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Zhang Y, Dai QD, Wang JA, Xu LP, Chen Q, Jin YZ. Dynamically changing antineutrophil cytoplasmic antibodies in granulomatosis with polyangiitis: A case report. World J Clin Cases 2024; 12:2881-2886. [DOI: 10.12998/wjcc.v12.i16.2881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/04/2024] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is one of the most prevalent forms of the antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. GPA is characterized histologically by necrotizing granulomatous inflammation in addition to vasculitis. The diagnosis of GPA depends on clinical presentation, serological evidence of a positive ANCA, and/or histological evidence of necrotizing vasculitis or granulomatous destructive parenchymal inflammation. Cytoplasmic ANCA (c-ANCA) is positive in 65%-75% of GPA patients, accompanied by proteinase 3 (PR3), the main target antigen of c-ANCA, another 5% of GPA patients had negative ANCA.
CASE SUMMARY The patient, a 52-year-old male, presented with unexplained nasal congestion, tinnitus, and hearing loss. After a duration of 4 months experiencing these symptoms, the patient subsequently developed fever and headache. The imaging examination revealed the presence of bilateral auricular mastoiditis and partial paranasal sinusitis, and the ANCA results were negative. The anti-infective therapy proved to be ineffective, but the patient's symptoms and fever were quickly relieved after 1 wk of treatment with methylprednisolone 40 mg once a day. However, after continuous use of methylprednisolone tablets for 3 months, the patient experienced a recurrence of fever accompanied by right-sided migraine, positive c-ANCA and PR3, and increased total protein in cerebrospinal fluid. The patient was diagnosed with GPA. After receiving a treatment regimen of intravenous methylprednisolone 40 mg/d and cyclophosphamide 0.8 g monthly, the patient experienced alleviation of fever and headache. Additionally, the ANCA levels became negative and there has been no recurrence.
CONCLUSION For GPA patients with negative ANCA, there is a potential for early missed diagnosis. The integration of histopathological results and multidisciplinary communication plays a crucial role in facilitating ANCA-negative GPA.
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Affiliation(s)
- Yan Zhang
- Department of Rheumatism and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University/Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Qiao-Ding Dai
- Department of Rheumatism and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University/Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Ji-An Wang
- Department of Rheumatism and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University/Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Li-Ping Xu
- Department of Rheumatism and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University/Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Qiang Chen
- Department of Orthopaedics, The Affiliated Xiaoshan Hospital of Hangzhou Normal University, Hangzhou 311202, Zhejiang Province, China
| | - Yang-Zi Jin
- Department of Otolaryngology, The First Affiliated Hospital of Zhejiang Chinese Medical University/Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou 310006, Zhejiang Province, China
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Fernandes-Serodio J, Prieto-González S, Espígol-Frigolé G, Ríos-Garcés R, Gómez-Caverzaschi V, Araújo O, Espinosa G, Jordà-Sánchez R, Alba MA, Quintana L, Blasco M, Guillen E, Viñas O, Ruiz-Ortiz E, Pelegrín L, Sainz de la Maza M, Sánchez-Dalmau B, García-Herrera A, Solé M, Castillo P, Aldecoa I, Cano MD, Sellarés J, Hernández-González F, Agustí C, Lucena CM, López-Rueda A, Sánchez M, Benegas M, Capurro S, Sanmartí R, Grau JM, Vilaseca I, Alobid I, Cid MC, Hernández-Rodríguez J. Significance of clinical-immunological patterns and diagnostic yield of biopsies in microscopic polyangiitis and granulomatosis with polyangiitis. J Intern Med 2024; 295:651-667. [PMID: 38462959 DOI: 10.1111/joim.13777] [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] [Indexed: 03/12/2024]
Abstract
BACKGROUND Microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are the two major antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). OBJECTIVES To characterize a homogenous AAV cohort and to assess the impact of clinicopathological profiles and ANCA serotypes on clinical presentation and prognosis. Clinical differences in GPA patients according to ANCA serotype and the diagnostic yield for vasculitis of biopsies in different territories were also investigated. RESULTS This retrospective study (2000-2021) included 152 patients with AAV (77 MPA/75 GPA). MPA patients (96.1% myeloperoxidase [MPO]-ANCA and 2.6% proteinase 3 [PR3]-ANCA) presented more often with weight loss, myalgia, renal involvement, interstitial lung disease (ILD), cutaneous purpura, and peripheral nerve involvement. Patients with GPA (44% PR3-ANCA, 33.3% MPO, and 22.7% negative/atypical ANCA) presented more commonly with ear, nose, and throat and eye/orbital manifestations, more relapses, and higher survival than patients with MPA. GPA was the only independent risk factor for relapse. Poor survival predictors were older age at diagnosis and peripheral nerve involvement. ANCA serotypes differentiated clinical features in a lesser degree than clinical phenotypes. A mean of 1.5 biopsies were performed in 93.4% of patients in different territories. Overall, vasculitis was identified in 80.3% (97.3% in MPA and 61.8% in GPA) of patients. CONCLUSIONS The identification of GPA presentations associated with MPO-ANCA and awareness of risk factors for relapse and mortality are important to guide proper therapeutic strategies in AAV patients. Biopsies of different affected territories should be pursued in difficult-to-diagnose patients based on their significant diagnostic yield.
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Affiliation(s)
- João Fernandes-Serodio
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
- Systemic Immuno-mediated Diseases Unit (UDIMS), Department of Internal Medicine IV, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Sergio Prieto-González
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Roberto Ríos-Garcés
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Verónica Gómez-Caverzaschi
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Olga Araújo
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Raül Jordà-Sánchez
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Marco A Alba
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Luis Quintana
- Department of Nephrology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Elena Guillen
- Department of Nephrology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Odette Viñas
- Department of Immunology, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
| | - Estíbaliz Ruiz-Ortiz
- Department of Immunology, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
| | - Laura Pelegrín
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maite Sainz de la Maza
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Bernardo Sánchez-Dalmau
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Adriana García-Herrera
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Manel Solé
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Paola Castillo
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Iban Aldecoa
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - María D Cano
- Department of Anatomic Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Jacobo Sellarés
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Fernanda Hernández-González
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carlos Agustí
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carmen M Lucena
- Department of Pulmonary Medicine, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antonio López-Rueda
- Interventional Neuroradiology Unit, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marcelo Sánchez
- Department of Radiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Mariana Benegas
- Department of Radiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Sebastián Capurro
- Department of Radiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Raimon Sanmartí
- Department of Rheumatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Josep M Grau
- Department of Internal Medicine, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Isabel Vilaseca
- Department of Otorhinolaryngology, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Isam Alobid
- Department of Otorhinolaryngology, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria C Cid
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Hernández-Rodríguez
- Department of Autoimmune Diseases, Vasculitis Research Unit, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) in Autoimmune Diseases and Autoinflammatory Diseases, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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Arnold S, Kitching AR, Witko-Sarsat V, Wiech T, Specks U, Klapa S, Comdühr S, Stähle A, Müller A, Lamprecht P. Myeloperoxidase-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e300-e313. [PMID: 38574743 DOI: 10.1016/s2665-9913(24)00025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 04/06/2024]
Abstract
Myeloperoxidase (MPO)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (MPO-ANCA-associated vasculitis) is one of two major ANCA-associated vasculitis variants characterised by systemic necrotising vasculitis with few or no immune deposits. MPO-ANCA-associated vasculitis predominantly affects small blood vessels and, in contrast to its counterpart proteinase 3-ANCA-associated vasculitis, is generally not associated with granulomatous inflammation. The kidneys and lungs are the most commonly affected organs. The pathogenesis of MPO-ANCA-associated vasculitis is characterised by loss of tolerance to the neutrophil enzyme MPO. This loss of tolerance leads to a chronic immunopathological response where neutrophils become both the target and effector of autoimmunity. MPO-ANCA drives neutrophil activation, leading in turn to tissue and organ damage. Clinical trials have improved the therapeutic approach to MPO-ANCA-associated vasculitis. However, there remains substantial unmet need regarding relapse frequency, toxicity of current treatment, and long-term morbidity. In this Series paper, we present the current state of research regarding pathogenesis, diagnosis, and treatment of MPO-ANCA-associated vasculitis.
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Affiliation(s)
- Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia; Departments of Nephrology and Pediatric Nephrology, Monash Health, Clayton, VIC, Australia
| | - Veronique Witko-Sarsat
- INSERM U1016, Institut Cochin, CNRS UMR8104, Université Paris Cité et Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Thorsten Wiech
- Section of Nephropathology, Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sebastian Klapa
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Sara Comdühr
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Anja Stähle
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Antje Müller
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany.
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Manabe A, Kadoba K, Hiwa R, Kotani T, Shoji M, Shirakashi M, Tsuji H, Kitagori K, Akizuki S, Nakashima R, Yoshifuji H, Yamamoto W, Okazaki A, Matsuda S, Gon T, Watanabe R, Hashimoto M, Morinobu A. Risk factors for serious infections and infection-related mortality in patients with microscopic polyangiitis: Multicentre REVEAL cohort study. Mod Rheumatol 2024:roae024. [PMID: 38564330 DOI: 10.1093/mr/roae024] [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: 11/30/2023] [Accepted: 02/18/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Infections are a critical concern for patients with microscopic polyangiitis (MPA). This study aimed to identify the risk factors associated with serious infections (SIs) and infection-related mortality in patients with MPA, as well as the effect of glucocorticoid (GC) dose tapering on these outcomes. METHODS This multicentre, retrospective, and observational study utilised data from a cohort of patients with MPA in Japan [Registry of Vasculitis Patients to Establish REAL World Evidence (REVEAL) cohort]. Patients were categorised based on the occurrence of SIs or infection-related deaths, and various characteristics were compared among the groups. RESULTS Among 182 patients, 66 (36.2%) experienced 129 SIs and 27 (14.8%) developed infection-related deaths. Advanced age, elevated C-reactive protein (CRP) levels, and higher ratio of the GC dose at 3 months to the initial dose were identified as independent risk factors for SIs. Older age was also associated with infection-related deaths. Furthermore, the cumulative incidence of infection-related deaths was significantly higher in patients with a higher ratio of the GC dose at 24 months to the initial dose. CONCLUSION Older age, elevated CRP levels, and slower GC dose tapering predispose patients to SIs and infection-related deaths. Strategies, such as rapid GC dose tapering, are anticipated to mitigate the risk of infections.
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Affiliation(s)
- Atsushi Manabe
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keiichiro Kadoba
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Hiwa
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takuya Kotani
- Department of Internal Medicine IV, Division of Rheumatology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Mikihito Shoji
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mirei Shirakashi
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideaki Tsuji
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koji Kitagori
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuji Akizuki
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ran Nakashima
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Wataru Yamamoto
- Department of Health Information Management, Kurashiki Sweet Hospital, Okayama, Japan
| | - Ayana Okazaki
- Department of Internal Medicine IV, Division of Rheumatology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shogo Matsuda
- Department of Internal Medicine IV, Division of Rheumatology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Takaho Gon
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Motomu Hashimoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Li S, Yao S, Tie X, Shi X, Feng R, Su X, Wang L. Enteric-coated Mycophenolate Sodium therApy versus cyclophosphamide for induction of Remission in Microscopic PolyAngiitis (EMSAR-MPA trial): study protocol for a randomised controlled trial. BMJ Open 2024; 14:e074662. [PMID: 38471694 PMCID: PMC10936518 DOI: 10.1136/bmjopen-2023-074662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Several studies have demonstrated that mycophenolate mofetil (MMF) may be an excellent alternative to cyclophosphamide (CYC) or rituximab for the induction of remission in non-life-threatening anti-neutrophil cytoplasmic antibodies associated vasculitis because of its strong immunosuppressive potency and low toxicity profile. Enteric-coated mycophenolate sodium (EC-MPS) was introduced to reduce gastrointestinal adverse reactions of MMF. This study will evaluate the efficacy and safety of EC-MPS combined with glucocorticoid in patients with active and non-life-threatening microscopic polyangiitis (MPA). METHODS AND ANALYSIS This study is a multicentre, open-label, randomised controlled, non-inferiority trial. A total of 110 patients with active and non-life-threatening MPA from 11 hospitals in Shanxi Province of China will be recruited and randomised in a 1:1 ratio to receive either EC-MPS or CYC. All patients will receive the same glucocorticoid plan. We will compare oral EC-MPS (720-1440 mg/day) with intravenous pulsed CYC (7.5-15 mg/kg) administered for 3-6 months. All patients will be switched from their assigned treatment (EC-MPS or CYC) to oral azathioprine (2 mg/kg/day) after remission has been achieved, between 3 and 6 months. Azathioprine will be continued until the study ends at 18 months. The primary end point of efficacy is the remission rate at 6 months. Follow-up will continue for 18 months in order to detect an influence of induction regimen on subsequent relapse rates. ETHICS AND DISSEMINATION This study has received approval from the Ethics Committee of the Second Hospital of Shanxi Medical University (2022YX-026). All participants are required to provide written informed consent and no study-related procedures will be performed until consent is obtained. The results of this trial will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER ChiCTR2200063823.
