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Floege J, Jayne DR, Sanders JSF, Tesar V, Rovin BH. KDIGO 2024 Clinical Practice Guideline for the Management of Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. Kidney Int 2024; 105:S71-S116. [PMID: 38388102 DOI: 10.1016/j.kint.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/20/2023] [Indexed: 02/24/2024]
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Chua JCM, Dentrinos LV, Kitching AR, Ryan J. Variation in approaches to acute ANCA-associated vasculitis in Australia and New Zealand: rituximab, plasma exchange and glucocorticoids. Intern Med J 2024. [PMID: 38323357 DOI: 10.1111/imj.16340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 01/10/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare autoimmune disease which is managed by a range of specialities. There are limited data on treatment practices in Australia and New Zealand. AIMS To understand current patterns of acute AAV treatment in Australia and New Zealand. METHODS An online survey was conducted between July and October 2022 investigating physicians' views on the management of AAV, focusing on induction therapy. The survey contained questions pertaining to access to treatment and responses to clinical management scenarios. Eosinophilic granulomatosis with polyangiitis was not included. A chi-squared test of independence was performed for statistical analysis. RESULTS From a total of 55 responses, plasma exchange was difficult to access for 44% of respondents, more so in rural centres, and they also had difficulty accessing infusion centres. New Zealand clinicians had more difficulty accessing rituximab, with only 44% reporting easy access compared with Australian clinicians (93%). With clinical management scenarios, there was variation in the dosing regimen of glucocorticoids and initiation of plasma exchange, with 42% of respondents prescribing a glucocorticoid regimen different from the standard of care, the 'reduced-dose' arm of the Plasma Exchange and Glucocorticoids for the Treatment of ANCA-Associated Vasculitis trial. The choice of cyclophosphamide or rituximab for induction therapy was based on patient characteristics and medical history. CONCLUSIONS There is substantial variation in approaches to the acute management of AAV in Australia and New Zealand, including differences in resource availability. This variation in care demonstrates the need to implement current practice guidelines and institute contemporary monitoring of AAV management, to achieve best patient outcomes.
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Affiliation(s)
- Justin C M Chua
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
| | - Laura V Dentrinos
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
| | - Arthur R Kitching
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Nephrology, Monash Health, Melbourne, Victoria, Australia
| | - Jessica Ryan
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
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Klapa S, Arnold S, Lamprecht P. [Granulomatosis with polyangiitis and microscopic polyangiitis]. Laryngorhinootologie 2024. [PMID: 38211619 DOI: 10.1055/a-2217-4457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) are two entities of ANCA-associated vasculitis (AAV). Both diseases are characterised by systemic necrotising small-vessel vasculitis, which can affect any organ. In GPA, extravascular necrotising granulomatous inflammation, usually affecting the respiratory tract, is found in addition. In the majority of cases, the clinical presentation is dominated by a pulmonary-renal syndrome with alveolar haemorrhage and rapidly progressive glomerulonephritis. Other organ involvement is found as well. In GPA, the upper respiratory tract is commonly affected. GPA is associated with anti-neutrophil cytoplasmic autoantibodies (ANCA) with specificity for proteinase 3 (PR3-ANCA) and MPA with specificity for myeloperoxidase (MPO-ANCA). Immunosuppressive therapy depends on disease activity and the severity of organ involvement.
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Affiliation(s)
- Sebastian Klapa
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
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Ishikawa Y, Tokutsu K, Nakayamada S, Kuchiba A, Fushimi K, Matsuda S, Tanaka Y. Short-term effectiveness and safety of rituximab versus cyclophosphamide for life-threatening ANCA-associated vasculitis: a propensity score analysis of the real-world nationwide database. Ann Rheum Dis 2024; 83:103-111. [PMID: 37726117 DOI: 10.1136/ard-2023-224472] [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: 05/22/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES Life-threatening antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with rapidly progressive glomerulonephritis (RPGN) and/or alveolar haemorrhage (AH) has a poor prognosis. Rituximab (RTX) is as effective as cyclophosphamide (CY) in remission induction therapy; however, the effectiveness and safety of RTX have not been established in life-threatening AAV. This study aimed to investigate the short-term effectiveness and safety of RTX in life-threatening AAV with RPGN and/or AH. METHODS Between April 2018 and March 2020, cases treated with systemic glucocorticoids and RTX or intravenous CY (IVCY) was extracted from a Japanese nationwide inpatient database. Effectiveness was evaluated by in-hospital mortality and severe renal dysfunction requiring haemodialysis (HD) at discharge. Safety was evaluated by the in-hospital incidence of infections. The propensity score (PS) for RTX was estimated. Multivariable Cox and logistic regression with adjustment for PS were conducted to estimate the association of RTX with outcomes. RESULTS From 16 001 612 hospitalised records, 687 life-threatening AAV cases were extracted. No significant difference in in-hospital mortality (adjusted HR 1.06; 95% CI 0.62 to 1.80) was found between the groups. Although the RTX group had a lower risk of fungal infections (adjusted OR (aOR) 0.45; 95% CI 0.23 to 0.84) and pneumocystis pneumonia (aOR 0.58; 95% CI 0.32 to 1.00), they might have an increased risk of severe renal dysfunction requiring HD at discharge (aOR 2.58; 95% CI 1.02 to 6.91). CONCLUSIONS In life-threatening AAV, RTX has similar short-term effectiveness on mortality to IVCY. Although RTX might have a lower risk of fungal infections and pneumocystis pneumonia, the short-term renal prognosis might be inferior to IVCY.
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Affiliation(s)
- Yuichi Ishikawa
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
- Graduate School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Japan
- Sato Clinic, Shibuya-ku, Japan
| | - Kei Tokutsu
- Preventive Medicine and Community Health, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Aya Kuchiba
- Graduate School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Japan
| | - Kiyohide Fushimi
- Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Bunkyo-ku, Japan
| | - Shinya Matsuda
- Preventive Medicine and Community Health, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
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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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Tao J, Liu S, Montez-Rath M, Charu V, Chertow GM. Antineutrophil Cytoplasmic Antibody-Associated Vasculitis with Active Kidney Involvement in the United States: 2016-2020. GLOMERULAR DISEASES 2024; 4:33-42. [PMID: 38328771 PMCID: PMC10849749 DOI: 10.1159/000536168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/05/2024] [Indexed: 02/09/2024]
Abstract
Introduction Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and its subtypes, granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA), frequently present with acute kidney injury and can often lead to kidney failure, even with successful induction therapy. Few contemporary, nationally representative studies have described hospital complications of AAV. Methods Using data from the 2016-2020 National Inpatient Sample, a nationally representative database, we identified hospitalizations from adults with a new diagnosis of AAV (subtype or unspecified) and an inpatient kidney biopsy during the index hospitalization. We described baseline characteristics, associated inpatient procedures and complications, and compared lengths of stay and costs by geographic region, hospital characteristics, and AAV subtype. Results We identified an average of 1,329 cases of hospitalized AAV with a concurrent kidney biopsy per year over the 5-year period. More than 50% were not designated as having a specific subtype, likely owing to delays in documentation of histopathology. Kidney involvement was severe as the majority of patients developed acute kidney injury, and the proportion of patients who required inpatient dialysis was approximately 24%. Approximately 20% of patients developed hypoxia. Inpatient plasmapheresis was delivered to 20.4% and 20.6% of patients with GPA and MPA, respectively. There were no clinically meaningful or statistically significant differences in adjusted length of stay or inpatient costs among AAV subtypes. Admission in the Midwest region was associated with shorter hospital stays and lower costs than that in the Northeast, South, or West regions of the USA (adjusted p = 0.007 and <0.001, respectively). Conclusion AAV with acute kidney involvement remains a challenging, high-risk condition. Maintaining a high index of suspicion and a low threshold for kidney biopsy should help ameliorate short- and long-term complications.
