Impact of renal involvement on survival in ANCA-associated vasculitis

Serum calprotectin and renal function decline in ANCA-associated vasculitides: a post hoc analysis of MAINRITSAN trial

OBJECTIVE

Serum calprotectin appears to be an interesting biomarker associated with renal vascular disease activity in antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). The aim of this study was to assess whether serum calprotectin levels can predict decline in renal function in AAV patients receiving maintenance therapy.

METHODS

Serum calprotectin levels were assessed at inclusion and month 6 in AAV patients, in complete remission after induction therapy, randomly assigned to rituximab or azathioprine. Renal function decline was defined as a 25% decrease in estimated glomerular filtration rate (eGFR) and a change in the eGFR category, or a decrease of 15 mL/min/1.73 m2. Relapse was defined as a Birmingham Vasculitis Activity Score >0 attributable to active vasculitis.

RESULTS

Seventy-six AAV were included. Serum calprotectin increased from baseline to month 6 in patients with renal function decline (7940 (-226.0, 28 691) ng/ml vs -4800 (-18 777, 3708) ng/ml; p<0.001). An increase of calprotectin level was associated with a higher risk of subsequent renal function decline even after adjustment (OR 6.50 (95% CI 1.7 to 24.9) p=0.006). A significantly higher risk of relapse was observed in proteinase 3- AAV patients with an increase of serum calprotectin levels (OR 5.6 (95% CI 1.0 to 31.2), p=0.03).

CONCLUSION

An increase in serum calprotectin by month 6 compared with inclusion during remission-maintenance therapy in AAV was associated with a higher risk of renal function decline in the following 12 months.

TRIAL REGISTRATION NUMBER

NCT00748644.

ANCA-associated vasculitis following ChAdOx1 nCoV19 vaccination: case-based review

For the foreseeable future, vaccines are the cornerstone in the global campaign against the Coronavirus Disease-19 (COVID-19) pandemic. As the number and fatalities due to COVID-19 decline and the lockdown anywise rescinded, we recognize an increase in the incidence of autoimmune disease post-COVID-19 vaccination. However, the causality of the most vaccine-induced side effects is debatable and, at best, limited to a temporal correlation. We herein report a case of a 51-year-old gentleman who developed Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis (AAV) 2 week post-COVID-19 vaccination. The patient responded favorably to oral steroids and rituximab. Additionally, we conducted a case-based review of vaccine-associated AAV describing their clinical manifestations and treatment response of this emerging entity.

Reasons for hospitalization and in-hospital mortality for anti-neutrophil cytoplasmic antibody vasculitides: analysis of the National Inpatient Sample

OBJECTIVE

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a heterogeneous group of conditions resulting in frequent hospitalizations and high in-hospital mortality (IHM). Our study aimed to use the National Inpatient Sample (NIS) to determine and categorize the main reasons for hospital admission and IHM in patients with AAV.

METHODS

We performed a retrospective study of adult AAV hospitalizations in 2016, 2017, and 2018 in acute care hospitals across the USA conducted using the NIS database. We classified the main reasons for hospital admission and IHM into 19 different categories using the principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis.

RESULTS

A total of 41,155 hospitalizations had either a principal or secondary ICD-10 code for AAV (GPA or MPA). Rheumatologic and respiratory diagnoses were the most common reasons for hospitalization, while infectious and respiratory diagnoses were the most common reasons for IHM. Sepsis, unspecified organism A41.9, was the most common specific principal diagnosis for hospitalized and deceased AAV patients.

CONCLUSIONS

Our results show that the leading reasons for hospitalization and mortality for AAV patients were rheumatologic, respiratory, and infectious diagnoses. This data suggests that careful monitoring and management of infectious and pulmonary complications in AAV may improve hospital outcomes. Key points • AAV is a heterogeneous group of conditions resulting in frequent hospitalizations and high IHM. In our study, AAV hospitalizations ended in IHM 4.5% of the time, substantially greater than non-ANCA patients. • The leading reasons for hospital admission for AAV patients were rheumatologic and respiratory diagnoses, but the main reason for IHM were infectious and respiratory diagnoses. • Sepsis was the most common principal diagnosis for hospitalized and deceased AAV patients. • Our results highlight the importance of close monitoring and timely management of infectious and respiratory complications to improve hospitalization outcomes.

Is granulomatosis with polyangiitis in Asia different from the West?

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.

Rheumatology science and practice in India

The practice of rheumatology in a country like India presents its own unique challenges, including the need to manage patients in a cost-constrained setting, where the lack of uniform government funding for healthcare merits the need to optimize the use of cheaper medicines, as well as devise innovative strategies to minimize the use of costlier drugs such as biologic disease-modifying agents. Use of immunosuppressive agents is also associated with increased risks of infectious complications, such as the reactivation of tuberculosis. In this narrative review, we provide a flavor of such challenges unique to Rheumatology practice in India, and review the published literature on the management of common rheumatic diseases from India. In addition, we critically review existing guidelines for the management of rheumatic diseases from this part of the world. We also discuss infectious etiologies of rheumatic complaints, such as leprosy, tuberculosis, and Chikungunya arthritis, which are often encountered here, and pose a diagnostic as well as therapeutic challenge for clinicians. There remains a need to identify and test more cost-effective strategies for Indian patients with rheumatic diseases, as well as the requirement for more government participation to enhance scant facilities for the treatment of such diseases as well as foster the development of healthcare services such as specialist nurses, occupational therapists and physiotherapists to enable better management of these conditions.