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Affiliation(s)
- Sijia Li
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Shulei Yao
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xuan Tie
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xiaojing Shi
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Rongrong Feng
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xiaole Su
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
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Chen Y, Gou L, Wang L, Qian M, Wu Q, Zheng W, Li M, Zeng X, Zhang F. Clinical characteristics of hypertrophic cranial pachymeningitis in granulomatosis with polyangiitis: a retrospective single-center study in China. Arthritis Res Ther 2024; 26:6. [PMID: 38169421 PMCID: PMC10759605 DOI: 10.1186/s13075-023-03239-9] [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] [Received: 04/15/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Hypertrophic cranial pachymeningitis (HCP) is uncommon but a poorly understood complication of granulomatosis with polyangiitis (GPA). OBJECTIVES We conducted this retrospective study to elucidate the clinical characteristics and factors independently associated with granulomatosis with polyangiitis (GPA) complicated by hypertrophic cranial pachymeningitis (HCP) in China. METHODS We collected the medical records of 78 patients diagnosed with GPA who were admitted to the inpatient department of Peking Union Medical College Hospital between January 2003 and September 2021. Clinical features, laboratory and radiological findings, and Birmingham Vasculitis Activity Scores (excluding meningitis score) were recorded. A binary logistic regression analysis was performed to analyze factors independently associated with GPA-related HCP. RESULTS Headache (100%) and cranial nerve palsy (61.5%) were common manifestations of HCP. Compared to 52 GPA patients without HCP, 26 patients with HCP required more time from initial symptoms to diagnosis, with a lower ratio of pulmonary and renal involvement, a higher ratio of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) positivity, conductive or sensorineural hearing loss, mastoiditis, and decreased vision or sudden visual loss. Binary logistic regression analysis indicated that proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA) negativity (OR 10.698, p = 0.001), conductive or sensorineural hearing loss (OR 10.855, p = 0.005), and decreased vision or sudden visual loss (OR 8.647, p = 0.015) were significantly associated with GPA-related HCP. Of the 26 patients, 18 received methylprednisolone pulse treatment, and 18 received intrathecal injections of dexamethasone and methotrexate. CONCLUSIONS HCP was a severe manifestation of GPA in our study. Independent factors associated with the occurrence of HCP in patients with GPA included PR3-ANCA negativity, conductive or sensorineural hearing loss, and decreased vision or sudden visual loss. Furthermore, GPA-related HCP was associated with higher disease activity, requiring more intensive treatments.
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Affiliation(s)
- Yiran Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Lijuan Gou
- Department of Pediatrics Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China.
| | - Min Qian
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qingjun Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Wenjie Zheng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China.
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7
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Mullen SA, Griffin JB, Lloyd-McLennan A, Siller A, Arthur M, Georgesen CJ. Atypical Pattern of Leukocytoclastic Vasculitis in Granulomatosis With Polyangiitis. Cureus 2023; 15:e49056. [PMID: 38116340 PMCID: PMC10730025 DOI: 10.7759/cureus.49056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly Wegener's granulomatosis, is a small- and medium-vessel vasculitis with characteristic cutaneous morphologic presentation and systemic involvement. Most patients have palpable purpura at some point in their disease course, but this is not always the presenting manifestation. This autoimmune disorder can affect a range of organs, with the upper and lower respiratory tract, kidneys, and nervous system being commonly implicated, while gastrointestinal and cardiac involvement is less frequent. This is a 44-year-old female presenting to the emergency department (ED) with polyarthralgia and palpable purpura. Palpable purpura was distributed on the oral palate, elbow, and lower back, and a punch biopsy revealed leukocytoclastic vasculitis (LCV). While this was an atypical distribution for leukocytoclastic vasculitis, the skin biopsy provided the necessary evidence to diagnose GPA. This case characterizes non-specific and atypical signs and symptoms of GPA that all providers should be aware of in order to diagnose the condition early in its disease course.
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Affiliation(s)
- Sarah A Mullen
- College of Medicine, University of Nebraska Medical Center, Omaha, USA
| | - Julia B Griffin
- College of Medicine, Creighton University School of Medicine, Omaha, USA
| | | | - Alfredo Siller
- Dermatology, University of Nebraska Medical Center, Omaha, USA
| | - Megan Arthur
- Dermatology, University of Nebraska Medical Center, Omaha, USA
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8
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Gavica JC, Raymond L. Significance of early treatment in granulomatosis with polyangiitis vasculitis. Clin Case Rep 2023; 11:e7972. [PMID: 37780916 PMCID: PMC10533380 DOI: 10.1002/ccr3.7972] [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] [Received: 06/04/2023] [Revised: 07/07/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023] Open
Abstract
Vasculitis is a multisystemic disease that affects vessels of different sizes. Its presentation can vary widely depending on the system involved. It may present with constitutional symptoms or with specific features of end-organ involvement. The diagnosis is built on a compatible pattern of clinical features supported by specific serological or radiological investigations and confirmatory biopsy. Tissue biopsy is vital to confirm the diagnosis of vasculitis; however, this should not delay treatment when presentation strongly suggests vasculitis. We describe a case of a 72-year-old man treated with steroids, plasma exchange, and rituximab for suspected granulomatosis with polyangiitis (GPA) given his clinical presentation including suspected scleritis of the right eye, hearing changes, sinusitis, diffuse alveolar hemorrhage, pulmonary lesions, kidney failure, palpable purpura, and radiological evidence of pansinusitis and pulmonary lesions without waiting for serology or tissue confirmation. This case highlights the importance of recognizing the clinical features of GPA to initiate prompt treatment as it can progress rapidly and be fatal.
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Affiliation(s)
| | - Leslie Raymond
- Department of Internal MedicineNCH Healthcare SystemNaplesFloridaUSA
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9
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Kuang Q, He X, Jia L, Zhang Z, Gui C, Gao C, Xia Z. Case report: A pediatric case of MPO-ANCA-associated granulomatosis with polyangiitis superimposed on post-streptococcal acute glomerulonephritis. Front Pediatr 2023; 11:1148132. [PMID: 37492611 PMCID: PMC10364118 DOI: 10.3389/fped.2023.1148132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
An eight-year-old girl was admitted with vomiting, gross hematuria, and progressive renal dysfunction. A renal biopsy revealed endocapillary proliferative glomerulopathy and crescent formation. Immunofluorescence staining revealed diffuse granular deposits of IgG and C3. Post-streptococcal acute glomerulonephritis (PSAGN) was suspected, based on the elevated anti-streptolysin O levels, decreased serum C3 concentrations, and histologic findings. The myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) test was positive, and the young patient gradually developed palisaded neutrophilic and granulomatous dermatitis (PNGD), orbital and paranasal sinus granulomatous neoplasms, along with intermittent nose, head, and orbital pain. Finally, she was diagnosed with the rare MPO-ANCA-associated granulomatosis with polyangiitis (GPA) superimposed on PSAGN. The patient was treated with aggressive renal replacement therapy, methylprednisolone pulse therapy, and intravenous pulse cyclophosphamide; her renal function normalized, and her pain symptoms improved.
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10
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Byszewska A, Skrzypiec I, Rymarz A, Niemczyk S, Rękas M. Ocular Involvement of Granulomatosis with Polyangiitis. J Clin Med 2023; 12:4448. [PMID: 37445483 DOI: 10.3390/jcm12134448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly referred to as Wegener's disease, is a form of ANCA-associated vasculitis. It manifests mainly in the kidneys and the upper respiratory tract, but ocular involvement is not uncommon. In this article, four cases with ocular manifestations are presented with comprehensive photographic documentation. We describe the way to proper diagnosis, which may be long, the possible treatment, and the final outcomes. Our patients had the following ocular manifestations of GPA: retinal vasculitis, anterior necrotizing scleritis, medial orbital wall and orbital floor erosion with middle face deformation, compressive optic neuropathy due to retrobulbar inflammatory mass, and the abscess of the eyelids, inflammatory intraorbital mass causing exophthalmos and diplopia. This manuscript includes the description of severe forms of GPA, the initial signs and symptoms, relapses, and difficulties in achieving remission. The extraocular involvement is described with diagnostic modalities and laboratory findings. One of the reported cases was diagnosed by an ophthalmologist on the basis of ocular symptoms in the early stages of the disease. Our outcomes are compared with those discussed in the literature.
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Affiliation(s)
- Anna Byszewska
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Izabela Skrzypiec
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Aleksandra Rymarz
- Nephrology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Stanisław Niemczyk
- Nephrology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Marek Rękas
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
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11
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Andrade MM, Fernandes M, Freire S, Cruz D. Limited Antineutrophil Cytoplasmic Antibodies (ANCA)-Negative Granulomatosis With Polyangiitis: Successful Response to Rituximab. Cureus 2023; 15:e41826. [PMID: 37575714 PMCID: PMC10423013 DOI: 10.7759/cureus.41826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), a systemic vasculitis, is commonly characterized by the presence of antineutrophil cytoplasmic antibodies (ANCA). However, a subset of patients with limited disease may exhibit ANCA negativity. In this article, we report the case of a 40-year-old female diagnosed with GPA with intolerance to methotrexate titration and glucocorticoid therapy, leading to the initiation of rituximab treatment. Subsequently, the patient exhibited sustained clinical, laboratory, and radiological improvement. The identification of limited GPA has important therapeutic implications as the effectiveness of the medical treatment in ANCA-negative GPA may differ. Rituximab has emerged as an optimal treatment, irrespective of ANCA status, offering prolonged responses and a favorable tolerance profile in these patients.
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Affiliation(s)
| | - Manuel Fernandes
- Pulmonology, Hospital de Cascais, Dr. José de Almeida, Cascais, PRT
| | - Sara Freire
- Internal Medicine, Hospital de Cascais, Dr. José de Almeida, Cascais, PRT
| | - Diogo Cruz
- Internal Medicine, Hospital de Cascais, Dr. José de Almeida, Cascais, PRT
- Clínica Universitária de Medicina I, Faculdade de Medicina da Universidade de Lisboa, Lisboa, PRT
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12
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Qudsiya Z, Viqas Z, Baker DL. A Runny Nose Leads to a Rare Diagnosis: Chronic Sinusitis as a Sole Manifestation of Limited Granulomatosis With Polyangiitis. Cureus 2023; 15:e39203. [PMID: 37337503 PMCID: PMC10276886 DOI: 10.7759/cureus.39203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/21/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic antibody (ANCA)-associated necrotizing vasculitis of small to medium-sized blood vessels. The typical presentation is the classic triad of upper airway, pulmonary, and renal involvement. However, it can rarely present with the involvement of a single organ system known as limited granulomatosis with polyangiitis. We present a case of a 53-year-old male with chronic rhinosinusitis as the only manifestation of limited GPA. The diagnosis was established incidentally based on biopsy findings from the paranasal sinuses obtained during functional endoscopic sinus surgery. Subsequent testing revealed a positive cytoplasmic antineutrophilic antibody. No evidence of systemic involvement was noted. Prednisone and azathioprine were initiated leading to significant improvement. Although upper respiratory tract involvement is common in GPA, it is rare for the condition to be limited to this organ system. Our case of limited GPA is distinct in that it represents a rare presentation of this already rare disease.