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Affiliation(s)
- Jianling Tao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maria Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vivek Charu
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Zhang P, Yao J, Gao CL, Fang X, Zhang ZQ, Xia ZK. Validation of a renal risk score in a cohort of children with ANCA-associated glomerulonephritis. J Investig Med 2023; 71:854-864. [PMID: 37615067 DOI: 10.1177/10815589231186534] [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] [Indexed: 08/25/2023]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is extremely rare in children. Renal involvement is a common and severe complication of AAV as it can cause end stage kidney disease (ESKD). ANCA renal risk score (ARRS) is helpful in predicting long-term ESKD in patients with ANCA-associated glomerulonephritis (AAGN). This retrospective study included 61 consecutive patients with kidney biopsy specimen-proven AAGN from Clinical Center for Children's Kidney Disease in China. Each patient was assessed by eGFR, normal glomeruli, and tubular atrophy/interstitial fibrosis, and the renal outcome was evaluated using the ARRS. Based on the ARRS, 27 (44.26%), 21 (34.43%), and 13 (21.31%) patients were divided into the low-risk, medium-risk, and high-risk groups, respectively. The median follow-up period was 46.36 (14.58-95.62) months. The high-risk group had worse renal outcomes than the low-risk group (p< 0.05) and the medium-risk group (p < 0.05). COX multivariate regression analysis showed that eGFR ≤ 15 ml/min/1.73 m2 (p = 0.015, Hazard Ratio (HR) = 9.574, 95% CI 4.205-25.187) and ARRS (p = 0.012, HR = 2.115, 95% CI 1.206-4.174) were independent risk factors for ESKD.The area under the curve for ESKD prediction of ARRS was 0.880, and the best cutoff value was 5.50. Delong test result showed that ARRS exhibited better predictive value for ESKD than the Berden classification (p < 0.001) and rapidly progressive glomerulonephritis (p < 0.001). This is the first study to investigate the value of the ARRS for predicting renal prognosis among Chinese children. The ARRS is a preferred index that can predict ESKD in Chinese children with AAGN.
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Affiliation(s)
- Pei Zhang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Jun Yao
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Chun-Lin Gao
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Xiang Fang
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zhi-Qiang Zhang
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zheng-Kun Xia
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
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Turkmen K, Ozer H, Tesar V. An update on dıagnosıs and treatment of ANCA assocıated renal vasculıtıs. Int Urol Nephrol 2023; 55:2817-2827. [PMID: 37010734 DOI: 10.1007/s11255-023-03565-6] [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: 03/09/2022] [Accepted: 03/17/2023] [Indexed: 04/04/2023]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides are a group of diseases characterised by necrotizing inflammation of small vessels such as arterioles, venules, and capillaries. ANCA-associated vasculitides (AAV) are referred to as small vessel vasculitides. Three AAV subgroups, namely granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic GPA (EGPA), are defined according to clinical features. The most common disease with renal involvement in AAV is MPA Approximately 90% of patients with MPA have renal involvement. While this rate is 70-80% in GPA, less than half of EGPA patients have renal involvement. Untreated survival in AAVs is less than one year. With appropriate immunosuppressive therapy, the 5-year renal survival rate is 70-75%. Without therapy, the prognosis is poor but treatments, typically immunosuppressants, have improved survival, albeit with considerable morbidity from glucocorticoids and other immunosuppressive medications. Current challenges include improving the measures of disease activity and risk of relapse, uncertainty about optimal therapy duration and a need for targeted therapies with fewer adverse effects. In this review, we described the treatment of renal involvement in AAV in line with current studies.
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Affiliation(s)
- Kultigin Turkmen
- Meram Medical Faculty, Department of Internal Medicine, Division of Nephrology, Necmettin Erbakan University, Konya, Turkey
| | - Hakan Ozer
- Meram Medical Faculty, Department of Internal Medicine, Division of Nephrology, Necmettin Erbakan University, Konya, Turkey.
| | - Vladimir Tesar
- Department of Nephrology, Charles University, Faculty of Medicine and General University Hospital, Prague, Czech Republic
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Casal Moura M, Gauckler P, Anders HJ, Bruchfeld A, Fernandez-Juarez GM, Floege J, Frangou E, Goumenos D, Segelmark M, Turkmen K, van Kooten C, Tesar V, Geetha D, Fervenza FC, Jayne DRW, Stevens KI, Kronbichler A. Management of antineutrophil cytoplasmic antibody-associated vasculitis with glomerulonephritis as proposed by the ACR 2021, EULAR 2022 and KDIGO 2021 guidelines/recommendations. Nephrol Dial Transplant 2023; 38:2637-2651. [PMID: 37164940 PMCID: PMC10615627 DOI: 10.1093/ndt/gfad090] [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: 02/11/2023] [Indexed: 05/12/2023] Open
Abstract
Updated guidelines on the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) were released in 2021 by the American College of Rheumatology jointly with the Vasculitis Foundation and, subsequently, in 2022 by the European Alliance of Associations for Rheumatology. In addition, in 2021, the Kidney Disease: Improving Global Outcomes had released updated recommendations on the treatment of AAV with glomerulonephritis (AAV-GN). Kidney involvement is particularly relevant in microscopic polyangiitis and granulomatosis with polyangiitis, but is less frequent in eosinophilic granulomatosis with polyangiitis. The management of AAV-GN has been a focus for drug development and change over the past 10 years. Avoidance of progression to end-stage kidney disease (ESKD) or kidney failure is one of the main unmet needs in the management of AAV, with ESKD having a major impact on morbidity, health costs and mortality risk. Relevant changes in AAV-GN management are related to remission-induction treatment of patients with severe kidney disease, the use of glucocorticoids and avacopan, and remission-maintenance treatment. All the documents provide guidance in accordance with the evidence-based standard of care available at the time of their release. With our work we aim to (i) show the progress made and identify the differences between guidelines and recommendations, (ii) discuss the supporting rationale for those, and (iii) identify gaps in knowledge that could benefit from additional research and should be revised in subsequent updates.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Faculdade de Medicina da Universidade do Porto, Departamento de Biomedicina, Porto, Portugal
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Hans-Joachim Anders
- Department of Internal Medicine IV, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | | | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, SHSO, Cyprus; Medical School, University of Nicosia, Nicosia, Cyprus
| | - Dimitrios Goumenos
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | - Marten Segelmark
- Division of Nephrology, Department of Clinical Sciences Lund, Lund University and Skane University Hospital, Lund, Sweden
| | - Kultigin Turkmen
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Cees van Kooten
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czechia
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Kate I Stevens
- Division of Nephrology and Transplantation, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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10
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Lee YJ, Ahn SM, Oh JS, Kim YG, Lee CK, Yoo B, Hong S. Recovery and long-term renal outcome of patients with anti-neutrophil cytoplasmic antibody-associated vasculitis who are on dialysis at presentation. JOURNAL OF RHEUMATIC DISEASES 2023; 30:251-259. [PMID: 37736589 PMCID: PMC10509644 DOI: 10.4078/jrd.2023.0031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/17/2023] [Accepted: 08/04/2023] [Indexed: 09/23/2023]
Abstract
Objective Renal involvement in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) can lead to severe renal dysfunction requiring dialysis at diagnosis. We aimed to study the clinical and pathologic characteristics of patients with AAV dependent on dialysis at presentation and the long-term renal outcomes of patients who recovered from dialysis. Methods This retrospective study analyzed data of patients diagnosed with AAV who were on dialysis from July 2005 to May 2021 at a single tertiary center in Korea. Results Thirty-four patients were included in the study (median age 64.5 years, females 61.8%), of which 13 discontinued and 21 continued dialysis. The proportion of normal glomeruli (p<0.001) and interstitial fibrosis (p=0.024) showed significant differences between both groups. Multivariable analysis showed that the proportion of normal glomeruli was associated with dialysis discontinuation (odds ratio=1.29, 95% confidence interval 0.99~1.68, p=0.063), although without statistical significance. Treatment modalities, including plasmapheresis, did not show significance with dialysis discontinuation. In the follow-up analysis of 13 patients who had discontinued dialysis for a median of 81 months, 12 did not require dialysis, and their glomerular filtration rate values significantly increased at follow-up time compared to when they stopped dialysis (37.5 [28.5~45.5] vs. 24.0 [18.5~30.0] mL/min/1.73 m²; p=0.008). Conclusion Approximately 38% of AAV patients on dialysis discontinued dialysis, and the recovered patients had improved renal function without dialysis during longer follow-up. Patients with AAV on dialysis should be given the possibility of dialysis discontinuation and renal recovery, especially those with normal glomeruli in kidney pathology.
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Affiliation(s)
- Yeo-Jin Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo-Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji-Seon Oh
- Department of Information Medicine, Big Data Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Wallace ZS, Fu X, Cook C, Ahola C, Williams Z, Doliner B, Hanberg JS, Stone JH, Zhang Y, Choi HK. Comparative Effectiveness of Rituximab- Versus Cyclophosphamide-Based Remission Induction Strategies in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis for the Risk of Kidney Failure and Mortality. Arthritis Rheumatol 2023; 75:1599-1607. [PMID: 37011036 PMCID: PMC10523845 DOI: 10.1002/art.42515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/23/2023] [Accepted: 03/31/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE To compare rituximab- versus cyclophosphamide-based remission induction strategies for the long-term risks of kidney failure and death in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in a real-world cohort. METHODS We performed a cohort study using the Mass General Brigham AAV Cohort, which includes proteinase 3-ANCA+ and myeloperoxidase (MPO)-ANCA+ AAV patients diagnosed from January 1, 2002 to December 31, 2019. We included cases in which the initial remission induction strategy was based either on rituximab or cyclophosphamide. The primary outcome was the composite outcome of kidney failure or death. We used multivariable Cox proportional hazards models and propensity score-matched analyses to assess the association of rituximab- versus cyclophosphamide-based treatment strategies with the composite outcome of kidney failure or death. RESULTS Of 595 included patients, 352 patients (~60%) received rituximab-based and 243 patients (~40%) received cyclophosphamide-based regimens. The mean age was 61 years, 58% of patients were female, 70% of patients were MPO-ANCA+, and 69% of patients had renal involvement (median estimated glomerular filtration rate 37.3 ml/minute/1.73 m2 ). There were 133 events at 5 years, and the incidence rates in rituximab- and cyclophosphamide-based regimens were 6.8 and 6.1 per 100 person-years, respectively. The risk of kidney failure or death was similar in both groups in multivariable-adjusted analyses (hazard ratio [HR] 1.03 [95% confidence interval (95% CI) 0.55-1.93]) and in propensity score-matched analyses (HR 1.05 [95% CI 0.55-1.99]) at 5 years. Our findings were similar when outcomes were assessed at 1 and 2 years as well as in subgroups stratified according to renal involvement and severity as well as major organ involvement. CONCLUSION Rituximab- and cyclophosphamide-based remission induction strategies for AAV are associated with similar risks of kidney failure and death.
