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Reggiani F, Stella M, Calatroni M, Sinico RA. Treatment strategies for ANCA-associated vasculitides: from standard protocols to future horizons. Expert Rev Clin Immunol 2024; 20:765-780. [PMID: 38445642 DOI: 10.1080/1744666x.2024.2326628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION ANCA-associated vasculitides (AAV), classified into granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis represent a group of disorders characterized by necrotizing vasculitis of small vessels, endothelial injury and tissue damage. The outcomes and prognosis of AAV have undergone significant changes with the introduction of glucocorticoids (GCs) and other immunosuppressants (cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil). The enhanced understanding of pathogenesis has subsequently led to the incorporation into clinical practice of drugs targeting specific therapeutic targets. AREAS COVERED After an extensive literature search of Pubmed, Medline, Embase of the most recent evidence, we provide an overview of available treatments, highlighting how newer drugs have integrated into standard protocols. Our review also explores potential new therapeutic targets, including B cell depletion and inhibition, T cell inhibition, complement inhibition, and IL-5 and IgE inhibition. EXPERT OPINION There is hope that the new treatment targets currently under study in AAV may enable a faster and more lasting clinical response, ensuring the reduction of possible side effects from therapies. Moreover, numerous aspects necessitate further exploration in the future, such as tailoring of GCs, integration of GCs-sparing agents, efficacy of combination therapy, optimal maintenance therapy, to reduce organ-damage and improve quality of life.
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Affiliation(s)
- Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matteo Stella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
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2
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 93] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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3
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Alchi MB, Lever R, Flossmann O, Jayne D. Efficacy and safety of low- versus high-dose glucocorticoid regimens for induction of remission of anti-neutrophil cytoplasm antibody-associated vasculitis: a systematic review and meta-analysis. Scand J Rheumatol 2023; 52:564-573. [PMID: 37339385 DOI: 10.1080/03009742.2023.2211387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/04/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Glucocorticoids (GCs) remain a cornerstone of the initial management of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV), but have several dose-dependent side effects, in particular infections. The optimal dosing and tapering of oral GCs for remission induction are unknown. A systematic review and meta-analysis was undertaken to determine the efficacy and safety of low- versus high-dose GC regimens. METHOD A systematic search of MEDLINE, Embase, and PubMed databases was conducted. Clinical studies using a GC-based induction protocol were selected. A daily dose of 0.5 mg/kg or < 30 mg/day oral prednisolone equivalent by the start of week 4 of the induction tapering schedule marked the threshold between high- and low-dose GCs. Risk ratios (RRs) were calculated by the random effects model for outcomes of remission and infection. Relapse events were summarized using risk differences with 95% confidence intervals (CIs). RESULTS In total, 1145 participants were included in three randomized controlled trials and two observational studies, of whom 543 were assigned to the low-dose GC group and 602 to the high-dose GC group. A low-dose GC regimen was non-inferior to high-dose GCs with respect to outcomes of remission (RR 0.98, 95% CI 0.95-1.02, p = 0.37; I2 = 0%) and relapse (risk difference 0.03, 95% CI -0.01 to 0.06, p = 0.15; I2 = 12%), while significantly reducing the incidence of infection (RR 0.60, 95% CI 0.39-0.91, p = 0.02; I2 = 65%). CONCLUSION Studies with low-dose GC regimens in AAV are associated with fewer infections while obtaining equivalent efficacy.
