most serious non-pulmonary complications are those related to cerebral and gastrointestinal hemorrhage. Cerebral hemorrhage is the clearly the most critical issue with a persistent high mortality rate. The prognosis of gastrointestinal hemorrhage, once an ominous complication has improved with medical and surgical intervention. Not to be dismissed are the consequences of hemorrhagic issues related to skin, soft tissue or muscle involvement. Muscle hematomas, while rare, also accompanied by significant morbidity.
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Affiliation(s)
- Yali Cao
- a Department of Nephrology , China-Japan Friendship Hospital , Beijing , P. R. China
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43
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Hirayama K, Kobayashi M, Usui J, Arimura Y, Sugiyama H, Nitta K, Muso E, Wada T, Matsuo S, Yamagata K. Pulmonary involvements of anti-neutrophil cytoplasmic autoantibody-associated renal vasculitis in Japan. Nephrol Dial Transplant 2015; 30 Suppl 1:i83-93. [PMID: 25613541 DOI: 10.1093/ndt/gfu385] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pulmonary involvement is one of the hallmark lesions of anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) as well as rapidly progressive glomerulonephritis (RPGN). However, the pulmonary involvement of AAV patients seems to differ between Europe and Japan, as does the ANCA serotype. METHODS This retrospective and prospective multicenter cohort study collected the clinical data of the features and outcomes of 1772 RPGN patients treated from 1989 to 2007 in Japan. Based on this nationwide RPGN survey, we analyzed the cases of 1147 AAV patients. RESULTS We found that 52.3% of the AAV patients had pulmonary involvements: 15.4% of the AAV patients had alveolar hemorrhage (AH), 26.2% had interstitial lung disease (ILD), 2.8% had bronchial asthma, 2.4% had pulmonary granuloma and 12.8% had a chest X-ray abnormality without AH, ILD or pulmonary granuloma. Patient survival was significantly different among the following six groups: the 5-year survival rate was 41.5% in the patients with AH, 50.2% in those with ILD, 67.9% in those with bronchial asthma, 62.5% in those with pulmonary granuloma, 55.8% in those with chest X-ray abnormality and 73.3% in those without pulmonary involvement. AH was one of the predictors of 1- and 5-year mortality for patient survival in AAV, and ILD was added as one of the predictors of 5-year mortality. CONCLUSION In these AAV patients, not only AH but also ILD was frequently observed. AH was associated with the prognosis, but ILD was associated with the long-term prognosis of AAV.
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Affiliation(s)
- Kouichi Hirayama
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki, Japan
| | - Masaki Kobayashi
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki, Japan
| | - Joichi Usui
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshihiro Arimura
- First Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Hitoshi Sugiyama
- Department of Chronic Kidney Disease and Peritoneal Dialysis, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Eri Muso
- Division of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Institute, Osaka, Japan
| | - Takashi Wada
- Department of Disease Control and Homeostasis, Kanazawa University, Kanazawa, Japan
| | - Seiichi Matsuo
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Westman K, Flossmann O, Gregorini G. The long-term outcomes of systemic vasculitis. Nephrol Dial Transplant 2015; 30 Suppl 1:i60-6. [PMID: 25601266 DOI: 10.1093/ndt/gfu392] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patients with generalized ANCA-associated small vessel vasculitis (AAV) have a very poor outcome if the ANCA-associated vasculitis is not diagnosed, evaluated and treated properly. The introduction of treatment with immunosuppressive therapy has improved patient survival dramatically but with considerable side effects. Besides, almost 50% of surviving patients experience a relapse of vasculitis. Since 1995, the European Vasculitis Society (EUVAS) has designed and conducted several clinical trials on patients with AAV independently of pharmaceutical companies. The studies included patients with newly diagnosed AAV and were stratified according to renal function and generalized versus more localized forms. As the immediate patient survival has improved, the longer term outcome has become more important. There are several reports on outcome of patients with ANCA-associated vasculitis, but the patient groups were heterogeneous regarding diagnosis as well as treatment and follow-up. Therefore, EUVAS decided to further evaluate the effect and possible adverse events of the original randomized trials. This review presents an overview on long-term follow-up of patients with ANCA-associated vasculitis, with focus on relapse rate, patient and renal survival and development of cardiovascular disease and malignancy.