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Affiliation(s)
- Zainab Qudsiya
- Internal Medicine, St. Luke's Hospital, Chesterfield, USA
| | - Zaineb Viqas
- Internal Medicine, ECU Health Medical Center, Greenville, USA
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13
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Banos A, Thomas K, Garantziotis P, Filia A, Malissovas N, Pieta A, Nikolakis D, Panagiotopoulos AG, Chalkia A, Petras D, Bertsias G, Boumpas DT, Vassilopoulos D. The genomic landscape of ANCA-associated vasculitis: Distinct transcriptional signatures, molecular endotypes and comparison with systemic lupus erythematosus. Front Immunol 2023; 14:1072598. [PMID: 37051253 PMCID: PMC10083368 DOI: 10.3389/fimmu.2023.1072598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
IntroductionAnti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) present with a complex phenotype and are associated with high mortality and multi-organ involvement. We sought to define the transcriptional landscape and molecular endotypes of AAVs and compare it to systemic lupus erythematosus (SLE).MethodsWe performed whole blood mRNA sequencing from 30 patients with AAV (granulomatosis with polyangiitis/GPA and microscopic polyangiitis/MPA) combined with functional enrichment and network analysis for aberrant pathways. Key genes and pathways were validated in an independent cohort of 18 AAV patients. Co-expression network and hierarchical clustering analysis, identified molecular endotypes. Multi-level transcriptional overlap analysis to SLE was based on our published data from 142 patients.ResultsWe report here that “Pan-vasculitis” signature contained 1,982 differentially expressed genes, enriched in leukocyte differentiation, cytokine signaling, type I and type II IFN signaling and aberrant B-T cell immunity. Active disease was characterized by signatures linked to cell cycle checkpoints and metabolism pathways, whereas ANCA-positive patients exhibited a humoral immunity transcriptional fingerprint. Differential expression analysis of GPA and MPA yielded an IFN-g pathway (in addition to a type I IFN) in the former and aberrant expression of genes related to autophagy and mRNA splicing in the latter. Unsupervised molecular taxonomy analysis revealed four endotypes with neutrophil degranulation, aberrant metabolism and B-cell responses as potential mechanistic drivers. Transcriptional perturbations and molecular heterogeneity were more pronounced in SLE. Molecular analysis and data-driven clustering of AAV uncovered distinct transcriptional pathways that could be exploited for targeted therapy.DiscussionWe conclude that transcriptomic analysis of AAV reveals distinct endotypes and molecular pathways that could be targeted for therapy. The AAV transcriptome is more homogenous and less fragmented compared to the SLE which may account for its superior rates of response to therapy.
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Affiliation(s)
- Aggelos Banos
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Konstantinos Thomas
- Clinical Immunology- Rheumatology Unit, 2nd Department of Medicine and Laboratory, General Hospital of Athens Ippokrateio, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Garantziotis
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Department Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Anastasia Filia
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Nikolaos Malissovas
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antigone Pieta
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Dimitrios Nikolakis
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Amsterdam Institute for Gastroenterology Endocrinology and Metabolism, Department of Gastroenterology, Academic Medical Center, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, Netherlands
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute for Infection & Immunity, Department of Experimental Immunology, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Alexandros G. Panagiotopoulos
- Clinical Immunology- Rheumatology Unit, 2nd Department of Medicine and Laboratory, General Hospital of Athens Ippokrateio, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aglaia Chalkia
- Nephrology Department, General Hospital of Athens Ippokrateio, Athens, Greece
| | - Dimitrios Petras
- Nephrology Department, General Hospital of Athens Ippokrateio, Athens, Greece
| | - George Bertsias
- Department of Rheumatology and Clinical Immunology, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
- Department of Immunity, Institute of Molecular Biology and Biotechnology-Foundation of Research and Technology-Hellas (FORTH), Heraklion, Greece
| | - Dimitrios T. Boumpas
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
- Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology- Rheumatology Unit, 2nd Department of Medicine and Laboratory, General Hospital of Athens Ippokrateio, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- *Correspondence: Dimitrios Vassilopoulos,
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14
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Doliner B, Rodriguez K, Montesi SB, Fu X, Sharma A, Wallace ZS. Interstitial lung disease in ANCA-associated vasculitis: associated factors, radiographic features and mortality. Rheumatology (Oxford) 2023; 62:716-725. [PMID: 35699465 PMCID: PMC9891428 DOI: 10.1093/rheumatology/keac339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/19/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To evaluate the prevalence, clinical and radiographic features, and long-term outcomes of interstitial lung disease (ILD) in a United States-based ANCA-associated vasculitis (AAV) cohort. METHODS In this retrospective cohort study, we identified cases of ILD within the 2002-2019 Mass General Brigham AAV Cohort, a consecutive inception cohort of PR3- or MPO-ANCA+ AAV patients. ILD diagnosis and classification as fibrotic or non-fibrotic were confirmed by review of available chest imaging by two board-certified radiologists. Cox proportional hazard models, with age as the time scale, were used to estimate the association of AAV-ILD with all-cause mortality. RESULTS Of 684 patients in the MGB AAV Cohort, 91 (13%) had ILD which preceded the diagnosis of AAV by a mean of 2.2 years. AAV-ILD patients were older (67 vs 60 years, P < 0.001) than patients without ILD but the distribution of sex and race was similar. AAV-ILD patients were more often MPO-ANCA+ (93% vs 65%, P < 0.001); among MPO-ANCA+ patients (n = 470), 85 (18%) had ILD. The majority of ILD was fibrotic (76%) and UIP was the most common ILD pattern (42%). The baseline forced vital capacity (FVC) % predicted among ILD patients was 81 ± 20%. Fibrotic AAV-ILD was associated with a 58% higher risk of death (aHR 1.58, 95% CI 1.06, 2.37) compared with AAV patients without ILD. CONCLUSION ILD is a frequent complication of AAV, especially MPO-ANCA+ AAV, often preceding recognition of AAV. Fibrotic AAV-ILD is associated with a higher risk of death than AAV without ILD.
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Affiliation(s)
- Brett Doliner
- Department of Medicine, Massachusetts General Hospital.,Harvard Medical School
| | | | - Sydney B Montesi
- Harvard Medical School.,Division of Pulmonary and Critical Care Medicine
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Mongan Institute.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Zachary S Wallace
- Harvard Medical School.,Clinical Epidemiology Program, Mongan Institute.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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15
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Scurt FG, Bose K, Hammoud B, Brandt S, Bernhardt A, Gross C, Mertens PR, Chatzikyrkou C. Old known and possible new biomarkers of ANCA-associated vasculitis. J Autoimmun 2022; 133:102953. [PMID: 36410262 DOI: 10.1016/j.jaut.2022.102953] [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: 07/07/2022] [Revised: 11/06/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises a group of multisystem disorders involving severe, systemic, small-vessel vasculitis with short- and long term serious and life-threating complications. Despite the simplification of treatment, fundamental aspects concerning assessment of its efficacy and its adaptation to encountered complications or to the relapsing/remitting/subclinical disease course remain still unknown. The pathogenesis of AAV is complex and unique, and despite the progress achieved in the last years, much has not to be learnt. Foremost, there is still no accurate marker enabling us to monitoring disease and guide therapy. Therefore, the disease management relays often on clinical judgment and follows a" trial and error approach". In the recent years, an increasing number of new molecules s have been explored and used for this purpose including genomics, B- and T-cell subpopulations, complement system factors, cytokines, metabolomics, biospectroscopy and components of our microbiome. The aim of this review is to discuss both the role of known historical and clinically established biomarkers of AAV, as well as to highlight potential new ones, which could be used for timely diagnosis and monitoring of this devastating disease, with the goal to improve the effectiveness and ameliorate the complications of its demanding therapy.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany.
| | - K Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - S Brandt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - A Bernhardt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - C Gross
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
| | - Peter R Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Germany
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16
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Alba MA, Jennette JC, Hu Y, Poulton CJ, Blazek L, Derebail VK, Falk RJ, Hogan SL. Relevance of Combined Clinicopathologic Phenotype and Antineutrophil Cytoplasmic Autoantibody Serotype in the Diagnosis of Antineutrophil Cytoplasmic Autoantibody Vasculitis. Kidney Int Rep 2022; 7:2676-2690. [PMID: 36506241 PMCID: PMC9727534 DOI: 10.1016/j.ekir.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), 2 major clinicopathologic variants of antineutrophil cytoplasmic autoantibody (ANCA) vasculitides, are mostly associated with proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, respectively. Less is known regarding the uncommon forms of ANCA vasculitis, PR3-ANCA MPA and MPO-ANCA GPA. Methods In this cohort study we detailed the clinical presentation and outcome of patients with PR3-ANCA MPA and MPO-ANCA GPA from the Glomerular Disease Collaborative Network (GDCN) inception cohort. Baseline clinical manifestations, relapses, end-stage kidney disease (ESKD), and survival were compared within MPA cases by PR3-ANCA (n = 116) versus MPO-ANCA (n = 173) and within GPA cases by PR3-ANCA (n = 108) versus MPO-ANCA (n = 43). Fisher's exact test and Wilcoxon two sample test were used for comparisons. Proportional hazards models were used to evaluate the development of relapses, ESKD, and death. Results Patients with PR3-ANCA MPA were younger (53 years vs. 62 years, P = 0.0007) and had increased prevalence of joint involvement (56% vs. 40%, P = 0.0115) and ear, nose, and throat (ENT) involvement (44% vs. 26%, P = 0.002) than MPO-ANCA MPA. Relapses, ESKD, and survival were similar between both MPA subsets. Within the GPA group, patients with MPO-ANCA GPA were older (61 years vs. 46 years, P = 0.0007) and more likely female (56% vs. 35%, P = 0.027) than PR3-ANCA GPA patients. MPO-ANCA GPA was also characterized by less prevalent ENT manifestations (58% vs. 77%, P = 0.028) and neurologic manifestations (5% vs. 25%, P = 0.0029), and increased ESKD and mortality. Conclusions PR3-ANCA MPA and MPO-ANCA GPA are clinicopathologically distinct subsets of ANCA vasculitis that differ from MPO-ANCA MPA and PR3-ANCA GPA. Although the impact of these differences on the clinical management and outcome warrants further evaluation, these results support the recommendation of including both the phenotypic diagnosis and ANCA serotype in the diagnosis of ANCA vasculitis.
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Affiliation(s)
- Marco A. Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Blazek
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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17
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Trivioli G, Marquez A, Martorana D, Tesi M, Kronbichler A, Lyons PA, Vaglio A. Genetics of ANCA-associated vasculitis: role in pathogenesis, classification and management. Nat Rev Rheumatol 2022; 18:559-574. [PMID: 36109667 DOI: 10.1038/s41584-022-00819-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 12/15/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) comprises granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), that share features of pauci-immune small-vessel vasculitis and the positivity of ANCA targeting proteinase-3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). AAV syndromes are rare, complex diseases and their aetio-pathogenesis is mainly driven by the interaction between environmental and genetic factors. In patients with GPA and MPA, the genetic associations are stronger with ANCA specificity (PR3- versus MPO-ANCA) than with the clinical diagnosis, which, in keeping with the known clinical and prognostic differences between PR3-ANCA-positive and MPO-ANCA-positive patients, supports an ANCA-based re-classification of these disorders. EGPA is also made up of genetically distinct subsets, which can be stratified on ANCA-status (MPO ANCA-positive versus ANCA-negative); these subsets differ in clinical phenotype and possibly in their response to treatment. Interestingly, MPO-ANCA-positive patients with either MPA or EGPA have overlapping genetic determinants, thus strengthening the concept that this EGPA subset is closely related to the other AAV syndromes. The genetics of AAV provides us with essential information to understand its varied phenotype. This Review discusses the main findings of genetic association studies in AAV, their pathogenic implications and their potential effect on classification, management and prognosis.
