EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update

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.

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

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.

Systematic literature review informing the 2022 update of the EULAR recommendations for the management of ANCA-associated vasculitis (AAV): Part 2 - Treatment of eosinophilic granulomatosis with polyangiitis and diagnosis and general management of AAV

OBJECTIVE

To summarise and update evidence to inform the 2022 update of the European Alliance of Associations of Rheumatology (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

Three systematic literature reviews (SLR) were performed. PubMed, EMBASE and the Cochrane library were searched from 1 February 2015 to 25 February 2022. The evidence presented herein covers the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) as well as diagnostic testing and general management of all AAV syndromes.

RESULTS

For the treatment of EGPA, diagnostic procedures and general management 3517, 4137 and 4215 articles were screened and 26, 110 and 63 articles were included in the final evidence syntheses, respectively. For EGPA patients with newly diagnosed disease without unfavourable prognostic factors, azathioprine (AZA) combined with glucocorticoids (GC) is not superior to GC monotherapy to induce remission (LoE 2b). In patients with active EGPA and unfavourable prognostic factors, cyclophosphamide or rituximab can be used for remission induction (LoE 2b). Treatment with Mepolizumab added to standard treatment results in higher rates of sustained remission in patients with relapsing or refractory EGPA without active organ-threatening or life-threatening manifestations (LoE 1b) and reduces GC use. Kidney biopsies have prognostic value in AAV patients with renal involvement (LoE 2a). In the context of suspected AAV, immunoassays for proteinase 3 and myeloperoxidase-ANCA have higher diagnostic accuracy compared with indirect immunofluorescent testing (LoE 1a).

CONCLUSION

This SLR provides current evidence to inform the 2022 update of the EULAR recommendations for the management of AAV.

Facing the Challenge of Drug-Induced Acute Interstitial Nephritis

BACKGROUND

Acute interstitial nephritis (AIN) is one of the chief causes of acute kidney injury (AKI). AIN might be produced by drugs, infections, autoimmune diseases, or can be idiopathic. Among these etiologies, drug-induced AIN (DI-AIN) is the dominant one in many countries. Even when DI-AIN is suspected, identification of the putative drug is challenging.

SUMMARY

DI-AIN is an increasingly common cause of AKI. Diagnosis continues to pose a challenge for physicians due to nonspecific clinical symptoms, and the fact that it can be triggered by a wide variety of medications. Furthermore, the gold standard for the diagnosis is kidney biopsy. All these aspects render the diagnosis more difficult. The withdrawal of the causative drug of DI-AIN is the centerpiece of the treatment, and if early restoration of original kidney function is not obtained, several studies support the treatment with steroids especially when they are started quickly.

KEY MESSAGES

Almost all drugs have the potential to produce drug-induced acute interstitial nephritis (DI-AIN); however, antibiotics, nonsteroidal anti-inflammatory agents, and proton pump inhibitors account for the majority of the reported cases. DI-AIN is produced by an idiosyncratic delayed type IV hypersensitivity reaction, but the precise pathophysiological mechanism remains to be elucidated. DI-AIN symptoms are nonspecific, and most of the patients will present mild symptoms including malaise, nausea, and vomiting. The classical triad, associating fever, rash, and eosinophilia, is seldom present. Nonoliguric acute kidney injury is the main renal manifestation of DI-AIN. Tubular nonnephrotic range proteinuria is usually present. Diagnosis of DI-AIN relies on maintaining a high index of suspicion in those patients at greater risk, but kidney biopsy is required to confirm diagnosis. Histologically, AIN is characterized by the presence of an extensive interstitial infiltrate, mainly composed of lymphocytes and monocytes, but eosinophils, plasma cells, histiocytes, and polymorphonuclear cells can also be found. The withdrawal of the presumed causative drug of DI-AIN is the mainstay of the treatment. When there is no evidence of kidney function recovery after an interval of 5-7 days since interrupting the treatment with the suspected drug, several studies support the treatment with steroids, especially when they are promptly started. Early corticosteroids would decrease the inflammatory infiltrates of the kidney interstitium, thus preventing the risk of subsequent fibrosis.

AB0628 Systematic literature review informing the 2022 Update of the EULAR recommendations for the management of ANCA-associated vasculitis: Focus on diagnostic and follow-up procedures

Background

The 2008 and 2016 European Alliance of Associations for Rheumatology (EULAR) recommendations for the management of ANCA-associated vasculitis (AAV)1,2 have supported clinicians with recommendations for the accurate diagnosis, monitoring and for the management of the long-term complications of patients with ANCA-associated vasculitis (AAV). Since the publication of the last EULAR guidelines, several high-impact research articles have provided further evidence to improve diagnosis and monitoring of AAV-patients.

Objectives

The aim of this systematic review was collecting evidence supporting the 2022 update of the AAV management recommendations.