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Affiliation(s)
- Kerstin Westman
- Department of Nephrology, Clinical Sciences, Lund University, Skane University Hospital Malmö, Lund, Sweden
| | | | - Gina Gregorini
- Department of Nephrology, A.O. Spedali Civili, Brescia, Italy
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Fukui S, Iwamoto N, Tsuji S, Umeda M, Nishino A, Nakashima Y, Suzuki T, Horai Y, Koga T, Kawashiri SY, Ichinose K, Hirai Y, Tamai M, Nakamura H, Origuchi T, Kawakami A. Diffuse alveolar hemorrhage emerging one week after starting high-dose corticosteroid therapy for granulomatosis with polyangiitis (GPA) with systemic lupus erythematosus (SLE). Intern Med 2015; 54:2681-6. [PMID: 26466711 DOI: 10.2169/internalmedicine.54.5299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 69-year-old man was diagnosed with granulomatosis with polyangiitis (GPA) based on the presence of skin granuloma, refractory otitis media, renal insufficiency and myeloperoxidase-antineutrophil cytoplasmic antibody positivity and slight lung opacity. He was treated with high-dose corticosteroid therapy. Despite the initial improvement of his renal function and a decrease in his C-reactive protein level, he suffered from an alveolar hemorrhage one week after the start of corticosteroid therapy. An anti-dsDNA antibody test was positive and the patient had hypocomplementemia. Elements of both GPA and systemic lupus erythematosus were thought to have affected his clinical course.
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Affiliation(s)
- Shoichi Fukui
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
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Abstract
PURPOSE OF REVIEW This article reviews the use of plasma exchange for the treatment of antineutrophil cytoplasm antibody-associated vasculitis (AAV) with a focus on current controversies and knowledge gaps. RECENT FINDINGS Experimental evidence suggesting that antineutrophil cytoplasm antibodies are pathogenic continues to evolve and support the theory that rapid removal of antineutrophil cytoplasm antibody with plasma exchange may be beneficial. Although early, small trials of plasma exchange in rapidly progressive glomerulonephritis and vasculitis suggested that plasma exchange may improve a patient's potential for renal recovery, more recent analyses have called the net benefit of plasma exchange into question. Furthermore, there is uncertainty as to whether plasma exchange is beneficial to patients with particular organ manifestations of their AAV (e.g., lung hemorrhage). SUMMARY Whether plasma exchange should be used routinely in antineutrophil cytoplasm antibody-associated vasculitis, in patients with certain manifestations or severity of disease only, or not at all, remains unclear. Given that plasma exchange is expensive and invasive, further research to resolve these uncertainties is required.
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Affiliation(s)
- Michael Walsh
- aDepartment of Medicine bDepartment of Clinical Epidemiology and Biostatistics, McMaster University cPopulation Health Research Institute, McMaster University/Hamilton Health Sciences, Hamilton, Canada
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Abnormal expression pattern of the IL-2 receptor β-chain on CD4+ T cells in ANCA-associated vasculitis. DISEASE MARKERS 2014; 2014:249846. [PMID: 24648606 PMCID: PMC3933302 DOI: 10.1155/2014/249846] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/17/2013] [Accepted: 12/04/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND/AIM ANCA-associated vasculitis (AAV) is a small-vessel vasculitis of autoimmune origin. In addition to autoantibodies, T cells have a pivotal pathophysiological role in this disease. T-cell homeostasis and immune tolerance critically depend on IL-2 and its receptor expressed by T cells. In this study, we investigated the IL-2 receptor (IL-2r) expression on CD4(+) T cells in AAV. METHODS Thirty patients with AAV and 15 age-matched healthy controls (HC) were enrolled. T cells from peripheral blood were analysed by flow cytometry for expression of the IL-2r α - and β-chain. RESULTS The IL-2r α-chain was overexpressed in AAV as compared to HC (36 ± 16% versus 20 ± 9%, P < 0.005). The IL-2r-β-chain expression was significantly reduced on CD25(+) CD4(+) T-cells and CD4(+)CD25(+)FoxP3(pos) regulatory T-cells (Tregs; AAV versus HC: 48 ± 14% versus 62 ± 9%, P = 0.002 and 38 ± 18% versus 68 ± 5%, P = 0.002). Low β -chain expression in AAV was associated with relapsing disease and systemic vasculitis with renal involvement. CONCLUSION The IL-2r expression pattern is abnormal in AAV. To our knowledge, we are the first to show that the β -chain expression is drastically diminished on T cells in AAV and related to a less favorable disease course. Given the indispensable function of the β -chain in IL-2 signaling of T cells, diminished expression may contribute to disturbed immune homeostasis in AAV.
