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Osman M, Cohen Tervaert JW, Pagnoux C. Avacopan for the treatment of ANCA-associated vasculitis: an update. Expert Rev Clin Immunol 2023; 19:461-471. [PMID: 36545762 DOI: 10.1080/1744666x.2023.2162041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids (GC) have been part of the standard treatment of anti-neutrophil cytoplasm autoantibodies (ANCA)-associated vasculitides (AAV) for more than 60 years. Various therapeutic advances have occurred over the past 2 decades and led to a significant reduction of GC exposure, but most patients still have to suffer from complications of GC, including infections, metabolic abnormalities, and cardiovascular morbidity. In 2007, activation of the complement pathway was demonstrated to play a role in the pathogenesis of AAV. Avacopan, an oral competitive inhibitor of the C5a receptor (C5aR1, CD88), was then developed, with an additional aim to decrease the use of GC. AREAS COVERED In this article, we briefly summarize the rationale for targeting the complement pathway in AAV, and review relevant findings from pre-clinical, phase I, II, and III studies, subsequent and more recent case reports and series on the efficacy and safety of avacopan. EXPERT OPINION Based on the results of these studies, avacopan was approved in most countries since late 2021, as an adjunctive induction treatment for patients with AAV. Several newer questions now are pending answers, including as to how avacopan should be used in real-world practice, beyond how it was given in the original clinical trials.
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Affiliation(s)
- Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Christian Pagnoux
- Vasculitis clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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2
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Jaroenlapnopparat A, Banankhah P, Khoory J, Jani C, Sehra S. A Diagnostic Dilemma of a Case of Granulomatosis With Polyangiitis (GPA) Presenting With Thrombotic Vasculopathy. Cureus 2023; 15:e34479. [PMID: 36874702 PMCID: PMC9981548 DOI: 10.7759/cureus.34479] [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: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare disease with a prevalence of about three in 100,000 persons in the United States. GPA is an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis affecting predominantly small-sized vessels. It can present with localized or systemic symptoms with multiple organ involvement, thus making diagnosis challenging. Common skin lesions in GPA are palpable purpura, petechiae, ulcers, and livedo reticularis. These lesions usually have underlying vasculitis with or without granuloma on histology findings. To date, there have been no previous reports about thrombotic vasculopathy in GPA before. We present a case of a 25-year-old female who presented with intermittent joint pain for weeks, purpuric rash, and mild hemoptysis for a few days. A review of systems was notable for a 15-pound weight loss in one year. Physical examination was significant for a purpuric rash on the left elbow and toe, and left knee swelling and erythema. Presenting laboratory results were notable for anemia, indirect hyperbilirubinemia, mildly elevated D-dimers, and microscopic hematuria. Chest radiograph revealed confluent airspace disease. Extensive infectious workup was negative. A skin biopsy of her left toe revealed dermal intravascular thrombi without evidence of vasculitis. The thrombotic vasculopathy did not favor vasculitis but raised concern for a hypercoagulable state. However, extensive hematologic workup was negative. Bronchoscopy findings were consistent with diffuse alveolar hemorrhage. Later, cytoplasmic ANCA (c-ANCA) and anti-proteinase 3 (PR3) antibody titers were positive. Her diagnosis was unclear since both skin biopsy and bronchoscopy were nonspecific and inconsistent with her positive antibody results. The patient eventually underwent a kidney biopsy, which showed pauci-immune necrotizing and crescentic glomerulonephritis. Finally, a diagnosis of granulomatosis with polyangiitis was made based on the kidney biopsy and positive c-ANCA. The patient was treated with steroids and IV rituximab and discharged home with outpatient rheumatology follow-up. Due to multiple signs and symptoms including thrombotic vasculopathy, there was a diagnostic dilemma requiring a multidisciplinary approach. This case highlights the importance of pattern recognition for the diagnostic framework of rare disease entities and the multidisciplinary collaborative efforts required to reach the final diagnosis.
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Affiliation(s)
| | - Peymaan Banankhah
- Internal Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, USA
| | - Joseph Khoory
- Internal Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, USA
| | - Chinmay Jani
- Internal Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, USA
| | - Shiv Sehra
- Rheumatology, Mount Auburn Hospital, Harvard Medical School, Cambridge, USA
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3
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Kumar K, Seetharam K, Poonam F, Gulati A, Sadiq A, Shetty V. The Role of Cardiac Imaging in the Evaluation of Cardiac Involvement in Systemic Diseases. Cureus 2021; 13:e20708. [PMID: 35106243 PMCID: PMC8788898 DOI: 10.7759/cureus.20708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/05/2022] Open
Abstract
For systemic diseases like rheumatoid arthritis, systemic lupus erythematosus (SLE), systemic sclerosis, systemic vasculitis, myopathies, and mixed connective tissue diseases, cardiac disease is a major contributing factor for morbidity and mortality. The cardiovascular manifestations are the result of various pathophysiological components, which complicate management. Furthermore, the signs and symptoms can be subtle and missed due to the complex nature of the underlying condition. As a result, various imaging approaches play an imperative role in diagnosis and prognosis. The evolving role of these modalities could lead to risk stratification and improved therapies in the future. In conclusion, our review article will highlight the role of cardiac imaging in the evaluation of cardiac involvement for systemic diseases.
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Laustrup H, Voss A, Lund PE. Granulomatosis with polyangiitis and cardio vascular co-morbidity in Denmark. A registry-based study of 21 years of follow-up. J Transl Autoimmun 2021; 4:100136. [PMID: 34901815 PMCID: PMC8637641 DOI: 10.1016/j.jtauto.2021.100136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To describe the epidemiology of granulomatosis with polyangiitis (GPA) in Denmark. To investigate if cardiovascular (CV) related comorbidity and death were increased among Danish AAV patients registered with a diagnosis of granulomatosis with polyangiitis (GPA) in Denmark. To investigate if there was a temporal relation between diagnosis of GPA and CV disease and death. METHODS A population-based cohort study was performed using the Danish Civil Registration System, the Danish National Patient Registry and the Danish Cause of Death Register in the period January 1, 1995, to December 31, 2015. Patients registered twice or more with a diagnosis of GPA were included. Annual incidence rate (IR), point prevalence (PP) and standardized mortality rate (SMR) were calculated. The entire adult population in Denmark served as control population. CV morbidity and death caused by CV disease was registered. RESULTS We identified 1829 individuals with GPA. The median annual IR was 20.5/1,000,000 and PP increased from 64 to 277/1,000,000 in 2015. Overall SMR was 2.14. Among patients with GPA 171 had a hospital diagnosis of acute myocardial infarction (AMI). Compared to the control population, the hazard ratio (HR) of AMI was 2.47 (95% CI 1.24-4.94) during the first 3 months after the GPA diagnosis. From 3 months to one year declining to 1.41 (95%CI 0.80-2.49) and after 10 years the HR was still slightly increased to 1.64 (95%CI 1.20-2.23). The risk of a diagnosis of heart failure (HF) was markedly increased with a HR at 7.22 (95% CI 4.55-11.46) during the first 3 months after a GPA diagnosis, after three months up to one year 2.94 (95%CI 1.87-4.69), and 2.07 (95% CI 1.54-2.78) after 10 years. The total number of CV deaths in the GPA cohort was 307. During the first three months after a GPA diagnosis, the HR was increased to 9.51 (95%CI 7.12-12.70) declining to 2.51 (95% CI 1.77-3.58) after one year, but still increased to 1.56 (95% CI 1.23-1.98) after 10 years. Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation. CONCLUSION In a population-based study on GPA, we found stable incidence, increasing prevalence and an overall increased SMR. The risk of CV comorbidity and of CV death among patients with a register diagnosis of GPA was increased.
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Affiliation(s)
- Helle Laustrup
- Department of Rheumatology, Odense University Hospital, Denmark
| | - Anne Voss
- Department of Rheumatology, Odense University Hospital, Denmark
| | - Peter Enemark Lund
- Master of Science: Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
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Borowiec A, Kowalik I, Chwyczko T, Jankowski J, Kandyba P, Życińska K. Predictors of cardiovascular events in patients with primary systemic vasculitis: A 5 years prospective observational study. Eur J Intern Med 2021; 91:70-74. [PMID: 34074580 DOI: 10.1016/j.ejim.2021.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA) - associated systemic vasculitis and is characterised by inflammation of blood vessels. Systemic vasculitis exhibits an enhanced cardiovascular morbidity and cardiovascular disease (CVD) has become a leading cause of death in this group of patients. OBJECTIVES The aim of the present study was to assess the prevalence of clinical manifestation of atherosclerosis and its relation with classic risk factors for atherosclerosis, echocardiographic parameters and laboratory findings in GPA patients. PATIENTS AND METHODS The group of consecutive patients with GPA were followed in the study. RESULTS One hundred six patients with GPA (mean age 50.4 ± 14.9 yrs, 67 female) were prospectively followed for 5.1 ± 1.6 yrs. In 19 patients (18%) cardiovascular disease (9 acute coronary syndromes, 4 symptomatic peripheral vascular diseases and 6 strokes) occurred in association with GPA. In a multivariate model, only age was predictive of cardiovascular events in this group of patients (OR=1.078, 95% CI: 1.025-1.134, p = 0.003). During observation in patients without CVD the level of hs-CRP and D-dimer were significantly reduced on the follow-up visit (p = 0.041, p = 0.0002). On the other hand, in patients with CV events there was no significant differences in both markers' concentrations despite clinical remission. CONCLUSIONS The age was the only independent predictor of cardiovascular events. Persistent elevation of inflammatory and prothrombotic markers despite clinical remission of the disease could be an indicator of premature atherosclerosis development in patients with systemic vasculitis.
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Affiliation(s)
- Anna Borowiec
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland; National Institute of Oncology, Warsaw, Poland.
| | | | | | - Jan Jankowski
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland
| | - Piotr Kandyba
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland
| | - Katarzyna Życińska
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland; Central Clinical Hospital of Ministry of MSWiA, Warsaw, Poland
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Tieu J, Lester S, Raymond W, Keen HI, Hill CL, Nossent J. Mortality and cause of death in patients with AAV/PAN in Australia-a population-based study. Rheumatology (Oxford) 2021; 61:1062-1071. [PMID: 34117869 DOI: 10.1093/rheumatology/keab469] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We compared survival and causes of death in Western Australian (WA) anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) and polyarteritis nodosa (PAN) patients with controls and the WA population. METHODS In this data linkage study, we identified patients with incident AAV/PAN and age, sex and temporally matched controls 1980 - 2014 from the WA Rheumatic Disease Epidemiological Registry. Survival analyses and time-varying analyses were performed. RESULTS 614 patients with incident AAV/PAN were compared with 6672 controls; 229 AAV/PAN patients died over 5277 person years of follow-up and 1009 controls died over 73835 person years.Survival was reduced in patients with AAV/PAN compared with matched controls (hazard ratio (HR) 3.5 (95% confidence interval (CI) 3.1, 4.1)), and matched WA population rates (standardised mortality ratio (SMR) 3.3 (95%CI 2.9, 3.8)). Greatest excess mortality in AAV/PAN patients was observed in the first year after diagnosis and remained higher than controls throughout follow-up. Greater excess mortality was observed in patients >60 years at diagnosis.In cause-specific analyses, mortality HR for vasculitis, infection, non-infective respiratory disease were greatest early after diagnosis and remained persistently elevated. The HR for malignancy and cerebrovascular disease related deaths increased during follow-up, and were constant for ischaemic heart disease (IHD) related deaths. CONCLUSION Mortality was increased in AAV/PAN patients compared with controls, with patients older at diagnosis at greater risk. These findings provide mortality risk for AAV/PAN in an Australian population, highlighting key contributors to mortality at different time periods over follow-up and potential areas of focus for reducing mortality.
