Pregnancy outcome in patients with a medical history of immunoglobulin A vasculitis: a case-control study

OBJECTIVE

Data on obstetric outcomes in patients with a history of immunoglobulin A vasculitis (IgA-V) are lacking. The aim of this study was to assess maternal, neonatal, and vasculitis outcomes during pregnancy.

METHOD

We conducted a French retrospective case-control study. Pregnancies of patients with a history of IgA-V (cases) were retrospectively studied and compared to pregnancies in women who developed IgA-V after their pregnancies and to pregnancies in healthy women (controls).

RESULTS

Twenty-six pregnancies in patients with a history of IgA-V were included and compared to 15 pregnancies in women who later developed IgA-V and 52 pregnancies in healthy women. Both gestational hypertension and pre-eclampsia were more frequent in the case group than in the other groups (23% vs 0% vs 0%, p < 0.01; 12% vs 7% vs 0%, p = 0.04). Hypertensive disorder of pregnancy occurred more frequently in patients with pre-existing kidney disease (78% vs 12%, p < 0.01). Caesarean section was more often performed in the case group than in the other groups (27% vs 0% vs 10%, p = 0.04). No foetal loss or maternal deaths occurred. There were no differences in delivery term or birth weight. No vasculitis flares were observed during pregnancy.

CONCLUSION

Women with a history of IgA-V appear to be at higher risk for gestational hypertension and pre-eclampsia, especially in cases with renal involvement; however, both mother and newborn outcomes appear to be favourable.

Impact of rituximab on humoral response to SARS-CoV-2 vaccination in previously vaccinated patients with autoimmune diseases

SARS-CoV-2 infection is more severe in patients undergoing rituximab (RTX) treatment. Humoral response to vaccination is severely impaired in patients already treated with RTX, but data on antibody persistence in patients initiating RTX are lacking. We evaluated the impact of RTX initiation on humoral response to SARS-CoV-2 vaccination in previously vaccinated patients with immune-mediated inflammatory diseases. We performed a retrospective, multicenter study evaluating the evolution of anti-spike antibodies and breakthrough infections after initiation of RTX in previously vaccinated patients with protective levels of anti-SARS-CoV-2 antibodies. Threshold for anti-S antibodies positivity and protection were 30 and 264 BAU/mL, respectively. We included 31 previously vaccinated patients initiating RTX (21 female, median age 57 years). At first RTX infusion, 12 (39%) patients had received 2 doses of vaccine, 15 (48%) had received 3 doses, and 4 (13%) had received 4 doses. The most frequent underlying diseases were ANCA-associated vasculitis (29%) and rheumatoid arthritis (23%). Median anti-S antibody titers at RTX initiation, 3 months, and 6 months were 1620 (589-2080), 1055 (467-2080), and 407 (186-659) BAU/mL, respectively. Overall, antibody titers waned by almost two-fold at 3 months and four-fold at 6 months. Median antibody titers were significantly higher in patients who received ≥3 doses compared to those who received only 2 doses. Three patients developed SARS-CoV-2 infection without any severe symptom. Anti-SARS-CoV-2 antibody titers in previously vaccinated patients decline after RTX initiation similarly to general population. Specific monitoring is useful to anticipate prophylactic strategies. Key Points • Anti-SARS-CoV-2 antibody titers in previously vaccinated patients decline after rituximab initiation similarly to the general population. • The number of dose of vaccine before rituximab initiation is associated with higher antibody titers at month 3. • Monitoring antibody levels is mandatory to initiate prophylactic strategies in this population.

