Developing a disease-specific patient reported outcome measure to enhance understanding of the lived experiences of ANCA associated vasculitis: A protocol paper

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a chronic, relapsing-remitting condition associated with increased morbidity. Previous research has shown patients with AAV report high levels of fatigue, pain, depression and anxiety. Over recent years successful work has been carried out to improve clinical outcomes, resulting in reduced mortality and end stage kidney disease (ESKD). Despite this, little work has been done to better understand the role of the patient within this condition. The prevalence of AAV is increasing and to date, there is a shortage of specific tools that assess and measure key features relating to patient reported outcomes (PROs). This protocol details how we can better understand the lived experiences of those with AAV through the development of a disease specific, patient reported outcome measure (PROM), to be used in clinic practice. This will allow us to recognise and validate PROs and the impact the disease and its treatment has on patients' health related quality of life (HRQoL). In addition, we aim to identify potential differences in PRO's between demographics, organ involvement and treatment subgroups in AAV as well as outcomes relating to the patient experience. Patients from a single centre in the UK will be recruited to take part in the exploratory qualitative study which will include focus groups and semi-structured interviews. The inclusion criteria comprise anyone with a diagnosis of AAV and willing to participate, including those who have active or relapsing disease, those are economically active, unemployed, retired and patients receiving renal replacement therapy. The aim of the project is to identify key issues patients experience in relation to their disease and its management and how these can be better assessed in a new PROM developed for use in the clinic setting. This will enable better delivery of individualised care and inform shared decision making, while also serving as a platform for future research looking at PROs in other glomerulonephritides.

The Improved Kidney Risk Score in ANCA-Associated Vasculitis for Clinical Practice and Trials

SIGNIFICANCE STATEMENT

Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. More than 1500 patients were collated in an international longitudinal study to revise the ANCA kidney risk score. The score showed satisfactory performance, mimicking the original study (Harrell's C=0.779). In the development cohort of 959 patients, no additional parameters aiding the tool were detected, but replacing the GFR with creatinine identified an additional cutoff. The parameter interstitial fibrosis and tubular atrophy was modified to allow wider access, risk points were reweighted, and a fourth risk group was created, improving predictive ability (C=0.831). In the validation, the new model performed similarly well with excellent calibration and discrimination ( n =480, C=0.821). The revised score optimizes prognostication for clinical practice and trials.

BACKGROUND

Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. A retrospective international longitudinal cohort was collated to revise the ANCA renal risk score.

METHODS

The primary end point was ESKD with patients censored at last follow-up. Cox proportional hazards were used to reweight risk factors. Kaplan-Meier curves, Harrell's C statistic, receiver operating characteristics, and calibration plots were used to assess model performance.

RESULTS

Of 1591 patients, 1439 were included in the final analyses, 2:1 randomly allocated per center to development and validation cohorts (52% male, median age 64 years). In the development cohort ( n =959), the ANCA renal risk score was validated and calibrated, and parameters were reinvestigated modifying interstitial fibrosis and tubular atrophy allowing semiquantitative reporting. An additional cutoff for kidney function (K) was identified, and serum creatinine replaced GFR (K0: <250 µ mol/L=0, K1: 250-450 µ mol/L=4, K2: >450 µ mol/L=11 points). The risk points for the percentage of normal glomeruli (N) and interstitial fibrosis and tubular atrophy (T) were reweighted (N0: >25%=0, N1: 10%-25%=4, N2: <10%=7, T0: none/mild or <25%=0, T1: ≥ mild-moderate or ≥25%=3 points), and four risk groups created: low (0-4 points), moderate (5-11), high (12-18), and very high (21). Discrimination was C=0.831, and the 3-year kidney survival was 96%, 79%, 54%, and 19%, respectively. The revised score performed similarly well in the validation cohort with excellent calibration and discrimination ( n =480, C=0.821).

CONCLUSIONS

The updated score optimizes clinicopathologic prognostication for clinical practice and trials.