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Affiliation(s)
- Zachary S Wallace
- Rheumatology Unit, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Claire Cook
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Catherine Ahola
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Zachary Williams
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, and Mongan Institute, Massachusetts General Hospital, Boston
| | - Brett Doliner
- Department of Medicine, Massachusetts General Hospital, Boston
| | | | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
| | - Yuqing Zhang
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Mongan Institute, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
| | - Hyon K Choi
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, and Mongan Institute, Massachusetts General Hospital, Boston, and Department of Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts
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12
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Mansour I, Murugapandian S, Tanriover B, Thajudeen B. Contemporary Monoclonal Antibody Utilization in Glomerular Diseases. Mayo Clin Proc Innov Qual Outcomes 2023; 7:276-290. [PMID: 37448529 PMCID: PMC10338194 DOI: 10.1016/j.mayocpiqo.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Therapeutic monoclonal antibodies (MAbs) have been one of the fastest growing drug classes in the past 2 decades and are indicated in the treatment of cancer, autoimmune disorders, solid organ transplantation, and glomerular diseases. The Food and Drug Administration has approved 100 MAbs between 1986 and 2021, and MAbs account for 20% of Food and Drug Administration's new drug approval every year. MAbs are preferred over traditional immunosuppressive agents because of their high specificity, reduced number of drug-drug interactions, and low toxicity, which make them a prime example of personalized medicine. In this review article, we provide an overview of the taxonomy, pharmacology, and therapeutic applications of MAbs in glomerular diseases. We searched the literature through PubMed using the following search terms: monoclonal antibodies, glomerular diseases, pharmacokinetics, pharmacodynamics, immunoglobulin, murine, chimeric,humanized, and fully human, and limited our search to years 2018-2023. We selected peer-reviewed journal articles with an evidence-based approach, prioritizing randomized control trials in specific glomerular diseases, if available. Advances in the MAb field have resulted in a significant paradigm shift in targeted treatment of immune-mediated glomerular diseases, and multiple randomized control trials are currently being conducted. Increased recognition is critical to expand their use in experimental research and personalized medicine.
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Affiliation(s)
- Iyad Mansour
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
| | | | - Bekir Tanriover
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
| | - Bijin Thajudeen
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
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13
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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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14
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Krishnan A, Walsh M, Collister D. Management of antineutrophil cytoplasmic antibody-associated vasculitis: a changing tide. Curr Opin Nephrol Hypertens 2023; 32:278-283. [PMID: 36811629 DOI: 10.1097/mnh.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Antineutrophil cytoplasmic antibody associated vasculitis (AAV) is a group of autoimmune disorders of small blood vessels. While outcomes in AAV have improved with the use of glucocorticoids (GC) and other immunosuppressants, these treatments are associated with significant toxicities. Infections are the major cause of mortality within the first year of treatment. There is a move towards newer treatments with better safety profiles. This review reflects on recent advances in the treatment of AAV. RECENT FINDINGS The role of plasma exchange (PLEX) in AAV with kidney involvement has been clarified with new BMJ guideline recommendations following the publication of PEXIVAS and an updated meta-analysis. Lower dose GC regimens are now standard of care. Avacopan (C5a receptor antagonist) was noninferior to a regimen of GC therapy and is a potential steroid-sparing agent. Lastly, rituximab-based regimens were noninferior to cyclophosphamide in two trials for induction of remission and superior to azathioprine in one trial of maintenance of remission. SUMMARY AAV treatments have changed tremendously over the past decade with a drive towards targeted PLEX use, increased rituximab use and lower GC dosing. Striking a crucial balance between morbidity from relapses and toxicities from immunosuppression remains a challenging path to navigate.
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Affiliation(s)
- Anoushka Krishnan
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Michael Walsh
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton
| | - David Collister
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
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15
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Maheshwari M, Athiraman H. Eyes on the Line: A Case of Ocular Granulomatosis With Polyangiitis. Cureus 2023; 15:e37723. [PMID: 37081899 PMCID: PMC10110410 DOI: 10.7759/cureus.37723] [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: 04/17/2023] [Indexed: 04/22/2023] Open
Abstract
Antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis is a small vessel vasculitis with a positive ANCA in the serum. One of three diseases that fall under this category is granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis. This case report presents a patient with an ocular manifestation of GPA, rendering a difficult diagnosis and multi-specialty approach to managing the disease.
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16
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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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17
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Morris A, Geetha D. Advances in remission induction therapy for ANCA-associated vasculitis. Best Pract Res Clin Rheumatol 2023; 37:101828. [PMID: 37244804 DOI: 10.1016/j.berh.2023.101828] [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: 03/29/2023] [Revised: 04/09/2023] [Accepted: 04/23/2023] [Indexed: 05/29/2023]
Abstract
Since its first description 40 years ago, huge strides have been made in the management of ANCA-associated vasculitis with improved patient outcomes. The use of cyclophosphamide and/or B-cell depleting therapy alongside glucocorticoids remains the cornerstone of therapy in organ or life-threatening disease, but recent trials have re-evaluated existing treatment strategies, alongside the development of new treatment targets. This has led to refinement of the role of plasma exchange, the use of reduced dosing of oral glucocorticoids with improved patient outcomes, as well as other treatment adjuvants/options of steroid minimization including C5a receptor antagonism and IL-5 inhibition. In this review we examine developments in remission induction therapy for ANCA-associated vasculitis.
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Affiliation(s)
- Adam Morris
- Renal Medicine, Royal Preston Hospital, Preston, UK
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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18
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Liu L, Lu H, Zou G, Wang H, Li J, Yang Y, Zhang J, Wang X, Li W, Zhuo L. Efficacy and safety of low-dose rituximab as induction therapy for antineutrophil cytoplasmic antibody-associated vasculitis with renal involvement: a Chinese case series. BMC Nephrol 2023; 24:28. [PMID: 36755215 PMCID: PMC9906883 DOI: 10.1186/s12882-023-03075-8] [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] [Received: 02/03/2022] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Rituximab (RTX) is a standard therapy for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, the most frequently used dose may lead to severe adverse effects (SAEs). We explored the efficacy and safety of low-dose RTX in Chinese patients with AAV. METHODS A total of 22 Chinese patients diagnosed with AAV with renal involvement, including 8 treated with low-dose RTX (400 mg of RTX total over 4 weeks) and 14 treated with cyclophosphamide (CYC), were evaluated. The baseline clinical and pathological data and laboratory parameters during follow-up at months 1, 3, 6, and 12 were collected retrospectively. RESULTS The baseline data showed no significant differences between the two groups. The median peripheral CD19+ cell counts in the RTX group decreased from 315.0/μL to 1.5/μL at 2 weeks, and to 2.5/μL at 1 month after the first dose. The median SCr level decreased from 267.8 μmol/L before treatment to 151.45 μmol/L at 1 month, 132.75 μmol/L at 3 months, 123.2 μmol/L at 6 months, and 151.9 μmol/L at 12 months in RTX-treated patients. The improvements in renal function, proteinuria, and ANCA titre were not significantly different between the two groups. The SAE rate was significantly lower in the RTX group (one SAE of pneumonia) compared with the CYC group. CONCLUSIONS This is the first report that low-dose RTX could be effective for the treatment of Chinese patients with AAV with renal involvement.
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Affiliation(s)
- Lin Liu
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Haitao Lu
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Guming Zou
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Haifeng Wang
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Jing Li
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Yue Yang
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Jian Zhang
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Xueling Wang
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Wenge Li
- grid.415954.80000 0004 1771 3349Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029 People’s Republic of China
| | - Li Zhuo
- Department of Nephrology, China-Japan Friendship Hospital, No.2, East Yinghua Street, Beijing, 100029, People's Republic of China.