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Affiliation(s)
- Joanna Tieu
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia.,Rheumatology Unit, Lyell McEwin Hospital, Adelaide, Australia
| | - Susan Lester
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Warren Raymond
- School of Medicine, University of Western Australia, Perth, Australia
| | - Helen I Keen
- School of Medicine, University of Western Australia, Perth, Australia.,Rheumatology Department, Fiona Stanley Hospital, Perth, Australia
| | - Catherine L Hill
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Johannes Nossent
- School of Medicine, University of Western Australia, Perth, Australia.,Rheumatology Department, Sir Charles Gairdner Hospital, Perth, Australia
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Osman M, Cohen Tervaert JW, Pagnoux C. Avacopan for the treatment of ANCA-associated vasculitis. Expert Rev Clin Immunol 2021; 17:717-726. [PMID: 34006155 DOI: 10.1080/1744666x.2021.1932466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Anti-neutrophil cytoplasm autoantibodies (ANCA)-associated vasculitides (AAVs) are a group of rare heterogeneous diseases characterized by blood vessel inflammation resulting in organ destruction and death. Although various treatment strategies have resulted in marked improvement in vasculitis-specific outcomes, many patients with AAV continue to suffer from complications related to the prolonged use of glucocorticoids (GC) such as infections, metabolic abnormalities, and increased cardiovascular morbidity. Recently, activation of the alternative complement pathway has been implicated in the augmentation of the damage caused by AAV via the complement C5a receptor (C5aR1, CD88). Specifically targeting this pathway may lead to improved outcomes in patients with AAV.Areas covered: In this article, we have summarized the rationale for targeting the complement pathway in AAV. The relevant pre-clinical, phase I, II and III findings with emphasis on the efficacy, and safety of avacopan, a new oral competitive inhibitor that interferes with the binding of C5a to C5aR1 (CD88), are reviewed.Expert opinion: These results are encouraging, may led to major changes in the treatment approach for AAV, and give rise to future studies utilizing complement inhibitors in AAV patients, and potentially in other immune mediated diseases.
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Affiliation(s)
- Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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8
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Visceral adipose tissue in granulomatosis with polyangiitis: association with disease activity parameters. Clin Rheumatol 2021; 40:2835-2841. [PMID: 33483919 DOI: 10.1007/s10067-021-05592-z] [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: 10/06/2020] [Revised: 12/21/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the body composition (BC) of patients with granulomatosis with polyangiitis (GPA) compared to healthy controls, emphasizing visceral adipose tissue (VAT) and associated BC parameters with disease activity, the damage index, and inflammatory parameters in patients with GPA. METHODS This study was conducted in 43 patients with GPA and 43 healthy controls matched by sex, age, and body mass index (BMI). BC was analyzed using dual-energy X-ray absorptiometry (DXA). The fat mass parameters evaluated were total fat mass (FM), adiposity (%), the fat mass index (FMI: fat mass/ht2), and VAT (g, cm2, cm3). Disease activity was assessed by the Birmingham Vasculitis Activity Score (BVAS). Damage was assessed by the Vasculitis Damage Index (VDI). C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were measured. RESULTS Comparing patients with GPA with healthy controls, patients had a significantly greater VAT (VAT in g: 685.81 ± 306.10 vs. 581.21 ± 235.57, p = 0.04; VAT in cm2: 142.23 ± 63.48 vs. 119.84 ± 49.54, p = 0.03; VAT in cm3: 741.33 ± 330.97 vs. 628.44 ± 254.66, p = 0.04). Patients with higher VAT (≥ 768 g) had an increased value of ESR (22.77 ± 26.79 vs. 11.57 ± 11.30 mm/1st hour, p = 0.04) and an increased value of BVAS (3.18 ± 4.15 vs. 0.90 ± 1.70, p = 0.01) when compared to patients with less VAT (< 768 g). CONCLUSION Patients with GPA have altered BC compared to healthy controls. Moreover, higher VAT was associated with disease activity and higher inflammatory markers, suggesting a relationship between GPA activity and adiposity parameters. Key points • Granulomatosis with polyangiitis patients have increased visceral adipose tissue when compared to health controls; • Granulomatosis with polyangiitis patients with higher values of visceral adipose tissue have worse disease activity and higher inflammatory markers; • This paper represents important contribution to the well-studied association between vasculitis and inflammatory markers, adding the role of adipose visceral tissue in the disease physiopathology.
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Wallace ZS, Fu X, Harkness T, Stone JH, Zhang Y, Choi H. All-cause and cause-specific mortality in ANCA-associated vasculitis: overall and according to ANCA type. Rheumatology (Oxford) 2021; 59:2308-2315. [PMID: 31846030 DOI: 10.1093/rheumatology/kez589] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/31/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE The objective of this study was to evaluate causes of death in a contemporary inception cohort of ANCA-associated vasculitis patients, stratifying the analysis according to ANCA type. METHODS We identified a consecutive inception cohort of patients newly diagnosed with ANCA-associated vasculitis from 2002 to 2017 in the Partners HealthCare System and determined vital status through the National Death Index. We determined cumulative mortality incidence and standardized mortality ratios (SMRs) compared with the general population. We compared MPO- and PR3-ANCA+ cases using Cox regression models. RESULTS The cohort included 484 patients with a mean diagnosis age of 58 years; 40% were male, 65% were MPO-ANCA+, and 65% had renal involvement. During 3385 person-years (PY) of follow-up, 130 patients died, yielding a mortality rate of 38.4/1000 PY and a SMR of 2.3 (95% CI: 1.9, 2.8). The most common causes of death were cardiovascular disease (CVD; cumulative incidence 7.1%), malignancy (5.9%) and infection (4.1%). The SMR for infection was greatest for both MPO- and PR3-ANCA+ patients (16.4 and 6.5). MPO-ANCA+ patients had an elevated SMR for CVD (3.0), respiratory disease (2.4) and renal disease (4.5). PR3- and MPO-ANCA+ patients had an elevated SMR for malignancy (3.7 and 2.7). Compared with PR3-ANCA+ patients, MPO-ANCA+ patients had a higher risk of CVD death [hazard ratio 5.0 (95% CI: 1.2, 21.2]; P = 0.03]. CONCLUSION Premature ANCA-associated vasculitis mortality is explained by CVD, infection, malignancy, and renal death. CVD is the most common cause of death, but the largest excess mortality risk in PR3- and MPO-ANCA+ patients is associated with infection. MPO-ANCA+ patients are at higher risk of CVD death than PR3-ANCA+ patients.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Mongan Institute.,Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, all at.,Massachusetts General Hospital.,Harvard Medical School, Boston, MA, USA
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Mongan Institute.,Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, all at.,Massachusetts General Hospital
| | - Tyler Harkness
- Clinical Epidemiology Program, Mongan Institute.,Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, all at.,Massachusetts General Hospital
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, all at.,Massachusetts General Hospital.,Harvard Medical School, Boston, MA, USA
| | - Yuqing Zhang
- Clinical Epidemiology Program, Mongan Institute.,Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, all at.,Massachusetts General Hospital.,Harvard Medical School, Boston, MA, USA
| | - Hyon Choi
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, all at.,Massachusetts General Hospital.,Harvard Medical School, Boston, MA, USA
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Soulaidopoulos S, Madenidou AV, Daoussis D, Melissaropoulos K, Mavrogeni S, Kitas G, Dimitroulas T. Cardiovascular Disease in the Systemic Vasculitides. Curr Vasc Pharmacol 2020; 18:463-472. [PMID: 32000652 DOI: 10.2174/1570161118666200130093432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/28/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023]
Abstract
The vasculitides are a heterogeneous group of disorders, characterized by inflammatory cell infiltration and necrosis of blood vessels that cause vascular obstruction or aneurysm formation, affecting various organs such as lungs, kidneys, skin and joints. Cardiac involvement is commonly encountered in primary systemic vasculitis and it is associated with increased morbidity and mortality. Depending on the dominant pathophysiological mechanism, heart complications may manifest in different ways, including myocardial ischemia due to impaired micro- or macrovascular circulation, progressive heart failure following valvular heart disease and myocardial dysfunction, (sub) clinical myocarditis, pericarditis, pulmonary hypertension as well as arteritis of coronary vessels. Beyond cardioprotective regimens, aggressive immunosuppression reduces the inflammatory burden and modulates the progression of cardiovascular complications. Perioperative management of inflammation, when surgical treatment is indicated, improves surgical success rates and postoperative long-term prognosis. We aim to provide an overview of the pathogenetic, diagnostic and therapeutic principles of cardiovascular involvement disease in the various forms of systemic vasculitis.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Athens School of Medicine, Hippokration Hospital, Athens, Greece
| | | | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, Faculty of Medicine, University of Patras Medical School, Patras, Greece
| | - Konstantinos Melissaropoulos
- Department of Rheumatology, Patras University Hospital, Faculty of Medicine, University of Patras Medical School, Patras, Greece
| | | | - George Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, United Kingdom
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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11
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Garner S, Khalidi N. Updates in the treatment of granulomatosis with polyangiitis and microscopic polyangiitis: At a crossroad. Presse Med 2020; 49:104038. [PMID: 32634467 DOI: 10.1016/j.lpm.2020.104038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
There have been great advances in the management of ANCA associated vasculitis over the past decades. We have gone from an era where the disease was almost universally fatal to trying to prevent long-term side effects of treatment regimens. With the ability to use pulse cyclophosphamide or rituximab as alternates to oral cyclophosphamide for induction of remission, side effects of therapy have been greatly reduced. New approaches have drastically changed our approach to maintenance and we now favor much longer durations of maintenance therapy, as they are more successful in preventing relapse. Steroids have long been the bane of treatment as they are associated with a significant risk of infection and metabolic consequences. We are now in a steroid-sparing and looking ahead to a steroid-free era with new data being published showing lower doses of steroids being equally effective and several ongoing seminal trials looking at agents that could completely replace steroids very early on.