A systematic review of patient reported outcome measures in patients with anti-neutrophil cytoplasmic antibody associated vasculitis

OBJECTIVES

ANCA associated vasculitis (AAV) is associated with significant morbidity, fatigue, pain and poor health-related quality of life (HRQoL). This review aims to assess the comprehensiveness of existing patient reported outcome measures (PROMs) used in AAV and identify associations with poorer HRQoL outcomes.

METHODS

A literature review of studies using PROMs, including those labelled HRQoL in people with AAV as a primary or secondary study outcome were screened and reviewed up to July 2023. Quality was assessed using the Critical Appraisal Skills Programme.

RESULTS

A total of 30 articles were included which utilised 22 different PROM tools. 76.7% (n = 23) used the SF-36 or a variation as a generic measure of health status and or HRQoL. Two studies developed a disease specific PROM. The AAV-PRO showed good psychometric properties but potential limitations in capturing all relevant aspects of the disease experience for AAV patients. Factors associated with poorer HRQoL included: neurological and sinonasal involvement, women and younger patients. 86.6% of studies showed no meaningful relationships between the SF-36 and BVAS, VDI or disease duration. Depression and anxiety were common and socioeconomic factors such as unemployment were significantly associated with poorer mental health outcomes. Glucocorticoids were found to be independently associated with worse SF-36 scores.

CONCLUSION

Generic PROMs are useful in measuring significant changes but lack sensitivity to specific symptoms and unique AAV-related issues, while existing disease specific PROMs have limitations and may not fully capture AAV patient's perspective on disease and treatment burden.

Recrudescence of Severe Carbamazepine- Induced DRESS Syndrome after Initiation of Levetiracetam

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially fatal cutaneous hypersensitivity reaction commonly precipitated by antiepileptic drugs (AEDs). Cross-reactivity among aromatic AEDs is well-documented, but between aromatic and nonaromatic AEDs. We report a patient with severe DRESS syndrome precipitated by aromatic AED carbamazepine with recrudescence approximately 2 weeks after substitution with nonaromatic AED levetiracetam. The patient was treated with high-dose corticosteroids and switched to the benzodiazepine AED clobazam. At follow-up appointment several weeks later, the patient's rash, liver injury, and eosinophilia had resolved.

Low-Dose Intravenous Methylprednisolone in Remission Induction Therapy for ANCA-Associated Vasculitis

Key Points

The contribution of IV methylprednisolone to glucocorticoid toxicity is often overlooked with limited evidence supporting its use. Markedly reduced cumulative glucocorticoid dosing for remission induction therapy in AAV is safe and effective. Reduced IV methylprednisolone and radical steroid avoidance strategies have not been shown to have any significant adverse effect on outcomes.

Background

Glucocorticoids (GCs) remain integral to the management of ANCA-associated vasculitis (AAV), but are associated with significant adverse effects. Recent studies have shown reduced oral GC dosing to be safe and effective; however, data guiding the use of intravenous (IV) methylprednisolone (MTP) are limited.

Method

A single-center retrospective cohort of patients with AAV were divided into two groups: low-dose GC (patients receiving 250 mg of IV MTP, followed by a tapering course of 30 mg of prednisolone daily) versus high-dose GC (1.5 g of IV MTP, followed by a tapering course of 40–60 mg of prednisolone daily). Primary outcomes included ESKD and mortality, and secondary outcomes included GC-related toxicity, remission, and relapse rates. This study was applied to patients with newly diagnosed AAV, including those with severe or life-threatening disease.

Results

Sixty-five patients were included in the final analysis—34 in the high-dose treatment group and 31 in the low-dose treatment group. At diagnosis, more advanced renal impairment and histological disease were present in the low-dose cohort. The rate of ESKD was similar between the groups at 6 and 12 months (P = 0.22, P = 0.60, respectively). More deaths occurred in the high-dose group (26.5% versus 6.5%, P = 0.05), although this was not significant on multivariable analysis (P = 0.06). Remission rates were comparable, and there was no significant difference in relapses. Adverse events were seen in both groups, but patients in the high-dose group experienced a higher incidence of severe infections, weight gain, and steroid-induced diabetes.