Methods

The recommendations were developed based on the 2014 EULAR standardized operating procedures (SOP)3. Areas of interest were adopted from the 2016 recommendations and updated by identifying additional items through a Delphi exercise. Key questions were framed in the PICO (Population, Intervention, Comparator, Outcome) format. Keywords identifying topics of interest for the diagnosis and follow up were gathered based on the PICO questions and then incorporated into a search string. A systematic literature research (SLR) was performed according to the EULAR SOP. PubMed (Medline), Embase and the Cochrane Library databases were searched for articles providing data on the search questions. Abstracts of the annual meetings of EULAR, ACR, ERA-EDTA, ASN and the Vasculitis and ANCA Workshops were also screened, but restricted to randomized controlled clinical trials (RCTs).

After deduplication, publications were first sorted by title and abstract and then full text review was done for eligible articles. The data were extracted from included articles and grouped according to the PICO questions. Data extraction results were collected in evidence tables.

The Cochrane revised tool for assessing risk of bias for RCTs (RoB2), ROBINS-1 for observational studies, QUADAS II for diagnostic accuracy studies and AMSTAR II for meta-analyses were used for bias assessment. Evidence was categorized based on the GRADE system as per EULAR SOP3.

Results

Based on the results of the Delphi, 3 topics related to diagnosis and follow-up were identified that were transformed into PICO questions: the impact of tissue biopsies and positive ANCA testing to support the clinical diagnosis of AAV and the impact of clinical parameters and biomarkers on disease-related outcomes and treatment-related adverse events (Table 1). Other items that received lower scores in the Delphi exercise were added in the format of subquestions (e.g. diagnostic imaging). Based on these research questions, search strings for the SLR were created.

The SLR was still ongoing at the time this abstract has been written and results of the SLR will be presented at the meeting.

Table 1.

Topics of interest for diagnostic and follow-up testing identified in the Delphi exercise

PatientsDiagnostic / follow-up procedureOutcomeGranulomatosis with PolyangiitisTissue biopsyConfirmation of diagnosis of ANCA-associated vasculitisMicroscopic Polyangiitis Eosinophilic GranulomatosisANCA testing Clinical parametersDisease-related outcomes Treatment-related adversewith PolyangiitisImaging Biomarkersevents

Conclusion

This SLR identified recent developments affecting key areas of AAV diagnosis and follow-up. The results of this SLR provide systematic evidence to inform the 2022 update of the EULAR recommendations for the management of AAV, which will also be presented at this meeting.

References

[1]Mukhtyar C, et al. EULAR Recommendations for the management of primary small and medium vessel vasculitis. Ann Rheum Dis. 2008;68:310-317.

[2]Yates M et al. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis. 2016 Sep;75(9):1583-94

[3]van der Heijde D et al. 2014 Update of the EULAR standardised operating procedures for EULAR-endorsed recommendations. Ann Rheum Dis. 2015 Jan;74(1):8-13.

Acknowledgements

The project is funded by EULAR.

Disclosure of Interests

Beatriz Sanchez-Alamo: None declared, Jan Schirmer: None declared, Sara Monti: None declared, Bernhard Hellmich Speakers bureau: Abbvie, BMS, Chugai, GSK, MSD, Novartis, Pfizer, Roche, Vifor, Consultant of: Boehringer, BMS, Chugai, GSK, InflaRx, Novartis, Roche, Vifor, David Jayne Speakers bureau: Vifor, Consultant of: Astra-Zeneca, Boehringer, BMS, Chemocentryx, Chugai, GSK, Novartis, Roche, Takeda

POS0830 SYSTEMATIC LITERATURE REVIEW INFORMING THE 2022 UPDATE OF THE EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF ANCA-ASSOCIATED VASCULITIS: FOCUS ON TREATMENT STRATEGIES

Background

The 2008 and 2016 European Alliance of Associations for Rheumatology (EULAR) recommendations for the management of ANCA-associated vasculitis (AAV)1,2 have supported clinicians with comprehensive recommendations for the treatment of patients with AAV in daily practice. During the past 5 years, the publication of several high-impact randomized-controlled studies have further improved the standard of care of AAV.

Objectives

The aim of this systematic review was to collect evidence supporting the 2022 update the AAV management recommendations.

Methods

The recommendations were developed based on an evidence-based approach as outlined in the 2014 EULAR standardized operating procedures (SOP)3. Areas of interest were adopted from the 2016 recommendations and updated by identifying additional topics through a Delphi process. Key questions were framed in the PICO (Population, Intervention, Comparator, Outcome) format and a search strategy consisting of keywords identifying treatment-related topics of interest was created based on the PICO questions. Aspects of drug treatment and other therapeutic interventions in AAV were included in the search, with a focus on remission induction, maintenance treatment and steroid sparing protocols. Outcomes such as survival, remission/relapses, infectious complications and malignancies were also covered. PubMed (Medline), Embase and the Cochrane Library databases were searched for articles providing data on the search questions. Abstracts of the annual meetings of EULAR, ACR, ERA-EDTA, ASN and the Vasculitis and ANCA Workshops were also screened, but restricted to randomized controlled clinical trials (RCTs).