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Chen C, Zhu YH, Qian HY, Yang LY, Huang JA. Sudden and rapid progression of lung affectation but stability in kidney function: a case report of anti-neutrophil cytoplasmic antibody-associated vasculitis. Int Med Case Rep J 2014; 7:7-10. [PMID: 24403845 PMCID: PMC3883597 DOI: 10.2147/imcrj.s49674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report the case of a patient with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) who exhibited sudden progression of lung infiltration while maintaining stable kidney function. The 69-year-old man was diagnosed with AAV and renal insufficiency 4 years ago. Pulmonic affectation was detected in the right lower lobe of lung by a computed tomography (CT) scan. After beginning cyclophosphamide pulse therapy and sequential therapy with low-dose prednisone, he underwent a 4-year follow-up to detect changes in hemoglobin levels and serum creatinine levels, and had chest CT examinations. The CT scan and creatinine assay showed stable pulmonic fibrosis and kidney function. Although there was no increase of creatinine and detectable perinuclear ANCA, the patient suffered a pulmonary hemorrhage and levels of hemoglobin became progressive lower; the lung infiltration was found to be enlarged compared to the last examination the previous year. After immunosuppressive therapy for one week, the lung fibrosis was progressive, increased pulmonary hemorrhage occurred, and the patient died due to respiratory failure but not end-stage renal failure.
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Affiliation(s)
- Cheng Chen
- Respiratory Division, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Ye-Han Zhu
- Respiratory Division, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Hong-Ying Qian
- Respiratory Division, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Ling-Yi Yang
- Respiratory Division, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Jian-An Huang
- Respiratory Division, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
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Dellaripa PF, Fischer A, Flaherty KR. Pulmonary Manifestations of Vasculitis. PULMONARY MANIFESTATIONS OF RHEUMATIC DISEASE 2014. [PMCID: PMC7120293 DOI: 10.1007/978-1-4939-0770-0_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paul F. Dellaripa
- Harvard Medical School, Department of Medicine, Division of Rheumatology Brigham and Women’s Hospital, Boston, Massachusetts USA
| | - Aryeh Fischer
- Division of Rheumatology, Autoimmune and Interstitial Lung Disease Program, Department of Medicine, National Jewish Health, Denver, Colorado USA
| | - Kevin R. Flaherty
- Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan USA
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Abstract
Antineutrophil cytoplasmic autoantibody (ANCA)-associated diseases are small-vessel vasculitides, encompassing granulomatosis with polyangiitis (formerly Wegener's granulomatosis), microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Once considered life-threatening diseases, the introduction of stage-adapted immunosuppressive therapy and medications with decreased toxicity has improved patients' survival. Treatment is biphasic, consisting of induction of remission (3-6 months) for rapid control of disease activity and maintenance of remission (at least 18 months) to prevent disease relapse using therapeutic alternatives that have reduced toxicity. This Review summarizes current treatment strategies for these diseases, with a special focus on long-term follow-up data from key randomized controlled trials and new developments in remission induction and maintenance therapy. Current treatment strategies have substantial short-term and long-term adverse effects, and relapses are frequent; thus, less-toxic and more-effective approaches are needed. Moreover, the optimal intensity and duration of maintenance therapy remains under debate. Clinical trials have traditionally considered ANCA-associated vasculitides as a single disease entity. However, future studies must stratify participants according to their specific disease, clinical features (different types of organ manifestation, PR3-ANCA or MPO-ANCA positivity) and disease severity.
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