Conclusion

We demonstrate that a markedly reduced dose of IV MTP with a lower overall cumulative dose of GCs is safe and effective in the management of severe AAV disease, with no significant difference in primary outcomes.

Rituximab in the treatment of primary FSGS: time for its use in routine clinical practice?

Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome and whilst advances have been made in the pathophysiology, diagnostics and management of other podocytopathies, primary FSGS remains the most elusive. It has been assumed for a long time that a circulatory permeability factor exists that mediates podocyte injury, and the potential for autoantibody-mediated disease therefore raises the question as to whether patients may benefit from targeted B-cell therapy with rituximab. The prospective case series of seven patients by Roccatello et al. adds to the limited but growing evidence suggesting that B-cell depletion therapy can be safe and effective in the treatment of primary FSGS. In this editorial we explore the available evidence that suggests how and in whom rituximab may play a role in the management of primary FSGS, as well as the limitations and other potential future treatments. Further research and randomized controlled trials are needed to include larger numbers of patients, feature genetic screening and incorporate data on B-cell kinetics as a potential guide for dosing and frequency of rituximab.

COVID-19 Infection and Vaccination and Its Relation to Amyloidosis: What Do We Know Currently?

Amyloidosis is a complex disorder characterized by deposited insoluble fibrillar proteins which misfold into β-pleated sheets. The pathogenesis of amyloidosis can vary but can be the result of immune dysregulation that occurs from sustained high inflammatory states, often known as AA amyloidosis. Multi-organ involvement including hepatic, gastrointestinal, renal, cardiac and immunological pathological manifestations has been observed amongst individuals presenting with amyloidosis. The recent global pandemic of severe acute respiratory syndrome coronavirus 2, also referred to as coronavirus 2019 (COVID-19), has been shown to be associated with multiple health complications, many of which are similar to those seen in amyloidosis. Though COVID-19 is recognized primarily as a respiratory disease, it has since been found to have a range of extra-pulmonary manifestations, many of which are observed in patients with amyloidosis. These include features of oxidative stress, chronic inflammation and thrombotic risks. It is well known that viral illnesses have been associated with the triggering of autoimmune conditions of which amyloidosis is no different. Over the recent months, reports of new-onset and relapsed disease following COVID-19 infection and vaccination have been published. Despite this, the exact pathophysiological associations of COVID-19 and amyloidosis remain unclear. We present a scoping review based on our systematic search of available evidence relating to amyloidosis, COVID-19 infection and COVID-19 vaccination, evaluating current perspectives and providing insight into knowledge gaps that still needs to be addressed going forward.

Risk Stratification to Predict Renal Survival in Anti-Glomerular Basement Membrane Disease

SIGNIFICANCE STATEMENT

Most patients with anti-glomerular basement membrane (GBM) disease present with rapidly progressive glomerulonephritis, and more than half develop ESKD. Currently, no tools are available to aid in the prognostication or management of this rare disease. In one of the largest assembled cohorts of patients with anti-GBM disease (with 174 patients included in the final analysis), the authors demonstrated that the renal risk score for ANCA-associated vasculitis is transferable to anti-GBM disease and the renal histology is strongly predictive of renal survival and recovery. Stratifying patients according to the percentage of normal glomeruli in the kidney biopsy and the need for RRT at the time of diagnosis improves outcome prediction. Such stratification may assist in the management of anti-GBM disease.

BACKGROUND

Prospective randomized trials investigating treatments and outcomes in anti-glomerular basement membrane (anti-GBM) disease are sparse, and validated tools to aid prognostication or management are lacking.

METHODS

In a retrospective, multicenter, international cohort study, we investigated clinical and histologic parameters predicting kidney outcome and sought to identify patients who benefit from rescue immunosuppressive therapy. We also explored applying the concept of the renal risk score (RRS), currently used to predict renal outcomes in ANCA-associated vasculitis, to anti-GBM disease.