French practical guidelines for the diagnosis and management of AA amyloidosis

AA amyloidosis is secondary to the deposit of excess insoluble Serum Amyloid A (SAA) protein fibrils. AA amyloidosis complicates chronic inflammatory diseases, especially chronic inflammatory rheumatisms such as rheumatoid arthritis and spondyloarthritis; chronic infections such as tuberculosis, bronchectasia, chronic inflammatory bowel diseases such as Crohn's disease; and auto-inflammatory diseases including familial Mediterranean fever. This work consists of the French guidelines for the diagnosis workup and treatment of AA amyloidosis. We estimate in France between 500 and 700 cases in the whole French population, affecting both men and women. The most frequent organ impaired is kidney which usually manifests by oedemas of the lower extremities, proteinuria, and/or renal failure. Patients are usually tired and can display digestive features anf thyroid goiter. The diagnosis of AA amyloidosis is based on detection of amyloid deposits on a biopsy using Congo Red staining with a characteristic green birefringence in polarized light. Immunohistochemical analysis with an antibody directed against Serum Amyloid A protein is essential to confirm the diagnosis of AA amyloidosis. Peripheral inflammatory biomarkers can be measured such as C Reactive protein and SAA. We propose an algorithm to guide the etiological diagnosis of AA amyloidosis. The treatement relies on the etiologic treatment of the undelying chronic inflammatory disease to decrease and/or normalize Serum Amyloid A protein concentration in order to stabilize amyloidosis. In case of renal failure, dialysis or even a kidney transplant can be porposed. Nowadays, there is currently no specific treatment for AA amyloidosis deposits which constitutes a therapeutic challenge for the future.

Impact de l’initiation d’un traitement par rituximab sur la réponse humoral à la vaccination anti-SARS-CoV-2 chez des patients ayant une maladie auto-immune et préalablement vaccinés

Introduction

L’infection à SARS-CoV-2 est plus sévère chez les patients ayant une maladie auto-immune traitée par rituximab. La réponse humorale à la vaccination anti-SARS-CoV-2 est fortement altérée chez les patients sous rituximab avec une production d’anticorps neutralisants corrélée au taux de lymphocytes B circulants. Notre objectif était d’évaluer l’impact de l’initiation d’un traitement par rituximab sur la réponse humorale au vaccin anti-SARS-CoV-2 chez des patients ayant une maladie auto-immune et préalablement vaccinés.

Patients et méthodes

Nous avons réalisé une étude rétrospective, descriptive, bicentrique, incluant des patients ayant été préalablement vaccinés par au moins 2 doses de vaccin anti-SARS-CoV-2 avec un taux d’anticorps anti-Spike protecteur (supérieur à 264 BAU/mL), et chez qui un traitement par rituximab était initié pour une maladie auto-immune, ou repris après plus d’un an d’interruption. Les critères de jugement principaux étaient l’évolution du taux d’anticorps anti-Spike à 3 mois et 6 mois après initiation du rituximab et la survenue d’une COVID-19. Un taux d’anticorps protecteur était défini par des IgG anti-Spike > 264 BAU/mL et une sérologie positive par un taux > 30 BAU/mL.

Résultats

Nous avons inclus 24 patients traités de novo par rituximab (17 femmes, âge médian 55 ans). Les pathologies les plus fréquentes étaient la polyarthrite rhumatoïde (29,2 %) et les vascularites associées aux ANCA (25 %). Le traitement le plus souvent associé était la corticothérapie orale (71 % des cas) avec une dose médiane de 17,5 (IQR : 6–40) mg/jour. Au moment de l’initiation du traitement par rituximab, 13 patients avaient reçu 2 doses de vaccin (54,2 %), 9 patients avaient reçu 3 doses (37,5 %) et 2 patients avaient reçu 4 doses (8,3 %). Le vaccin majoritaire était le BNT162B2 (83 %). Le délai médian entre la dernière dose de vaccin et l’administration du rituximab était de 35 jours (IQR : 15–54). Le taux d’anticorps était divisé par 3 à 3 mois de l’initiation du rituximab, et par presque 5 à 6 mois. À 3 mois, 13/14 (92,9 %) patients avaient un taux détectable d’anticorps anti-spike et 11/14 patients (78,6 %) avaient un taux protecteur. À 6 mois, 19/19 (100 %) des patients avaient un taux détectable et 13/19 (68,4 %) avaient un taux protecteur. Neuf patients ont reçu une dose supplémentaire de vaccin entre la première perfusion de rituximab et l’analyse à 6^e mois sans impact significatif sur l’évolution du taux d’anticorps. Aucune variable n’était significativement associée à un taux protecteur d’anticorps à 6 mois, notamment les pathologies, les traitements associés et le taux d’IgG total. Cependant, une tendance vers des taux d’anticorps plus élevés à 6 mois était observée chez les patients ayant reçu 3 doses de vaccins avant le rituximab en comparaison avec ceux ayant reçu 2 doses. Trois patients ont développé une COVID-19 après initiation du traitement par rituximab, de forme modérée et sans nécessité d’hospitalisation dans tous les cas.

