Clinical Characteristics and Prognostic Analysis of Microscopic Polyangiitis With Diffuse Alveolar Hemorrhage

Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Diffuse Alveolar Hemorrhage With Avacopan

OBJECTIVE

Avacopan, an activated complement factor 5 receptor antagonist, has been approved as adjunct therapy for severe active antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Current evidence supports the management of AAV presenting with diffuse alveolar hemorrhage (DAH) by administering glucocorticoids combined with either rituximab or cyclophosphamide in addition to supportive care. The role of avacopan in patients with DAH as a primary severe disease manifestation of AAV has not been well established. Furthermore, concerns remain regarding timely access to avacopan, the best glucocorticoid tapering regimen, and long-term efficacy and safety of the drug. We sought to identify clinical features and outcomes of patients presenting with DAH secondary to AAV who received avacopan in addition to glucocorticoids and rituximab or cyclophosphamide.

METHODS

We performed a retrospective cohort study of all consecutive patients presenting with DAH as part of active severe granulomatosis with polyangiitis or microscopic polyangiitis. Demographic and clinical characteristics were collected at presentation and follow-up.

RESULTS

Fifteen patients met inclusion criteria and were observed for a median time of 17 weeks (interquartile range [IQR] 6-37 weeks) after initiation of avacopan. Patients were predominantly female and White, had never smoked, and were a median age of 66 years (IQR 52-72 years) at diagnosis. The majority had newly diagnosed severe AAV with renal involvement. Three patients progressed to respiratory failure. The timing of avacopan introduction and patterns of glucocorticoid tapers varied widely in this cohort. Two serious adverse events related to infection were observed, including one opportunistic infection leading to the patient's death, although neither was directly attributed to avacopan administration.

CONCLUSION

We describe the clinical course of patients who presented with the severe AAV disease manifestation of DAH and received avacopan as adjunct therapy. Most patients achieved remission during follow-up, and adverse events, including infection, were observed.

KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases

The KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases represents the first update to this set of recommendations since the initial set of KDIGO guideline recommendations was published in 2012. The pace of growth in our molecular understanding of glomerular disease has quickened and a number of newer immunosuppressive and targeted therapies have been introduced since the original set of guideline recommendations, making such an update necessary. Despite these updates, many areas of controversy remain. In addition, further updates since the publication of KDIGO 2021 have occurred which this guideline does not encompass. With this commentary, the KDOQI work group has generated a chapter-by-chapter companion opinion article that provides commentary specific to the implementation of the KDIGO 2021 guideline in the United States.

Rheumatic diseases associated with alveolar hemorrhage: analysis of the national inpatient sample

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 (OR_adj) 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) (OR_adj 72.56) (95% C.I. 50.607-104.043), antiphospholipid antibody syndrome (APLS) (OR_adj 6.51) (95% C.I. 3.734-11.366), eosinophilic granulomatosis with polyangiitis (EGPA) (OR_adj 7.13) (95% C.I. 1.886-26.926), Goodpasture's (OR_adj 30.58) (95% C.I. 16.360-57.176), rheumatoid arthritis (RA) (OR_adj 1.60) (95% C.I. 1.158-2.212), sarcoidosis (OR_adj 3.99) (95% C.I. 2.300-6.926), and systemic lupus (SLE) (OR_adj 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.

A prognostic analysis of antisynthetase syndrome-related interstitial lung disease

OBJECTIVE

To analyze prognostic factors of antisynthetase syndrome (ASS)-related interstitial lung disease (ILD).

METHODS

We retrospectively collected the data of 77 inpatients with ASS-ILD at our hospital from January 1, 2018, to January 1, 2021. The improvement/stability group and deterioration/death group were defined according to their follow-up outcome. Clinical data of the 2 groups were compared. Univariate analysis was adopted to screen the possible prognostic factors and then logistic regression was used for multivariate analysis.

RESULT

After 6 to 42 months of follow-up, 52 patients (67.5%) were classified into the improvement/stability group, and 25 patients (32.5%) were classified into the deterioration/death group. According to the multivariate stepwise logistic regression analysis, respiratory failure (odds ratio [OR] = 6.71, 95% CI: 1.64-27.38, P = .008) and elevated muscle enzymes (OR = 4.31, 95% CI: 1.03-18.05, P = .045) were found to be independent risk factors, while mechanic's hands (OR = 0.06, 95% CI: 0.01-0.37, P = .003) and anti-Jo-1 antibody (OR = 0.24, 95% CI: 0.06-0.93, P = .039) were protective factors.

CONCLUSION

The prognostic assessment of ASS-ILD patients should be emphasized. Patients with a poor prognosis should be identified early based on their risk factors to guide clinical management decisions.