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Wallace ZS, Fu X, Cook C, Ahola C, Williams Z, Doliner B, Hanberg JS, Stone JH, Zhang Y, Choi HK. Comparative Effectiveness of Rituximab- Versus Cyclophosphamide-Based Remission Induction Strategies in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis for the Risk of Kidney Failure and Mortality. Arthritis Rheumatol 2023; 75:1599-1607. [PMID: 37011036 PMCID: PMC10523845 DOI: 10.1002/art.42515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/23/2023] [Accepted: 03/31/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE To compare rituximab- versus cyclophosphamide-based remission induction strategies for the long-term risks of kidney failure and death in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in a real-world cohort. METHODS We performed a cohort study using the Mass General Brigham AAV Cohort, which includes proteinase 3-ANCA+ and myeloperoxidase (MPO)-ANCA+ AAV patients diagnosed from January 1, 2002 to December 31, 2019. We included cases in which the initial remission induction strategy was based either on rituximab or cyclophosphamide. The primary outcome was the composite outcome of kidney failure or death. We used multivariable Cox proportional hazards models and propensity score-matched analyses to assess the association of rituximab- versus cyclophosphamide-based treatment strategies with the composite outcome of kidney failure or death. RESULTS Of 595 included patients, 352 patients (~60%) received rituximab-based and 243 patients (~40%) received cyclophosphamide-based regimens. The mean age was 61 years, 58% of patients were female, 70% of patients were MPO-ANCA+, and 69% of patients had renal involvement (median estimated glomerular filtration rate 37.3 ml/minute/1.73 m2 ). There were 133 events at 5 years, and the incidence rates in rituximab- and cyclophosphamide-based regimens were 6.8 and 6.1 per 100 person-years, respectively. The risk of kidney failure or death was similar in both groups in multivariable-adjusted analyses (hazard ratio [HR] 1.03 [95% confidence interval (95% CI) 0.55-1.93]) and in propensity score-matched analyses (HR 1.05 [95% CI 0.55-1.99]) at 5 years. Our findings were similar when outcomes were assessed at 1 and 2 years as well as in subgroups stratified according to renal involvement and severity as well as major organ involvement. CONCLUSION Rituximab- and cyclophosphamide-based remission induction strategies for AAV are associated with similar risks of kidney failure and death.
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Affiliation(s)
- Zachary S Wallace
- Rheumatology Unit, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Claire Cook
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Catherine Ahola
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Zachary Williams
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Brett Doliner
- Department of Medicine, Massachusetts General Hospital, Boston
| | | | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
| | - Yuqing Zhang
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Mongan Institute, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
| | - Hyon K Choi
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Mongan Institute, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
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Stone CA, Robinson LB, Li L, Krantz MS, Kwah JH, Ortega G, Mancini C, Wolfson AR, Saff RR, Samarakoon U, Hong DI, Koo G, Chow TG, Gruchalla R, Liao JX, Kuster JK, Price C, Ahola C, Khan DA, Phillips EJ, Banerji A, Blumenthal KG. Clinical Phenotypes of Immediate First-Dose Reactions to mRNA COVID-19: A Multicenter Latent Class Analysis. J Allergy Clin Immunol Pract 2023; 11:458-465.e1. [PMID: 36108922 PMCID: PMC9468049 DOI: 10.1016/j.jaip.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/10/2022] [Accepted: 08/28/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although immediate potentially allergic reactions have been reported after dose 1 of mRNA coronavirus disease 2019 (COVID-19) vaccines, comprehensively defined subtypes have not been clearly distinguished. OBJECTIVE To define distinct clinical phenotypes of immediate reactions after dose 1 of mRNA COVID-19 vaccination, and to assess the relation of clinical phenotype to mRNA COVID-19 vaccine second dose tolerance. METHODS This retrospective study included patients with 1 or more potentially allergic symptoms or signs within 4 hours of receiving dose 1 of an mRNA COVID-19 vaccine and assessed by allergy/immunology specialists from 5 U.S. academic medical centers (January-June 2021). We used latent class analysis-an unbiased, machine-learning modeling method-to define novel clinical phenotypes. We assessed demographic, clinical, and reaction characteristics associated with phenotype membership. Using log-binomial regression, we assessed the relation between phenotype membership and second dose tolerance, defined