Conclusion

La baisse du taux d’anticorps anti-spike après initiation d’un traitement par rituximab semble rapide, mais comparable à la baisse constatée dans la population générale [1], avec néanmoins une majorité des patients gardant des taux protecteurs d’anticorps. Une fois le traitement par rituximab débuté, une dose de vaccin supplémentaire ne semblait pas permettre l’augmentation des taux d’anticorps.

Stratégies innovantes de vaccination anti-pneumococcique par rapport au schéma standard chez les patients atteints de vascularites associées aux ANCA recevant du rituximab : essai contrôlé randomisé multicentrique (PNEUMOVAS)

Introduction

Les patients recevant des glucocorticoïdes et du rituximab (RTX) présentent un risque accru d’infections, en particulier d’infections invasives à pneumocoque. Les réponses vaccinales au virus de la grippe, au Streptococcus pneumoniae et au SARS-CoV-2 sous traitement par RTX sont fortement altérées. Chez les patients atteints de maladies auto-immunes recevant de tels traitements, en particulier ceux atteints de vascularites associées aux ANCA (AAV), il est donc nécessaire de développer des stratégies vaccinales anti-pneumococciques améliorées pour augmenter la réponse immunitaire et la protection vaccinale.

Patients et méthodes

Cet essai multicentrique de phase 2, randomisé, ouvert, a comparé deux stratégies innovantes de vaccin anti-pneumococcique « renforcées » au schéma de vaccination standard chez des patients atteints de VAA recevant un traitement par RTX. Des patients adultes atteints de VAA nouvellement diagnostiquée ou en rechute, présentant une maladie active (BVAS ≥ 3) et devant recevoir du RTX comme traitement d’induction (375 mg/m²/semaine pendant 4 semaines consécutives), ont été randomisés avec un rapport 1:1:1 dans trois bras parallèles : schéma standard associant une dose de vaccin pneumococcique conjugué 13-valent (PCV13) au jour 0 suivie d’une dose de vaccin non conjugué 23-valent (PPV23) au mois 5 (M5) (bras 1) ; double dose de PCV13 au jour 0 et au jour 7 suivie d’une dose de PPV23 à M5 (bras 2) ; ou 4 doses de PCV13 au jour 0 suivies d’une dose de PPV23 à M5 (bras 3). Le critère d’évaluation principal était la réponse immunitaire à M6 contre les 12 sérotypes de pneumocoque communs aux vaccins PCV13 et PPV23, classée selon quatre catégories ordonnées de réponse : réponse positive en anticorps contre 0–3, 4–6, 7–9 ou 10–12 sérotypes. Une réponse positive par sérotype était définie par un titre ELISA d’IgG spécifiques ≥ 1 μg/mL et une augmentation de deux fois par rapport au jour 0. Le critère d’évaluation primaire a été analysé dans un modèle de régression logistique à chances proportionnelles avec une correction de Bonferonni pour les 2 bras innovants. Les critères d’évaluation secondaires étaient les réactions locales et systémiques sollicitées 7 jours après chaque vaccination et tout événement indésirable lié ou pouvant être lié à l’immunisation vaccinale.

Résultats

Quatre-vingt-quinze participants ont été analysés dans la population modifiée en intention de traiter (âge moyen 60 ± 16,6 ans, 50 % d’hommes, 74 personnes atteintes d’une maladie nouvellement diagnostiquée, 66 d’une granulomatose avec polyangéite et 29 d’une polyangéite microscopique, BVAS moyen 15,3 ± 6,9), dont 30 affectés au bras 1, 32 au bras 2 et 33 au bras 3.

À M6, une réponse immunitaire contre 0–3, 4–6, 7–9 ou 10–12 sérotypes était observée chez 83,3 %, 13,3 %, 3,3 % et 0 % dans le bras 1 ; 56,3 %, 28,1 %, 15,6 % et 0 % dans le bras 2 ; et 60,6 %, 33,3 %, 6,1 % et 0 % dans le bras 3. Les patients du bras 2 étaient significativement plus susceptibles de se trouver dans une catégorie de réponse supérieures par rapport au régime standard après ajustement sur l’âge, avec un odds ratio proportionnel (pOR) de 4,1 (IC97,5 % : 1,1–15,9, p = 0,018), tandis que le bras 3 montrait une tendance non significative à améliorer les réponses vaccinales (pOR : 3,1, IC97,5 % : 0,8–11,9, p = 0,062). Une analyse de sensibilité sur une population per-protocole excluant les patients ayant subi des vaccinations ou des prises de sang hors des délais donnait des estimations concordantes.