RESULTS

The final analysis included 174 patients (out of a total of 191). Using Cox and Kaplan-Meier methods, we found that the RRS was a strong predictor for ESKD. The 36-month renal survival was 100%, 62.4%, and 20.7% in the low-risk, moderate-risk, and high-risk groups, respectively. The need for renal replacement therapy (RRT) at diagnosis and the percentage of normal glomeruli in the biopsy were independent predictors of ESKD. The best predictor for renal recovery was the percentage of normal glomeruli, with a cut point of 10% normal glomeruli providing good stratification. A model with the predictors RRT and normal glomeruli ( N ) achieved superior discrimination for significant differences in renal survival. Dividing patients into four risk groups led to a 36-month renal survival of 96.4% (no RRT, N ≥10%), 74.0% (no RRT, N <10%), 42.3% (RRT, N ≥10%), and 14.1% (RRT, N <10%), respectively.

CONCLUSIONS

These findings demonstrate that the RRS concept is transferrable to anti-GBM disease. Stratifying patients according to the need for RRT at diagnosis and renal histology improves prediction, highlighting the importance of normal glomeruli. Such stratification may assist in the management of anti-GBM disease.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3.

A Meta-Analysis and Cohort Study of Histopathologic and Clinical Outcomes in ANCA-Negative versus -Positive Vasculitis

BACKGROUND

ANCA-negative pauci-immune glomerulonephritis (PIGN) represents a rare and often under-studied subgroup of the vasculitides. This study aims to investigate differences in the clinical phenotype, renal histological features, and clinical outcomes of patients with PIGN, with and without serum ANCA positivity.

METHODS

A cohort of biopsy-proven PIGN with and without detectable circulating ANCA was constructed from a single center between 2006 and 2016. Primary outcomes compared clinical presentation and histopathological features according to ANCA status, with multivariate Cox regression to compare mortality and ESKD. A systematic review and meta-analysis of the published literature was undertaken.

RESULTS

In our cohort of 146 patients, 22% (n=32) had ANCA-negative disease, with a comparatively younger mean age at diagnosis; 51.4 versus 65.6 years (P<0.001). In total, 14 studies, inclusive of our cohort, were eligible for meta-analysis, totaling 301 patients who were ANCA negative. Those with ANCA-negative disease tended to have fewer extrarenal symptoms and a higher frequency of renal-limited disease, but both failed to reach statistical significance (P=0.92 and P=0.07). The risk of ESKD was significantly higher in seronegative disease (RR, 2.28; 95% confidence interval, 1.42 to 3.65; P<0.001), reflecting our experience, with a fivefold increased risk of ESKD in ANCA-negative disease (P<0.001). No significant difference in the chronicity of histopathological findings was seen and the meta-analysis showed no difference in morality (RR, 1.22; 95% confidence interval, 0.63 to 2.38; P=0.55).

CONCLUSION

Our findings demonstrate that ANCA-negative PIGN presents in younger patients, with fewer extrarenal manifestations and higher ESKD risk, despite a lack of difference in histopathology. This study provides the impetus for further research into the pathogenesis, treatment response, and duration of immunotherapy in ANCA-negative disease. We suggest that the absence of positive ANCA serology should not discourage treatment and for clinical trials to include patients who are ANCA negative.

The Limitations of Frailty Assessment Tools in ANCA-Associated Vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) can be associated with a high burden of morbidity and mortality in an ageing population. It is increasingly recognised that individualised management is needed. Few studies have looked specifically at frailty related outcomes in AAV and a gap remains in understanding the application of frailty assessment tools in these patients. We carried out a single centre, cohort study between 2017 to 2022. Forty-one patients who had newly diagnosed or relapsing AAV and aged ≥65 years were included. The Clinical Frailty Scale (CFS) score at presentation was assessed by health care practitioners and interval CFS scores were carried out a minimum of 6 weeks from diagnosis. The aim was to determine if patients living with frailty had worse outcomes or if their perceived frailty improved with immunosuppressive treatment. The median CFS at diagnosis was 4 (vulnerable) and this remained at follow up. There was no significant interval change in CFS (P=0.16) suggesting that the patients did not become frailer and instead there was a tendency towards improved frailty scores at re-assessment. There was no significant difference in end stage kidney disease between those with higher (>5) or lower (≤5) CFS (P=1.0), although crude mortality was higher among those with an initial CFS >5 (P=0.03). Overall, we demonstrated that CFS has limitations in determining patients that may be frail as a result of disease burden with the potential to improve with treatment and clinicians should be mindful of this when making decisions relating to management.