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Pediatric ANCA vasculitis: clinical presentation, treatment, and outcomes in a French retrospective study. Pediatr Nephrol 2023:10.1007/s00467-022-05855-0. [PMID: 36622443 DOI: 10.1007/s00467-022-05855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 11/20/2022] [Accepted: 12/08/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pediatric ANCA vasculitis is a rare group of diseases with a scarcity of data in children. Annual incidence appeared to increase in the last several years, placing higher interest in the clinical and therapeutical outcomes of the disorder. Also, the growing use of rituximab questions the latest outcomes in these diseases. We therefore conducted a retrospective study to better understand the current characteristics, management, and the latest outcomes of the disorder. METHODS We conducted a 9-year retrospective study of 46 children in 14 different centers across France to describe their clinical and laboratory presentations, therapeutic regimens, and kidney outcome. RESULTS P-ANCA appeared to be a potential marker for higher relapse risk. Compared to adults, we found that ear-nose-throat presentations were frequent (45.7%) and more severe. Despite an evolution in the treatment management, kidney outcome remained poor with a substantial proportion of chronic kidney disease (54.8% at 1 year). Mortality stays low with 3 patients (6.5%) deceased at the end of our study. CONCLUSION Clinical presentation was as previously described and time to diagnosis remains long. P-ANCA is a statistically significant marker for increased relapse risk. We observed a modification in the treatment regimens over the past several years with a growing use of rituximab and a decreasing use of cyclophosphamide. Despite these changes, kidney outcome remains poor and prospective studies should be conducted to assess the most appropriate therapeutic modality for each patient. A higher resolution version of the Graphical abstract is available as Supplementary information.
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20
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Casal Moura M, Specks U, Tehranian S, Sethi S, Zubidat D, Nardelli L, dos Santos FG, Sousa C, León-Róman J, Bobart SA, Greene E, Zand L, Fervenza FC. Maintenance of Remission and Risk of Relapse in Myeloperoxidase-Positive ANCA-Associated Vasculitis with Kidney Involvement. Clin J Am Soc Nephrol 2023; 18:47-59. [PMID: 36526414 PMCID: PMC10101626 DOI: 10.2215/cjn.06460622] [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: 06/02/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The optimal strategy for remission-maintenance therapy in patients with myeloperoxidase-ANCA (MPO-ANCA)-associated vasculitis is not established. Defining parameters to guide maintenance therapy is required. METHODS This was a retrospective cohort study of all patients with MPO-ANCA-associated vasculitis (microscopic with polyangiitis and granulomatosis with polyangiitis) and GN followed at the Mayo Clinic between 1996 and 2015. Relapse rate, MPO-ANCA status, and remission-maintenance therapies were reviewed. Logistic regression models, Kaplan-Meier method, and Cox proportional hazards regression models were applied. RESULTS We analyzed 159 patients with active MPO-ANCA-associated vasculitis with GN. Sixty-six (42%) patients had at least one relapse, and 52 (33%) relapsed before 60 months. Patients with MPO-ANCA who became persistently negative did not relapse (hazard ratio [HR], 0.03; 95% confidence interval [95% CI], 0.002 to 0.431; P =0.01). The reappearance of MPO-ANCA was associated with a higher risk of relapse (HR, 1.91; 95% CI, 1.109 to 3.293; P =0.02). Immunosuppression was withdrawn in 80 (50%) patients, and this was less likely in those who received cyclophosphamide for remission induction or in patients with persistently positive MPO-ANCA (odds ratio [OR], 0.44; 95% CI, 0.228 to 0.861; P =0.02 and OR, 0.42; 95% CI, 0.213 to 0.820; P =0.01, respectively). Relapse frequency was not different between patients with persistently positive MPO-ANCA and patients with MPO-ANCA reappearance (44% versus 39%, P =0.49), irrespective of remission-maintenance treatment. Ear, nose, and throat involvement (OR, 6.10; 95% CI, 1.280 to 29.010; P =0.02) and MPO-ANCA reappearance (OR, 9.25; 95% CI, 3.126 to 27.361; P <0.001) were independently associated with relapse after treatment withdrawal. CONCLUSIONS Patients persistently MPO-ANCA negative are at low risk for relapse even without remission-maintenance therapy. Persistence or subsequent reappearance of MPO-ANCA is associated with a higher risk of relapse. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast.aspx?p=CJASN&e=2023_01_10_CJN06460622.mp3.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Departamento de Biomedicina, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shahrzad Tehranian
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Dalia Zubidat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Luca Nardelli
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Fernanda G. dos Santos
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ciria Sousa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Juan León-Róman
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shane A. Bobart
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Nephrology and Hypertension, Cleveland Clinic Florida, Weston, Florida
| | - Eddie Greene
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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22
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Klapa S, Arnold S, Lamprecht P. Granulomatose mit Polyangiitis und mikroskopische
Polyangiitis. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1963-7586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ZusammenfassungDie Granulomatose mit Polyangiitis (GPA) und mikroskopische Polyangiitis (MPA)
sind zwei zur ANCA-assoziierten Vaskulitis (AAV) zählende
Entitäten. Beiden Erkrankungen liegt eine systemische nekrotisierende
Kleingefäßvaskulitis zugrunde, die jedes Organ betreffen kann.
Bei der GPA ist zusätzlich eine in der Regel den Respirationstrakt
betreffende extravaskuläre nekrotisierende granulomatöse
Entzündung vorzufinden. Das klinische Bild wird in der Mehrzahl der
Fälle durch ein pulmo-renales Syndrom mit alveolärer
Hämorrhagie und rapid-progressiver Glomerulonephritis sowie weitere
Organmanifestationen bestimmt. Bei der GPA imponiert zudem die fast regelhafte
Mitbeteiligung des oberen Respirationstrakts. Die GPA ist mit Anti-Neutrophilen
zytoplasmatischen Autoantikörpern (ANCA) mit einer Spezifität
für die Proteinase 3 (PR3-ANCA) und die MPA für Myeloperoxidase
(MPO-ANCA) assoziiert. Die immunsuppressive Therapie richtet sich nach der
Krankheitsaktivität und Schwere der Organbeteiligung.
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Affiliation(s)
- Sebastian Klapa
- Department of Rheumatology and Clinical Immunology, University of
Lübeck, Lübeck, Germany
| | - Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of
Lübeck, Lübeck, Germany
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of
Lübeck, Lübeck, Germany
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23
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Chevet B, Cornec D, Casal Moura M, Cornec-Le Gall E, Fervenza FC, Warrington KJ, Specks U, Berti A. Diagnosing and treating ANCA-associated vasculitis: an updated review for clinical practice. Rheumatology (Oxford) 2022; 62:1787-1803. [PMID: 36315063 DOI: 10.1093/rheumatology/keac623] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/14/2022] [Accepted: 10/05/2022] [Indexed: 03/29/2023] Open
Abstract
Abstract
ANCA-associated vasculitides (AAV) are a group of rare, primary, systemic necrotizing small-vessel vasculitides. Granulomatosis with polyangiitis and microscopic polyangiitis account for ∼80–90% of all AAV. Exposure to silica dust, farming and chronic nasal Staphylococcus aureus carriage are associated with increased risk of developing AAV. When a diagnosis of AAV is suspected, as in patients with multisystem organ dysfunction or those with features such as chronic recurrent rhinosinusitis, cavitated lung nodules, palpable purpura or acute kidney injury, then appropriate further investigations are needed, including ANCA testing. In this scenario, a structured clinical assessment should be conducted, evaluating all the organs possibly involved, and tissue biopsy may be necessary for confirmation of the diagnosis. Therapeutic algorithms vary based on the severity of AAV, the clinical diagnosis/ANCA specificity, and the patient’s age, weight, comorbidities and prognosis. Recent data favour rituximab as a preferable option for both induction and maintenance of remission. In addition, regimens with less glucocorticoids are equally effective and safer in inducing remission compared with conventional regimens, and avacopan is an effective glucocorticoid-sparing option. In contrast, there is not compelling evidence to support the routine use of plasma exchange in addition to standard remission-induction therapy in AAV. ANCA and other biomarkers can be helpful in association with clinical assessment to guide diagnosis and treatment decisions. Patients should be frequently evaluated during follow-up for possible disease relapses or treatment-related morbidity, and for monitoring damage accrual, especially metabolic and cardiovascular damage.