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12
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Smith R. Complications of therapy for ANCA-associated vasculitis. Rheumatology (Oxford) 2020; 59:iii74-iii78. [PMID: 31967652 DOI: 10.1093/rheumatology/kez618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/04/2019] [Indexed: 01/30/2023] Open
Abstract
The introduction of immunosuppressive therapies has transformed ANCA-associated vasculitis (AAV) from a largely fatal condition to a chronic relapsing disorder. However, progressive organ damage and disability, both from the disease process itself and from therapies used for treatment, eventually affect the majority of patients. Infection, rather than uncontrolled vasculitis, is the greatest cause of early mortality and remains a major problem thereafter. Increased rates of malignancy and cardiovascular disease are additional important long term sequelae. This review focuses on the complications associated with the immunosuppressive therapies most commonly used to treat ANCA-associated vasculitis, and considers prophylactic and monitoring strategies to minimize these risks. Achieving a balance between immunosuppression to reduce relapse risk and minimizing the adverse effects associated with therapy has become key. The contribution of glucocorticoids to treatment toxicity is increasingly being recognized, and future therapeutic strategies must concentrate on glucocorticoid minimization or sparing strategies. Development of robust predictors of an individual's future clinical course is needed in order to individually tailor treatment regimens.
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Affiliation(s)
- Rona Smith
- Department of Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.,University of Cambridge, UK
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13
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Neumann I. Immunosuppressive and glucocorticoid therapy for the treatment of ANCA-asssociated vasculitis. Rheumatology (Oxford) 2020; 59:iii60-iii67. [DOI: 10.1093/rheumatology/keaa035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
ANCA-associated vasculitis (AAV) is a systemic, potentially organ and life threatening chronic autoimmune disease. With current management strategies, such as high-dose glucocorticoids in combination with cyclophosphamide or rituximab, outcomes have progressively improved with overall remission rates of 70–90%. However, relapse rates after discontinuation of therapy are consistently high, and treatment-related toxicity, mainly driven by glucocorticoids, still determines morbidity and quality of life. Prevention of relapses while minimizing adverse events is a major goal of long-term treatment, but the optimal duration of maintenance therapy and the role and utility of glucocorticoids in this context remains controversial. This review of induction and maintenance treatment of AAV aims to offer practical advice on immunosuppressive therapies and patient care, addressing individual risk factors and their therapeutic implications. It will discuss benefits and harms of the use of glucocorticoids, particularly focusing on recent advances in steroid sparing concepts.
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Affiliation(s)
- Irmgard Neumann
- Vasculitis.at, Vienna, Austria
- IZZ, Immunologiezentrum Zurich, Zurich, Switzerland
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Merkel PA, Jayne DR, Wang C, Hillson J, Bekker P. Evaluation of the Safety and Efficacy of Avacopan, a C5a Receptor Inhibitor, in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Treated Concomitantly With Rituximab or Cyclophosphamide/Azathioprine: Protocol for a Randomized, Double-Blind, Active-Controlled, Phase 3 Trial. JMIR Res Protoc 2020; 9:e16664. [PMID: 32088663 PMCID: PMC7175182 DOI: 10.2196/16664] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis is a serious, often life-threatening disease. In new-onset disease or a relapse, the standard treatment is immunosuppressive therapy with glucocorticoids; these therapies are associated with substantial short- and long-term toxicity. Complement component 5a (C5a) binding to C5a receptor (C5aR) may play a central role in the pathogenesis of ANCA-associated vasculitis. Avacopan is a novel, orally bioavailable, and highly selective antagonist of human C5aR. Avacopan does not interfere with the production of C5b or the membrane attack complex (ie, terminal complement complex) and does not block C5a binding to a second receptor, C5L2 (also called C5aR2), shown to be protective in antimyeloperoxidase glomerulonephritis. This trial will evaluate if avacopan replaces the need for chronic glucocorticoids in the treatment of ANCA-associated vasculitis. Objective The aim of this study is to determine the proportions of patients in remission at week 26 and with sustained remission at week 52, defined as Birmingham Vasculitis Activity Score=0, and not taking glucocorticoids within the 4 weeks before week 26 and week 52, respectively. Methods The Avacopan Development in Vasculitis to Obtain Corticosteroid elimination and Therapeutic Efficacy study is a randomized, double-blind, active-comparator (prednisone), 2-arm study evaluating the safety and efficacy of avacopan versus prednisone, administered in combination with other immunosuppressive therapy. Eligible subjects will have active disease requiring induction of remission. Subjects are stratified based on the type of immunosuppressive therapy, ANCA subtype, and new or relapsing disease. Target sample size is 300 patients, enrolled at over 200 sites globally. All authors and local ethics committees approved the study design. All patients will provide informed consent. Results Enrollment of patients was completed in Q4 2018. Topline results are anticipated to be published by Q3 2020. Conclusions Results will be released irrespective of whether the findings are positive or negative. Trial Registration ClinicalTrials.gov NCT02994927; https://clinicaltrials.gov/ct2/show/NCT02994927 International Registered Report Identifier (IRRID) DERR1-10.2196/16664
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Affiliation(s)
- Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - David R Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Chao Wang
- Biostatistics, Pharma Data Associates, LLC, Piscataway, NJ, United States
| | - Jan Hillson
- Research and Development, ChemoCentryx, Inc, Mountain View, CA, United States
| | - Pirow Bekker
- Research and Development, ChemoCentryx, Inc, Mountain View, CA, United States
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15
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Kelleher C, Kocinsky H. Novel Complement Therapeutics in Development as Potential Treatment for Renal Disease. Adv Chronic Kidney Dis 2020; 27:95-103. [PMID: 32553251 DOI: 10.1053/j.ackd.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 11/11/2022]
Abstract
The complement system is an evolutionarily ancient arm of the innate immune system. It remains, however, one of the last major pathways in immunology for which specific pharmaceutical antagonists have been developed. In recent years, a fundamental role for complement has been described in many different renal diseases, including both pauci-immune as well as immune-complex diseases. Since the 2011 FDA approval of eculizumab, the only marketed complement antagonist, no new therapeutics have entered clinical practice. There are now multiple new agents in clinical trials, from oral molecules to small inhibitory RNA, that target the classical, lectin, and alternative pathways. Herein we summarize several potential renal diseases in which complement inhibitors may provide a therapeutic benefit, as well as specific complement inhibitors in development.
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16
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Mavrogeni SI, Dimitroulas T, Kitas GD. Cardiovascular magnetic resonance in the diagnosis and management of cardiac and vascular involvement in the systemic vasculitides. Curr Opin Rheumatol 2020; 31:16-24. [PMID: 30407225 DOI: 10.1097/bor.0000000000000560] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Cardiac manifestations in systemic vasculitides, either primary or secondary due to infection, malignancy or autoimmune rheumatic diseases may be life-threatening. Cardiovascular (CVD) magnetic resonance (CMR) has been recently proposed as an ideal noninvasive tool to evaluate systemic vasculitides. In the present article, we present an overview of CMR in the diagnosis and follow-up of cardiac involvement in systemic vasculitides. RECENT FINDINGS CMR is a noninvasive, nonradiating modality, capable to assess cardiac function, perfusion and tissue characterization that can be of great diagnostic value in both primary and secondary systemic vasculitides. It has been already documented that CMR is superior to other imaging modalities, because it has great versatility and higher spatial resolution that allows the detection of early CVD phenomena occurring during systemic vasculitides. Magnetic resonance angiography and oedema-fibrosis imaging detect early CVD involvement such as acute and/or chronic inflammation, coronary macro-micro-circulation abnormalities and/or small vessel vasculitis. SUMMARY CMR due to its great versatility gives valuable information about cardiac function, perfusion, type of fibrosis and vascular integrity that may significantly contribute to treatment decisions beyond vascular scores, other disease activity or severity indices or the acute phase response.
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Affiliation(s)
| | | | - George D Kitas
- Arthritis Research UK Centre for Epidemiology, Manchester University, Manchester, UK
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17
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Sánchez-Díaz G, Escobar F, Villaverde-Hueso A, de la Paz MP, Alonso-Ferreira V. Temporal and Cartographic Analyses of the Distribution within Spain of Mortality Due to Granulomatosis with Polyangiitis (1984⁻2016). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16081388. [PMID: 30999675 PMCID: PMC6518272 DOI: 10.3390/ijerph16081388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/12/2019] [Accepted: 04/13/2019] [Indexed: 11/16/2022]
Abstract
The aim is to conduct a descriptive, population-based study in order to assess temporal and spatial changes in mortality due to granulomatosis with polyangiitis (GPA) in Spain from 1984 to 2016. Mortality data were obtained from the Spanish Annual Death Registry. Deaths in which GPA was the underlying cause were selected using the 446.4 and M31.3 codes from the International Classification of Diseases, 9th and 10th revision. Annual average age at death and age-adjusted mortality rates were calculated. Geographic analysis was performed at municipality and district level. Variations in mortality according to the type of municipality (urban, agro-urban or rural), district and geographic location (degrees of latitude) were assessed using standardized mortality ratios (SMRs) and smoothed-SMRs. Over the whole period, 620 deaths due to GPA were identified. Age at death increased at an average annual rate of 0.78% over the period 1987–2016 (p < 0.05). Age-adjusted mortality rates increased by an annual average of 20.58% from 1984 to 1992, after which they fell by 1.91% a year (p < 0.05). The agro-urban category had the highest percentage (4.57%) of municipalities with a significantly higher GPA mortality rate than expected. Geographic analysis revealed four districts with a higher risk of death due to GPA, two in the North of Spain and two in the South. This population-based study revealed an increase in the age at death attributed to GPA. Age-adjusted mortality rates went up sharply until 1992, after which they started to decline until the end of the study period. Geographic differences in mortality risk were identified but further studies will be necessary to ascertain the reasons for the distribution of GPA disease.
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Affiliation(s)
- Germán Sánchez-Díaz
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Department of Geology, Geography and Environmental Sciences, University of Alcala, 28801 Alcalá de Henares, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), 28029 Madrid, Spain.
| | - Francisco Escobar
- Department of Geology, Geography and Environmental Sciences, University of Alcala, 28801 Alcalá de Henares, Spain.
| | - Ana Villaverde-Hueso
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), 28029 Madrid, Spain.
| | - Manuel Posada de la Paz
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), 28029 Madrid, Spain.
| | - Verónica Alonso-Ferreira
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), 28029 Madrid, Spain.