Les réactions locales et/ou systémiques dans les 7 jours après chaque vaccination, et tout événement indésirable lié ou possiblement lié à la vaccination au cours des 6 premiers mois, sont survenus en plus grand nombre avec les schémas renforcés mais étaient principalement des réactions locales de grade 1 ou 2. Aucun événement indésirable grave lié à la vaccination n’a été observé.

Au cours du suivi, 8 poussées de vascularite sont survenues chez 6 patients, en médiane 87 jours après la dernière vaccination : un patient dans le bras 1, 2 dans le bras 2, et 3 dans le bras 3.

Conclusion

Chez les patients atteints de VAA recevant un traitement par RTX, une stratégie innovante de vaccination anti-pneumococcique renforcée, basée sur une double dose de PCV13 au jour 0 et au jour 7 suivie d’une dose unique de PPV23 à M5, améliore significativement les réponses en anticorps contre Streptococcus pneumoniae par rapport au schéma standard.

OP0280 WEANING OF MAINTENANCE IMMUNOSUPPRESSIVE THERAPY IN LUPUS NEPHRITIS (WIN-Lupus): A MULTICENTER RANDOMIZED CONTROLLED TRIAL

Background

Lupus nephritis (LN) is a frequent complication of systemic lupus erythematosus (SLE). Severe (proliferative) forms of LN are treated with an induction immunosuppressive therapy (IST), followed by a maintenance IST, to target remission and avoid relapses. The optimal duration of maintenance IST for proliferative LN is unknown.

Objectives

The WIN-Lupus trial tested whether IST discontinuation after 2-3 years in proliferative LN was non-inferior to IST continuation for 2 more years.

Methods

WIN-Lupus is an investigator-initiated academic randomized controlled trial, conducted in 28 French centers. Patients on maintenance IST with azathioprine or mycophenolate mofetil for a minimum of 2 years and a maximum of 3 years, and who were taking Hydroxychloroquine, were randomized (1:1) between 2 groups: IST continuation and IST discontinuation. The primary endpoint was the relapse rate of proliferative LN at 24 months. Secondary endpoints were the rate of severe SLE flares, survival without renal relapse or severe flare, adverse events, kidney function, disease activity, corticosteroid exposure, patient-reported outcome and medico-economic impact.

Results

Between 2011 and 2016, 125 patients were screened and 96 were randomized in the trial: 48 in the IST continuation group, 48 in the IST discontinuation group. In the per-protocol population, a relapse of proliferative LN occurred in 5/40 (10.4%) patients with IST continuation, and in 12/44 (25%) patients with IST discontinuation (difference 14.8%, 95%CI [-1.9; 31.5]). Non-inferiority was not demonstrated for relapse rate. Time to renal relapse did not differ between groups (p=0.092). Severe SLE flares (renal or extra-renal) were less frequent in patients with IST continuation compared to IST discontinuation (5/40 vs 14/44 patients, p=0.035). IST discontinuation was associated with lower health-related costs. Adverse events did not differ between groups.

Conclusion

Non-inferiority of maintenance IST discontinuation after 2 to 3 years was not demonstrated for renal relapse. IST discontinuation was associated with a higher risk of severe SLE flare.

References

[1]Moroni G et al. When and how is it possible to stop therapy in patients with lupus nephritis? Clin J Am Soc Nephrol. 2021. CJN.04830421. doi: 10.2215/CJN.04830421.

[2]Fanouriakis A et al. 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis. 2020;79(6):713-723.

[3]Jourde-Chiche N et al. Proliferative lupus nephritis treatment: practice survey in nephrology and internal medicine in France. Nephrol Ther. 2014;10(3):170-6.

[4]Zen M et al. Immunosuppressive therapy withdrawal after remission achievement in patients with lupus nephritis. Rheumatology (Oxford). 2021;keab373. doi: 10.1093/rheumatology/keab373.

[5]Malvar A et al. Kidney biopsy-based management of maintenance immunosuppression is safe and may ameliorate flare rate in lupus nephritis. Kidney Int. 2020;97(1):156-162.