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Affiliation(s)
- M B Alchi
- School of Pharmacy, University College London, London, UK
| | - R Lever
- School of Pharmacy, University College London, London, UK
| | - O Flossmann
- Berkshire Kidney Unit, Royal Berkshire Hospital, Reading, UK
| | - D Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Schirmer JH, Sanchez-Alamo B, Hellmich B, Jayne D, Monti S, Luqmani RA, Tomasson G. Systematic literature review informing the 2022 update of the EULAR recommendations for the management of ANCA-associated vasculitis (AAV): part 1-treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:e003082. [PMID: 37479496 PMCID: PMC10364171 DOI: 10.1136/rmdopen-2023-003082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/16/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To summarise and update evidence to inform the 2022 update of the EULAR recommendations for the management of antineutrophil cytoplasm antibody-associated vasculitis (AAV). METHODS A systematic literature review (SLR) was performed to identify current evidence regarding treatment of AAV. PubMed, EMBASE and the Cochrane library were searched from 1 February 2015 to 25 February 2022. The evidence presented here is focused on the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RESULTS 3517 articles were screened and 175 assessed by full-text review. Ninety articles were included in the final evidence synthesis. Cyclophosphamide and rituximab (RTX) show similar efficacy for remission induction (level of evidence (LoE) 1a) but RTX is more effective in relapsing disease (LoE 1b). Glucocorticoid (GC) protocols with faster tapering result in similar remission rates but lower rates of serious infections (LoE 1b). Avacopan can be used to rapidly taper and replace GC (LoE 1b). Data on plasma exchange are inconsistent depending on the analysed trial populations but meta-analyses based on randomised controlled trials demonstrate a reduction of the risk of end-stage kidney disease at 1 year but not during long-term follow-up (LoE 1a). Use of RTX for maintenance of remission is associated with lower relapse rates compared with azathioprine (AZA, LoE 1b). Prolonged maintenance treatment results in lower relapse rates for both, AZA (LoE 1b) and RTX (LoE 1b). CONCLUSION This SLR provides current evidence to inform the 2022 update of the EULAR recommendations for the management of AAV.
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Affiliation(s)
- Jan Henrik Schirmer
- Clinic for Internal Medicine I, Rheumatology and Clinical Immunology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Beatriz Sanchez-Alamo
- Nephrology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
- Nephrology, Skåne University Hospital, Lund, Sweden
| | - Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken Kirchheim/Teck, University Tübingen, Kirchheim-Teck, Germany
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, University of Pavia; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raashid Ahmed Luqmani
- Oxford NIHR Biomedical Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gunnar Tomasson
- Faculty of Medicine, University of Iceland, Landspitali University Hospital, Reykjavik, Iceland
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5
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Gérard M, de Boysson H, Morello R, Martin-Silva N, Leroux AC, Dumont A, Maigné G, Boutemy J, Khoy K, Mariotte D, Lobbedez T, Aouba A, Deshayes S. Early infectious risk in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis according to remission-induction therapy. Scand J Rheumatol 2023; 52:161-173. [PMID: 35048797 DOI: 10.1080/03009742.2021.2001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Few comparative data exist on early infections secondary to remission-induction therapy (RIT) with rituximab (RTX) versus cyclophosphamide (CYC) in newly diagnosed anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. We compared and analysed the rates and predictors of severe infection in such patients within the first 6 months following RIT. METHOD From the Caen University Hospital databases, we included all consecutive adults newly diagnosed with ANCA-positive granulomatosis with polyangiitis or microscopic polyangiitis between January 2006 and December 2019. We compared rates of survival without severe infection and survival without infections of any severity within 6 months of RIT and used a multivariate Cox analysis to identify predictors of infection. RESULTS We included 145 patients, 27 in the RTX and 118 in the CYC group. Patients in the RTX group more frequently had pneumococcal vaccination (p < 0.01) and creatinine < 150 µmol/L; other characteristics were comparable between the two groups. Overall, 37 severe infections and 65 infections of any severity were recorded. Rates of survival without severe infection were similar in both groups (p = 0.69), but survival without infections of any severity was lower in the RTX group (p = 0.005). In multivariate analysis, risk factors at diagnosis for severe infections included chronic urinary tract disease, dialysis, and absence of trimethoprim-sulfamethoxazole prophylaxis (p < 0.01 each). CONCLUSIONS Within 6 months of RIT, rates of survival without severe infection were similar in newly diagnosed ANCA-positive AAV patients treated with RTX or CYC, but survival rates without infections of any severity appeared to be lower with RTX treatment.