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18
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Robson JC, Jayne D, Merkel PA, Dawson J. Systemic vasculitis and patient-reported outcomes: how the assessment of patient preferences and perspectives could improve outcomes. Patient Relat Outcome Meas 2019; 10:37-42. [PMID: 30804691 PMCID: PMC6372855 DOI: 10.2147/prom.s163601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The systemic vasculitides are a group of multisystem diseases, which can be life and organ threatening. High-dose immunosuppressants are required to control inflammation in vital organs, such as the kidneys, lungs, skin, joints, and eyes. Patients report a range of impacts on their health-related quality of life due to symptoms, irreversible damage, and the adverse effects of medications. The measurement of patient perspectives within clinical studies in vasculitis is essential to capture outcomes of greatest importance to patients. Validated generic, disease-specific and symptom-specific patient-reported outcomes available for use in patients with systemic vasculitis are reviewed here.
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Affiliation(s)
- Joanna C Robson
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK,
- Faculty of Health and Applied Sciences, University Hospitals Bristol NHS Trust, Bristol, UK,
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine
- Department of Biostatistics, Epidemiology, and Informatic, University of Pennsylvania, Philadelphia, PA, USA
| | - Jill Dawson
- Nuffield Department of Population Health (HSRU), University of Oxford, Oxford, UK
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19
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Panupattanapong S, Stwalley DL, White AJ, Olsen MA, French AR, Hartman ME. Epidemiology and Outcomes of Granulomatosis With Polyangiitis in Pediatric and Working-Age Adult Populations In the United States: Analysis of a Large National Claims Database. Arthritis Rheumatol 2018; 70:2067-2076. [PMID: 29806148 PMCID: PMC6258356 DOI: 10.1002/art.40577] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 05/24/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The incidence and prevalence of granulomatosis with polyangiitis (GPA) in the US is not well characterized. Owing to its rarity, outcomes data in pediatric-onset GPA are also lacking. The aims of this study were to describe the epidemiology of GPA and outcomes in GPA patients in the US, and to compare outcomes between pediatric and working-age adult patients. METHODS A retrospective cohort study using the 2006-2014 Truven Health Analytics MarketScan Commercial Claims and Encounters Database was conducted. The incidence and prevalence rates of pediatric and adult GPA (age <65 years) were calculated. Outcomes among the 2 age groups were analyzed. RESULTS A total of 5,562 cases of GPA were identified, of which 214 (3.8%) were pediatric onset and 5,348 (96.2%) were adult onset. The incidence rate of pediatric-onset GPA was 1.8 cases per 1 million person-years, compared to 12.8 cases per 1 million person-years in working-age adults. There was a slight female preponderance in both groups (63% and 53% among pediatric and adult GPA patients, respectively). Rates of hospitalization and severe infections were high in both children and working-age adults, but children had more frequent hospitalizations (rate ratio [RR] 1.3 [95% confidence interval (95% CI) 1.1-1.4]) and 2-3-times higher rates of leukopenia (RR 2.6 [95% CI 1.5-4.3]), neutropenia (RR 2.2 [95% CI 1.2-4.0]), and hypogammaglobulinemia (RR 3.7 [95% CI 2.0-6.4]). Time-to-event analyses showed no differences in the time to hospitalization, severe infection, major relapse, or end-stage renal disease. CONCLUSION This study represents the largest cohort of GPA reported to date. Pediatric GPA patients experienced more frequent hospitalizations and were more vulnerable to hematologic complications than non-elderly adult patients.
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Affiliation(s)
| | | | - Andrew J. White
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Margaret A. Olsen
- Division of Infectious Diseases, Department of Medicine
- Division of Public Health Sciences, Department of Surgery
| | | | - Mary E. Hartman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University, St. Louis, MO
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20
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Miloslavsky EM, Niles JL, Wallace ZS, Cortazar FB, Fernandes A, Laliberte K, Stone JH. Reducing glucocorticoid duration in ANCA-associated vasculitis: A pilot trial. Semin Arthritis Rheum 2018. [DOI: 10.1016/j.semarthrit.2018.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Epidemiology of Granulomatosis with Polyangiitis in Poland, 2011-2015. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1116:131-138. [PMID: 29971682 DOI: 10.1007/5584_2018_239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a form of vasculitis that affects small- and medium-sized vessels in many organs. The aim of the study was to describe the epidemiology of GPA in Poland in 2011-2015, including the incidence and prevalence rates. The authors conducted a retrospective, population-based study, using hospital discharge records with GPA diagnosis. GPA incidence was estimated on the basis of the data from the Polish hospital morbidity study carried out by the National Institute of Public Health. The final study group consisted of 1491 patients (749 females, 742 males) who were first time hospitalized with the diagnosis of GPA. The average annual incidence of GPA in Poland was 7.7/1,000,000 (95% CI, 4.1-11.4), and the point prevalence at the end of 2015 was 36/1,000,000. A statistically significant decrease in the GPA incidence was noticed in this study. A 1-year survival rate for GPA was 94%. In conclusion, the incidence and prevalence rates of GPA in Poland are similar to that reported in other European countries. The study provides recent epidemiological data on GPA in Poland, which may be useful for comparisons with other geographical regions.
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22
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Marzano AV, Raimondo MG, Berti E, Meroni PL, Ingegnoli F. Cutaneous Manifestations of ANCA-Associated Small Vessels Vasculitis. Clin Rev Allergy Immunol 2018; 53:428-438. [PMID: 28578472 DOI: 10.1007/s12016-017-8616-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Skin lesions are frequent manifestations of underlying systemic conditions, including systemic autoimmune vasculitis. In particular, anti-neutrophil cytoplasmic antibodies (ANCA) are associated with distinct forms of vasculitis characterized by inflammatory cell infiltration of the walls of small and medium-sized vessels leading to vascular destruction and tissue necrosis. ANCA-associated vasculitis is rare and systemic diseases, which can be classified based on different distribution of vascular inflammation and presence or absence of granulomatosis and asthma. Despite their diversities, ANCA-associated vasculitis, namely microscopic polyangiitis, granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis, can all display a broad variety of cutaneous manifestations, which can appear during the course of the disease or even as first sign at the time of onset. Different skin manifestations might coexist in the same patient and occur in different occasions during the course of the vasculitis. Thus, a deep knowledge of the spectrum of skin lesions as part of ANCA-associated vasculitis is mandatory for a correct diagnostic process, whenever cutaneous vasculitis is suspected. Due to this broad variety of manifestations, the diagnosis of skin involvement in ANCA-associated vasculitis is very challenging and it must be supported by a detailed medical history, accurate physical examination, specific histopathological analysis of skin biopsy and the presence of ANCA serology. In this review, we focus on the cutaneous manifestations that can develop in the context of ANCA-associated vasculitis, detailing the clinical features, the histopathological aspects as well as the direct immunofluorescence studies for each of the three conditions. Moreover, we acknowledged the differential diagnoses that must be ruled out in the diagnostic process and the main therapeutic approaches available for treatment of ANCA-associated vasculitis.
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Affiliation(s)
- Angelo Valerio Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Unità Operativa di Dermatologia, IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Maria Gabriella Raimondo
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Emilio Berti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Unità Operativa di Dermatologia, IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Pier Luigi Meroni
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy. .,Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy.
| | - Francesca Ingegnoli
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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23
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Shobha V, Fathima S, Prakash R. Granulomatosis with polyangiitis: clinical course and outcome of 60 patients from a single center in South India. Clin Exp Med 2018; 18:347-353. [PMID: 29492716 PMCID: PMC7102363 DOI: 10.1007/s10238-018-0492-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/19/2018] [Indexed: 12/18/2022]
Abstract
Granulomatosis with polyangiitis (GPA) previously known as Wegener's granulomatosis is one of the forms of idiopathic systemic vasculitis. There is very scanty data available on GPA in Asian and Indian population. We studied data of 60 patients from southern India, diagnosed with GPA to describe the physical characteristics, the treatment, and outcome. Patients who fulfilled any two of the four criteria proposed by the American College of Rheumatology, and those with clinical features of GPA with ANCA positivity and histopathological confirmation, were included in the study. Disease activity and damage were assessed by Birmingham Vasculitis Activity Score v. 3 (BVAS v. 3) and Vasculitis Damage Index (VDI), respectively. Relapses were defined as recurrence of GPA of sufficient severity to require treatment or increase in the dose of treatment on a patient who was previously stable. Out of 60 patients, initial BVAS evaluation showed that 57 (95%) patients had severe disease and 3 (5%) patients had limited disease where median BVAS was 21.5 (range 17-44). Follow-up BVAS evaluation for severe disease showed that 13 (22.8%) patients continued with severe disease of which 9 patients did not survive, 24 (42.3%) had remission, 11 (19.2%) had persistent disease, and 9 (15.7%) were lost to follow-up. The mean VDI score was 2.5 ± 2. Renal involvement was established in 42 (70%) patients. Upper and lower respiratory involvement was seen in 38 (63%) patients. Nervous system involvement was noted in the 15 (25%) patients. Articular manifestations were seen in 16 (27%) patients. Diverse clinical manifestation delay early diagnosis and treatment of this potentially treatable vasculitis. Focused approach could expedite early diagnosis and can reduce the mortality.
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Affiliation(s)
- Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St. Johns National Academy of Health Sciences, Bengaluru, India.
| | - Saba Fathima
- Department of Medicine, St. John's National Academy of Health Sciences, Bengaluru, India
| | - Ravi Prakash
- Department of Nephrology, St. John's National Academy of Health Sciences, Bengaluru, India
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24
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La-Crette J, Royle J, Lanyon PC, Ferraro A, Butler A, Pearce FA. Long-term outcomes of daily oral vs. pulsed intravenous cyclophosphamide in a non-trial setting in ANCA-associated vasculitis. Clin Rheumatol 2017; 37:1085-1090. [PMID: 29247314 PMCID: PMC5880843 DOI: 10.1007/s10067-017-3944-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/13/2017] [Accepted: 11/23/2017] [Indexed: 11/29/2022]
Abstract
We aimed to compare risk of death, relapse, neutropenia and infection requiring hospital admission between unselected ANCA-associated vasculitis (AAV) patients according to whether cyclophosphamide induction was by daily oral (PO) or pulse intravenous (IV) route. We identified all newly diagnosed AAV patients treated with PO or IV cyclophosphamide between March 2007 and June 2013. We used Cox and logistic regression models to compare mortality, relapse and adverse events and adjusted these for age, renal function and other significant confounders. Fifty-seven patients received PO and 57 received IV cyclophosphamide. One-year survival was 86.0% in PO and 98.2% in IV patients; all-time adjusted hazard ratio (HR) for PO compared to that of IV cyclophosphamide was 1.8 (95% CI 0.3–10.6, P = 0.54). One-year relapse-free survival was 80.7% in PO compared to 87.3% in IV patients, all-time adjusted HR 3.8 (0.2–846, P = 0.37). During the first 12 months, neutropenia of ≤ 0.5 × 109/L occurred in 9 (16%) PO and 0 (0%) IV cyclophosphamide patients (P = 0.003). The number of patients admitted with one or more infections was 16 (28%) in the PO group and 9 (16%) in the IV group, adjusted OR 2.2 (0.6–8.6, P = 0.23). We observed an increased risk of neutropenia, a trend towards increased risk of death and an admission with infection with PO cyclophosphamide. This adds certainty to previous studies, indicating that PO administration induces greater marrow toxicity. Infection-related admissions within 12 months of starting cyclophosphamide were higher than those in clinical trials, possibly reflecting the unselected nature of this cohort.