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Affiliation(s)
- Baptiste Chevet
- LBAI, UMR1227, Univ Brest, Inserm, Labex IGO, CHU de Brest, Brest, France
| | - Divi Cornec
- LBAI, UMR1227, Univ Brest, Inserm, Labex IGO, CHU de Brest, Brest, France
| | - Marta Casal Moura
- Department Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | | | | | - Ulrich Specks
- Department Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Alvise Berti
- Rheumatology, Santa Chiara Regional Hospital, APSS Trento, and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Italy
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24
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Khil J, Nguyen TM, Troxell ML, Zheng S. Systemic Lupus Erythematosus and ANCA-Associated Vasculitis Overlap Syndrome: A Case Report. Kidney Med 2022; 4:100544. [DOI: 10.1016/j.xkme.2022.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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25
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Rituximab treatment in ANCA-associated vasculitis patients: outcomes of a real-life experience from an observational cohort. Clin Rheumatol 2022; 41:2809-2816. [PMID: 35507201 PMCID: PMC9065666 DOI: 10.1007/s10067-022-06192-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022]
Abstract
Rituximab is a first-line therapy in patients with anti-neutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV). Among previous studies evaluating its efficacy, the Hispanic/Latino population has been underrepresented. This study aimed to assess the outcomes of AAV patients treated with rituximab in a tertiary care center in Mexico. This is a retrospective cohort study including patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), or renal-limited vasculitis (RLV), who received at least one dose of rituximab (induction or maintenance therapy) from January 2014 to October 2020. Demographic, clinical, serological, histopathological, and treatment-related variables were retrieved. Outcomes were the rate of remission at 6 months during induction and the rate of relapses during maintenance. Damage, serious infections, and death were assessed. Differences between patients with and without remission were analyzed. Forty-two patients received rituximab, 34 of them as induction to remission. Twenty-two patients (65%) achieved remission after 6 months. Patients who achieved remission were younger than those who did not (50 vs. 60 years, p = 0.03). During induction, severe infections, most frequently pneumonia, occurred in 9 (26%), and one patient died. Twenty-four patients received rituximab as maintenance; of them, 23 (96%) achieved complete response, and 8 (33%) experienced relapses (median follow-up time 19 months). During maintenance, severe infections (pneumonia) occurred in 5 patients (21%), and 3 of them (13%) died. In this observational cohort study, the outcomes were similar to the ones reported in other populations, whereas severe infections were frequent and associated with mortality.
Key Points • In this study, the outcomes of 42 Mexican patients with ANCA-associated vasculitis treated with rituximab were assessed in a real-life setting. • At 6 months, 65% of the patients achieved remission with rituximab, especially those younger than 50 years of age. • During maintenance therapy with rituximab, 96% of the patients achieved complete response, and 33% experienced relapses. • Severe infections, mostly pneumonia, occurred in 26% of patients during induction and 21% of patients during maintenance therapy with rituximab. |
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26
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Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
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27
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Roccatello D, Sciascia S, Murgia S, Quattrocchio G, Ferro M, De Simone E, Naretto C, Barreca A, Sammartino A, Rossi D, Fenoglio R. Treating Patients With ANCA-Associated Vasculitis and Very Severe Renal Injury With an Intensified B Cell Depletion Therapy: Comparison With a Control Cohort Receiving a Conventional Therapy. Front Immunol 2022; 13:777134. [PMID: 35401565 PMCID: PMC8988143 DOI: 10.3389/fimmu.2022.777134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/01/2022] [Indexed: 01/04/2023] Open
Abstract
Rituximab (RTX), an anti-CD20 monoclonal antibody, has shown to be an effective induction treatment for small-vessel vasculitides associated with antineutrophil cytoplasm antibodies (AAV) in both newly diagnosed and relapsing patients. However, the role of RTX in the management of the most severe cases of AAV remains to be fully elucidated. The aim of this study was to assess both safety and efficacy of an intensified B-cell depletion therapy (IBCDT) protocol, including RTX, cyclophosphamide (CYC), and methylprednisolone pulses without additional maintenance immunosuppressive therapy in a cohort of 15 AAV patients with the most severe features of AVV renal involvement (as <15 ml/min GFR and histological findings of paucimmune necrotizing glomerulonephritis with more than 50% crescents of non-sclerotic glomeruli at the renal biopsy). Results of the IBCDT regimen have been compared to those obtained in a control cohort of 10 patients with AAV treated with a conventional therapy regimen based on oral CYC and steroids followed by a prolonged maintenance therapy with azathioprine (AZA). Plasma exchange was equally employed in the study and the control group. Complete clinical remission (BVAS 0) was observed at 6 months in 14 of 15 patients treated with IBCDT (93%). All cases who achieved a complete clinical remission experienced a depletion of peripheral blood B cells at the end of therapy. Of the 10 dialysis dependent patients at onset, 6 subjects (60%) experienced a functional recovery allowing the suspension of dialysis treatment. When compared to the control group, no statistically significant difference was observed in patients treated with IBCDT in terms of overall survival, 6-month therapeutic response rate, and 6-, and 12-month functional renal recovery. The cumulative total dose of CYC in the case group was on average 1 g/patient while in the control group on average 8.5 g/patient (p = 0.00008). Despite the retrospective design and relative limited sample size, IBCDT appeared to be safe and had the same efficacy profile when compared to the conventional therapy with CYC plus AZA in the management of the most severe patients with AAV. Additionally, this avoided the need of prolonged maintenance therapy for long, and limited the exposure to CYC with consequent reduced toxicity and drug-related side effect rates.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Stefano Murgia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Giacomo Quattrocchio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Michela Ferro
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Emanuele De Simone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | | | - Andrea Sammartino
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Torino, Italy.,Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
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28
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Nezam D, Porcher R, Grolleau F, Morel P, Titeca-Beauport D, Faguer S, Karras A, Solignac J, Jourde-Chiche N, Maurier F, Sakhi H, El Karoui K, Mesbah R, Carron PL, Audard V, Ducloux D, Paule R, Augusto JF, Aniort J, Tiple A, Rafat C, Beaudreuil S, Puéchal X, Gobert P, Massy Z, Hanrotel C, Bally S, Martis N, Durel CA, Desbuissons G, Godmer P, Hummel A, Perrin F, Néel A, De Moreuil C, Goulenok T, Guerrot D, Grange S, Foucher A, Deroux A, Cordonnier C, Guilbeau-Frugier C, Modesto-Segonds A, Nochy D, Daniel L, Moktefi A, Rabant M, Guillevin L, Régent A, Terrier B. Kidney Histopathology Can Predict Kidney Function in ANCA-Associated Vasculitides with Acute Kidney Injury Treated with Plasma Exchanges. J Am Soc Nephrol 2022; 33:628-637. [PMID: 35074934 PMCID: PMC8975074 DOI: 10.1681/asn.2021060771] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/24/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Data from the PEXIVAS trial challenged the role of plasma exchange (PLEX) in ANCA-associated vasculitides (AAV). We aimed to describe kidney biopsy from patients with AAV treated with PLEX, evaluate whether histopathologic findings could predict kidney function, and identify which patients would most benefit from PLEX. METHODS We performed a multicenter, retrospective study on 188 patients with AAV and AKI treated with PLEX and 237 not treated with PLEX. The primary outcome was mortality or KRT at 12 months (M12). RESULTS No significant benefit of PLEX for the primary outcome was found. To identify patients benefitting from PLEX, we developed a model predicting the average treatment effect of PLEX for an individual depending on covariables. Using the prediction model, 223 patients had a better predicted outcome with PLEX than without PLEX, and 177 of them had >5% increased predicted probability with PLEX compared with without PLEX of being alive and free from KRT at M12, which defined the PLEX-recommended group. Risk difference for death or KRT at M12 was significantly lower with PLEX in the PLEX-recommended group (-15.9%; 95% CI, -29.4 to -2.5) compared with the PLEX not recommended group (-4.8%; 95% CI, 14.9 to 5.3). Microscopic polyangiitis, MPO-ANCA, higher serum creatinine, crescentic and sclerotic classes, and higher Brix score were more frequent in the PLEX-recommended group. An easy to use score identified patients who would benefit from PLEX. The average treatment effect of PLEX for those with recommended treatment corresponded to an absolute risk reduction for death or KRT at M12 of 24.6%. CONCLUSIONS PLEX was not associated with a better primary outcome in the whole study population, but we identified a subset of patients who could benefit from PLEX. However, these findings must be validated before utilized in clinical decision making.