After deduplication publications were sorted by title and abstract first. There was full text review for articles eligible after title/abstract screening. The data were extracted from included articles and grouped according to the PICO questions. Data extraction results were collected in evidence tables.

The Cochrane revised tool for assessing risk of bias for RCTs (RoB2), ROBINS-1 for observational studies and AMSTAR II for meta-analyses were used for bias assessment. Evidence was categorized based on the GRADE system as per EULAR SOP3.

Results

Based on the results of the Delphi, 11 topics related to therapeutic interventions were identified that were transformed into PICO questions (Table 1). Other items that received lower scores were added in the format of subquestions. Based on these research questions, search strings for the SLR were created.

Table 1.

Key topics of interest for treatment strategies identified in the Delphi exercise grouped according to the PICO format

PatientsIntervention & ComparatorsOutcomeDiagnosisCyclophosphamideDisease-related outcomesGranulomatosis with PolyangiitisRituximabTreatment-related adverse eventsMicroscopic PolyangiitisMycophenolateEosinophilic Granulomatosis with PolyangiitisMethotrexateDisease severityAzathioprineNew-onset diseaseGlucocorticoidsRelapsing diseaseAvacopanOrgan- or life-threatening diseaseMepolizumabNot organ- or life-threatening diseasePlasma exchange

The SLR was still ongoing at the time this abstract has been written and results of the SLR will be presented at the meeting.

Conclusion

This SLR identified recent developments affecting key areas of AAV treatment, that provide systematic evidence to inform the 2022 update of the EULAR recommendations for the management of AAV, which will also be presented at this meeting.

References

[1]Mukhtyar C, et al. EULAR Recommendations for the management of primary small and medium vessel vasculitis. Ann Rheum Dis. 2008;68:310-317.

[2]Yates M et al. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis. 2016 Sep;75(9):1583-94

[3]van der Heijde D et al. 2014 Update of the EULAR standardised operating procedures for EULAR-endorsed recommendations. Ann Rheum Dis. 2015 Jan;74(1):8-13.

Acknowledgements

The project is funded by EULAR.

Disclosure of Interests

Jan Schirmer: None declared, Beatriz Sanchez-Alamo: None declared, Sara Monti: None declared, Bernhard Hellmich Speakers bureau: Abbvie, BMS, Chugai, GSK, MSD, Novartis, Pfizer, Roche, Vifor, Consultant of: Boehringer, BMS, Chugai, GSK, InflaRx, Novartis, Roche, Vifor, David Jayne Speakers bureau: Vifor, Consultant of: Astra-Zeneca, Boehringer, BMS, Chemocentryx, Chugai, GSK, Novartis, Roche

Urinary Dickkopf-3 (uDKK3): a new biomarker for CKD progression and mortality?

BACKGROUND

Kidney fibrosis has been reported to be a prognostic factor in CKD progression. Previous studies have shown that the assessment of urinary Dickkopf-3 (uDKK3), a stress induced tubular epithelial-derived profibrotic glycoprotein, might be a potential tubulointerstitial fibrosis biomarker and might identify patients at short-term risk of eGFR loss. We aim to evaluate uDKK3 as a potential biomarker for progression of CKD in a cohort with various etiologies of CKD, and subsequently in an overt diabetic nephropathy cohort.

METHODS

We prospectively studied two independent cohorts comprising a total of 351 patients with stage 2-3 CKD. Combined primary outcome consisted of a 50% increase in serum creatinine, ESKD or death. Progreser cohort included patients with heterogeneous etiologies and Pronedi cohort 101 patients with overt diabetic nephropathy. Median time of follow-up was 36 (30-39) and 36 (16-48) months, respectively.

RESULTS

At baseline, median uDKK3 was 2200 (671 - 7617) pg/mg in the Progreser cohort and 3042 (661-9747) pg/mg in the Pronedi cohort. There were any statically significant differences in uDKK3 ratio between both cohorts, nor between CKD etiologies. Baseline uDKK3 was significantly higher in patients who reached primary outcome. In the Cox proportional-hazard model, the highest levels of uDKK3 were found to be an independent factor for renal progression in Progreser cohort (HR 1.91, CI95% 1.04 - 3.52) and in Pronedi cohort (HR 3.03, CI95% 1.03-8.92). uDKK3 gradually increased in the following months, especially in patients with higher proteinuria. Treatment with RAAS-blockers did not modify uDKK3 after 4 nor 12 months of treatment.

CONCLUSIONS

uDKK3 identifies patients at high risk of CKD progression regardless of the cause of kidney injury. uDKK3 might serve as a useful biomarker for kidney disease progression and therefore could be used by clinicians to optimize staging for renal progression and monitor the response to potential treatments.