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Affiliation(s)
- M Gérard
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - H de Boysson
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - R Morello
- Functional Unit of Biostatistics and Clinical Research, CHU de Caen Normandie, Caen, France
| | - N Martin-Silva
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - A-C Leroux
- Department of Nephrology, Centre Hospitalier Mémorial, Saint-Lô, France
| | - A Dumont
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - G Maigné
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - J Boutemy
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France
| | - K Khoy
- Department of Immunology, CHU de Caen Normandie, Caen, France
| | - D Mariotte
- Department of Immunology, CHU de Caen Normandie, Caen, France
| | - T Lobbedez
- Department of Nephrology, CHU de Caen Normandie, Caen, France
| | - A Aouba
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
| | - S Deshayes
- Department of Internal Medicine, CHU de Caen Normandie, Caen, France.,Faculty of Caen, Université de Caen Normandie (UNICAEN), Caen, France
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Gulati K, Pusey CD. Plasma exchange as an adjunctive therapy in anti-neutrophil cytoplasm antibody-associated vasculitis. Expert Rev Clin Immunol 2023; 19:417-430. [PMID: 36860127 DOI: 10.1080/1744666x.2023.2184354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
INTRODUCTION We summarize evidence for the role of therapeutic plasma exchange (TPE) in the treatment of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). TPE rapidly removes ANCA IgG, complement and coagulation factors important in the pathogenesis of AAV. TPE has been used in patients with rapidly deteriorating renal function to achieve early disease control, allowing time for immunosuppressive agents to prevent resynthesis of ANCA. The PEXIVAS trial challenged the utility of TPE in AAV, as it did not show benefit of adjunctive TPE on a combined end point of end stage kidney disease (ESKD) and death. AREAS COVERED We analyze data from PEXIVAS and other trials of TPE in AAV, an up-to-date meta-analysis, and recently published large cohort studies. EXPERT OPINION There remains a role for the use of TPE in AAV in certain groups of patients, in particular those with severe renal involvement (Cr >500 μmol/L or dialysis-dependent). It should be considered in patients with Cr >300 μmol/L and rapidly deteriorating function, or with life-threatening pulmonary hemorrhage. A separate indication is patients double positive for anti-GBM antibodies and ANCA. TPE may have the greatest benefit as part of steroid-sparing immunosuppressive treatment strategies.
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Affiliation(s)
- Kavita Gulati
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Charles D Pusey
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Inflammatory Disease, Imperial College London, London, UK
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Austin K, Janagan S, Wells M, Crawshaw H, McAdoo S, Robson JC. ANCA Associated Vasculitis Subtypes: Recent Insights and Future Perspectives. J Inflamm Res 2022; 15:2567-2582. [PMID: 35479831 PMCID: PMC9037725 DOI: 10.2147/jir.s284768] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 12/19/2022] Open
Abstract
The ANCA associated vasculitides (AAVs) affect a range of internal organs including ear nose and throat, respiratory tract, kidneys, skin and nervous system. They include granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). The AAVs are treated with high dose glucocorticoids, immunosuppressants, and targeted biological medications. Since the 1990s classification criteria for the AAVs have been based on clinical features, laboratory tests and basic imaging; an initiative to update the classification criteria incorporating newer tests, for example, anti-neutrophil cytoplasmic antibodies (ANCA) and novel imaging techniques will be published this year. There is also evidence for classification of patients based on ANCA subtype; those with anti-proteinase 3 antibodies (PR3) or anti-myeloperoxidase antibodies (MPO) have differences in response to treatment and clinical outcomes. An update is described within this review. The pathogenesis of AAV involves necrotizing inflammation of small to medium blood vessels involving multiple immunological pathways. We present an update on emerging evidence related to auto-antibodies, complement and lymphocyte pathways. This review describes emerging treatment regimens, including evidence for plasma exchange in severe disease and the inhibitor of the complement C5a receptor (C5aR) inhibitor, Avacopan. Lastly, patient reported outcomes are key secondary outcomes in randomised controlled trials and increasingly clinical practice, we report development in disease specific and glucocorticoid-specific PROs.