Monoclonal gammopathy of undetermined significance causing large vessel vasculitis

A man in his late 50s presented with unilateral pain and discolouration of his fourth and fifth toes suggestive of digital ischaemia. He had a medical history of two unprovoked venous thromboembolisms in the preceding 18 months and a history of monoclonal gammopathy of undetermined significance (MGUS). A CT scan showed evidence of large vessels vasculitis in the absence of circulating antineutrophil cytoplasmic antibodies. Biopsy of the toes showed evidence of light chain and immunoglobulin deposition on immunofluorescence suggesting vasculitis secondary to his haematological diagnosis of MGUS. The patient was treated with high dose glucocorticoids and immunosuppressive treatment with a significant improvement in his symptoms and features of digital ischaemia.

FC064: Histopathological and Clinical Outcomes of Anca Negative Versus Anca Positive Pauci-Immune Glomerulonephritis

BACKGROUND

It has been suggested that pauci-immune small vessel vasculitis exhibits a different spectrum of disease in the absence of detectable circulating anti-neutrophil cytoplasmic autoantibodies (ANCA). This study aims to investigate the differences in clinical presentation, renal histopathological and clinical outcomes amongst vasculitis patients with or without detectable circulating ANCA.

METHOD

A cohort study of biopsy proven pauci-immune glomerulonephritis was constructed from a single centre between 2006 and 2016 and followed up until June 2021. Patients were stratified by ANCA status at the time of diagnosis and primary outcomes compared the histopathological classification, clinical presentation and outcomes including mortality and end stage renal disease (ESRD) of those with ANCA negative and positive disease. Secondary outcomes looked at multivariate survival and logistic models comparing remission and relapse rates between the two groups.

RESULTS

From 146 patients, 21.9% (n = 32) had ANCA negative disease with a male predominance of 66% (n = 21) and a younger mean age at diagnosis compared to those with positive ANCA serology; 51.44 ± 19.57 years versus 65.6 ± 12.10 years, respectively (P  ≤ 0.001). ANCA negative serology was associated with more renal limited disease (n = 20, 62.3% versus n = 44, 38.6% ANCA positive) and the presence of extra-renal disease with ENT and constitutional symptoms occurred more frequently in ANCA positive patients (27% versus 0%; P = 0.0013).

There was a comparable spread across the Berden classification, with no significant difference seen between the positive and negative groups (Table 1). The predominant class across both cohorts was focal classification. At the time of diagnosis, ANCA-negative patients had lower eGFR than those with positive ANCA serology (14.0 versus 18.0 mL/min/1.73 m2; P = 0.09 922). At the end of follow-up, 53.1% (n = 17) of ANCA-negative patients had progressed to end stage renal disease (ESRD) which was higher than those with ANCA positivity (n = 13, 11.7%). When adjusting for age, sex and induction therapy, the hazard ratio (HR) for ESRD was five times higher in ANCA-negative patients compared to ANCA positive [HR 5.20 (2.02–13.39); P ≤ 0.001].

Mortality rates were higher in the ANCA-negative cohort (Figure 1). Following HR calculations and multivariate analysis, age was associated with a higher risk of death. In addition, despite the ANCA-negative cohort being younger, when adjusting for age, sex and induction therapy, the HR of death was three times higher in the ANCA-negative cohort [HR 3.0 (1.36–6.63); P = 0.007].