Acknowledgements

Groupe Coopératif sur le Lupus Rénal (GCLR)

Disclosure of Interests

Noemie JOURDE-CHICHE Speakers bureau: Vifor Pharma, Grant/research support from: Fresenius Medical Care: grant paid to my institution (AP-HM) for the CINEVAS study in ANCA-associated vasculitis, Nathalie Costedoat-Chalumeau Grant/research support from: AP-HP received a research support from ROCHE for the OBILUP trial, Karine Baumstarck: None declared, LAURENCE BOUILLET Speakers bureau: GSK, novartis, biocryst, takeda, behring, Paid instructor for: takeda, novartis, Consultant of: GSK, novartis, biocryst, takeda, behring, blueprint, Grant/research support from: takeda, gsk, sanofi, biocryst, novartis, Stéphane Burtey: None declared, Valerie Caudwell: None declared, Laurent Chiche Speakers bureau: BMS, Paid instructor for: BMS, Lionel Couzi Speakers bureau: Astellas, Chiesi, Novartis, Sandoz, Ostuka, GSK, Biotest, Consultant of: Biotest, Hansa, Novartis, Grant/research support from: Novartis, Astellas, Christophe DELIGNY: None declared, Bertrand Dussol Speakers bureau: Genzyme, Novonordisk, Grant/research support from: Shire, Stanislas Faguer Speakers bureau: Asahi, Vifor Pharma, Sanofi, Consultant of: Abyonyx Pharma, Pierre Gobert: None declared, Guillaume Gondran Speakers bureau: Pfizer, Novartis, Consultant of: Genzyme, Antoine Huart Speakers bureau: Janssen, Paid instructor for: Pfizer, Aurélie Hummel: None declared, Emilie Kalbacher: None declared, Alexandre Karras Speakers bureau: Vifor, GSK, Astra-Zeneca, Roche, Paid instructor for: Vifor, Sanofi, Alexion, Consultant of: Novartis, GSK, Bohringer-Ingelheim, Marc Lambert Speakers bureau: CHUGAI-ROCHE, BAYER, PFIZER, LEOPHARMA, Paid instructor for: CHUGAI-ROCHE, Consultant of: CHUGAI-ROCHE, BAYER, PFIZER, LEOPHARMA, Grant/research support from: CHUGAI-ROCHE, Véronique LE GUERN: None declared, Sandrine Loubiere: None declared, Helene Maillard: None declared, Francois Maurier: None declared, Micheline Pha: None declared, Viviane Queyrel Paid instructor for: GSK, Consultant of: Boehringer Ingelheim, Francoise Sarrot-Reynauld: None declared, David Verhelst: None declared, Eric Hachulla Speakers bureau: Johnson & Johnson, GSK, Roche-Chugai, Consultant of: Johnson & Johnson, Boehringer Ingelheim, Bayer, GSK, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: CSL Behring, GSK, Roche-Chugai and Johnson & Johnson, Zahir Amoura Speakers bureau: GSK, CSL Behring, Consultant of: GSK, Grant/research support from: GSK, Eric Daugas Speakers bureau: GSK, Amgen, Paid instructor for: GSK, Astra Zeneca, Consultant of: GSK, Astra Zeneca, Amgen, Grant/research support from: ROCHE for the OBILUP trial (AP-HP)

Renal and overall outcomes of double-positive (ANCA and anti-GBM antibodies) patients compared to ANCA-associated vasculitis patients with severe renal involvement: A multicenter retrospective study with systematic renal pathology analysis

Objective: Double-positive patients (DPPs), combining serum and/or histological findings for glomerular basement membrane (GBM) disease and anti-neutrophil cytoplasmic antibodies (ANCAs), are rare and poorly described. This study aimed to compare characteristics between DPPs and ANCA-associated vasculitis (AAV) patients with severe renal involvement.Method: This retrospective multicentre study compared 33 DPPs and 45 AAV patients with severe renal involvement (serum creatinine > 300 μmol/L), all with biopsy-proven nephropathy.Results: All DPPs (including 18% exhibiting negative serum anti-GBM antibodies) presented severe acute kidney failure with histological GBM involvement. Compared to AAV patients, they had higher serum creatinine (719 vs 501 μmol/L; p = 0.006) and a higher proportion of patients requiring initial renal replacement therapy (82% vs 36%; p < 0.001). Berden classification differed significantly (p = 0.003), with more crescentic glomerulonephritis and fewer sclerotic lesions in DPPs. One-year renal survival was significantly lower in DPPs than in AAV patients (27% vs 64%; p < 0.0002). With comparable proportions of ANCA subtypes (two-thirds with anti-myeloperoxidase autoantibodies), numbers of extrarenal manifestations (mostly pulmonary in two-thirds), remission-inducing immunosuppressants, and median follow-ups (3 years) between groups, relapse rates were similar: 9.1% of DPPs and 10% of AAV patients.Conclusion: Although DPPs have features of both kinds of vasculitis, the anti-GBM component is the dominant phenotype, with more severe renal presentation and prognosis compared to AAV patients with severe renal failure. Simultaneous testing of both antibodies and systematically performed renal biopsy should be recommended in all rapidly progressing glomerulonephritis patients to recognize this difficult-to-treat, rare disease.