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Affiliation(s)
- Dorian Nezam
- Service de Néphrologie, Dialyse et Transplantation, CHU de Rouen, France
| | - Raphaël Porcher
- Centre de Recherche Épidémiologie et Statistiques, Université de Paris, Paris, France
| | - François Grolleau
- Centre de Recherche Épidémiologie et Statistiques, Université de Paris, Paris, France
| | - Pauline Morel
- Service de dialyse et aphérèse, AURA Paris Plaisance, Paris, France
| | | | - Stanislas Faguer
- Département de Néphrologie et Transplantation d’organes, Hôpital Rangueil, Toulouse, France
| | - Alexandre Karras
- Service de Néphrologie, Hôpital Européen Georges Pompidou, Université de Paris, Paris, France
| | - Justine Solignac
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception (APHM), Marseille, France
| | - Noémie Jourde-Chiche
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception (APHM), Marseille, France
| | - François Maurier
- Hôpital Belle-Isle, Groupe Hospitalier Associatif UNEOS, Metz, France
| | - Hamza Sakhi
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Creteil, France,Institut National de la Santé et de la Recherche Médicale U955, Institut Mondor de Recherche Biomédicale, Creteil, France
| | - Khalil El Karoui
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Creteil, France,Institut National de la Santé et de la Recherche Médicale U955, Institut Mondor de Recherche Biomédicale, Creteil, France
| | - Rafik Mesbah
- Service de Néphrologie, Centre Hospitalier, Boulogne-sur-mer, France
| | | | - Vincent Audard
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Creteil, France,Institut National de la Santé et de la Recherche Médicale U955, Institut Mondor de Recherche Biomédicale, Creteil, France
| | - Didier Ducloux
- Service de Néphrologie, Dialyse et Transplantation, CHU Besançon, France
| | - Romain Paule
- Service de Médecine Interne, Hôpital Foch, Suresnes, France
| | | | - Julien Aniort
- Service de Néphrologie, Dialyse et Transplantation rénale, CHU Gabriel Montpied, Clermont-Ferrand, France
| | - Aurélien Tiple
- Service de Néphrologie, CHU Jacques Lacarin, Vichy, France
| | - Cédric Rafat
- Unité de Néphrologie, Transplantation Rénale, Hôpital Tenon (Assistance Publique des Hôpitaux de Paris), Paris, France
| | - Séverine Beaudreuil
- Service de Néphrologie, Dialyse et Transplantation rénale, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Xavier Puéchal
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Pierre Gobert
- Service de Médecine Interne et Immunologie clinique, Clinique Rhône Durance, Avignon, France
| | - Ziad Massy
- Département de Néphrologie, Hôpital Ambroise Paré, Boulogne Billancourt, France
| | - Catherine Hanrotel
- Service de Néphrologie, Dialyse et Transplantation rénale, Hôpital La Cavale Blanche, Brest, France
| | - Stéphane Bally
- Service de Néphrologie Dialyse, Centre Hospitalier Métropole Savoie, Chambery, France
| | | | - Cécile-Audrey Durel
- Service de Médecine, Interne Hôpital Edouard Herriot, Hospices civils de Lyon, France
| | | | - Pascal Godmer
- Service de Médecine Interne, CHBA site de Vannes, Vannes, France
| | - Aurélie Hummel
- Service de Néphrologie et Transplantation Rénale, Hôpital Necker-Enfants Malades (Assistance Publique des Hôpitaux de Paris), Paris, France
| | | | - Antoine Néel
- Service de Médecine Interne, CHU de Nantes, France
| | | | - Tiphaine Goulenok
- Service de Médecine Interne, Hôpital Bichat (Assistance Publique des Hôpitaux de Paris), Paris, France
| | - Dominique Guerrot
- Service de Néphrologie, Dialyse et Transplantation, CHU de Rouen, France
| | - Steven Grange
- Service de Réanimation médicale, CHU Charles Nicolle, Rouen, France
| | - Aurélie Foucher
- Service de Médecine Interne, CHU site Sud Saint-Pierre, Saint-Pierre, France
| | - Alban Deroux
- Service de Médecine Interne, CHU de Grenoble, France
| | - Carole Cordonnier
- Service d’anatomie et de cytologie pathologiques, Hôpital Nord, CHU d’Amiens, France
| | - Céline Guilbeau-Frugier
- Service d’anatomie pathologique et histologie-cytologie, Hôpital de Rangueil-Larrey, CHU Toulouse, Toulouse, France
| | - Anne Modesto-Segonds
- Service d’anatomie pathologique et histologie-cytologie, Hôpital de Rangueil-Larrey, CHU Toulouse, Toulouse, France
| | - Dominique Nochy
- Service d’Anatomie et Cytologie Pathologiques, Hôpital Européen Georges Pompidou (Assistance Publique des Hôpitaux de Paris), Paris, France
| | - Laurent Daniel
- Service d’Anatomie et cytologie pathologiques, Hôpital La Timone (APHM), Marseille, France
| | - Anissa Moktefi
- Assistance Publique des Hôpitaux de Paris, Department of Pathology, Groupe Hospitalier Henri-Mondor 94010 Creteil, France
| | - Marion Rabant
- Department of Pathology, Necker Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Loïc Guillevin
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Alexis Régent
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
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Xia M, Yu R, Zheng Z, Li H, Feng J, Xie X, Chen D. Meta-Analytical Accuracy of ANCA Renal Risk Score for Prediction of Renal Outcome in Patients With ANCA-Associated Glomerulonephritis. Front Med (Lausanne) 2022; 8:736754. [PMID: 35071256 PMCID: PMC8770957 DOI: 10.3389/fmed.2021.736754] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022] Open
Abstract
Background: To evaluate the diagnostic accuracy of antineutrophil cytoplasmic antibody (ANCA) renal risk score (ARRS) for prediction of renal outcome in patients with ANCA-associated glomerulonephritis (ANCA-GN). Methods: We searched PubMed, EMBASE, Ovid, Web of Science, the Cochrane Library, and ClinicalTrials.gov for studies, which used ARRS to predict end-stage renal disease (ESRD) in patients with ANCA-GN. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. We calculated the combined patients with ESRD in the ARRS categories and presented the summary and individual estimates based on the ARRS categories. Then, the sensitivity, specificity, diagnostic odds ratio (DOR), positive/negative likelihood ratio, and the area under the receiver operating characteristic (AUROC) curves of the pooled data for ARRS were used to assess the accuracy of the “above the low-risk threshold” (ARRS ≥ 2) and “high-risk grade” (ARRS ≥ 8) for renal outcome of patients with ANCA-GN. The hierarchical summary ROC (HSROC) was used to verify the accuracy value. The clinical utility of ARRS was evaluated by the Fagan plot. Heterogeneity was explored using meta-regression and subgroup analysis. Results: A total of 12 distinct cohorts from 11 articles involving 1,568 patients with ANCA-GN were analyzed. The cumulative patients with ESRD at the maximum follow-up of 60 months was 5% (95% CI: 0.02–0.07; p < 0.001) for ANCA-GN with low ARRS (0–1 points) and significantly increased to 22% (95% CI: 0.15–0.29; p < 0.001) medium ARRS (2–7 points). The combined cumulative patients with ESRD was 59% (95% CI: 0.49–0.69; p < 0.001) high ARRS (8–11 points). The pooled sensitivity of ARRS ≥ 2 in predicting ESRD was 98% with a specificity of 30% and a DOR of 15.08 and the mean AUROC value was 0.82. The pooled sensitivity of ARRS ≥ 8 in predicting ESRD was 58% with a specificity of 86% and a DOR of 7.59. The meta-regression and subgroup analysis indicated that variation in the geographic regions, study design, index risk, follow-up time, age of patient, publication year, and number of patient could be the potential sources of heterogeneity in the diagnosis of ARRS ≥ 8. Conclusion: This meta-analysis emphasized the good performance of the ARRS score in predicting the renal outcome in patients with ANCA-GN. However, these findings should be verified by future large-scale prospective studies.
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Affiliation(s)
- Mengdi Xia
- Nanchong Key Laboratory of Basic Science and Clinical Research on Chronic Kidney Disease, Department of Nephrology, The Second Clinical Medical Institution of North Sichuan Medical College (Nanchong Central Hospital), Nanchong, China
| | - Ruiran Yu
- Department of Oncology, Anqing First People's Hospital of Anhui Medical University, Anqing, China
| | - Zaiqiong Zheng
- Nanchong Key Laboratory of Basic Science and Clinical Research on Chronic Kidney Disease, Department of Nephrology, The Second Clinical Medical Institution of North Sichuan Medical College (Nanchong Central Hospital), Nanchong, China
| | - Huan Li
- Nanchong Key Laboratory of Basic Science and Clinical Research on Chronic Kidney Disease, Department of Nephrology, The Second Clinical Medical Institution of North Sichuan Medical College (Nanchong Central Hospital), Nanchong, China
| | - Jie Feng
- Nanchong Key Laboratory of Basic Science and Clinical Research on Chronic Kidney Disease, Department of Nephrology, The Second Clinical Medical Institution of North Sichuan Medical College (Nanchong Central Hospital), Nanchong, China
| | - Xisheng Xie
- Nanchong Key Laboratory of Basic Science and Clinical Research on Chronic Kidney Disease, Department of Nephrology, The Second Clinical Medical Institution of North Sichuan Medical College (Nanchong Central Hospital), Nanchong, China
| | - Dongming Chen
- Department of Neurosurgery, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:4056-4064. [DOI: 10.1093/rheumatology/keac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/06/2022] [Indexed: 11/12/2022] Open
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Casal Moura M, Branco C, Martins-Martinho J, Ferraro JL, Berti A, Nogueira E, Ponte C. A glance into the future of anti-neutrophil cytoplasmic antibody-associated vasculitis. Ther Adv Musculoskelet Dis 2022; 14:1759720X221125979. [PMID: 36353270 PMCID: PMC9638684 DOI: 10.1177/1759720x221125979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
In the past decade, unprecedented progress has been made in understanding the
pathogenesis, diagnosis, assessment, and treatment of anti-neutrophil
cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). International
collaborations and input from several fields (e.g. immunology, rheumatology, and
nephrology) have been critical for analyzing demographics, disease
manifestations, and outcomes in clinical research studies. Such efforts opened
new avenues for generating novel questions and rationale to design better
clinical trials. In addition, clinical research has been a source of several
biological discoveries and the starting point for knowledge seeking on the
pathophysiology of AAV. Interestingly, the blending of clinical and basic
research provides a platform for personalized medicine. Despite recent revisions
on AAV classification, the incorporation of new findings on disease genetics and
immunologic responses may soon result in changes in clinical practice. These
advances will enhance the selection of more specific and targeted therapies.