CONCLUSION

Our single-centre experience suggests that ANCA negative disease tends to occur in younger patients, with a higher rate of renal limited disease. Seronegative disease is less likely to relapse but is associated with a high mortality rate. The reasons for these differences between ANCA-positive and ANCA-negative cohorts are complex and multifaceted. Some reports hypothesize that the cause for severe disease at presentation in the absence of circulating ANCA is due to a delay in diagnosis and treatment by clinicians [1,2]. This study provides the impetus for further trials looking at ANCA-negative and ANCA-positive disease.

MO257: Glucocorticoid Dosing in Induction Remission Treatments for ANCA-Associated Vasculitis

BACKGROUND

Anti-neutrophil cytoplasm antibodies (ANCA) associated vasculitis (AAV) is a rare and complex autoimmune disease. Induction remission and maintenance treatment typically includes glucocorticoids (GC) in addition to other immunosuppressive medications. Recent trials such as PEXIVAS (1) and ADVOCATE (2) have suggested lower dose GC as induction treatment with no significant detrimental effect on outcomes such as end-stage renal disease (ESRD) or mortality.

METHOD

A cohort study of biopsy-proven pauci-immune glomerulonephritis was constructed from a single centre between 2007 and 2021. Retrospective analysis of patients with AAV from a single centre in the North West, UK, compared ESRD and mortality between groups that received high dose versus low dose GC treatment at induction. High dose GC treatment was defined as 1.5 g intravenous (IV) methylprednisolone over 3 days followed by a tapering course of oral prednisolone starting with 60 mg per day. Low dose GC treatment was defined as a single dose of 250 mg pulsed IV methylprednisolone followed by a tapering course of oral prednisolone starting with 30 mg per day. Regression analysis was applied to outcomes including relapse and remission rates, glucocorticoid toxicity index (GTI) and significant adverse events.

RESULTS

Fifty-three patients with biopsy-proven ANCA vasculitis were identified. A total of 28 patients received high dose GC induction treatment and 25 patients received a lower dose GC induction regime. The median age for the high dose patients was 68 years (IQR 65–74), which was lower than the low dose patients; 70 years (IQR 58–78). There was a slight (60%) female preponderance in the low dose group compared with a slight male predominance in the high dose group (67%). The Charlson Comorbidity Index (CCI) was completed for all patients. The higher dose cohort had a mean CCI score of 4.8 whilst the lower dose cohort had a lower CCI of 3.8.

The number of patients requiring acute dialysis was similar across both the high dose and low dose groups (29% and 32%, respectively). ESRD was also similar between the two groups at 6 months (P = .39). Time to remission was shorter in the lower dose GC cohort (P = .01) and risk of relapse was also reduced (P = .04), as shown in Fig. 1. Those that received the lower dose GC regime were on less prednisolone at 6 months than those starting with a higher induction dose and this was statistically significant when adjusting for confounders including age, gender and co-morbidities (P = .01). The risk of death was higher in the high dose GC group (21.4% versus 4%, respectively), although this did not reach statistical significance (P = .09). In addition, the risk of adverse events and GC toxicity was higher in the high dose cohort; P = .55 and P = .12, respectively.

CONCLUSION

Treatment of ANCA vasculitis remains complex and glucocorticoids remain the cornerstone of induction remission treatment regimes. Whilst our initial data did not show a significant difference in mortality and ESRD outcomes between those that received high versus low dose GC treatment, it demonstrated that low dose GC may be sufficient in the management of AAV. Our small size study suggests a lower dose GC induction remission treatment regime to be safe, effective and associated with fewer adverse effects relating to GC toxicity. Further large studies are needed to look at the narrow therapeutic window of GC and the role of GC-sparing treatments so as to improve outcomes in these patients.

MO997: Covid-19 Antibody Responses in Renal Transplant Patients Following Booster Vaccination

BACKGROUND AND AIMS

The COVID-19 vaccination programme has been monumental in the protection against SARS-CoV-2 infection. However, recent research has shown suboptimal responses in immunosuppressed patients, such as those with solid organ transplant receiving immunosuppressive (IS) treatment. Whilst initial studies have suggested patients have improved humoral response to booster vaccines, the data are still limited [1]. We have examined the differences in SARS-CoV-2 anti-spike antibodies in renal transplant patients between second and third doses of the vaccine and aimed to determine if those that had a poor response to the initial vaccine course developed adequate immunity following booster vaccination.