POS0117 RENAL AND OVERALL OUTCOMES OF DOUBLE-POSITIVE (ANCA AND ANTI-GBM ANTIBODIES) PATIENTS COMPARED TO ANCA-ASSOCIATED VASCULITIS PATIENTS WITH SEVERE RENAL INVOLVEMENT: A MULTICENTER RETROSPECTIVE STUDY WITH SYSTEMATIC RENAL PATHOLOGY ANALYSIS

Background:

Among small vessel vasculitis, double-positive patients (DPP), combining serum and/or histologic findings for glomerular basement membrane (GBM) disease, and anti-neutrophil cytoplasmic antibodies (ANCA), is a rare, newly and poorly described condition.

Objectives:

We aimed to compare characteristics between DPP and ANCA-associated vasculitis patients (AAVP) with severe-renal-involvement.

Methods:

Retrospective multicenter study comparing 33 DPP and 45 severe-renal-involvement (serum creatinine >300 μmol/L) AAVP, all with biopsy-proven nephropathy.

Results:

Except for 2 patients (6%) who had pure renal presentation during their entire follow-up period, others exhibited at least one extrarenal manifestation: pulmonary involvement (64%), weight loss (39%), gastrointestinal involvement (33%), ENT manifestations (21%), musculoskeletal symptoms (21%), fever (18%), neurological (12%), cutaneous (6%) and/or cardiac (6%) signs. All DPP (including up to 18% exhibiting negative serum anti-GBM antibodies) presented severe acute kidney failure with histologic GBM involvement. Compared to our AAVP, they had higher serum creatinine (719 versus 501 μmol/L; p=0.006) and a higher of patients requiring initial renal replacement therapy (82% vs 36%; p<0.001). Berden classification significantly differed (p=0.003), with more crescentic glomerulonephritis and fewer sclerotic lesions in DPP. One-year renal survival was significantly lower in DPP than in AAVP (27% versus 64%; p<0.0002). With comparable proportions of ANCA subtypes (2/3 with anti-MPO autoantibodies), numbers of extrarenal manifestations, remission-inducing immunosuppressants and median follow-ups (three years) between groups, relapse rates were similar: 9.1% of DPP and 10% of AAVP. Please, see the table 1 for more detailed data.

Conclusion:

Although DPP have features of both kinds of eponymous vasculitis, the anti-GBM component is the dominant phenotype, with more severe renal presentation and prognosis compared to AAVP with severe renal failure. Simultaneous testing of both antibodies and a systematically performed renal biopsy should be recommended in all rapidly progressive glomerulonephritis patients to recognize this difficult-to-treat, rare disease.

Table 1.

Comparison of clinical characteristics and outcomes between the cohorts of DPP and AAVP

DPP n = 33AAVP n = 45pAge (year)71,5 [14 - 89]63 [45 - 93]0.14Male16 (48)19 (42)0.65Birmingham Vasculitis Activity Score18,1 ± 4,820,4 ± 5,40.07Organ involvement (except kidney)1,7 ± 0,81,9 ± 1,10.31Serum creatinine (µmol/L)719 [238 - 2412]501 [310 - 1683]0.006ANCA (MPO/PR3)22/1134/110.45Berden classificationn = 31n = 440.003s (sclerotic) / c (crescentic)6 (19) / 22 (71)12 (27) / 16 (37)f (focal) / m (mixed)0 / 3 (10)11 (25) / 5 (11)Brix renal risk scoren = 27n = 440.000014Low / Medium / High0 (0) / 4 (15) / 23 (85)1 (2) / 29 (66) / 14 (32)Initial immunosuppressive therapyIV Cyclophosphamide25 (76)40 (82)0.14Rituximab1 (3)3 (7)0.64Plasma exchanges25 (76)19 (42)0.005Maintenance treatment17 (48)40 (89)0.046Initial RRT requirement27 (82)16 (36)0.00007Renal recovery (% initial RRT requirement)4 (12)6 (38)0.91 year renal survival9 (27)29 (64)0.0002