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Affiliation(s)
- Keziah Austin
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
- Correspondence: Keziah Austin, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK, Email
| | - Shalini Janagan
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Matthew Wells
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
| | - Helena Crawshaw
- Department of Rheumatology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, UK
| | - Joanna C Robson
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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8
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Gulati K, Edwards H, Prendecki M, Cairns TD, Condon M, Galliford J, Griffith M, Levy JB, Tam FWK, Tanna A, Pusey CD, McAdoo SP. Combination treatment with rituximab, low-dose cyclophosphamide and plasma exchange for severe antineutrophil cytoplasmic antibody-associated vasculitis. Kidney Int 2021; 100:1316-1324. [PMID: 34560140 DOI: 10.1016/j.kint.2021.08.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 08/06/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis can present with life-threatening lung-kidney syndromes. However, many controlled treatment trials excluded patients with diffuse alveolar hemorrhage or severely impaired glomerular filtration rates, and so the optimum treatment in these cases is unclear. In this retrospective cohort study, we report the outcomes of 64 patients with life-threatening disease treated with a combination regimen of rituximab, low-dose intravenous cyclophosphamide, oral glucocorticoids, and plasma exchange. At entry, the median estimated glomerular filtration rate was 9 mL/min, 47% of patients required dialysis, and 52% had diffuse alveolar hemorrhage. All patients received a minimum of seven plasma exchanges, and the median cumulative doses of rituximab, cyclophosphamide, and glucocorticoid were 2, 3, and 2.6 g, respectively, at six months. A total of 94% of patients had achieved disease remission (version 3 Birmingham Vasculitis Activity Score of 0) at this time point, and 67% of patients who required dialysis recovered independent kidney function. During long-term follow-up (median duration 46 months), overall patient survival was 85%, and 69% of patients remained free from end-stage kidney disease, which compares favorably to a historic cohort with severe disease treated with a conventional induction regimen. Combination treatment was associated with prolonged B cell depletion and low rates of relapse; 87% of patients were in continuous remission at month 36. The serious infection rate during total follow-up was 0.28 infections/patient/year, suggesting that combination treatment is not associated with an enduring risk of infection. Thus, we suggest that combination immunosuppressive therapy may permit glucocorticoid avoidance and provide rapid and prolonged disease control in patients with severe ANCA-associated vasculitis.
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Affiliation(s)
- Kavita Gulati
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK
| | - Helena Edwards
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Maria Prendecki
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK
| | - Thomas D Cairns
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Marie Condon
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jack Galliford
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Megan Griffith
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK
| | - Jeremy B Levy
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK
| | - Frederick W K Tam
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK
| | - Anisha Tanna
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Charles D Pusey
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK
| | - Stephen P McAdoo
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Centre for Inflammatory Disease, Immunology & Inflammation, Imperial College London, London, UK.
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9
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Marques CDL. COVID-19 and Rheumatic Diseases: It Is Time to Better Understand This Association. J Rheumatol 2021; 48:318-320. [PMID: 34237001 DOI: 10.3899/jrheum.201541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Claudia D L Marques
- C.D. Marques, MD, PhD, Adjunct Professor of Rheumatology, Federal University of Pernambuco (UFPE), Recife, Pernambuco, Brazil.Address correspondence to Dr. C.D. Marques, Hospital das Clínicas, Universidade Federal de Pernambuco. Avenida Professor Moraes Rego, s/n - Recife - PE - CEP 50670-901 - Brazil.
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10
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Zhang A, Yao W, Liu W. The confused puzzles in antineutrophil cytoplasmic antibody-associated vasculitis activity evaluation: A case report. Clin Case Rep 2021; 9:e04497. [PMID: 34322254 PMCID: PMC8299101 DOI: 10.1002/ccr3.4497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/29/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of chronic multisystem autoimmune diseases with substantial mortality and morbidity and frequent relapses. The complexity of the disease condition and treatment-related adverse reactions as well as infections play important roles in the poor outcomes. Unfortunately, the subjective symptoms and objective indicators are not fully parallel, and manifestations between disease activity and treatment-related adverse reactions are often similar. Here, we describe a case of pulmonary mucormycosis in an old female patient with AAV to highlight these challenges.