METHOD

A cohort study of 63 renal transplant patients receiving immunosuppression was constructed from a single centre between December 2020 and December 2021. All patients received a full course of the UK government approved SARS-CoV-2 vaccine as well as a third booster dose. Enzyme-linked immunosorbent assays for SARS-CoV-2 anti-spike antibodies were carried out and titres of ≥0.8 U/mL were considered reactive.

RESULTS

Of the 63 patients included, the median age was 55 years (IQR: 44–66). All patients received three doses of the SARS-CoV-2 vaccine and anti-spike antibodies were checked 32.2 ± 17 days following the third dose. Thirty-eight patients received two doses of Oxford-AstraZeneca followed by one dose of Pfizer-BioNTech. Twenty-five patients received three doses of Pfizer-BioNTech.

46.0% (n = 29) of patients had a detectable antibody response following two doses of the vaccine and 87.3% (n = 55) had a discernible response following the booster. The average titre value rose by 201% between the second and third doses. Eight patients had undetectable antibodies following the second dose and half (n = 4) developed evidence of humoral immunity following the booster. Whilst increasing age and shorter time from transplantation was associated with poor humoral response to both second and third doses, it did not reach statistical significance; P = 0.29, P = 0.059 respectively. Ten patients had previous COVID-19 infection: 2 remained seronegative following 3 vaccines, and both were within 12 months of transplantation. Those receiving calcineurin inhibitors (CNI) and antimetabolite treatment were associated with lower antibody titres compared with those receiving CNI alone (Table 1).

CONCLUSION

We have shown that despite three doses of the vaccine, some high-risk renal transplant patients remain vulnerable to COVID-19 and fail to develop an adequate humoral response to the vaccine. Time from transplantation and IS medications have a significant effect on SARS-CoV-2 anti-spike antibody production. Whilst some studies have suggested those with solid organ transplants mount a lower immune response to mRNA based vaccines [2], our cohort did not demonstrate this difference. Going forward there are still a number of unanswered questions about the significance and effectiveness of COVID antibodies, as well as the long-term protection they offer [3]. Developing ways in which we can protect those with poor humoral response despite repeated vaccination is vital.

Cardiovascular disease and ANCA-associated vasculitis: Are we missing a beat?

The association between cardiovascular (CV) disease and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is well documented. The recent work by Massicotte-Azarniouch et al. confirms the risk and adds to the existing evidence by describing the highest risk in the first 3 months after diagnosis. In this review, we aim to put their findings into perspective and formulate implications for the care of AAV patients. We discuss mechanisms for increased CV disease in AAV, including the impact of traditional risk factors and disease-related risks such as renal impairment and anti-myeloperoxidase (MPO) ANCA serotype. We also provide a brief primer on the impact of inflammatory-driven endothelial dysfunction and platelet activation on accelerated atherosclerosis in AAV patients. These features alongside the impact of disease activity and systemic inflammation provide potential explanations to why the incidence of CV events is highest in the first 3 months from diagnosis. We suggest future avenues of research, provide some suggestions to address and treat CV risk based on current evidence, and highlight the importance of addressing this topic early on. Addressing modifiable risk factors, dialogue with patients, patient information and a structured approach overall will be key to improve CV outcomes in AAV.

Glucocorticoid Therapy in ANCA Vasculitis: Using the Glucocorticoid Toxicity Index as an Outcome Measure

Background

ANCA-associated vasculitis (AAV) is an autoimmune disease. Induction remission and maintenance treatment typically includes high-dose, tapering glucocorticoids (GC), in addition to other immunosuppressive medication. The use of theGlucocorticoid Toxicity Index (GTI) provides a global, quantifiable assessment tool in which clinicians can assess GC-associated morbidity. Recent trials in AAV have exposed the need for systemic assessment of GC burden. In this small cohort study, we look to address these issues and the justification of newer GC sparing agents, such as C5a inhibitors.