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Affiliation(s)
- Jonathan La-Crette
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jeremy Royle
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter C Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Nottingham NHS Treatment Centre, Nottingham, UK.,Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
| | - Alastair Ferraro
- Department of Renal Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Butler
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Fiona A Pearce
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK. .,Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK. .,Division of Epidemiology and Public Health, B126, Clinical Sciences Building, City Hospital, University of Nottingham, Nottingham, NG5 1PB, UK.
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25
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Perez MO, Oliveira RM, Levy-Neto M, Caparbo VF, Pereira RM. Serum 25-hydroxyvitamin D levels in patients with Granulomatosis with Polyangiitis: association with respiratory infection. Clinics (Sao Paulo) 2017; 72:723-728. [PMID: 29319717 PMCID: PMC5738555 DOI: 10.6061/clinics/2017(12)02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/29/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To determine the possible association of serum 25-hydroxyvitamin D (25OHD) levels with disease activity and respiratory infection in granulomatosis with polyangiitis patients during two different periods: winter/spring and summer/autumn. METHODS Thirty-two granulomatosis with polyangiitis patients were evaluated in the winter/spring, and the same patients (except 5) were evaluated in summer/autumn (n=27). The 25OHD levels were measured by radioimmunoassay. Disease activity was assessed by the Birmingham Vasculitis Activity Score Modified for Wegener's Granulomatosis (BVAS/WG) and antineutrophil cytoplasmic antibody (ANCA) positivity. Respiratory infection was defined according the Centers for Disease Control and Prevention criteria. RESULTS 25OHD levels were lower among patients in winter/spring than in summer/autumn (32.31±13.10 vs. 38.98±10.97 ng/mL, p=0.04). Seven patients met the criteria for respiratory infection: 5 in winter/spring and 2 in summer/autumn. Patients with respiratory infection presented lower 25OHD levels than those without infection (25.15±11.70 vs. 36.73±12.08 ng/mL, p=0.02). A higher frequency of low vitamin D levels (25OHD<20 ng/mL) was observed in patients with respiratory infection (37.5% vs. 7.8, p=0.04). Serum 25OHD levels were comparable between patients with (BVAS/WG≥1 plus positive ANCA) and without disease activity (BVAS/WG=0 plus negative ANCA) (35.40±11.48 vs. 35.34±13.13 ng/mL, p=0.98). CONCLUSIONS Lower 25OHD levels were associated with respiratory infection but not disease activity in granulomatosis with polyangiitis patients. Our data suggest that hypovitaminosis D could be an important risk factor for respiratory infection in granulomatosis with polyangiitis patients.
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Affiliation(s)
- Mariana O. Perez
- Divisao de Reumatologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Mauricio Levy-Neto
- Divisao de Reumatologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Valeria F. Caparbo
- Divisao de Reumatologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rosa M.R. Pereira
- Divisao de Reumatologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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26
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King C, Harper L. Avoidance of Harm From Treatment for ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:230-243. [PMID: 29201630 PMCID: PMC5694500 DOI: 10.1007/s40674-017-0082-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Purpose of review With established immunosuppressant treatment regimens for anti-neutrophil cytoplasm antibody-associated vasculitides (AAV), prognosis has significantly improved. The mainstay of treatment still comprises high-dose corticosteroids and cyclophosphamide for severe forms, although rituximab is being increasingly utilised instead of cyclophosphamide as induction therapy. AAV patients experience an excess of infections, malignancies and cardiovascular events as compared to the general population, which is a combination of the systemic inflammatory process associated with vasculitis and the adverse events from treatment. Recent findings Successful therapy should focus on suppressing disease activity and minimising treatment-related toxicity. Infection is the largest contributor to morbidity and mortality in the first year of treatment, and annual pneumococcal and influenza vaccinations, Pneumocystis jiroveci prophylaxis and tuberculosis (TB) and Hepatitis B virus screening are advised. Patients on high-dose corticosteroid treatment should have regular blood sugar monitoring, a FRAX assessment with vitamin D and calcium supplementation, consideration of prophylaxis for gastric ulcers and a cardiovascular risk assessment. Patients who are treated with cyclophosphamide could also receive MESNA to reduce the risk of chemical cystitis. Cyclophosphamide, methotrexate and azathioprine all require blood monitoring schedules due to the risk of bone marrow suppression, liver and renal toxicity. Hypogammaglobulinaemia is a recognised risk of rituximab treatment. Patients of reproductive age need to be counselled on the infertility risks with cyclophosphamide and the teratogenicity associated with it, methotrexate and mycophenolate mofetil. Summary A greater focus on identifying clinical and biological markers that will help identify those patients at greatest risk of relapse, e.g. GPA and PR3-ANCA specificity, from those patients at greatest risk of toxicity, e.g. increasing age and declining GFR, is required to allow treatment to be tailored accordingly.
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Affiliation(s)
- Catherine King
- Centre for Translational Inflammation Research University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - Lorraine Harper
- Centre for Translational Inflammation Research University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB UK
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Berti A, Cornec D, Crowson CS, Specks U, Matteson EL. The Epidemiology of Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis in Olmsted County, Minnesota: A Twenty-Year US Population-Based Study. Arthritis Rheumatol 2017; 69:2338-2350. [PMID: 28881446 DOI: 10.1002/art.40313] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 08/29/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate the annual incidence, prevalence, and mortality of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) and its subsets, granulomatosis with polyangiitis (Wegener's) (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA), in a US-based adult population. METHODS All medical records of patients with a diagnosis of, or suspicion of having, AAV in Olmsted County, Minnesota from January 1, 1996 to December 31, 2015 were reviewed. AAV incidence rates were age- and sex-adjusted to the 2010 US white population. Age- and sex-adjusted prevalence of AAV was calculated on January 1, 2015. Survival rates observed in the study cohort were compared with expected rates in the Minnesota population. RESULTS Of the 58 incident cases of AAV in Olmsted County during the study period, 23 (40%) were cases of GPA, 28 (48%) were cases of MPA, and 7 (12%) were cases of EGPA. Overall, 28 (48%) of the patients with AAV were women and 57 (98%) were white. The mean ± SD age at diagnosis was 61.1 ± 16.5 years. Thirty-four patients (61%) had myeloperoxidase (MPO)-ANCAs, and 17 (30%) were positive for proteinase 3 (PR3)-ANCAs; 5 (9%) were ANCA-negative. The annual incidence of AAV was 3.3 per 100,000 population (95% confidence interval [95% CI] 2.4-4.1). The incidence rates of GPA, MPA, and EGPA were 1.3 (95% CI 0.8-1.8), 1.6 (95% CI 1.0-2.2), and 0.4 (95% CI 0.1-0.6), respectively. The overall prevalence of AAV was 42.1 per 100,000 (95% CI 29.6-54.6). The mortality rate among AAV patients overall, and among patients with EGPA, those with MPA, and those with MPO-ANCAs, was increased in comparison to the Minnesota general population (each P < 0.05), whereas mortality rates among patients with GPA, those with PR3-ANCAs, and ANCA-negative patients did not differ from that in the general population. CONCLUSION The annual incidence of AAV in Olmsted County, Minnesota over the 20 years of the study was 3.3 per 100,000, with a prevalence of 42.1 per 100,000, which is substantially higher than the rates reported in other areas worldwide. The incidence of GPA was similar to that of MPA. Patients with MPA and those with EGPA, but not patients with GPA, experienced higher rates of mortality than that in the Minnesota general population. MPO-ANCAs were a marker of poor survival in this population of patients with AAV.
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Affiliation(s)
- Alvise Berti
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,San Raffaele Scientific Institute, Milan, Italy.,Santa Chiara Hospital, Trento, Italy
| | - Divi Cornec
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, CHU de Brest, Brest, France
| | | | - Ulrich Specks
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Eric L Matteson
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Granulomatosis with polyangiitis (Wegener's granulomatosis): a rare variant of sudden natural death. Int J Legal Med 2017; 132:243-248. [PMID: 29086054 DOI: 10.1007/s00414-017-1723-2] [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: 08/25/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is the most common form of life-threatening small-vessel vasculitis. Although its exact pathogenesis remains unclear, GPA is believed to belong to the wide complex of autoimmune diseases due to the presence of anti-neutrophil cytoplasmatic antibodies with cytoplasmic staining pattern (c-ANCA) that is expressed in activated neutrophils. GPA predominantly manifests at the upper and lower respiratory tract and the kidneys, but the impairment of multiple organ systems is possible as well. The so-called classical clinical triad of GPA comprises sinusitis, pneumonia, and glomerulonephritis. Despite the fact that there is an elevated risk of mortality for patients suffering from GPA, sudden death due to GPA is a rare and difficult differential diagnosis of sudden natural death in forensic case work. In the present article, the rare case of a 41-year-old male, who died of a sudden death due to previously undiagnosed GPA, is demonstrated. The final diagnosis was feasible by close interdisciplinary collaboration, considering the entire body of findings obtained during autopsy, histopathological investigation, and analysis of the clinical records. Therefore, it remains necessary to point out that especially for rare causes of death, interdisciplinary collaboration is essential in order to concretize the cause of death and exclude rare differential diagnoses of sudden unexpected death of hospitalized patients in forensic case work.
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Pearce FA, Grainge MJ, Lanyon PC, Watts RA, Hubbard RB. The incidence, prevalence and mortality of granulomatosis with polyangiitis in the UK Clinical Practice Research Datalink. Rheumatology (Oxford) 2017; 56:589-596. [PMID: 28013209 DOI: 10.1093/rheumatology/kew413] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Indexed: 11/13/2022] Open
Abstract
Objective To estimate the incidence, prevalence and mortality of granulomatosis with polyangiitis in the UK. Methods We conducted a historical cohort study using data from the Clinical Practice Research Datalink and Hospital Episode Statistics (HES). We calculated incidence rate ratios, adjusted for age, gender and ethnicity, using Poisson regression. Results We identified 462 cases diagnosed between 1997 and 2013. Our overall estimate of incidence was 11.8 (95% CI: 10.7, 12.9)/million person-years. The incidence was 0.88 (95% CI: 0.40, 1.96) in children (aged <16 years) and 14.0 (95% CI: 12.8, 15.4) in adults. The incidence was lower in females (adjusted incidence rate ratio = 0.68; 95% CI: 0.56, 0.81) and highest in the 55-69 year age group (adjusted incidence rate ratio = 6.8, 95% CI: 4.9, 9.6; reference group 16-39 years). The incidence was not significantly different in the Black/Minority Ethnic population from that in the White population (adjusted odds ratio = 0.78, 95% CI: 0.53, 1.13, P = 0.13). The prevalence in 2013 was 134.9 (95% CI: 121.3, 149.6)/million. Mortality was 13.6% at 1-year, and higher in the HES- than in the Clinical Practice Research Datalink-identified cases (hazard ratio = 3.16, 95% CI: 2.19, 4.56, P < 0.001). Conclusion By combining primary and secondary care datasets, we have found the incidence and mortality of granulomatosis with polyangiitis to be higher than previously reported. We predict that at present each year in the UK there will be ∼700 new cases, of whom 95 will die within 12 months.