However, current unmet needs in the management of AAV are still sizable and
heavily impact long-term survival. Especially, frequent relapses, damage
accrual, and high morbidity contribute to poor outcomes. Finally, the lack of
defined biomarkers for disease activity and the prognosis is a permanent
challenge in AAV research. Our work provides an overview of the current state of
the art in AAV literature and suggests bridges for the remaining knowledge gaps.
It offers potential future directions for the clinical assessment, management,
and research in the field toward a more personalized medicine approach.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, 200 First Street, Rochester, MN 55905-0002, USA
- Department of Medicine, Faculty of Medicine, Porto University, Porto, Portugal
| | - Carolina Branco
- Renal Transplant and Nephrology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - José Luís Ferraro
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Alvise Berti
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Rheumatology Department, Santa Chiara Hospital and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy
| | - Estela Nogueira
- Renal Transplant and Nephrology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Plasma Exchange in ANCA-Associated Vasculitis: A Narrative Review. J Clin Med 2021; 10:jcm10215154. [PMID: 34768675 PMCID: PMC8584508 DOI: 10.3390/jcm10215154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/23/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is an adjunctive intervention to immunosuppression for the treatment of severe renal involvement or lung hemorrhage in patients with ANCA-associated vasculitis (AAV). Patients with AAV have an increased risk for progression to end-stage kidney disease (ESKD) or death despite advances in immunosuppressive therapy. The potential pathogenicity of ANCA makes TPE a reasonable treatment approach for the life-threatening complications of AAV. The efficacy of intensive TPE in rapidly progressive glomerulonephritis was originally described in small studies almost four decades ago. Further randomized trials examined the addition of TPE to standard of care, exhibiting mixed results in both patient and renal survival. The largest clinical trial to date, PEXIVAS, failed to demonstrate a clear benefit for TPE in severe AAV. In light of new evidence, the role of TPE remains controversial across the vasculitis medical community. The purpose of this review is to summarize the clinical indications and the current available data for the use of TPE in patients with severe AAV.
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 661] [Impact Index Per Article: 220.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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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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Moura MC, Fervenza FC, Specks U, Sethi S. Kidney Biopsy Chronicity Grading in Antineutrophil Cytoplasmic Antibody Associated Vasculitis. Nephrol Dial Transplant 2021; 37:1710-1721. [PMID: 34436585 PMCID: PMC9395375 DOI: 10.1093/ndt/gfab250] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Indexed: 12/30/2022] Open
Abstract
Background Kidney biopsy is valuable for prognostic assessment of renal outcomes in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with glomerulonephritis (AAV-GN) but the impact of chronic changes is not determined. Methods We conducted a retrospective cohort study of myeloperoxidase (MPO)- or proteinase 3 (PR3)-ANCA-positive patients with AAV and active renal disease. We applied the Mayo Clinic Chronicity Score (MCCS) and validated and evaluated its implications on outcome prediction in AAV-GN. Results We analyzed 329 patients with kidney biopsies available to score. The extent of chronicity was graded by MCCS as minimal [102 (31.0%)], mild [106 (32.2%)], moderate [86 (26.1%)] and severe [35 (10.6%)]. The MCCS grades correlated with the degree of renal function impairment at presentation [mean estimated glomerular filtration rate (eGFR) 48.3 versus 29.2 versus 23.7 versus 18.5 mL/min/1.73 m2, respectively; P < 0.0001]. Higher degrees of the individual components of the MCCS (glomerulosclerosis, interstitial fibrosis, tubular atrophy and arteriosclerosis) were associated with lower median eGFR (P < 0.0001) and decreased event-free [kidney failure (KF) and death] survival (P = 0.002, P < 0.0001, P < 0.0001 and P = 0.017, respectively). Patients with lower MCCS grades recovered renal function more frequently (P < 0.0001). Increasing MCCS grades were associated with decreased renal recovery (P = 0.001), more frequent events and shorter time to KF (P < 0.0001), KF and death (P < 0.0001) and death (P = 0.042), independent of the remission induction treatment used (cyclophosphamide or rituximab). The MCCS stratified renal outcomes for each MCCS grade and can be used in clinical practice as a cutoff for KF prediction (MCCS ≥4). Conclusions Chronic changes on kidney histology independently predict renal function, outcomes and response to treatment in AAV-GN.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA College of Medicine and Science, Rochester, MN, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA College of Medicine and Science, Rochester, MN, USA
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic
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Tampe D, Ströbel P, Korsten P, Hakroush S, Tampe B. Consideration of Therapeutic Plasma Exchange in Association With Inflammatory Lesions in ANCA-Associated Glomerulonephritis: A Real-World Retrospective Study From a Single Center. Front Immunol 2021; 12:645483. [PMID: 34220805 PMCID: PMC8248537 DOI: 10.3389/fimmu.2021.645483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/01/2021] [Indexed: 01/09/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systemic vasculitis, most frequently presenting as microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA). Pathogenic ANCAs trigger a deleterious immune response resulting in pauci-immune necrotizing and crescentic glomerulonephritis (GN). Standard therapeutical regimens include aggressive immunosuppressive therapy. Since some patients require renal replacement therapy (RRT) despite intensive immunosuppressive therapy, additional therapeutic plasma exchange (PEX) to deplete pathogenic ANCAs has been recommended but its value has recently been questioned. Because therapeutic decision making is crucial in these critically ill patients, we here aimed to identify inflammatory lesions in association with PEX consideration in a retrospective study from a single center tertiary hospital in a real-world population of 46 patients with severe AAV requiring intensive care treatment. The decision to consider PEX was more likely in patients with need for intensive care treatment and severe renal dysfunction. In contrast, short-term outcomes did not depend on clinical, or laboratory characteristics assessed at admission. Histopathological analysis confirmed active disease reflected by increased glomerular necrosis and crescents, but these histopathological findings did not associate with short-term outcome either. Interestingly, only increased global glomerular sclerosis in renal biopsies associated with a detrimental short-term outcome. In conclusion, our study investigated determinants for the consideration of therapeutic PEX in patients with severe AAV requiring intensive care treatment. This aspect underscores the need for renal biopsy and requires further investigation in a prospective controlled setting for therapeutic decision making especially in patients with severe AAV requiring intensive care treatment, especially important for treating intensivists.
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Affiliation(s)
- Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Samy Hakroush
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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Specks U, Fussner LA, Cartin-Ceba R, Casal Moura M, Zand L, Fervenza FC. Plasma exchange for the management of ANCA-associated vasculitis: the con position. Nephrol Dial Transplant 2021; 36:231-236. [PMID: 33374017 DOI: 10.1093/ndt/gfaa312] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023] Open
Abstract
Advances in the diagnosis and treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis have led to continued improvement in survival and prognosis over the course of the last 4 decades. Nevertheless, the most acute and severe disease manifestations, including severe kidney disease and alveolar hemorrhage, continue to be associated with increased early mortality from disease activity or treatment complications as well as risk for the development of end-stage kidney disease (ESKD), which in turn directly affects the overall prognosis of ANCA-associated vasculitis. Plasma exchange (PLEX) has long been proposed and used for these most severe disease manifestations under the assumption that its effects are swift and supported by our understanding of the pathogenic role of ANCA. Yet convincing evidence of a beneficial effect of PLEX in ANCA-associated vasculitis has been lacking, as early studies and small trials have generated conflicting results. The controversy regarding PLEX has been accentuated recently as the largest randomized controlled trial ever conducted in ANCA-associated vasculitis, the Plasma Exchange and Glucocorticoids in Severe ANCA-associated Vasculitis trial, which was specifically designed to evaluate the efficacy of PLEX in patients with severe renal disease or alveolar hemorrhage, failed to show a difference in the combined primary outcome measure of death or ESKD in patients who received PLEX versus those who did not. In light of these disappointing results, we herein review the currently available data on PLEX for ANCA-associated vasculitis and explain why we believe that these data no longer support the use of PLEX in ANCA-associated vasculitis.