as either no symptoms or mild, self-limited symptoms resolving with antihistamines alone. A sensitivity analysis considered second dose tolerance as objective signs only. RESULTS We identified 265 patients with dose-1 immediate reactions with 3 phenotype clusters: (1) Limited or Predominantly Cutaneous, (2) Sensory, and (3) Systemic. A total of 223 patients (84%) received a second dose and 200 (90%) tolerated their second dose. Sensory cluster (all patients had the symptom of numbness or tingling) was associated with a higher likelihood of second dose intolerance, but this finding did not persist when accounting for objective signs. CONCLUSIONS Three novel clinical phenotypes of immediate-onset reactions after dose 1 of mRNA COVID-19 vaccines were identified using latent class analysis: (1) Limited or Predominantly Cutaneous, (2) Sensory, and (3) Systemic. Whereas these clinical phenotypes may indicate differential mechanistic etiologies or associations with subsequent dose tolerance, most individuals proceeding to their second dose tolerated it.
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Affiliation(s)
- Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lacey B Robinson
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - Lily Li
- Harvard Medical School, Boston, Mass; Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Jason H Kwah
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - Gilbert Ortega
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christian Mancini
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - Anna R Wolfson
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Rebecca R Saff
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - David I Hong
- Harvard Medical School, Boston, Mass; Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rebecca Gruchalla
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jane X Liao
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - John K Kuster
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - Christina Price
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - Catherine Ahola
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - David A Khan
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Aleena Banerji
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass.
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McDermott G, Fu X, Cook C, Ahola C, Doliner B, Hanberg J, Stone JH, Choi HK, Zhang Y, Wallace ZS. The effect of achieving serological remission on subsequent risk of relapse, end-stage renal disease and mortality in ANCA-associated vasculitis: a target trial emulation study. Ann Rheum Dis 2022; 81:1438-1444. [PMID: 35697489 PMCID: PMC9474699 DOI: 10.1136/annrheumdis-2022-222439] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the effect of achieving a negative postinduction antineutrophil cytoplasmic antibody ANCA) assay on the risk of relapse, end-stage renal disease (ESRD) and death in ANCA-associated vasculitis (AAV). METHODS We emulated a target trial using observational data from the Mass General Brigham AAV cohort comparing patients who achieved versus did not achieve serological remission (negative ANCA assay) within 180 days of induction. Outcomes were relapse, ESRD or death within 5 years, obtained from medical records, the US Renal Data System and the National Death Index. We placed a 'clone' of each patient in both trial arms, censored those deviating from their assigned protocol and weighted each by the inverse probability of censoring. Outcomes were assessed by pooled logistic regression. RESULTS The study included 506 patients with AAV. The mean age was 61 years (SD 18) and the majority were women (58%), white (87%), myeloperoxidase-ANCA+ (72%) and had renal involvement (68%). Rituximab (59%) or cyclophosphamide (33%) was most often used for induction treatment. Within 5 years, 81 (16%) died, 51 (10%) had ESRD and 64 (13%) had relapse. Patients treated to a negative ANCA assay within 180 days had HR 0.55 (95% CI 0.38 to 0.81) for relapse and HR 0.87 (95% CI 0.61 to 1.25) for the composite of ESRD or death within 5 years. CONCLUSIONS In this emulated target trial from a large AAV cohort, achieving serological remission within 180 days of induction was associated with lower risk of relapse, but no statistically significant difference in ESRD or mortality outcomes.
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Affiliation(s)
- Gregory McDermott
- Department of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Claire Cook
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catherine Ahola
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brett Doliner
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer Hanberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hyon K Choi
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuqing Zhang
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
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