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Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Ana Marquez
- Institute of Parasitology and Biomedicine "López-Neyra", CSIC, Granada, Spain
| | - Davide Martorana
- Medical Genetics Unit, Department of Diagnostics, University Hospital of Parma, Parma, Italy
- CoreLab Unit, Research Center, University Hospital of Parma, Parma, Italy
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Vasculitis and Lupus Service, Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.
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18
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Austin K, Janagan S, Wells M, Crawshaw H, McAdoo S, Robson JC. ANCA Associated Vasculitis Subtypes: Recent Insights and Future Perspectives. J Inflamm Res 2022; 15:2567-2582. [PMID: 35479831 PMCID: PMC9037725 DOI: 10.2147/jir.s284768] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 12/19/2022] Open
Abstract
The ANCA associated vasculitides (AAVs) affect a range of internal organs including ear nose and throat, respiratory tract, kidneys, skin and nervous system. They include granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). The AAVs are treated with high dose glucocorticoids, immunosuppressants, and targeted biological medications. Since the 1990s classification criteria for the AAVs have been based on clinical features, laboratory tests and basic imaging; an initiative to update the classification criteria incorporating newer tests, for example, anti-neutrophil cytoplasmic antibodies (ANCA) and novel imaging techniques will be published this year. There is also evidence for classification of patients based on ANCA subtype; those with anti-proteinase 3 antibodies (PR3) or anti-myeloperoxidase antibodies (MPO) have differences in response to treatment and clinical outcomes. An update is described within this review. The pathogenesis of AAV involves necrotizing inflammation of small to medium blood vessels involving multiple immunological pathways. We present an update on emerging evidence related to auto-antibodies, complement and lymphocyte pathways. This review describes emerging treatment regimens, including evidence for plasma exchange in severe disease and the inhibitor of the complement C5a receptor (C5aR) inhibitor, Avacopan. Lastly, patient reported outcomes are key secondary outcomes in randomised controlled trials and increasingly clinical practice, we report development in disease specific and glucocorticoid-specific PROs.
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Affiliation(s)
- Keziah Austin
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
- Correspondence: Keziah Austin, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK, Email
| | - Shalini Janagan
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Matthew Wells
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
| | - Helena Crawshaw
- Department of Rheumatology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, UK
| | - Joanna C Robson
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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19
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Puéchal X, Iudici M, Pagnoux C, Cohen P, Hamidou M, Aouba A, Lifermann F, Ruivard M, Aumaître O, Bonnotte B, Maurier F, Le Gallou T, Hachulla E, Karras A, Khouatra C, Jourde-Chiche N, Viallard JF, Blanchard-Delaunay C, Godmer P, Le Quellec A, Quéméneur T, de Moreuil C, Mouthon L, Terrier B, Guillevin L. Comparative study of granulomatosis with polyangiitis subsets according to ANCA status: data from the French Vasculitis Study Group Registry. RMD Open 2022; 8:rmdopen-2021-002160. [PMID: 35296533 PMCID: PMC8928389 DOI: 10.1136/rmdopen-2021-002160] [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: 12/13/2021] [Accepted: 02/21/2022] [Indexed: 01/08/2023] Open
Abstract
Objective To investigate whether antineutrophil cytoplasm antibody (ANCA)-negative and myeloperoxidase (MPO)-ANCA–positive granulomatosis with polyangiitis (GPA) differ from proteinase-3 (PR3)-ANCA–positive GPA. Methods Diagnostic characteristics and outcomes of newly diagnosed French Vasculitis Study Group Registry patients with ANCA-negative, MPO-ANCA–positive or PR3-ANCA–positive GPA satisfying American College of Rheumatology criteria and/or Chapel Hill Conference Consensus Nomenclature were compared. Results Among 727 GPA, 62 (8.5%) were ANCA-negative, 119 (16.4%) MPO-ANCA–positive and 546 (75.1%) PR3-ANCA–positive. ANCA-negative patients had significantly (p<0.05) more limited disease (17.7% vs 5.8%) and less kidney involvement (35.5% vs 58.9%) than those PR3-ANCA–positive or MPO-ANCA–positive, with comparable relapse-free (RFS) and overall survival (OS). MPO-ANCA–positive versus PR3-ANCA–positive and ANCA-negative patients were significantly more often female (52.9% vs 42.1%), older (59.8 vs 51.9 years), with more frequent kidney involvement (65.5% vs 55.2%) and less arthralgias (34.5% vs 55.1%), purpura (8.4% vs 17.1%) or eye involvement (18.5% vs 28.4%); RFS was similar but OS was lower before age adjustment. PR3-positive patients’ RFS was significantly lower than for ANCA-negative and MPO-positive groups combined, with OS higher before age adjustment. PR3-ANCA–positivity independently predicted relapse for all GPA forms combined but not when comparing only PR3-ANCA–positive versus MPO-ANCA–positive patients. Conclusions Based on this large cohort, ANCA-negative versus ANCA-positive patients more frequently had limited disease but similar RFS and OS. MPO-ANCA–positive patients had similar RFS but lower OS due to their older age. PR3-ANCA–positive GPA patients’ RFS was lower than those of the two other subsets combined but that difference did not persist when comparing only PR3 versus MPO-ANCA–positive patients.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France
| | - Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France.,Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France.,Vasculitis Clinic, Mont Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France
| | - Mohamed Hamidou
- Internal Medicine, Hôtel-Dieu University Hospital, Nantes, France
| | - Achille Aouba
- Internal Medicine, Côte-de-Nacre Hospital, University of Caen Normandy, Caen, France
| | | | - Marc Ruivard
- Internal Medicine, Clermont-Ferrand University Hospitals, Clermont-Ferrand, France
| | - Olivier Aumaître
- Internal Medicine, Clermont-Ferrand University Hospitals, Clermont-Ferrand, France
| | - Bernard Bonnotte
- Internal Medicine and Clinical Immunology, François Mitterrand Hospital, University of Burgundy, Dijon, France
| | | | - Thomas Le Gallou
- Internal Medicine and Clinical Immunology, University of Rennes 1, Rennes, France
| | - Eric Hachulla
- Internal Medicine, Claude-Huriez Hospital, Lille University School of Medicine, Lille, France
| | - Alexandre Karras
- Nephrology, European Hospital Georges Pompidou, AP-HP.Centre, University of Paris, Paris, France, Paris, France
| | - Chahéra Khouatra
- Respiratory Medicine, Louis Pradel Hospital, University of Claude Bernard Lyon 1, Lyon, France
| | | | | | | | - Pascal Godmer
- Internal Medicine, Bretagne -Atlantique Hospital, Vannes, France
| | - Alain Le Quellec
- Internal Medicine, Saint Eloi Hospital, University of Montpellier 1, Montpellier, France
| | - Thomas Quéméneur
- Nephrology and Internal Medicine, Valenciennes Hospital, Valenciennes, France
| | - Claire de Moreuil
- Internal Medicine, La Cavale Blanche University Hospital, Brest, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP.Centre, University of Paris, Paris, France
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20
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Chandwar K, Kishor K, Mukherjee S, Dhakad U. Salivary gland involvement in granulomatosis with polyangiitis: Case report and review of literature. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_105_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Merino-Vico A, van Hamburg JP, Tas SW. B Lineage Cells in ANCA-Associated Vasculitis. Int J Mol Sci 2021; 23:387. [PMID: 35008813 PMCID: PMC8745114 DOI: 10.3390/ijms23010387] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/21/2021] [Accepted: 12/28/2021] [Indexed: 12/18/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systemic autoimmune disease that affects small sized blood vessels and can lead to serious complications in the lungs and kidneys. The prominent presence of ANCA autoantibodies in this disease implicates B cells in its pathogenesis, as these are the precursors of the ANCA-producing plasma cells (PCs). Further evidence supporting the potential role of B lineage cells in vasculitis are the increased B cell cytokine levels and the dysregulated B cell populations in patients. Confirmation of the contribution of B cells to pathology arose from the beneficial effect of anti-CD20 therapy (i.e., rituximab) in AAV patients. These anti-CD20 antibodies deplete circulating B cells, which results in amelioration of disease. However, not all patients respond completely, and this treatment does not target PCs, which can maintain ANCA production. Hence, it is important to develop more specific therapies for AAV patients. Intracellular signalling pathways may be potential therapeutic targets as they can show (disease-specific) alterations in certain B lineage cells, including pathogenic B cells, and contribute to differentiation and survival of PCs. Preliminary data on the inhibition of certain signalling molecules downstream of receptors specific for B lineage cells show promising therapeutic effects. In this narrative review, B cell specific receptors and their downstream signalling molecules that may contribute to pathology in AAV are discussed, including the potential to therapeutically target these pathways.
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Affiliation(s)
- Ana Merino-Vico
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.M.-V.); (J.P.v.H.)
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jan Piet van Hamburg
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.M.-V.); (J.P.v.H.)
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sander W. Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.M.-V.); (J.P.v.H.)
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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22
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Patterns of lung diseases predict survival in patients with MPO-ANCA-associated vasculitis: a single-center retrospective study. Clin Rheumatol 2021; 41:783-793. [PMID: 34839416 DOI: 10.1007/s10067-021-05964-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/26/2021] [Accepted: 10/11/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study aimed to explore differences in clinical features and prognosis among patients with varied myeloperoxidase (MPO) antineutrophil cytoplasmic antibody-associated vasculitis (MPO-AAV) associated lung diseases. METHODS Patients with MPO-AAV-associated lung diseases were enrolled in this retrospective cohort study at a single center. Clinical features and laboratory data at the time of diagnosis were compared among patients with various lung disease patterns. Kaplan-Meier and Cox regression analyses were performed to analyze overall survival. RESULTS A total of 155 patients were finally included and categorized into five groups, as follows: 72 had a usual interstitial pneumonia (UIP) pattern, 40 had non-UIP interstitial pneumonia, 18 had bronchiectasis (BR), 13 had necrotizing granuloma (NG), and 12 had diffuse alveolar hemorrhage (DAH). Among the five groups, patients with DAH had higher dyspnea and hemoptysis frequencies, lower PaO2/FiO2 levels, elevated C-reactive protein levels, and the poorest prognosis. The overall survival (OS) in the DAH group (median OS: 3.2 months) was significantly poorer than that in the NG group (median OS: not reached, log rank P < 0.001), the BR group (median OS: not reached, log rank P < 0.001), and the non-UIP IP group (median OS: 61.1 months, log rank P = 0.001). The UIP group had significantly more ex-smokers than the other groups (P < 0.001) and the second poorest survival (median OS: 39.1 months). The NG group tended to have female predominance, a higher incidence of ENT involvement, less severe renal involvement, and the best survival. After adjusting for multi-model Cox regression analysis, DAH and UIP (hazard ratio: 19.301 and 9.940, respectively, compared with NG) were independent predictors of all-cause mortality. CONCLUSIONS Various patterns of lung disease-associated MPO-AAV may potentially predict patient survival. Key Point • The present study described the clinical and prognostic features of various lung diseases-associated MPO-AAV, indicating the potential prediction for the survival of MPO-AAV patients.