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Affiliation(s)
- Fiona A Pearce
- Division of Epidemiology and Public Health, University of Nottingham
| | - Matthew J Grainge
- Division of Epidemiology and Public Health, University of Nottingham
| | - Peter C Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham
| | | | - Richard B Hubbard
- Division of Epidemiology and Public Health, University of Nottingham
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Wallace ZS, Lu N, Miloslavsky E, Unizony S, Stone JH, Choi HK. Nationwide Trends in Hospitalizations and In-Hospital Mortality in Granulomatosis With Polyangiitis (Wegener's). Arthritis Care Res (Hoboken) 2017; 69:915-921. [PMID: 27389595 DOI: 10.1002/acr.22976] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/21/2016] [Accepted: 06/28/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Granulomatosis with polyangiitis (Wegener's) (GPA) is a type of antineutrophil cytoplasmic antibody-associated vasculitis that often entails severe end-organ damage and treatment-related complications that frequently lead to hospitalization and death. Nationwide trends in hospitalizations and in-hospital mortality over the past 2 decades are unknown and were evaluated in this study. METHODS Using the National Inpatient Sample, the largest all-payer inpatient database in the US, trends in hospitalizations with a discharge diagnosis of GPA (formerly Wegener's granulomatosis; International Classification of Disease, Ninth Revision, Clinical Modification code 446.4) between 1993 and 2011 were studied. Analyses were performed using hospital-level sampling weights to obtain US national estimates. RESULTS From 1993 to 2011, the annual hospitalization rate for patients with a principal diagnosis of GPA increased by 24%, from 5.1 to 6.3 per 1 million US persons (P < 0.0001 for trend); however, in-hospital deaths in this group declined by 73%, from 9.1% to 2.5% (P < 0.0001 for trend), resulting in a 66% net reduction in the annual in-hospital mortality rate. The median length of stay declined by 20%, from 6.9 days in 1993 to 5.5 days in 2011 (P = 0.0002 for trend). Infection was the most common principal discharge diagnosis when GPA was a secondary diagnosis, including among those who died during hospitalization. CONCLUSION The findings from these nationally representative, contemporary inpatient data indicate that the in-hospital mortality of GPA has declined substantially over the past 2 decades, while the overall hospitalization rate for GPA increased slightly. Infection remains a common principal hospitalization diagnosis among GPA patients, including hospitalizations resulting in mortality.
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Affiliation(s)
- Zachary S Wallace
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Na Lu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eli Miloslavsky
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastian Unizony
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hyon K Choi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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31
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Jayne DRW, Bruchfeld AN, Harper L, Schaier M, Venning MC, Hamilton P, Burst V, Grundmann F, Jadoul M, Szombati I, Tesař V, Segelmark M, Potarca A, Schall TJ, Bekker P. Randomized Trial of C5a Receptor Inhibitor Avacopan in ANCA-Associated Vasculitis. J Am Soc Nephrol 2017; 28:2756-2767. [PMID: 28400446 DOI: 10.1681/asn.2016111179] [Citation(s) in RCA: 362] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/12/2017] [Indexed: 12/24/2022] Open
Abstract
Alternative C activation is involved in the pathogenesis of ANCA-associated vasculitis. However, glucocorticoids used as treatment contribute to the morbidity and mortality of vasculitis. We determined whether avacopan (CCX168), an orally administered, selective C5a receptor inhibitor, could replace oral glucocorticoids without compromising efficacy. In this randomized, placebo-controlled trial, adults with newly diagnosed or relapsing vasculitis received placebo plus prednisone starting at 60 mg daily (control group), avacopan (30 mg, twice daily) plus reduced-dose prednisone (20 mg daily), or avacopan (30 mg, twice daily) without prednisone. All patients received cyclophosphamide or rituximab. The primary efficacy measure was the proportion of patients achieving a ≥50% reduction in Birmingham Vasculitis Activity Score by week 12 and no worsening in any body system. We enrolled 67 patients, 23 in the control and 22 in each of the avacopan groups. Clinical response at week 12 was achieved in 14 of 20 (70.0%) control patients, 19 of 22 (86.4%) patients in the avacopan plus reduced-dose prednisone group (difference from control 16.4%; two-sided 90% confidence limit, -4.3% to 37.1%; P=0.002 for noninferiority), and 17 of 21 (81.0%) patients in the avacopan without prednisone group (difference from control 11.0%; two-sided 90% confidence limit, -11.0% to 32.9%; P=0.01 for noninferiority). Adverse events occurred in 21 of 23 (91%) control patients, 19 of 22 (86%) patients in the avacopan plus reduced-dose prednisone group, and 21 of 22 (96%) patients in the avacopan without prednisone group. In conclusion, C5a receptor inhibition with avacopan was effective in replacing high-dose glucocorticoids in treating vasculitis.
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Affiliation(s)
- David R W Jayne
- Department of Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom;
| | - Annette N Bruchfeld
- Department of Renal Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Lorraine Harper
- Department of Nephrology, University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
| | | | - Michael C Venning
- Department of Renal Medicine, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Patrick Hamilton
- Department of Renal Medicine, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Volker Burst
- Department of Nephrology, Rheumatology, Diabetology and General Internal Medicine, Uniklinik Cologne, Cologne, Germany
| | - Franziska Grundmann
- Department of Nephrology, Rheumatology, Diabetology and General Internal Medicine, Uniklinik Cologne, Cologne, Germany
| | - Michel Jadoul
- Service de Nephrologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Vladimír Tesař
- Department of Nephrology, Charles University, Prague, Czech Republic
| | - Mårten Segelmark
- Department of Nephrology, Linköping University, Linköping, Sweden; and
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Biscetti F, Carbonella A, Parisi F, Bosello SL, Schiavon F, Padoan R, Gremese E, Ferraccioli G. The prognostic significance of the Birmingham Vasculitis Activity Score (BVAS) with systemic vasculitis patients transferred to the intensive care unit (ICU). Medicine (Baltimore) 2016; 95:e5506. [PMID: 27902615 PMCID: PMC5134801 DOI: 10.1097/md.0000000000005506] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Systemic vasculitides represent a heterogeneous group of diseases that share clinical features including respiratory distress, renal dysfunction, and neurologic disorders. These diseases may often cause life-threatening complications requiring admission to an intensive care unit (ICU). The aim of the study was to evaluate the validity and responsiveness of Birmingham Vasculitis Activity Score (BVAS) score to predict survival in patients with systemic vasculitides admitted to ICU.A retrospective study was carried out from 2004 to 2014 in 18 patients with systemic vasculitis admitted to 2 different Rheumatology divisions and transferred to ICU due to clinical worsening, with a length of stay beyond 24 hours. We found that ICU mortality was significantly associated with higher BVAS scores performed in the ward (P = 0.01) and at the admission in ICU (P = 0.01), regardless of the value of Acute Physiology And Chronic Health Evaluation (APACHE II) scores (P = 0.50). We used receiver-operator characteristic (ROC) curve analysis to evaluate the possible cutoff value for the BVAS in the ward and in ICU and we found that a BVAS > 8 in the ward and that a BVAS > 10 in ICU might be a useful tool to predict in-ICU mortality.BVAS appears to be an excellent tool for assessing ICU mortality risk of systemic vasculitides patients admitted to specialty departments. Our experience has shown that performing the assessment at admission to the ward is more important than determining the evaluation before the clinical aggravation causing the transfer to ICU.
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Affiliation(s)
- Federico Biscetti
- Division of Rheumatology, Institute of Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University School of Medicine, Rome
| | - Angela Carbonella
- Division of Rheumatology, Institute of Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University School of Medicine, Rome
| | - Federico Parisi
- Division of Rheumatology, Institute of Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University School of Medicine, Rome
| | - Silvia Laura Bosello
- Division of Rheumatology, Institute of Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University School of Medicine, Rome
| | - Franco Schiavon
- Operative Unit of Rheumatology, Department of Internal Medicine, University of Padua, Padua, Italy
| | - Roberto Padoan
- Operative Unit of Rheumatology, Department of Internal Medicine, University of Padua, Padua, Italy
| | - Elisa Gremese
- Division of Rheumatology, Institute of Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University School of Medicine, Rome
| | - Gianfranco Ferraccioli
- Division of Rheumatology, Institute of Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University School of Medicine, Rome
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Sofos SS, Ewing J, Hughes LC, James MI. Toxic epidermal necrolysis and concurrent granulomatosis with polyangiitis (Wegener's granulomatosis). Management of a rare case and review of the literature. Scars Burn Heal 2016; 2:2059513116642129. [PMID: 29799572 PMCID: PMC5965317 DOI: 10.1177/2059513116642129] [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] [Indexed: 11/16/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare, acute life-threatening mucocutaneous
disorder that is characterised by epidermal loss/exfoliation exceeding 30% total
body surface area (TBSA) and is on a spectrum that includes erythema multiforme
and Stevens–Johnson syndrome (SJS). It is estimated that 80% of TEN cases are
related to medication reactions; the association based on the recognition that
TEN usually develops 1–3 weeks following administration of the suspect drug. It
is agreed that primary treatment consists of prompt withdrawal of causative
drugs and transfer to a regional burn unit. Transfer to a burn unit, no more
than 7 days after onset of symptoms, has been acknowledged as reducing the risk
of infections, hospital length of stay and infection-related mortality. Due to
the uncertainty surrounding TEN pathogenesis, several different modalities have
been proposed for the treatment of TEN, including high-dose intravenous
immunoglobulins, plasmapheresis, cyclophosphamide, cyclosporine and systemic
steroids; however, these therapies are relatively ineffective. The use of
systemic corticosteroids for treatment of TEN has in particular been deemed
controversial due to associations with increased infections leading to greater
length of hospital stay and increased mortality. Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s
granulomatosis, is a rare relapsing-remitting disorder of unknown aetiology,
characterised by granulomatosis inflammation and necrotising vasculitis
predominantly affecting small- to medium-sized vessels. While a 5-year survival
rate of 75–83% is now realised, relapse and associated morbidity is of
concern. The established treatment for GPA follows the recommendations of the French
National Authority for Health (HAS) for systematic necrotising vasculitis. With
induction treatment, it is recommended that GPA be treated with a combination of
systemic corticosteroids and immunosuppressants. A review of the literature failed to identify any previous case where both of
these conditions coincide. Our search was conducted through databases which
included MEDLINE, PubMed, Scopus, AMED, CINAHL and EMBASE, using keywords: toxic
epidermal necrolysis, Wegener’s granulomatosis, granulomatosis with
polyangiitis. We submit the rare case of a 22-year-old woman who presented to
our regional burn unit with both GPA and TEN, and we discuss the presentation,
investigation and multidisciplinary management of the patient, as well as
reviewing the literature regarding these two conditions. Toxic epidermal necrolysis is a potentially fatal condition where there is a
large area of skin exfoliated after the body’s reaction to a particular
medication. Its treatment is largely by stopping the medication that is thought
to have caused this reaction and also by regular dressings, thus keeping the
area clean from any infection. Granulomatosis with polyangiitis, also known as
Wegener’s granulomatosis, is another potentially fatal condition. Its treatment
is very specific; however, this treatment may be harmful to a patient with toxic
epidermal necrolysis. We describe the management of a patient who presented with
both conditions, which is an extremely rare event. We describe the diagnosis and
treatment during the patient’s inpatient stay at a regional burns unit. From
this case report we have shown insight into the multidisciplinary management
needed to manage such a complex patient, who made a full recovery.