Values are displayed as absolute number (%) or as median [range]. DPP: double positive patients; AAVP: ANCA associated vasculitis patients; MPO: myeloperoxidase; PR3: proteinase 3; RRT: renal replacement therapy; IV: intravenous.

Disclosure of Interests:

None declared

OP0030 GRANULOMATOSIS WITH POLYANGIITIS SUSTAINED REMISSION OFF-THERAPY: DATA FROM THE FRENCH VASCULITIS STUDY GROUP REGISTRY

Background:

Data on granulomatosis with polyangiitis (GPA) sustained remission off-therapy (SROT) are limited and it is unknown whether disease characteristics or treatment regimen may affect it.

Objectives:

This study aimed to assess SROT of GPA patients from the French Vasculitis Study Group registry, and identify factors associated with its occurrence and durability during follow-up.

Methods:

GPA had to satisfy the 1990 ACR classification criteria and/or revised Chapel Hill Nomenclature for study inclusion. SROT was defined as remission (BVAS=0) without glucocorticoids (GC) or immunosuppressants (IS), the latter for ≥6 months (ie 2 consecutive visits). SROT and its duration were extracted from the database. Data from patients with 3-, 5- and 10-year SROT were analyzed. Baseline characteristics of patients with 3-year GPA SROT were compared to those of registry GPA patients with available data at 3 years but not in SROT (controls), and 3-year SROT achieving 5-year SROT vs those who relapsed between 3 & 5 years. Patients with 3-year GPA SROT follow-up +7 years were analyzed according to maintained SROT or not.

Results:

Among 795 database patients with new-onset GPA, 259 achieved at least 1 SROT at some time during their disease, after a median [IQR] of 36 [28–63] months post-diagnosis. The first SROT lasted a median of 14 [I8-32] months. Among 202 of those patients who had follow-up, 73 (36%) remained in SROT for a median follow-up of 34 [14-45] months post-SROT. Among 434 (54%) patients followed for ≥3 years post-diagnosis, 82% had received GC and cyclophosphamide induction therapy. At 3 years post-diagnosis, 92 (21%) patients in SROT were compared to 342 (79%) controls who had relapsed or were still taking GC or IS. Patients achieving 3-year SROT vs controls, respectively, had more frequently received intravenous cyclophosphamide as induction therapy (89% vs 77%, P=0.01), with a higher median number of infusions (7.5 vs 6; P=0.05); no other clinical or biological baseline difference was found. Among those 92 3-year SROT patients, 74 had ≥2 years of additional follow-up: 46 (62%) attained 5-year SROT and 28 (38%) had relapsed after a mean follow-up of 13 months. Baseline clinical and biological characteristics of patients achieving 5-year SROT did not differ from those of 3-year SROT patients who relapsed. Among those 92 3-year SROT patients, 16 had ≥7 additional years of follow-up: 6 (38%) achieved 10-year SROT, ie 8% of 75 GPA with available data at 10 years, and 10 (63%) had relapsed a mean 35 ± 28 months after achieving 3-year SROT.

Conclusion:

Only 8% of GPA patients achieved 10-year SROT after conventional induction and maintenance therapies. No baseline clinical or biological characteristics helped distinguish patients achieving or maintaining SROT and those who relapsed. However, patients achieving 3-year SROT had received more intensive induction therapy than those who relapsed or were still on GC or IS at 3 years.

Disclosure of Interests:

None declared

OP0163 2019 UPDATE OF THE JOINT EUROPEAN LEAGUE AGAINST RHEUMATISM AND EUROPEAN RENAL ASSOCIATION–EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION (EULAR/ERA-EDTA) RECOMMENDATIONS FOR THE MANAGEMENT OF LUPUS NEPHRITIS

Background:

Up to 40% of systemic lupus erythematosus (SLE) patients develop kidney disease, which represents a major cause of morbidity.

Objectives:

To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN).