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23
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Kimura K, Fujii Y, Maekawa M, Tsukamoto H. Successful Rituximab Treatment in a Patient With ANCA-Negative Granulomatosis With Polyangitis: A Case Report. Mod Rheumatol Case Rep 2021; 6:93-96. [PMID: 34673983 DOI: 10.1093/mrcr/rxab034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/22/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022]
Abstract
A 68-year-old woman was referred to our hospital for further evaluation of fever, nasal congestion, deafness, and multiple pulmonary nodules refractory to antibiotic use. Despite negative findings of antineutrophil cytoplasmic antibodies, she was diagnosed with granulomatosis with polyangiitis based on the analysis of biopsy specimens of pulmonary nodules. The administrations of oral prednisolone and six intravenous cyclophosphamide (IVCY) resulted in the prompt relief of symptoms and disappearance of pulmonary nodules. However, 3 months after the completion of IVCY therapy, nasal congestion and deafness flared up with an increase in the C-reactive protein level; a repeat computed tomography revealed a left lung nodule. Consequently, she underwent remission induction and maintenance therapy with rituximab (RTX), which resulted in the symptomatic improvement and disappearance of pulmonary nodule after 6 months. The patient remained in remission thereafter. Therefore, RTX may be an effective therapeutic option even in the absence of detectable autoantibodies.
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Affiliation(s)
- Koichi Kimura
- Department of Rheumatology, Shin-Kokura Hospital, Kitakyushu, Japan
| | - Yusuke Fujii
- Department of Rheumatology, Shin-Kokura Hospital, Kitakyushu, Japan
| | - Makiko Maekawa
- Department of Rheumatology, Shin-Kokura Hospital, Kitakyushu, Japan
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24
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Cho LK, Carette S, Pagnoux C. ANCA status and renal parameters at month 12 post-diagnosis can help predict subsequent relapses in patients with granulomatosis with polyangiitis. Semin Arthritis Rheum 2021; 51:1011-1015. [PMID: 34416622 DOI: 10.1016/j.semarthrit.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the predictive value of disease characteristics at 12-month follow-up after the diagnosis of GPA for subsequent relapses in a cohort of patients followed at a tertiary vasculitis clinic. METHODS Demographic, clinical, and biological data at diagnosis and during follow-up from patients with GPA followed for at least 24 months at the Mount Sinai Hospital Vasculitis Clinic in Toronto, Canada were extracted from the Canadian Vasculitis Research Network (CanVasc) database and analyzed. The association between ANCA status and type (PR3- or MPO-ANCA), presence of microscopic hematuria, or serum creatinine level at follow-up month 12 ± 3 (M12) and relapses after M12 were assessed using Cox proportional hazard models. RESULTS A total of 113 GPA patients were included in this study (50 ANCA positive, 63 ANCA negative at M12). Patient demographics and disease characteristics were similar at diagnosis, including the treatments used for induction and at M12. The global 5-year relapse rate was 55.8%, without any difference in the relapse rates after M12 between those ANCA-positive or negative at M12. However, in multivariate analyses, MPO-ANCA positivity at M12 was predictive of increased relapses after M12 (hazard ratio [HR] 3.54, P=0.01), as was the presence of microhematuria at M12 (HR 1.91, P=0.04). In contrast, higher serum creatinine levels at M12 were associated with a decreased risk of subsequent relapse (HR 0.99, P=0.04). CONCLUSION In this cohort of patients with GPA, MPO-ANCA positivity and persistent microscopic hematuria at M12 were associated with increased risk of subsequent relapse, and could thus have value to predict disease outcome during follow-up.
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Affiliation(s)
- Lindsay K Cho
- Vasculitis Clinic, Mount Sinai Hospital, Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada.
| | - Simon Carette
- Vasculitis Clinic, Mount Sinai Hospital, Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada
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25
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Classification of ANCA-associated vasculitis: differences based on ANCA specificity and clinicopathologic phenotype. Rheumatol Int 2021; 41:1717-1728. [PMID: 34383129 DOI: 10.1007/s00296-021-04966-5] [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: 06/05/2021] [Accepted: 08/03/2021] [Indexed: 01/24/2023]
Abstract
The classification of vasculitis according to a schema with universal acceptance is challenging, given the heterogeneous and protean nature of these diseases. Formal nomenclature and classification criteria for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have suffered several changes since their first description; none provides comprehensive diagnostic and classification criteria. Different factors account for the difficulties in the classification of vasculitis, including the incomplete understanding of the pathogenesis, the multisystemic nature of the disease, the non-specific patterns of vascular involvement, the overlap between entities, and the presence of various classification systems. The present article reviews the classification of AAV considering different points of view, including clinical, serologic, pathogenetic, organ predilection, therapeutic, and prognostic factors, and provides perspectives on future challenges in the understanding of AAV. There is an unmet need for a unifying view of the disease spectrum that considers the constantly evolving paradigms.
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26
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Minaya NJ, Rao V, Naunheim MR, Song PC. Laryngeal Subsite Analysis of Granulomatosis With Polyangiitis (Wegener's). OTO Open 2021; 5:2473974X211036394. [PMID: 34396029 PMCID: PMC8361530 DOI: 10.1177/2473974x211036394] [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] [Received: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective To analyze specific intralaryngeal findings associated with granulomatosis with polyangiitis (GPA). Study Design Retrospective chart review. Setting Tertiary referral center. Methods A retrospective chart review was performed on all patients diagnosed with GPA who were evaluated at the laryngology division of Massachusetts Eye and Ear Infirmary between January 2006 and September 2019. Results Forty-four patients (14 male, 30 female) were evaluated for laryngeal pathology. The mean age at onset was 48 years. Nine patients (21%) were identified with only vocal fold disease, 11 (25%) with subglottic disease, and 8 (18%) with disease at the glottis and subglottis (transglottic). The remaining 16 patients (36%) had a normal airway upon examination although they presented with laryngeal symptoms. Patients with glottic disease had statistically significantly lower voice-related quality of life scores than patients with isolated subglottic stenosis. Conclusions Although laryngeal manifestations of GPA is often described as a subglottic disease presenting with respiratory symptoms, subsite analysis show that only 25% of patients had subglottic disease alone, with similar rates of glottic disease alone. Laryngeal subsites have different epithelial mucosa, function, and physiology, and understanding the specific sites of involvement will determine symptoms and enable better analysis of the underlying mechanisms of disease. Glottic disease is associated with a reduction in vocal fold motion and voice changes. Subglottic involvement presents more frequently with airway symptoms. Further research is necessary to better define the specific regions of laryngeal involvement in patients diagnosed with GPA.
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Affiliation(s)
- Natasha J Minaya
- Department of Otolaryngology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Vishwanatha Rao
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Naunheim
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Phillip C Song
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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27
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Update on Maintenance Therapies for ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00176-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Chen LW, Lina I, Motz K, Berges AJ, Ospino R, Seo P, Hillel AT. Factors Affecting Dilation Interval in Patients With Granulomatosis With Polyangiitis-Associated Subglottic and Glottic Stenosis. Otolaryngol Head Neck Surg 2021; 165:845-853. [PMID: 33845664 DOI: 10.1177/01945998211004264] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Subglottic stenosis (SGS) is a known complication of granulomatosis with polyangiitis (GPA). We investigated the impact of medical and surgical interventions on the surgical dilation interval and characterized patients with glottic involvement. STUDY DESIGN A retrospective chart review of patients with GPA-associated SGS was performed from 2010 to 2019. SETTING Tertiary academic medical center. METHODS The impact of medical and surgical interventions on dilation interval was assessed. The prevalence of glottic involvement was assessed, and clinical characteristics and outcomes were compared with patients without glottic involvement. RESULTS A total of 39 patients with GPA-associated SGS were analyzed. Dilation intervals in patients receiving leflunomide (n = 4; median, 484 days; 95% CI, 405-1099) were greater than in those not receiving leflunomide (median, 155 days; 95% CI, 48-305; P = .033). The surgical technique used did not affect dilation interval. Patients with glottic involvement (n = 13) had a greater incidence of dysphonia (13/13 vs 15/26 [58%], P = .007) and a shorter dilation interval with involvement (median, 91 days; interquartile range, 70-277) versus without involvement (median, 377 days; interquartile range, 175-1148; hazard ratio, 3.38; 95% CI, 2.26-5.05; P < .001). Of 13 patients, 8 (62%) did not have glottic involvement on first presentation. CONCLUSION Although GPA is classically thought to affect the subglottis, it also involves the glottis in a subset of patients. These patients have greater complaints of dysphonia and require more frequent surgery. Systemic therapy may increase dilation intervals. In this preliminary study, patients taking leflunomide demonstrated an improvement, highlighting the need for further study of immunosuppression regimens in the treatment of GPA-associated SGS.
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Affiliation(s)
- Lena W Chen
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ioan Lina
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kevin Motz
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexandra J Berges
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rafael Ospino
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip Seo
- The Johns Hopkins Vasculitis Center, Department of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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29
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Primary Nasocutaneous Fistulae in Granulomatosis With Polyangiitis: A Case Series and Literature Review. Ophthalmic Plast Reconstr Surg 2021; 37:55-60. [PMID: 32282641 DOI: 10.1097/iop.0000000000001678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the presentation, investigation, management, and outcomes of primary nasocutaneous fistulae in granulomatosis with polyangiitis and review the literature of this complication. METHODS Retrospective series of 5 patients with granulomatosis with polyangiitis and nasocutaneous fistulae and the medical and surgical management strategies employed. RESULTS Two cases presented with fistulae as the primary symptom of their systemic disease. Systemic management of granulomatosis with polyangiitis is a primary concern and two cases had inadequate control at presentation such that surgical intervention was deferred. Of the other 3 cases, 2 were closed using a median forehead flap and the other with an orbicularis advancement flap. An endonasal approach was attempted in 1 case but was unsuccessful due to the friable nature of the nasal mucosal tissue. CONCLUSIONS Nasocutaneous fistulae should alert the clinician to underlying granulomatosis with polyangiitis, which may be a presentation of this condition. Systemic management of disease is often a barrier to surgical management. Myocutaneous flaps may be the most reliable management option to achieve closure.