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Affiliation(s)
| | - J Ewing
- Whiston Hospital, Prescot, UK
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Liu X, Cui Y, Li Y, Wang C, Zhao H, Han J. Using inpatient data to estimate the prevalence of Wegener's granulomatosis in China. Intractable Rare Dis Res 2016; 5:31-5. [PMID: 26989646 PMCID: PMC4761581 DOI: 10.5582/irdr.2015.01015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
China lacks a registry for most rare diseases, so specific epidemiological data on those diseases are lacking. A strategy involving the DISMOD II model was recently formulated to estimate the epidemiological parameters of rare diseases, and this strategy has been used to study several rare diseases. The current study used this strategy to estimate the prevalence of one such rare disease, Wegener's granulomatosis (WG), in China based on its incidence, mortality, and rate of remission according to the software tool DISMOD II. The incidence of WG was calculated based on inpatient data from 100 hospitals throughout China. The cause-specific mortality from WG was estimated based on data from the National Vital Statistics System of the United States and adjusted for the Chinese population. The rate of disease remission was based on the results of previous study. The current results indicated that the prevalence of WG in China is 1.94/100,000, which is slightly lower than that in Europe and the United States. The mean age at onset of WG in China was calculated to be 38.9 years for males and 39.3 years for females and the duration of disease was 28 years for both male and female patients. These figures are similar to published data from other countries. In conclusion, the DISMOD II model was used to estimate the prevalence of WG in China, providing a basis to evaluate the potential disease burden and orphan drug use by patients with WG. The DISMOD II model could be used to estimate the prevalence of other rare diseases.
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Affiliation(s)
- Xiao Liu
- Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Yazhou Cui
- Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Yan Li
- Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Chao Wang
- Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Heng Zhao
- Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
| | - Jinxiang Han
- Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China
- Address correspondence to: Dr. Jinxiang Han, Shandong Medicinal Biotechnology Center, Key Laboratory for Biotech Drugs of the Ministry of Health, Key Laboratory for Rare Diseases of Shandong Province, Shandong Academy of Medical Sciences, College of Life Science and Medicine, Ji'nan University, Shandong Academy of Medical Sciences, Ji'nan, Shandong 250062, China. E-mail:
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Faurschou M, Ahlström MG, Lindhardsen J, Baslund B, Obel N. Impact of pre-existing co-morbidities on mortality in granulomatosis with polyangiitis: a cohort study. Rheumatology (Oxford) 2015; 55:649-53. [PMID: 26615030 DOI: 10.1093/rheumatology/kev390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the impact of pre-existing co-morbidities on mortality among patients affected by granulomatosis with polyangiitis (GPA). METHODS By means of the Danish National Hospital Register, we identified a cohort of patients hospitalized for GPA during 1994-2010 (n = 308). The burden of pre-existing co-morbidities among the patients was quantified according to the Charlson Comorbidity Index (CCI). Each patient was matched with five age- and gender-matched population controls with no pre-existing co-morbidities captured by the CCI (CCI score = 0). The study subjects were followed throughout 2010. Cox regression analyses were used to calculate mortality rate ratios (MRRs). RESULTS The median duration of follow-up in the GPA cohort was 5.8 years (interquartile range 2.3-10.0). Compared with their matched population controls, the MRR for patients presenting with a CCI score of 0 (n = 246) was 3.9 (95% CI 2.0, 7.5) during years 0-2 and 1.4 (95% CI 0.9, 2.0) from the second year of follow-up onwards. The corresponding MRRs were 13.3 (95% CI 5.8, 31) and 1.9 (95% CI 1.1, 3.6) for patients with a CCI score ⩾1 (n = 62). In a direct comparison, GPA patients with a CCI score ⩾1 were found to have significantly higher mortality than GPA patients with a CCI score of 0 during years 0-2 [adjusted MRR 3.4 (95% CI 1.6, 7.0)] but not after >2 years of follow-up [adjusted MRR 1.3 (95% CI 0.7, 2.6)]. CONCLUSION During early follow-up periods, the mortality among GPA patients with pre-existing co-morbidities is markedly higher than that among GPA patients with no pre-existing illnesses. Our analyses identify an increased CCI score for pre-existing co-morbidities as an important risk factor for a fatal outcome in GPA.
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Affiliation(s)
| | - Magnus G Ahlström
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Wallace ZS, Lu N, Unizony S, Stone JH, Choi HK. Improved survival in granulomatosis with polyangiitis: A general population-based study. Semin Arthritis Rheum 2015; 45:483-9. [PMID: 26323883 DOI: 10.1016/j.semarthrit.2015.07.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/06/2015] [Accepted: 07/30/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is associated with an increased risk of mortality; however, recent mortality trends in GPA are unknown. We evaluated this issue in a general population context. METHODS Using data collected between 1992 and 2013 by The Health Improvement Network in the United Kingdom, we identified individuals diagnosed as incident cases of GPA and up to 10 non-GPA controls matched on sex, age, year of birth, and year of GPA diagnosis. The cohort was divided into two based on the year of diagnosis (i.e., 1992-2002 and 2003-2013) to evaluate changes in mortality. We calculated hazard ratios for death using a Cox-proportional hazards model and the rate differences using an additive hazard model, while adjusting for potential confounders. RESULTS We identified 465 cases of GPA (mean age: 60 years, 52% male). The early cohort (1992-2002) GPA patients had considerably higher mortality rates than the late cohort (2003-2013) (i.e., 72.0 vs. 35.7 cases per 1000 person-years), as compared with a moderate improvement in the comparison cohorts between the two periods (19.8 vs. 17.0 cases per 1000 person-years). The corresponding absolute mortality rate difference was 52.2 (95% CI: 25.1-79.2) cases and 18.7 (95% CI: 8.3-29.1) cases per 1000 person-years (p for interaction = 0.025). The resulting HRs for mortality were 4.34 (95% CI: 2.72-6.92) and 2.41 (95% CI: 1.74-3.34), respectively (p for interaction = 0.043). CONCLUSION This population-based study suggests that survival of GPA patients has improved considerably over the past 2 decades, affirming the benefits of recent trends in the management of GPA and its complications.
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Affiliation(s)
- Zachary S Wallace
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Na Lu
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Clinical Epidemiology and Training Unit, Boston University School of Medicine, Boston, MA
| | - Sebastian Unizony
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John H Stone
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hyon K Choi
- Rheumatology, Allergy, and Immunology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Clinical Epidemiology and Training Unit, Boston University School of Medicine, Boston, MA
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Flossmann O. Risks of treatments and long-term outcomes of systemic ANCA-associated vasculitis. Presse Med 2015; 44:e251-7. [DOI: 10.1016/j.lpm.2015.02.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 02/16/2015] [Indexed: 10/23/2022] Open
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Sriskandarajah S, Aasarød K, Skrede S, Knoop T, Reisæter AV, Bjørneklett R. Improved prognosis in Norwegian patients with glomerulonephritis associated with anti-neutrophil cytoplasmic antibodies. Nephrol Dial Transplant 2015; 30 Suppl 1:i67-75. [PMID: 25694535 PMCID: PMC4371773 DOI: 10.1093/ndt/gfv008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Glomerulonephritis associated with anti-neutrophil cytoplasmic antibodies (ANCA) is associated with increased mortality and a high risk of end-stage renal disease (ESRD). Here, we investigated whether the prognosis has improved over the last 25 years. Methods Patients were identified in the Norwegian Kidney Biopsy Registry. We included all patients with pauci-immune crescentic glomerulonephritis and a positive ANCA test from 1988 to 2012. Deaths and ESRD in the cohort were identified through record linkage with the Norwegian Population Registry (deaths) and the Norwegian Renal Registry (ESRD). Outcomes of patients diagnosed in 1988–2002 were compared with outcomes of patients diagnosed in 2003–12. Results A cohort of 455 patients with ANCA-associated glomerulonephritis was identified. The mean follow-up was 6.0 years (range, 0.0–23.4). During the study period, 165 (36%) patients died and 124 (27%) progressed to ESRD. Compared with patients diagnosed in 1988–2002, those diagnosed in 2003–12 had higher mean initial estimated glomerular filtration rates (37 versus 27 mL/min/1.73 m2) and lower risk of ESRD (1-year risk: 13 versus 19%; 10-year risk: 26 versus 37%). The composite endpoint, ESRD or death within 0–1 year after diagnosis, was reduced from 34 to 25%. In patients over 60 years old, 1-year mortality fell from 33 to 20%. Conclusions In Norwegian patients with ANCA-associated glomerulonephritis, prognosis was significantly better in 2003–12 compared with 1988–2002. This improvement was probably partly due to a shorter diagnostic delay, and better therapeutic management in older patients.