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Affiliation(s)
- Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary and Critical Care Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Department of Critical Care, Mayo Clinic, Scottsdale, AZ, USA
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ladan Zand
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, USA
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Monti S, Brandolino F, Milanesi A, Xoxi B, Delvino P, Montecucco C. Novel Therapies for ANCA-associated Vasculitis. Curr Rheumatol Rep 2021; 23:38. [PMID: 33909172 DOI: 10.1007/s11926-021-01010-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the most recent evidence on the treatment innovations and future prospective in the management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). RECENT FINDINGS In AAV, a growing body of research is available on novel treatment options for remission induction and to clarify some uncertainties concerning the optimal use of available drugs. Efforts are being made to reduce the toxicity associated with high-dose, prolonged glucocorticoids (GC) regimens. Despite major advances in the prognosis of AAV, relapses are still common and the intensity and duration of remission treatment constitute a great challenge in the management of these chronic conditions. A paradigm shift in practice in the management of AAV is being supported by recent evidence suggesting the comparable efficacy and improved safety profile of schemes with a reduced dose of GC for the induction and maintenance of remission in patients with severe granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Moreover, recent appraisal of pathogenetic mechanisms, including complement activation pathways, has introduced the revolutionary concept of an alternative to GC, such as avacopan. Plasma exchange failed to prevent end-stage renal disease and mortality in patients with severe renal involvement or pulmonary haemorrhage according to a large multicentre randomised trial. Intensified immunosuppressive strategies for patients with life-threatening manifestations, including the combination of rituximab (RTX) with cyclophosphamide (CYC) have revealed promising preliminary data. New evidence for the use of alternative immunosuppressive agents (e.g. mycophenolate mofetil or abatacept) for the induction of remission in patients with non-severe disease is emerging. Several studies have been recently published, or are ongoing, to assess the optimal strategy and duration of maintenance of remission with the available treatment options (GC, azathioprine, and RTX). Preliminary evidence supports the superiority of a more prolonged course of maintenance treatment. The management of refractory or relapsing eosinophilic granulomatosis with polyangiitis (EGPA) has been improved by the recent demonstration of efficacy and safety of an interleukin-5 inhibitor, mepolizumab. Ongoing randomised studies will clarify the role of RTX in patients with severe manifestations of EGPA.
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Affiliation(s)
- Sara Monti
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy.
| | - Fabio Brandolino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Alessandra Milanesi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Blerina Xoxi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Paolo Delvino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
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Almaani S, Fussner LA, Brodsky S, Meara AS, Jayne D. ANCA-Associated Vasculitis: An Update. J Clin Med 2021; 10:jcm10071446. [PMID: 33916214 PMCID: PMC8037363 DOI: 10.3390/jcm10071446] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/28/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) represents a group of small vessel vasculitides characterized by granulomatous and neutrophilic tissue inflammation, often associated with the production of antibodies that target neutrophil antigens. The two major antigens targeted by ANCAs are leukocyte proteinase 3 (PR3) and myeloperoxidase (MPO). AAV can be classified into 3 categories based on patterns of clinical involvement: namely, granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic GPA (EGPA). Clinically, AAV involves many organ systems including the lungs, kidneys, skin, and nervous system. The prognosis of AAV has improved dramatically due to advances in the understanding of its pathogenesis and treatment modalities. This review will highlight some of the recent updates in our understanding of the pathogenesis, clinical manifestations, and treatment options in patients with AAV focusing on kidney involvement.
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Affiliation(s)
- Salem Almaani
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA
- Correspondence:
| | - Lynn A. Fussner
- Division of Pulmonary and Critical Care Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA;
| | - Sergey Brodsky
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA;
| | - Alexa S. Meara
- Division of Rheumatology, The Ohio State University Wexner Medical Center, Columbus, OH 43201, USA;
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridg CB2 0QQ, UK;
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Jain K, Jawa P, Derebail VK, Falk RJ. Treatment Updates in Antineutrophil Cytoplasmic Autoantibodies (ANCA) Vasculitis. KIDNEY360 2021; 2:763-770. [PMID: 34095854 PMCID: PMC8177081 DOI: 10.34067/kid.0007142020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/03/2021] [Indexed: 02/04/2023]
Abstract
ANCA vasculitis is a small-vessel vasculitis (SVV) resulting in inflammation of small- and medium-sized blood vessels. Since the initial description of SVV, there have been tremendous advances in our understanding of its pathogenesis. Over the last decade, we have made significant progress in understanding the pathogenesis and improving the treatment and prognosis of patients with ANCA vasculitis. Patient and renal survival has improved, and treatment is moving toward individualizing care, minimizing severe adverse events, and preventing relapse. This review focuses on treatment updates in ANCA vasculitis, duration of therapy, and management of relapses. We also describe the existing treatment protocols used at our institution.
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Affiliation(s)
- Koyal Jain
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pankaj Jawa
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Vimal K. Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J. Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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De Vriese AS, Fervenza FC. PEXIVAS: The End of Plasmapheresis for ANCA-Associated Vasculitis? Clin J Am Soc Nephrol 2021; 16:307-309. [PMID: 32963016 PMCID: PMC7863639 DOI: 10.2215/cjn.10550620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium,Department of Internal Medicine, Ghent University, Ghent, Belgium
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Yamada Y, Harada M, Hara Y, Iwabuchi R, Hashimoto K, Yamamoto S, Kamijo Y. Efficacy of plasma exchange for antineutrophil cytoplasmic antibody-associated systemic vasculitis: a systematic review and meta-analysis. Arthritis Res Ther 2021; 23:28. [PMID: 33446268 PMCID: PMC7809754 DOI: 10.1186/s13075-021-02415-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/04/2021] [Indexed: 02/08/2023] Open
Abstract
Objective To assess through systematic review and meta-analysis whether plasma exchange (PE) is associated with prognosis in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. Methods A systematic search of PubMed, MEDLINE, Embase, and CENTRAL databases from inception to 17 June 2020 was conducted. Ongoing or unpublished trials were also searched in ClinicalTrials.gov and the World Health Organization trials portal. Randomised controlled trials (RCTs) comparing PE vs. non-PE in AAV patients (microscopic polyangiitis [MPA], granulomatosis with polyangiitis [GPA], or eosinophilic granulomatosis with polyangiitis [EGPA]) were included. The combined risk ratio (RR) was calculated by the random-effects model using the Mantel-Haenszel method. Heterogeneity was measured using the I2 statistic. Primary outcomes were mortality, clinical remission (CR), and adverse events (AEs). Results Four RCTs comparing PE vs. no PE (N = 827) and 1 RCT comparing PE vs. pulse steroid treatment (N = 137) were included. All participants were MPA or GPA patients (no EGPA patients). PE was not associated with main primary outcomes compared with no PE (mortality RR 0.93 [95% confidence interval {CI} 0.70–1.24], I2 = 0%; CR RR 1.02 [95% CI 0.91–1.15], I2 = 0%; and AE RR 1.10 [95% CI 0.73–1.68], I2 = 37%) or pulse steroid (mortality RR 0.99 [95% CI 0.71–1.37]; CR [the Birmingham Vasculitis Activity score] mean difference − 0.53 [95% CI − 1.40–0.34]; and AE RR 1.05 [95% CI 0.74–1.48]). Focusing on the early treatment phases, PE was associated with a reduction in end-stage renal disease incidence compared with both no PE (PE 1/43 vs. no PE 10/41; RR 0.14 [0.03–0.77] at 3 months) and pulse steroid (PE 11/70 vs. pulse steroid 23/67; RR 0.46 [0.24–0.86] at 3 months). Conclusion We carried out a systematic review and meta-analysis targeting all AAV patients, including MPA, GPA, and EGPA. In AAV patients, performing PE was not associated with the risk of mortality, CR, and AE. No RCT exists evaluating the efficacy of PE for EGPA; hence, this is required in the future. The results may affect the development of guidelines for AAV and may indicate the direction of future clinical research on AAV. Trial registration UMIN R000045239, PROSPERO CRD42020182566. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02415-z.
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Affiliation(s)
- Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yuuta Hara
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Ryohei Iwabuchi
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Shuhei Yamamoto
- Department of Rehabilitation, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
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Circulating B Cells, Plasma Cells, and Treg Associate with ANCA Levels in ANCA-associated Vasculitis. Kidney Int Rep 2020; 6:496-500. [PMID: 33615075 PMCID: PMC7879119 DOI: 10.1016/j.ekir.2020.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/15/2020] [Accepted: 11/17/2020] [Indexed: 12/05/2022] Open
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