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Affiliation(s)
- Ai‐hua Zhang
- Department of NephrologyAffiliated Beijing Friendship HospitalNephrology FacultyCapital Medical UniversityBeijingChina
| | - Wei‐long Yao
- Department of NephrologyAffiliated Beijing Friendship HospitalNephrology FacultyCapital Medical UniversityBeijingChina
| | - Wen‐hu Liu
- Department of NephrologyAffiliated Beijing Friendship HospitalNephrology FacultyCapital Medical UniversityBeijingChina
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11
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Interstitial lung disease with myeloperoxidase-antineutrophil cytoplasmic antibody-associated vasculitis in elderly patients. Rheumatol Int 2021; 41:1641-1650. [PMID: 34056682 DOI: 10.1007/s00296-021-04891-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/14/2021] [Indexed: 11/27/2022]
Abstract
Anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) occurs in elderly people, and patients with anti-myeloperoxidase autoantibodies (MPO-ANCA)-positive AAV are often complicated with interstitial lung disease (ILD). This study aimed to evaluate the age-related clinical features of elderly patients with MPO-ANCA-positive AAV-ILD. This study retrospectively investigated 63 patients with MPO-ANCA-positive AAV-ILD, all of whom were 65 years or older at diagnosis. Clinical characteristics, causes of death and survival rates among three groups stratified by age (65-74 years, n = 29; 75-79 years, n = 18; over 80 years, n = 16) were compared. This study also examined the association with severe infections in these patients. Among the three age groups, there were significant differences in sex (P = 0.032), serum Krebs von den Lungen-6 (P < 0.01), and total ground-glass opacity score (P = 0.011). The causes of death were mainly severe infections and complications of ILD. Kaplan-Meier curve analysis showed a significantly lower 5-year survival rate in the oldest group (P < 0.01). Regarding severe infections in these patients, the 5-year cumulative incidence of severe infections was higher in the patients receiving steroid pulse therapy (P = 0.034). The clinical characteristics of MPO-ANCA-positive AAV-ILD differ with age in elderly patients, with age being an important poor prognostic factor in these patients. The administration of steroid pulse therapy is a significant risk factor of severe infection in MPO-ANCA-positive elderly patients with AAV-ILD.
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12
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Farrah TE, Prendecki M, Hunter RW, Lahiri R, Cairns TD, Pusey CD, McAdoo SP, Dhaun N. Glucocorticoid-free treatment of severe ANCA-associated vasculitis. Nephrol Dial Transplant 2021; 36:739-742. [PMID: 33367854 DOI: 10.1093/ndt/gfaa310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/05/2020] [Indexed: 01/01/2023] Open
Affiliation(s)
- Tariq E Farrah
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK.,Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Maria Prendecki
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Imperial College London, Hammersmith Hospital Campus, London, UK.,Department of Renal Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Robert W Hunter
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK.,Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rashmi Lahiri
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Thomas D Cairns
- Department of Renal Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Imperial College London, Hammersmith Hospital Campus, London, UK.,Department of Renal Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Imperial College London, Hammersmith Hospital Campus, London, UK.,Department of Renal Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Neeraj Dhaun
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK.,Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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13
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Therapeutic Recommendations for the Management of Older Adult Patients with Sjögren's Syndrome. Drugs Aging 2021; 38:265-284. [PMID: 33619703 DOI: 10.1007/s40266-021-00838-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 10/22/2022]
Abstract
Primary Sjögren's syndrome (SjS) is a systemic autoimmune disease most commonly diagnosed in middle-aged women. Although the disease can occur at all ages, it is diagnosed between 30 and 60 years of age in two-thirds of patients. In more than 20% of cases, the people are older than 65 years. In this review, we focus on the therapeutic management of primary SjS in older patients, following the recently published 2020 European League Against Rheumatism (EULAR) recommendations for the management of the disease with topical and systemic therapies. These recommendations are applicable to all patients with primary SjS regardless of age at diagnosis, although the therapeutic management in older patients requires additional considerations. Older patients are more likely to have pulmonary, liver, kidney, or heart-related comorbidities (even cognitive disturbances); caution is required when most drugs are used, including muscarinic agents, systemic corticosteroids and synthetic immunosuppressants. It is also important to monitor the use of eye drops containing steroids due to the increased risk of developing cataracts, a frequent ocular complication in the older population. In contrast, the majority of drugs that can be used topically (pilocarpine rinses, eye drops containing topical non-steroidal anti-inflammatory drugs (NSAIDs) or cyclosporine A, topical dermal formulations of NSAIDs) have shown an acceptable safety profile in older patients, as well as rituximab. A rigorous evaluation of the medical history of older patients is essential when drugs included in the EULAR guidelines are prescribed, with special attention to factors frequently related to ageing, such as polypharmacy, the existence of organ-specific comorbidities, or the enhanced susceptibility to infections.