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Affiliation(s)
| | - Knut Aasarød
- Department of Nephrology, St Olavs University Hospital, Trondheim, Norway Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Thomas Knoop
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anna Varberg Reisæter
- Norwegian Renal Registry, Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Rune Bjørneklett
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Novikov PI, Moiseev SV, Kuznetsova EI, Semenkova EN, Mukhin NA. Changing patterns of clinical severity and risk of mortality in granulomatosis with polyangiitis over four decades: the Russian experience. Rheumatol Int 2014; 35:891-8. [DOI: 10.1007/s00296-014-3154-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/08/2014] [Indexed: 12/01/2022]
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Catanoso M, Macchioni P, Boiardi L, Manenti L, Tumiati B, Cavazza A, Luberto F, Pipitone N, Salvarani C. Epidemiology of granulomatosis with polyangiitis (Wegener׳s granulomatosis) in Northern Italy: A 15-year population-based study. Semin Arthritis Rheum 2014; 44:202-7. [DOI: 10.1016/j.semarthrit.2014.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/03/2014] [Accepted: 05/02/2014] [Indexed: 11/29/2022]
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Comarmond C, Cacoub P. Granulomatosis with polyangiitis (Wegener): clinical aspects and treatment. Autoimmun Rev 2014; 13:1121-5. [PMID: 25149391 DOI: 10.1016/j.autrev.2014.08.017] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/22/2014] [Indexed: 11/17/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis, which affects small- and medium-sized blood vessels and is often associated with cytoplasmic ANCA. GPA occurs in patients between 45 and 60 years old of both genders, and is rarely observed in blacks. The prevalence of GPA increases along a south-north gradient in Europe (20 to 150/million). The main clinical characteristics involve the upper and/or lower respiratory tract and kidneys. Ear, nose and throat manifestations with recurrent sinusitis and crusting rhinorrhea are usually severe. Lung nodules are frequently seen, sometimes excavated. Renal involvement is characterized by rapidly progressive necrotizing glomerulonephritis with extracapillary crescents. Limited forms of GPA predominantly affect the upper respiratory tract, whereas generalized forms of GPA include renal manifestations and/or alveolar hemorrhage and/or vital organ involvement with an altered general condition. The combination of immunosuppressant drugs and corticosteroids has converted this typically fatal illness into one in which 80% of patients achieve remission. However, despite considerable therapeutic progress over the last decades, relapses remain frequent (50% at 5 years), and maintenance treatment is now the main therapeutic challenge.
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Affiliation(s)
- Cloé Comarmond
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Département Hospitalo-Unviversitaire I2B, UPMC Univ Paris 06, F-75013 Paris, France; INSERM UMR 7211, F-75005 Paris, France; CNRS, UMR 7211, F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France
| | - Patrice Cacoub
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Département Hospitalo-Unviversitaire I2B, UPMC Univ Paris 06, F-75013 Paris, France; INSERM UMR 7211, F-75005 Paris, France; CNRS, UMR 7211, F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France.
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Pinto B, Dhir V, Singh PK, Gowda KK, Sharma A. Granulomatosis with polyangiitis and severe respiratory involvement. J Emerg Med 2014; 47:e79-81. [PMID: 24998501 DOI: 10.1016/j.jemermed.2014.01.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 01/31/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Benzeeta Pinto
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pawan K Singh
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Krishne Gowda
- Department of Histopathology, 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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Mooney J, Spalding N, Poland F, Grayson P, Leduc R, McAlear CA, Richesson RL, Shereff D, Merkel PA, Watts RA. The informational needs of patients with ANCA-associated vasculitis-development of an informational needs questionnaire. Rheumatology (Oxford) 2014; 53:1414-21. [PMID: 24625507 DOI: 10.1093/rheumatology/keu026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of the study was to compare the informational needs of patients with ANCA-associated vasculitis (AAV). METHODS We developed a Vasculitis Informational Needs Questionnaire that was distributed to members of Vasculitis UK (VUK) by mail and registrants of the Vasculitis Clinical Research Consortium (VCRC) online registry with self-reported AAV. Patients were asked to use a 5-point scale (1 = not important, 5 = extremely important) to rank aspects of information in the following domains: disease, investigations, medication, disease management and psychosocial care. The source and preferred method of educational delivery were recorded. RESULTS There were 314 VUK and 273 VCRC respondents. Respondents rated information on diagnosis, prognosis, investigations, treatment and side effects as extremely important. Information on patient support groups and psychosocial care was less important. There was no difference in the ratings of needs based on group, sex, age, disease duration, disease or method of questionnaire delivery. The most-preferred methods of providing information for both groups were by a doctor (with or without written material) or web based; educational courses and compact disc/digital video disc (CD/DVD) were the least-preferred methods. CONCLUSION This study demonstrates that people with AAV seek specific information concerning their disease, treatment regimes and side effects and the results of investigations. Individuals preferred to receive this information from a doctor. Patients with AAV should be treated in a similar manner to patients with other chronic illnesses in which patient education is a fundamental part of care.
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Affiliation(s)
- Janice Mooney
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Nicola Spalding
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fiona Poland
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Peter Grayson
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Renee Leduc
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Carol A McAlear
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Rachel L Richesson
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Denise Shereff
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Peter A Merkel
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Richard A Watts
- School of Nursing Sciences, School of Allied Health Professionals, University of East Anglia, Norwich, UK, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, Duke University School of Nursing, Duke University, Durham, NC, USA and Norwich Medical School, University of East Anglia, Norwich, UK
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Outcome measures in primary systemic vasculitis. INDIAN JOURNAL OF RHEUMATOLOGY 2013. [DOI: 10.1016/j.injr.2013.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Clinical features and outcomes of 37 Argentinean patients with severe granulomatosis with polyangiitis (wegener granulomatosis). J Clin Rheumatol 2013; 19:62-6. [PMID: 23364664 DOI: 10.1097/rhu.0b013e31828632a3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most epidemiologic studies involving severe granulomatosis with polyangiitis (SGPA) patients have investigated populations from the northern hemisphere, whereas few studies have been conducted in South America. None of the South American studies have differentiated between localized GPA and SGPA. PURPOSE The present study was designed to describe a cohort of Argentinean patients who were diagnosed with SGPA and to compare this cohort with previously well-described cohorts. METHODS We performed a retrospective study that included 37 consecutive SGPA patients who were seen at 2 tertiary centers in Buenos Aires. RESULTS Nineteen patients (51.3%) were male, and 18 patients (49.7%) were female. The mean age at the onset of symptoms was 48.5 ± 12.01 years. Antineutrophil cytoplasmic antibody (ANCA) was detected in 34 patients (91.89%): 32 patients (86.48%) had a cytoplasmic staining pattern, whereas 2 patients (5.40%) had a perinuclear pattern. Three patients were ANCA-negative. Twenty-four patients (64%) achieved remission, and 7 patients (19%) had response as defined by at least 50% reduction in the disease activity score. Nineteen relapses were observed in 12 patients, and 2 of the relapses were fatal. Overall, there were 14 deaths (37.83%). CONCLUSIONS The present series demonstrated that Argentinean patients have similar demographics, clinical manifestations, and outcomes as the cohorts from the northern hemisphere. There was less granulomatous organ involvement (ear/nose/throat, lung granulomas) in the present cohort compared with other series.
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Evaluation of 10-year experience of Wegener's granulomatosis in Iranian children. ISRN RHEUMATOLOGY 2013; 2013:694928. [PMID: 23956873 PMCID: PMC3728496 DOI: 10.1155/2013/694928] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/03/2013] [Indexed: 11/18/2022]
Abstract
Wegener's granulomatosis or granulomatosis polyangiitis (GPA) is an uncommon chronic systemic vasculitis in children. The aim of this study was to describe pediatric patients with GPA in Iran. We studied records of all patients with GPA diagnosis who were referred to all Iranian Pediatric Rheumatology Division from 2002 to 2011. A total of 11 patients (5 females and 6 males) enrolled in this study. In children less than 15 years old, the prevalence of GPA is 0.6 per million. The mean age of GPA diagnosis was 11 years and average delay diagnosis was 20 months. Mortality rate was 18.1% due to pulmonary vasculitis and infection. The most common organ system involvement was upper and lower respiratory tract involvement (81.8% and 63.9%, resp.). Other common manifestations were renal (36.3), skin (27.2%), and eye involvement (18.2%).
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Abstract
Antineutrophil cytoplasm antibody associated vasculitis has been transformed from life-threatening conditions to chronic relapsing long-term diseases as a result of significant advances in immunosuppressive therapy. Although mortality still occurs, it is much less frequent, with an average 5-year survival of over 70 %. In the setting of chronic conditions, it becomes increasingly important to monitor the burden of disease in terms of both active inflammation requiring immunosuppression and chronic damage (scarring) from vasculitis and its treatment and associated comorbidity. The damage that accumulates in patients with vasculitis does not respond to immunosuppressive treatment. It is important to distinguish disease activity from disease damage to prevent unnecessary immunosuppression, but it is equally important to recognize damage for what it is, so that it can be addressed appropriately. Damage is an inevitable consequence of long-term vasculitis for over 80 % of patients, which should not surprise us given the severity of the original illness. There is potential value in measuring damage as a means of providing prognostic information. Using a quantified score such as the Vasculitis Damage Index (VDI) allows us to predict mortality. Patients with at least five items of damage on the VDI score have substantially worse mortality (7- to 11-fold worse risk), as compared with those with lesser amounts of damage. These findings should be taken into context when planning the management of patients with vasculitis, as well as in clinical trials of vasculitis. Disease damage is an important surrogate for long-term outcome in vasculitis, and studies should be designed to limit the amount of damage accumulating as a result of therapeutic intervention, rather than simply controlling disease activity, as is currently the aim in recent randomized controlled trials in vasculitis. Furthermore, careful cataloguing of damage, as well as disease activity items, provides much greater detail in describing and observing the long-term natural history of primary systemic vasculitis in patients treated with immunosuppressive agents who survive their initial disease process.
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Quality of life and outcome measures in vasculitis. Best Pract Res Clin Rheumatol 2013; 27:69-77. [PMID: 23507058 DOI: 10.1016/j.berh.2013.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 01/14/2013] [Indexed: 11/23/2022]
Abstract
The primary vasculitides are a life- and organ-threatening set of diseases with a course often marked by alternating periods of active vasculitis and remission. As opposed to clinical trials within the fields of cardiology and oncology, where treatment interventions have been tested in a controlled fashion using hard 'end' points, such as mortality and hospitalisation, surrogate 'end' points have to be used in randomised clinical trials (RCTs) in vasculitis. Given the multisystem nature of the vasculitides, their heterogeneous clinical presentations and rarity, outcome-measure development is a challenging task. The objective of this review is to summarise the data on how health-related quality of life is affected by vasculitis, to describe the currently used outcome measures and provide insight into future outcome-measures development. The primary focus is on anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, where the most data exist and outcome measure development is farthest along. Data on other vasculitides will also be briefly discussed.
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Cardiovascular disease due to accelerated atherosclerosis in systemic vasculitides. Best Pract Res Clin Rheumatol 2013; 27:33-44. [DOI: 10.1016/j.berh.2012.12.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 12/22/2012] [Accepted: 12/27/2012] [Indexed: 02/08/2023]
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