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30
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Oelzner P, Wolf G. Risikostratifizierung bei ANCA-assoziierten
Vaskulitiden. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1380-2984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungANCA-assoziierte Vaskulitiden (AAV) sind nekrotisierende Vaskulitiden der
kleinen bis mittelgroßen Gefäße, welche die
Granulomatose mit Polyangiitis (GPA), die mikroskopische Polyangiitis (MPA)
und die Eosinophile Granulomatose mit Polyangiitis (EGPA) umfassen. AAV
gehen häufig mit Organfunktion-bedrohenden Manifestationen und einer
entsprechend erhöhten Mortalität einher. Für die
Planung von Diagnostik, Therapie und Langzeitbetreuung ist daher eine
Risikostratifizierung im Hinblick auf Mortalität, Entwicklung
schwerer Organinsuffizienzen, insbesondere einer terminalen
Niereninsuffizienz, mögliche Therapieresistenz, Rezidive,
Infektionen und Malignome erforderlich. Wichtige Risikofaktoren für
erhöhte Mortalität und/oder terminale
Niereninsuffizienz sind neben der renalen Beteiligung per se eine bereits
zum Zeitpunkt der Diagnose deutlich eingeschränkte renale Funktion
einschliesslich initialer Dialysepflichtigkeit, eine hohe initiale
Aktivität der AAV gemessen am Birmingham Vaskulitis Activity Score,
aber auch kardiale und gastrointestinale Manifestationen, Infektionen,
Anämie sowie ein Alter von>65 Jahren. Histologisch ist der
Nachweis chronischer irreversibler glomerulärer und
tubulärer Läsionen in der Nierenbiopsie mit einer schlechten
Prognose im Hinblick auf die Nierenfunktion assoziiert. Basierend auf der
histopathologischen Klassifikation der ANCA-assoziierten Glomerulonephritis
(GN) ist der Befund einer sklerosierenden GN mit einer besonders
ungünstigen Prognose assoziiert, während die fokale GN sehr
selten zur terminalen Niereninsuffizienz führt. MPO-ANCA zeigen eine
Assoziation mit chronischen Läsionen in der Nierenbiopsie sowie
erhöhter Mortalität und erhöhtem Risiko für
terminale Niereninsuffizienz. Im Hinblick auf die pulmonale Beteiligung sind
alveoläre Hämorrhagie und interstitielle Lungenerkrankung
mit einer erhöhten Mortalität assoziiert. Bei EGPA wird die
Prognose entscheidend durch die Kardiomyopathie bestimmt. Risikofaktoren
für Rezidive weichen erheblich von denen für
Mortalität und terminale Niereninsuffizienz ab. Ein erhöhtes
Rezidivrisiko besteht bei Nachweis von PR3-ANCA, GPA und pulmonaler
Beteiligung. Auch bei granulomatösen Läsionen, Beteiligung
des oberen Respirationstraktes und kardiovaskulären Manifestationen
wird ein erhöhtes Rezidivrisiko beschrieben. Im Gegensatz zur
Assoziation einer initial schlechten Nierenfunktion mit Mortalität
und terminaler Niereninsuffizienz, wurde für Patienten mit initial
guter Nierenfunktion ein erhöhtes Rezidivrisiko gezeigt. Weitere
Risikofaktoren für Rezidive sind Staphylokokken-Besiedelung der
Nase, frühere Rezidive und ANCA-Positivität nach
Remissionsinduktion. Titeranstieg oder Wiederauftreten von ANCA zeigen nur
eine moderate Beziehung zum Rezidivrisiko. Der prädiktive Wert
für Rezidive ist offenbar bei bestimmten Subgruppen, wie bei
Patienten mit renaler Beteiligung und pulmonaler Hämorrhagie sowie
bei mit Rituximab-behandelten Patienten besser als bei Patienten mit
granulomatösen Manifestationen. Daher ist eine Therapieentscheidung
allein auf Basis der Entwicklung der ANCA-Titer nicht möglich.
Risikofaktoren für schwere Infektionen sind höher dosierte
und prolongierte Glukokortikoidtherapie, Leuko- und Lymphopenie,
höheres Lebenalter, Niereninsuffizienz und pulmonale Beteiligung.
Die Malignomrate insbesondere für Nicht-Melanom-Hauttumoren,
Harnblasenkarzinome und Leukämie ist bei AAV erhöht und
zeigt eine Assoziation mit hohen kumulativen Cyclophosphamiddosen. Da
insbesondere frühzeitige irreversible Organschäden die
Prognose bestimmen und Rezidive die Entwicklung irreversibler
Schäden treiben, sind frühestmögliche Diagnose und
Therapie sowie rasches Erkennen und Vermeiden von Rezidiven essentiell
für die Risikominimierung.
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Affiliation(s)
- Peter Oelzner
- Rheumatologie/Osteologie, Klinik für Innere Medizin
III, Universitätsklinikum Jena, Jena, Deutschland
| | - Gunter Wolf
- Nephrologie, Klinik für Innere Medizin III,
Universitätsklinikum Jena, Jena, Deutschland
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Exploratory classification of clinical phenotypes in Japanese patients with antineutrophil cytoplasmic antibody-associated vasculitis using cluster analysis. Sci Rep 2021; 11:5223. [PMID: 33664381 PMCID: PMC7933174 DOI: 10.1038/s41598-021-84627-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/15/2021] [Indexed: 11/08/2022] Open
Abstract
A novel patient cluster in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) may be identified in Japan. We performed multiple correspondence and cluster analysis regarding 427 clinically diagnosed AAV patients excluding eosinophilic granulomatosis with polyangiitis. Model 1 included the ANCA phenotype, items of the Birmingham Vasculitis Activity Score, and interstitial lung disease; model 2 included serum creatinine (s-Cr) and C-reactive protein (CRP) levels with model 1 components. In seven clusters determined in model 1, the ANCA-negative (n = 8) and proteinase 3-ANCA-positive (n = 41) groups emerged as two distinct clusters. The other five myeloperoxidase-ANCA-positive clusters were characterized by ear, nose, and throat (ENT) (n = 47); cutaneous (n = 36); renal (n = 256), non-renal (n = 33); and both ENT and cutaneous symptoms (n = 6). Four clusters in model 2 were characterized by myeloperoxidase-ANCA negativity (n = 42), without s-Cr elevation (< 1.3 mg/dL) (n = 157), s-Cr elevation (≥ 1.3 mg/dL) with high CRP (> 10 mg/dL) (n = 71), or s-Cr elevation (≥ 1.3 mg/dL) without high CRP (≤ 10 mg/dL) (n = 157). Overall, renal, and relapse-free survival rates were significantly different across the four clusters in model 2. ENT, cutaneous, and renal symptoms may be useful in characterization of Japanese AAV patients with myeloperoxidase-ANCA. The combination of s-Cr and CRP levels may be predictive of prognosis.
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Iudici M, Pagnoux C, Courvoisier DS, Cohen P, Hamidou M, Aouba A, Lifermann F, Ruivard M, Aumaître O, Bonnotte B, Maurier F, Decaux O, Hachulla E, Karras A, Khouatra C, Jourde-Chiche N, Viallard JF, Blanchard-Delaunay C, Godmer P, Quellec AL, Quéméneur T, de Moreuil C, Régent A, Terrier B, Mouthon L, Guillevin L, Puéchal X. Granulomatosis with polyangiitis: Study of 795 patients from the French Vasculitis Study Group registry. Semin Arthritis Rheum 2021; 51:339-346. [PMID: 33601189 DOI: 10.1016/j.semarthrit.2021.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 02/06/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To describe the characteristics and long-term outcomes of patients with granulomatosis with polyangiitis (GPA) from the French Vasculitis Study Group database. METHODS Patients' clinical and laboratory characteristics, Birmingham Vasculitis Activity Score (BVAS)-assessed disease activity, malignancies, opportunistic infections, and vital status were collected at diagnosis and each visit. Estimated probabilities and predictors of overall (OS) and relapse-free survival (RFS) were analyzed by Cox regression. RESULTS We enrolled 795 newly diagnosed patients, followed for a median of 3.5 years. Initial clinical manifestations involved ear, nose & throat (ENT; 80%), lungs (68%) and kidneys (56%). Among the 728 available ELISA results, 75.0% were PR3-ANCA-positive, 16.5% MPO-ANCA-positive and 62 (8.5%) ANCA-negative. Relapses occurred in 394 (50%) patients, involving ≥1 organ(s) affected at onset in 179 (46%), mainly ENT, lungs and kidneys, with mean BVAS 10.2 points below that at diagnosis (p<0.001). Five- and 10-year RFS rates were 37% and 17%, respectively. PR3-ANCA-positivity independently predicted relapse (p = 0.05) and prolonged survival (p = 0.038). OS-but not RFS-improved significantly over time (p<0.001); 10-year OS reached 88.2% (95% CI 83.9 to 92.7) for the 660 patients diagnosed after 2000. Infections were the main causes of death. Malignancy or opportunistic infection each occurred in ≤5% of the patients. CONCLUSION Survival has improved dramatically over the last decades but the high relapse rate remains a major concern for GPA patients, once again stressing the need for therapeutic strategy optimization to lower it. PR3-ANCA-positivity was associated with increased probability of relapse and survival.
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Affiliation(s)
- Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France; Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Switzerland
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France; Present address: Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Delphine S Courvoisier
- Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Switzerland
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Hôtel-Dieu, Nantes, France
| | - Achille Aouba
- Department of Internal Medicine, CHU Côte-de-Nacre, Caen, France
| | | | - Marc Ruivard
- Department of Internal Medicine, CHU, Clermont-Ferrand, France
| | | | | | | | - Olivier Decaux
- Department of Internal Medicine, CHU Sud, Rennes, France
| | - Eric Hachulla
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine and Clinical Immunology, Claude-Huriez Hospital, University of Lille, Lille, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Chahéra Khouatra
- Department of Respiratory Medicine, CHU Louis-Pradel and UMR754, Université Claude-Bernard Lyon 1, Lyon, France
| | - Noémie Jourde-Chiche
- Aix-Marseille Univ, C2VN, INSERM 1263, INRAE 1260, AP-HM, Department of Nephrology, CHU de la Conception, Marseille, France
| | | | | | - Pascal Godmer
- Department of Internal Medicine, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Alain Le Quellec
- Department of Internal Medicine, CHU Saint-Eloi, Montpellier, France
| | - Thomas Quéméneur
- Department of Nephrology and Internal Medicine, Centre Hospitalier, Valenciennes, France
| | - Claire de Moreuil
- Department of Internal Medicine, CHU La Cavale Blanche, Brest, France
| | - Alexis Régent
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France.
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Antineutrophil cytoplasmic antibodies (ANCA) - their role in pathogenesis, diagnosis, and treatment monitoring of ANCA-associated vasculitis. Cent Eur J Immunol 2021; 45:218-227. [PMID: 33456335 PMCID: PMC7792441 DOI: 10.5114/ceji.2019.92494] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/23/2020] [Indexed: 12/24/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) constitutes a group of rare diseases characterized by necrotizing inflammation of small blood vessels and the presence of ANCA. Increasing clinical and experimental evidences support their pathogenic role in AAV, but the exact mechanism is not fully understood. Recently, the important role of neutrophil extracellular traps (NETs) in pathogenesis of AAV is underlined. There is an indication that NETs can be a source for the formation of ANCA. The most common ANCA target antigens are myeloperoxidase (MPO) and proteinase 3 (PR3). Though the mechanism of action of ANCA is still under exploration, ANCA serology is being increasingly used for classification of AAV and revealed as kenner in defining various disease subsets associated with different genetic background, clinical features, treatment response, and prognosis. Controversy exists regarding the utility of serial measurements of ANCA in patients with AAV to monitor treatment and predict disease relapse.
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Berglin E, Mohammad AJ, Dahlqvist J, Johansson L, Eriksson C, Sjöwall J, Rantapää-Dahlqvist S. Anti-neutrophil cytoplasmic antibodies predate symptom onset of ANCA-associated vasculitis. A case-control study. J Autoimmun 2020; 117:102579. [PMID: 33340843 DOI: 10.1016/j.jaut.2020.102579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Anti-neutrophil cytoplasmic autoantibodies [ANCA) are important for diagnosis of ANCA-associated vasculitides (AAV). The timing of antibody development is not well established. To investigate the development of proteinase 3 (PR3)- and myeloperoxidase (MPO)-ANCA, blood samples collected before onset of symptoms of AAV were analysed. METHODS To identify AAV patients with blood samples predating symptoms, the National Patient Register and Cause of Death register were scrutinized for ICD codes for AAV and linked to the registers of five biobanks. Diagnoses of AAV and time point for symptom onset were confirmed by reviewing 504 case-record. Eighty-five AAV cases (34 males, 51 females) with samples >1 month < 10 years from AAV symptom onset and two controls matched for sex, age, and sampling time for each case were included. Samples were screened using ELISAs for ANCA and further analysed for PR3-or MPO- specificities. RESULTS In ANCA-screen 35.7% of the pre-symptomatic cases and 3.5% of controls tested positive (p < 0.01). 26.2% of the cases were PR3-ANCA+ and 10.7% MPO-ANCA+. Median (Q1-Q3) predating time for PR3-ANCA+ was 2.7 (0.3-7.7) years and MPO-ANCA+ 2.0 (0.9-3.5) years. PR3-ANCA was demonstrated in samples up to nine years before symptom onset. At symptom onset predating PR3-ANCA+ cases were younger than PR3-ANCA- (P < 0.01), and MPO-ANCA+ were older than MPO-ANCA- (p < 0.05). Predating MPO-ANCA+ cases vs. MPO-ANCA- and vs. PR3-ANCA+ cases had more often at symptoms onset manifestations from lungs, kidneys or peripheral nervous system (p < 0.01 and p < 0.05, respectively). CONCLUSION The PR3-and MPO-ANCAs are present years before AAV symptom onset and represent distinct diseases.