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14
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Obrișcă B, Vornicu A, Jurubiță R, Achim C, Bobeică R, Andronesi A, Sorohan B, Herlea V, Procop A, Dina C, Ismail G. Corticosteroids are the major contributors to the risk for serious infections in autoimmune disorders with severe renal involvement. Clin Rheumatol 2021; 40:3285-3297. [PMID: 33595739 DOI: 10.1007/s10067-021-05646-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION We sought to investigate the infection profile and associated risk factors in a compiled cohort of patients with autoimmune disorders with severe renal involvement treated with aggressive immunosuppressive (IS) regimens. METHODS A total of 162 patients with aggressive glomerulonephritis [101 with lupus nephritis (LN), 24 with cryoglobulinemic vasculitis (CryoVasc), and 37 with ANCA-associated vasculitis (AAV)] were retrospectively reviewed for any infection occurrence. Infection incidence, type, site, and grade (1-5) were recorded. Multivariate Cox proportional hazard regression analysis was performed to identify independent risk factors for infections. RESULTS A total of 179 infection episodes occurred during a follow-up of 468 patient-years. Eighty-two patients (50.6%) had at least one infection. The incidence rates of infections and severe infections were 38.2 and 14.3 events per 100 patient-years. Patients with AAV had more infections than those with CryoVasc and LN (100.6, 47.5, and 26.6 infections per 100-patient-years, respectively; p = 0.002). Most patients developed infections early during the initial induction therapy (62.1% in the first 6 months of follow-up). In multivariate Cox regression analysis, high-dose oral corticosteroids (≥ 0.5 mg/kg/day in the first month of induction therapy) was an independent predictor of any infection (HR 2.66; 95% CI, 1.5-4.73), severe infections (HR 2.45; 95% CI, 1.03-5.82), and pulmonary infections (HR 2.91; 95% CI, 1.05-8.01). Pulmonary involvement increased the risk for pulmonary infections (HR 3.67; 95% CI, 1.32-10.1) and severe infections (HR 2.45; 95% CI, 1.01-5.92). CONCLUSION Infections occur frequently with current IS regimens in aggressive glomerulonephritis. Pulmonary involvement and high-dose corticosteroid regimen were the most significant risk factors for infections. Key Points • Infections occur frequently with current immunosuppressive regimens in autoimmune aggressive glomerulonephritis. • High-dose corticosteroids are the major contributors to the risk for serious infections.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania. .,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Procop
- Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Constantin Dina
- Department of Anatomy, Ovidius University, Constanța, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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15
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Jourdain P, Brilland B, Medhioub O, Caron J, Samoreau C, Djema A, Gansey R, Coindre JP, Cousin M, Garnier AS, Henry N, Wacrenier S, Riou J, Piccoli GB, Augusto JF. Incidence and Temporal Trend in Risk Factors of Severe Infections in ANCA-Glomerulonephritis Patients. Kidney Int Rep 2021; 6:1161-1165. [PMID: 33912765 PMCID: PMC8071615 DOI: 10.1016/j.ekir.2020.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Pierre Jourdain
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,CRCINA, INSERM, Université de Nantes, Université d'Angers, Angers, France
| | - Ouassim Medhioub
- Micro et Nanomedecines Translationnelles, MINT, Université d'Angers, UMR INSERM 6021, UMR CNRS 6021, Angers, France
| | - Jeanne Caron
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Clément Samoreau
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Assia Djema
- Service de Néphrologie-Dialyse, CH de Cholet, Cholet, France
| | - Renaud Gansey
- Service de Néphrologie-Dialyse, CH de Laval, Laval, France
| | | | - Maud Cousin
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Anne Sophie Garnier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, CH de Laval, Laval, France
| | - Samuel Wacrenier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie-Dialyse, CH du Mans, Le Mans, France
| | - Jeremy Riou
- CRCINA, INSERM, Université de Nantes, Université d'Angers, Angers, France.,Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, 49100 Angers, France
| | - Giorgina Barbara Piccoli
- Service de Néphrologie-Dialyse, CH de Laval, Laval, France.,Department of Clinical and Biological Sciences University of Torino, Italy
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,CRCINA, INSERM, Université de Nantes, Université d'Angers, Angers, France
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16
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Caballero-Islas AE, Hoyo-Ulloa I, García-Castro A, Hinojosa-Azaola A. Severe infections in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis: a retrospective cohort study with a clinical phenotype approach. Rheumatol Int 2020; 40:1657-1666. [PMID: 32728838 DOI: 10.1007/s00296-020-04661-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/23/2020] [Indexed: 12/17/2022]