Methods:

We followed the EULAR standardised operating procedures for the publication of treatment recommendations. Delphi-based methodology led to 15 questions for systematic literature review (SLR), which was undertaken by three fellows.

Results:

The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNI), and management of end-stage-kidney-disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7gr/24h with [near-]normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3g/day, or mycophenolic acid at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500mg x6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1g/24h despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations.

Conclusion:

The updated recommendations intend to inform rheumatologists, nephrologists, patients, national professional societies, hospital officials, social security agencies and regulators about the treatment of LN based on most recent evidence.

Disclosure of Interests:

Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Myrto Kostopoulou: None declared, Kim Cheema: None declared, Hans-Joachim Anders: None declared, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Ingeborg Bajema Consultant of: GSK, John N. Boletis Grant/research support from: GSK, Pfizer, Paid instructor for: GSK, Abbvie, UCB, Enorasis, Eleni Frangou: None declared, Frederic Houssiau Grant/research support from: UCB, Consultant of: GSK, Jane Hollis: None declared, Alexandre Karras: None declared, Francesca Marchiori: None declared, Stephen Marks: None declared, Gabriela Moroni: None declared, Marta Mosca: None declared, Ioannis Parodis: None declared, Manuel Praga: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Vladimir Tesar: None declared, Maria Trachana: None declared, Ronald van Vollenhoven Grant/research support from: AbbVie, Amgen, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline (GSK), Janssen Research & Development, LLC, Lilly, Pfizer, Roche, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB and Vertex, Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GlaxoSmithKline, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Alexandre Voskuyl: None declared, Y.K. Onno Teng Grant/research support from: GSK, Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, Bernadette van Leeuw: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, Dimitrios Boumpas: None declared

Atteinte rénale du syndrome d’activation macrophagique

Le syndrome d’activation macrophagique (SAM) ou syndrome hémophagocytaire est une pathologie compliquant soit certains déficits immunitaires d’origine génétique, soit certaines maladies hématologiques (essentiellement des lymphomes non hodgkiniens), infectieuses (herpèsvirus, bactéries, parasites) ou auto-immunes (lupus, maladie de Still). Il se caractérise par une suractivation aiguë du système immunitaire et plus particulièrement des lymphocytes T cytotoxiques et des cellules histiocytaires/macrophagiques, déclenchant une production massive de cytokines pro-inflammatoires avec fièvre, pancytopénie, organomégalie, altérations du bilan hépatique et de la coagulation. Une défaillance multiviscérale est fréquente, nécessitant la prise en charge en réanimation et mettant souvent en jeu le pronostic vital, avec une mortalité qui reste dans certains cas à près de 50 %. Le SAM implique souvent le rein, par le biais d’une nécrose tubulaire aiguë, d’une néphropathie interstitielle inflammatoire ou d’une glomérulopathie sévère, responsable de syndrome néphrotique. La mise en évidence de ce syndrome n’est pas toujours facile chez un patient avec un tableau de sepsis ou de choc septique, mais elle peut guider la prise en charge thérapeutique, notamment l’initiation d’un traitement par chimiothérapie ou immunosuppresseurs, selon l’étiologie identifiée.

Disease severity of proliferative lupus nephritis in Maghrebians

Objective To study the influence of Maghrebian ethnicity on lupus nephritis. Methods We retrospectively reviewed the files of a cohort of 194 patients with proliferative lupus nephritis followed in seven lupus centres belonging to three groups: Europeans living in Belgium/France (E; n = 111); Maghrebians living in Europe, in casu Belgium/France (ME; n = 43); and Maghrebians living in Morocco (MM; n = 40). Baseline presentation was compared between these three groups but complete long-term outcome data were available only for E and ME patients. Results At presentation, the clinical and pathological characteristics of lupus nephritis did not differ between E, ME and MM patients. Renal relapses were more common in ME patients (54%) than in E patients (29%) ( P < 0.01). Time to renal flare and to end-stage renal disease was shorter in ME patients compared to E patients ( P < 0.0001 and P < 0.05, respectively). While proteinuria measured at month 12 accurately predicted a serum creatinine value of less than 1 mg/dl at 7 years in E patients, this was not the case in the ME group, in whom serum creatinine at month 12 performed better. Conclusion Despite a similar disease profile at onset, the prognosis of lupus nephritis is more severe in Maghrebians living in Europe compared to native Europeans, with a higher relapse rate.