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Affiliation(s)
- Ewa Berglin
- Department of Public Health and Medicine/Rheumatology, Umeå University, Umeå, Sweden.
| | - Aladdin J Mohammad
- Department of Clinical Sciences/Rheumatology, Lund University, Lund, Sweden; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
| | - Johanna Dahlqvist
- Department of Medical Biochemistry and Microbiology, and Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Linda Johansson
- Department of Public Health and Medicine/Rheumatology, Umeå University, Umeå, Sweden.
| | - Catharina Eriksson
- Department of Clinical Microbiology, Division of Infection and Immunology, Umeå University, Umeå, Sweden.
| | - Johanna Sjöwall
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Clinic of Infectious Diseases Linköping University Hospital, Linköping, Sweden.
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35
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Puéchal X, Iudici M, Pagnoux C, Karras A, Cohen P, Maurier F, Quéméneur T, Lifermann F, Hamidou M, Mouthon L, Terrier B, Guillevin L. Sustained Remission of Granulomatosis With Polyangiitis After Discontinuation of Glucocorticoids and Immunosuppressant Therapy: Data From the French Vasculitis Study Group Registry. Arthritis Rheumatol 2020; 73:641-650. [PMID: 33029946 DOI: 10.1002/art.41551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Data on sustained remission of granulomatosis with polyangiitis (GPA) after discontinuation of therapy (referred to as GPA with sustained remission off-therapy [SROT]) are scarce. In the present study, SROT among GPA patients from the French Vasculitis Study Group Registry was evaluated to identify factors associated with its occurrence and durability. METHODS For inclusion of patients in the study, the diagnosis of GPA had to meet the GPA classification criteria defined by the American College of Rheumatology and/or the revised Chapel Hill Consensus Conference nomenclature for vasculitis. SROT was defined as achievement of remission (a Birmingham Vasculitis Activity Score of 0) that was sustained for ≥6 consecutive months after having discontinued glucocorticoid (GC) and immunosuppressant treatments. The characteristics of the patients at baseline and treatments received were compared at 3, 5, and 10 years postdiagnosis according to whether or not SROT had been reached and maintained. RESULTS Among 795 patients with GPA, 92 GPA patients with SROT at 3 years postdiagnosis were compared to 342 control subjects who had experienced disease relapse and/or were still receiving GCs or immunosuppressants. No baseline differences were found, but patients with SROT at 3 years postdiagnosis had more frequently received intravenous cyclophosphamide as induction therapy compared to control subjects (P = 0.01), with a higher median number of infusions (P = 0.05). At 5 years postdiagnosis, no baseline differences were observed between groups, but patients with SROT at 5 years postdiagnosis had received more cyclophosphamide infusions compared to control subjects (P = 0.03). More patients with SROT had received rituximab as maintenance therapy than control subjects at 3 years and 5 years postdiagnosis (P = 0.09 and P < 0.001, respectively). Of the 74 patients enrolled in the GPA Registry with 10-year follow-up data after having received conventional maintenance therapy, 15 (20%) had reached SROT at 3 years, and 5 (7%) maintained SROT at 10 years postdiagnosis. CONCLUSION After conventional therapies, 7% of GPA patients had reached SROT at 10 years postdiagnosis. No baseline vasculitis characteristics distinguished patients who achieved/maintained SROT from those who experienced disease relapse and/or those who continued to receive GCs or immunosuppressant therapy, but patients with SROT had received more intensive induction therapy and rituximab as maintenance therapy more frequently.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
| | - Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
| | | | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
| | | | | | | | | | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, AP-HP, Paris, France
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Immunopathogenesis of ANCA-Associated Vasculitis. Int J Mol Sci 2020; 21:ijms21197319. [PMID: 33023023 PMCID: PMC7584042 DOI: 10.3390/ijms21197319] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune disorder which affects small- and, to a lesser degree, medium-sized vessels. ANCA-associated vasculitis encompasses three disease phenotypes: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). This classification is largely based on clinical presentations and has several limitations. Recent research provided evidence that genetic background, risk of relapse, prognosis, and co-morbidities are more closely related to the ANCA serotype, proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, compared to the disease phenotypes GPA or MPA. This finding has been extended to the investigation of biomarkers predicting disease activity, which again more closely relate to the ANCA serotype. Discoveries related to the immunopathogenesis translated into clinical practice as targeted therapies are on the rise. This review will summarize the current understanding of the immunopathogenesis of ANCA-associated vasculitis and the interplay between ANCA serotype and proposed disease biomarkers and illustrate how the extending knowledge of the immunopathogenesis will likely translate into development of a personalized medicine approach in the management of ANCA-associated vasculitis.
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Aitmehdi R, Moguelet P, Godot S, Chazerain P, Senet P, Barbaud A, Frances C, Chasset F. Response to rituximab of pseudotumoral digital nodules in a patient with granulomatosis with polyangiitis with alpha‐1 antitrypsin deficiency: A case report. Dermatol Ther 2020; 33:e13479. [DOI: 10.1111/dth.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/07/2020] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Raphaël Aitmehdi
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - Philippe Moguelet
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Pathologie, Hôpital Tenon Paris France
| | - Sophie Godot
- Service de Rhumatologie Groupe Hospitalier Diaconnesses Croix Saint Simon Paris France
| | - Pascal Chazerain
- Service de Rhumatologie Groupe Hospitalier Diaconnesses Croix Saint Simon Paris France
| | - Patricia Senet
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - Annick Barbaud
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - Camille Frances
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - François Chasset
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
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Quinn KA, Gelbard A, Sibley C, Sirajuddin A, Ferrada MA, Chen M, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Ytterberg SR, Merkel PA, Grayson PC. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology (Oxford) 2020; 58:2203-2211. [PMID: 31199488 DOI: 10.1093/rheumatology/kez217] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe tracheobronchial disease in patients with granulomatosis with polyangiitis (GPA) and evaluate the utility of dynamic expiratory CT to detect large-airway disease. METHODS Demographic and clinical features associated with the presence of subglottic stenosis (SGS) or endobronchial involvement were assessed in a multicentre, observational cohort of patients with GPA. A subset of patients with GPA from a single-centre cohort underwent dynamic chest CT to evaluate the airways. RESULTS Among 962 patients with GPA, SGS and endobronchial disease were identified in 95 (10%) and 59 (6%) patients, respectively. Patients with SGS were more likely to be female (72% vs 53%, P < 0.01), younger at time of diagnosis (36 vs 49 years, P < 0.01), and have saddle-nose deformities (28% vs 10%, P < 0.01), but were less likely to have renal involvement (39% vs 62%, P < 0.01). Patients with endobronchial disease were more likely to be PR3-ANCA positive (85% vs 66%, P < 0.01), with more ENT involvement (97% vs 77%, P < 0.01) and less renal involvement (42% vs 62%, P < 0.01). Disease activity in patients with large-airway disease was commonly isolated to the subglottis/upper airway (57%) or bronchi (32%). Seven of 23 patients screened by dynamic chest CT had large-airway pathology, including four patients with chronic, unexplained cough, discovered to have tracheobronchomalacia. CONCLUSION SGS and endobronchial disease occur in 10% and 6% of patients with GPA, respectively, and may occur without disease activity in other organs. Dynamic expiratory chest CT is a potential non-invasive screening test for large-airway involvement in GPA.
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Affiliation(s)
- Kaitlin A Quinn
- Division of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA.,Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Alexander Gelbard
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, TN, USA
| | - Cailin Sibley
- Division of Arthritis & Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
| | | | - Marcela A Ferrada
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Marcus Chen
- National Institutes of Health, NHLBI, Bethesda, MD, USA
| | - David Cuthbertson
- Biostatistics and Informatics, University of South Florida, Tampa, FL, USA
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada
| | - Nader A Khalidi
- Division of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Larry W Moreland
- Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, MN, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven R Ytterberg
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
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Berti A, Bond M, Volpe A, Felicetti M, Bortolotti R, Paolazzi G. Practical approach to vasculitides in adults: an overview of clinical conditions that can mimic vasculitides closely. ACTA ACUST UNITED AC 2020. [DOI: 10.4081/br.2020.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Primary systemic vasculitides are rare diseases affecting blood vessel walls. The type and patterns of distribution of the organs affected usually reflect the size of the vessels predominantly involved, and the patterns of clinical manifestations are generally useful to reach a specific diagnosis. However, presenting symptoms may lack adequate specificity for a prompt diagnosis, leading to a diagnostic (and therapeutic) delay, often causing irreversible damage to the affected organs. Due to their rarity and variable clinical presentation, the diagnosis of primary vasculitides could be challenging for physicians. Vasculitis mimickers, i.e. the clinical conditions that could be likely mistaken for vasculitides, need to be carefully ruled out, especially before starting the immunosuppressive therapy. We present here a practical approach to the diagnosis of primary systemic vasculitides involving large, medium and small size vessels, and reviewed most of the conditions that could mimic primary systemic vasculitides.
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Deshayes S, Martin Silva N, Khoy K, Yameogo S, Mariotte D, Lobbedez T, Aouba A. Clinical impact of subgrouping ANCA-associated vasculitis according to antibody specificity beyond the clinicopathological classification. Rheumatology (Oxford) 2020; 58:1731-1739. [PMID: 30805643 DOI: 10.1093/rheumatology/kez016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/09/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In ANCA-associated vasculitis (AAV), classifications have emerged to individualize homogeneous clinical and outcomes patterns, including the recently defined anti-MPO granulomatosis with polyangiitis (GPA) subgroup. This study aimed to retrospectively evaluate the impacts of re-classification based on clinicopathological criteria and/or ANCA specificity. METHODS A retrospective monocentric study conducted at Caen University Hospital led to the identification of PR3 or MPO-ANCA AAV patients from January 2000 or September 2011, respectively, to June 2016. Eosinophilic GPA patients were excluded. AAVs were thereby also classified either as GPA or microscopic polyangiitis (MPA) according to the European Medicines Agency vasculitis algorithm. RESULTS A total of 150 AAV patients were included (94 GPA, 56 MPA; 87 anti-PR3 and 63 anti-MPO patients). GPA patients exhibited a worse relapse-free survival but a better renal survival (P < 0.001 and P = 0.021, respectively) than MPA patients. Overall, relapse-free and renal survival rates were similar between anti-PR3 and anti-MPO patients (P = 0.35, 0.17 and 0.15, respectively). Similarly, the prognosis was identical between anti-MPO MPA patients and anti-PR3 MPA patients (P = 0.33, 0.19 and 0.65, respectively), and between anti-MPO GPA patients and anti-PR3 GPA patients (P = 0.06, 0.99 and 0.64, respectively). Moreover, anti-PR3 GPA and anti-MPO GPA patients exhibited no differences in clinical manifestations or BVAS score. CONCLUSION Clinicopathological classification appeared to be the strongest criterion for distinguishing among homogeneous prognoses of AAV. Individualizing the anti-MPO GPA subgroup does not appear to bring additional value to clinical practice, but multicentre studies are required to confirm this trend.