Abstract
Severe infections are common in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We aimed to describe the characteristics of patients with AAV and severe infections according to clinical phenotype. Retrospective cohort study including patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Baseline characteristics were compared between patients with and without at least one severe infection. Demographics, comorbidities, clinical characteristics, laboratory and treatment were retrieved at diagnosis and at every infectious event. One hundred and eight patients were included (57 with and 51 without infections). Patients with an infection had received more frequently methylprednisolone boluses at AAV diagnosis than patients without infections (OR 2.6, 95% CI 1.1-5.9, p = 0.01). There were a total of 108 severe infections in 57 patients (median follow-up 18 months). Thirty-two patients (56%) had an infectious complication within the first year of AAV diagnosis, 43 (75%) had pulmonary involvement during the first infection. The most frequent type of infection was pneumonia. Phenotypes were: Non-severe AAV (n = 11), severe PR3-AAV (n = 30), severe MPO-AAV (n = 9); the number of infectious events in each group was 11, 69, 18, respectively. Patients with severe MPO phenotype were older and required more frequently ICU stay compared to other phenotypes. Positive correlation was found between total of infections and pulmonary infiltrates due to vasculitis (ρ = 0.40, p = 0.003), endobronchial involvement (ρ = 0.40, p = 0.003), and alveolar hemorrhage (ρ = 0.34, p = 0.015). Severe infections, most commonly pneumonia, were frequent in this cohort, especially during the first year after diagnosis, in patients with pulmonary involvement and severe PR3 phenotype who received methylprednisolone boluses.
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Affiliation(s)
- Adrián E Caballero-Islas
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Irma Hoyo-Ulloa
- Internal Medicine and Infectious Diseases Services, Centro Médico ABC, Av. Carlos Fernández Graef 154, Santa Fe, Contadero, Cuajimalpa de Morelos, CP 05330, Mexico City, Mexico
| | - Annette García-Castro
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico.
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17
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Price E, MacPhie E, Kay L, Lanyon P, Griffiths B, Holroyd C, Abhishek A, Youngstein T, Bailey K, Clinch J, Shaikh M, Rivett A. Identifying rheumatic disease patients at high risk and requiring shielding during the COVID-19 pandemic. Clin Med (Lond) 2020; 20:256-261. [PMID: 32371418 PMCID: PMC7354033 DOI: 10.7861/clinmed.2020-0149] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Rheumatology teams care for patients with diverse, systemic autoimmune diseases who are often immunosuppressed and at high risk of infections. The current COVID-19 pandemic has presented particular challenges in caring for and managing this patient group. The office of the chief medical officer (CMO) for England contacted the rheumatology community to provide expert advice on the identification of extremely vulnerable patients at very high risk during the COVID-19 pandemic who should be 'shielded'. This involves the patients being asked to strictly self-isolate for at least 12 weeks with additional funded support provided for them to remain at home. A group of rheumatologists (the authors) have devised a pragmatic guide to identifying the very highest risk group using a rapidly developed scoring system which went live simultaneous with the Government announcement on shielding and was cascaded to all rheumatologists working in England.
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Affiliation(s)
- Elizabeth Price
- Great Western Hospital, Swindon, UK and president, British Society for Rheumatology, London, UK
| | - Elizabeth MacPhie
- Lancashire and South Cumbria NHS Foundation Trust, Preston, UK and chair of the Clinical Affairs Committee, British Society for Rheumatology, London, UK
| | - Lesley Kay
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK and joint national clinical lead for rheumatology, NHS England and Improvement, London, UK
| | - Peter Lanyon
- Nottingham University Hospitals NHS Trust, Nottingham, UK and national clinical co-lead for rheumatology, NHS Improvement, London, UK
| | - Bridget Griffiths
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK and chair of the Specialised Rheumatology Clinical Reference Group, NHS England, London, UK
| | | | - Abhishek Abhishek
- The University of Nottingham, Nottingham, UK and Nottingham Biomedical Research Centre, Nottingham, UK
| | - Taryn Youngstein
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kathryn Bailey
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jacqui Clinch
- Bristol Royal Hospital for Children, Bristol, UK and medical lead, Bath Centre for Pain Services, Bath, UK
| | | | - Ali Rivett
- British Society for Rheumatology, London, UK
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