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Affiliation(s)
- Samuel Deshayes
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Nicolas Martin Silva
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Kathy Khoy
- Department of Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Seydou Yameogo
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Delphine Mariotte
- Department of Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Thierry Lobbedez
- Department of Nephrology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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42
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Philip R, Dumont A, Le Mauff B, Martinet M, Martin Silva N, de Boysson H, Lobbedez T, Aouba A, Deshayes S. [ANCA and anti-MBG double-positive vasculitis: An update on the clinical and therapeutic specificities and comparison with the two eponymous vasculitis]. Rev Med Interne 2019; 41:21-26. [PMID: 31839271 DOI: 10.1016/j.revmed.2019.10.334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/21/2019] [Accepted: 10/21/2019] [Indexed: 01/19/2023]
Abstract
Double-positive vasculitis with anti-polynuclear cytoplasm (ANCA) and anti-glomerular basement membrane (GBM) antibodies is a rare entity of systemic vasculitis defined by the presence of ANCA and anti-GBM antibodies. The gradual accumulation of clinical and therapeutic data shows the usefulness of identifying and differentiating this entity from the two vasculitis respectively associated with the isolated presence of each of these two antibodies. Indeed, the double-positive ANCA and anti-GBM vasculitis appears to associate the characteristics of the demography and the extra-renal and pulmonary involvement of the ANCA-associated vasculitis on the one hand, and of the histological type and severe renal prognosis of the anti-MBG vasculitis on the other hand, with the renal involvement which is the only involvement consistently observed in double-positive vasculitis. The aim of this focus is to describe the epidemiological, clinico-biological, histological and prognostic characteristics of this entity, in light of recent literature and ongoing therapeutic changes in the two eponymous vasculitis.
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Affiliation(s)
- R Philip
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - A Dumont
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - B Le Mauff
- Laboratoire d'Immunologie, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - M Martinet
- Laboratoire d'Immunologie, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - N Martin Silva
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - H de Boysson
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - T Lobbedez
- Service de néphrologie, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - A Aouba
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France.
| | - S Deshayes
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
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Wallace ZS, Stone JH. Personalized Medicine in ANCA-Associated Vasculitis ANCA Specificity as the Guide? Front Immunol 2019; 10:2855. [PMID: 31867013 PMCID: PMC6909331 DOI: 10.3389/fimmu.2019.02855] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a small- to medium-vessel necrotizing vasculitis responsible for excess morbidity and mortality (1). The AAVs, which include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA), are among the most difficult types of vasculitis to treat. Although clinicopathologic disease definitions have been used traditionally to categorize patients into one of these three diagnoses, more recently ANCA specificity for either proteinase 3 (PR3) or myeloperoxidase (MPO) has been advocated for the purpose of disease classification (2). This is because differences in genetics, pathogenesis, risk factors, treatment responses, and outcomes align more closely with PR3- or MPO-ANCA type than with the clinocopathologic diagnosis. Moreover, classifying patients as GPA or MPA can be challenging because biopsies are not obtained routinely in most cases and existing classification systems can provide discrepant classification for the same patient (3). In this review, we address the recent literature supporting the use of ANCA specificity to study and personalize the care of AAV patients (Table 1). We focus particularly on patients with GPA or MPA.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Mongan Institute, Boston, MA, United States.,Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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44
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Kim SM, Choi SY, Kim SY, Kim J. Clinical characteristics of patients with vasculitis positive for anti-neutrophil cytoplasmic antibody targeting both proteinase 3 and myeloperoxidase: a retrospective study. Rheumatol Int 2019; 39:1919-1926. [PMID: 31552433 DOI: 10.1007/s00296-019-04447-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/16/2019] [Indexed: 10/26/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) may target proteinase 3 (PR3) or myeloperoxidase (MPO). Although a few patients with vasculitis have both MPO- and PR3-ANCA, the details of their clinical characteristics are not known. The objective of this study was to analyze the characteristics of patients with dual MPO- and PR3-ANCA-positive vasculitis. The medical records of patients with ANCA and vasculitis confirmed by biopsy were reviewed. The age at diagnosis, sex, and data on organ involvement of the kidney, lung, upper airways, skin, nervous system, and gastrointestinal tract were collected. Clinical variables were analyzed according to ANCA specificity. Of 85 patients with ANCA and vasculitis included in this study, 67 (78.8%) had MPO-ANCA, 10 (11.8%) had PR3-ANCA, and 8 (9.4%) had both MPO- and PR3-ANCA. Patients with MPO- PR3 + ANCA-associated vasculitis (AAV) were younger at diagnosis (median, 54.4 years; p < 0.05) than patients with MPO + PR3- AAV (67.0 years) or dual-ANCA AAV (MPO + PR3 + , 68.5 years). The initial glomerular filtration rate in patients with MPO + PR3- AAV (22.0 ml/min) was significantly lower than that in patients with MPO- PR3 + AAV (108.6 ml/min, p < 0.05), but was not different from that in dual-ANCA AAV patients (16.5 ml/min). Upper airway involvement also differed with ANCA type (MPO+ PR3- , 35.8% vs. MPO- PR3 + , 70.0% vs. MPO + PR3+ , 75.0%, p < 0.05). The involvement of other organs did not differ according to ANCA type. Age at diagnosis, kidney involvement, and upper airway involvement were associated with ANCA type. Patients with dual-ANCA-positive vasculitis had considerably more kidney dysfunction than patients with MPO- PR3+ AAV. They also had more upper airway involvement than patients with MPO+ PR3- AAV.
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Affiliation(s)
- Sun Moon Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Chungcheongbuk-do, South Korea
| | - Song-Yi Choi
- Department of Pathology, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Seon Young Kim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Jinhyun Kim
- Department of Internal Medicine, Chungnam National University College of Medicine, 262 Munhwaro, Jung-gu, Daejeon, 35015, Republic of Korea.
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45
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Pagnoux C, Mendel A. Treatment of systemic necrotizing vasculitides: recent advances and important clinical considerations. Expert Rev Clin Immunol 2019; 15:939-949. [DOI: 10.1080/1744666x.2019.1656527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
- Canadian Vasculitis research network (CanVasc), Canada
| | - Arielle Mendel
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
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46
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The complexity of classifying ANCA-associated small-vessel vasculitis in actual clinical practice: data from a multicenter retrospective survey. Rheumatol Int 2019; 40:303-311. [PMID: 31385079 DOI: 10.1007/s00296-019-04406-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
The different sets of criteria for diagnosis or classification of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) lead to numerous overlapping and reclassified diagnoses in clinical practice. We designed this study to assess the difficulties in classifying patients with AAV. As a secondary objective, different variables were tested to predict prognosis. We conducted a retrospective chart review in a Western Spain multicentre survey. A total of 115 adult patients diagnosed with AAV from 2002 to 2013 and followed for at least 3 years were included. They were classified according to (1) Chapel Hill Consensus Conference (CHCC), (2) European Medicines Agency algorithm and (3) French Vasculitis Study Group/European Vasculitis Society phenotypes. Fifty-three patients (46%) had neither distinctive histopathological data of a single AAV definition nor any surrogate markers for granulomatous inflammation and thus did not fulfill any diagnostic criteria. Ocular, ear, nose, throat, skin, and lung involvement were more frequent with proteinase 3 (PR3) antibodies, whereas peripheral neuropathy was more frequent with myeloperoxidase (MPO) antibodies. When the disease was severe at diagnosis, the HR for mortality was 10.44. When induction treatment was not given in accordance with the guidelines, the HR for mortality was 4.00. For maintenance treatment, the HR was 5.49 for mortality and 2.48 for relapse. AAV classification is difficult because many patients had neither specific clinical data nor distinctive histological features of a single CHCC definition. A structured clinical assessment of patient severity is the best tool to guide the management of AAV.
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Naidu GSRSNK, Misra DP, Rathi M, Sharma A. Is granulomatosis with polyangiitis in Asia different from the West? Int J Rheum Dis 2018; 22 Suppl 1:90-94. [PMID: 30338654 DOI: 10.1111/1756-185x.13398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 08/18/2018] [Accepted: 08/23/2018] [Indexed: 01/20/2023]
Abstract
The incidence and clinical features of antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) have been shown to vary according to geographical areas, with granulomatosis with polyangiitis (GPA) being more common in northern Europe and microscopic polyangiitis (MPA) being more common in Asian countries. The annual incidence of GPA among Asians varies between 0.37/million to 2.1/million population. The prevalence of GPA has been estimated to be 1.94/100 000 in a Chinese population. Polymorphisms in class II major histocompatibility genes and ETS1 proto-oncogene has been shown in Asian patients with GPA. There is a difference in mean age at onset and proteinase 3 (PR3) or myeloperoxidase (MPO) positivity in GPA patients from different Asian countries. Those from India had mean age of 40 years and those from Japan had mean age of 65 years. Sixty percent of GPA patients from China and Japan were MPO ANCA positive while the majority of patients from India and Korea were PR3 positive. Geographical variation with lower frequency of renal involvement in Indian studies and higher frequency in Chinese patients has also been noted. Treatment outcomes have been similar to those reported from other parts of the world. Remission was achieved in about two-thirds of patients while relapses were noted in one-third to half of the patients. Apart from minor differences in the organ systems involved, MPO-ANCA GPA and PR3-ANCA GPA had similar rates of remission and relapses.
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Affiliation(s)
- Godasi S R S N K Naidu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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van der Geest KSM, Brouwer E, Sanders JS, Sandovici M, Bos NA, Boots AMH, Abdulahad WH, Stegeman CA, Kallenberg CGM, Heeringa P, Rutgers A. Towards precision medicine in ANCA-associated vasculitis. Rheumatology (Oxford) 2018; 57:1332-1339. [PMID: 29045715 DOI: 10.1093/rheumatology/kex367] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 12/18/2022] Open
Abstract
ANCA-associated vasculitis (AAV) is characterized by inflammation and destruction of small and medium-sized vessels. Current management strategies for AAV have been validated in large groups of patients. However, recent insights indicate that distinct patient subsets may actually exist within AAV, thereby justifying the development of more personalized treatment strategies. In this review, we discuss current evidence for a better classification of AAV based on ANCA type. We describe how thus defined categories of AAV patients may differ in genetic background, clinical presentation, immune pathology, response to treatment and disease outcome. We also explore how these insights may provide a rationale for targeted treatments in different categories of AAV patients. Finally, we provide recommendations on how to further establish precision medicine in AAV.
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Affiliation(s)
- Kornelis S M van der Geest
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth Brouwer
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Stephan Sanders
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria Sandovici
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nicolaas A Bos
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annemieke M H Boots
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wayel H Abdulahad
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coen A Stegeman
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cees G M Kallenberg
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Heeringa
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Abraham Rutgers
- Vasculitis Expertise Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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49
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Pagnoux C, Springer J. Editorial: Classifying Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitides According to ANCA Type or Phenotypic Diagnosis: Salt or Pepper? Arthritis Rheumatol 2018; 68:2837-2840. [PMID: 27588958 DOI: 10.1002/art.39860] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/30/2016] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW Biomarkers are considered to be helpful in diagnosing, monitoring, predicting treatment response, and prognosis in clinical practice and as outcomes in clinical trials. In this article, we review the recent literature on new biomarkers and the expanding use of older ones in vasculitic conditions. RECENT FINDINGS In antineutrophil cytoplasmic antibody-associated vasculitis patients antineutrophil cytoplasmic antibody type may be useful as a predictor of relapse and response to rituximab. Moreover, serial measurements of proteinase-3 titer may help to predict relapse. Urinary soluble CD163 levels are promising for identifying active renal vasculitis. Imaging modalities such as positron emission tomography, computerized angiography tomography, and temporal artery ultrasound maintain their role in diagnosis and disease assessment in large vessel vasculitis. Fecal calprotectin is a useful marker of active gastrointestinal involvement in Behçet's syndrome. SUMMARY The publications reviewed here potentially may help to move the field of biomarkers in vasculitis management. However, more work toward understanding the underlying pathophysiology and effects of an intervention on the disease process are needed before true biomarkers can be realized. Further studies with appropriate control groups, using good definitions for disease states such as activity and remission are needed to guide our use of these markers correctly in the management of our patients.
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