Methods

A retrospective cohort study of 43 patients with biopsy AAV was constructed from a single center between 2012-2016, and followed up for 48 months. The GTI table made up of adverse features was used to quantify patients' GC toxicity. Electronic patient records were reviewed and scores calculated according to published methods. GTI scores were compared with cumulative steroid doses at separate intervals and incidences of adverse features in relation to the treatment timeline.

Results

The mean age was 65.9 (±11.06) years and treatment regimens consisted of glucocorticoids alongside cyclophosphamide or rituximab. Our results showed statistical significance in the association of cumulative GC doses and GTI scores (P=0.008; 95% CI, 1.31 to 8.05). Adverse features relating to mood disturbance and GC-induced psychosis occurred early, in contrast to adrenal insufficiency, which typically presented later in the follow-up. Infection-related adverse events were consistent throughout.

Conclusions

We demonstrated that higher cumulative doses of steroids in AAV lead to worse glucocorticoid-related toxicity. Using the GTI creates the potential to individualize and quantify the adverse effects patients experience as a result of GC treatment and permits more patient-centered management. Although glucocorticoids remain the main adjunctive immunosuppression of AAV treatment, the narrow therapeutic window supports the need for GC-sparing treatments.

Using CPAP in COVID-19 patients outside of the intensive care setting: a comparison of survival and outcomes between dialysis and non-dialysis dependent patients

BACKGROUND

SARS-CoV-2 (COVID-19) is a novel coronavirus associated with high mortality rates. The use of Continuous Positive Airway Pressure (CPAP) has been recognised as a management option for severe COVID-19 (NHS, Specialty guides for patient management during the coronavirus pandemic Guidance for the role and use of non-invasive respiratory support in adult patients with coronavirus (confirmed or suspected), https://www.nice.org.uk/guidance/ng159 ). We offered ward-based CPAP to COVID-19, dialysis patients not suitable for escalation to ICU. The aim of the study was to evaluate the use of CPAP for COVID-19 dialysis patients compared to non-dialysis COVID-19 patients outside of the intensive care setting. We further aimed to investigate factors associated with improved outcomes.

METHODS

Data was collected from a single centre (Royal Preston Hospital, UK), from March to June 2020. Treatment outcomes were compared for dialysis and non-dialysis dependent patients who received CPAP with limitations on their escalation and resuscitation status. Kaplan-Meier survival curves and Cox regression models were used to compare outcomes. The primary study outcome was 30 day mortality. Confounders including length of admission, systemic anticoagulation and ultrafiltration volumes on dialysis were also analysed.

RESULTS

Over the study period, 40 dialysis patients tested positive for COVID-19, with 30 requiring hospital admission. 93% (n = 28) required supplementary oxygen and 12% (n = 9) required CPAP on the ward. These patients were compared to a serial selection of 14 non-dialysis patients treated with CPAP during the same period. Results showed a significant difference in 30 day survival rates between the two groups: 88.9% in the dialysis group vs. 21.4% in the non-dialysis group. Statistical modelling showed that anticoagulation was also an important factor and correlated with better outcomes.

CONCLUSION

This is to the best of our knowledge, the largest series of COVID-19 dialysis patients treated with CPAP in a ward-based setting. In general, dialysis dependent patients have multiple co-morbidities including cardiovascular disease and diabetes mellitus making them vulnerable to COVID-19 and not always suitable for treatment in ICU. We showed a significantly lower 30 day mortality rate with the use of CPAP in the dialysis group (11.1%) compared to the non-dialysis group (78.6%). Despite a small sample size, we believe this study provides impetus for further work clarifying the role of CPAP in treating COVID-19 dialysis dependent patients.

Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.

The impact of COVID-19 pandemic on patients with ANCA associated vasculitis

INTRODUCTION

The coronavirus 2019 (COVID-19) pandemic has brought on challenges not only to acute care, but also chronic care of patients. Individuals maintained on immunosuppression appear to be especially susceptible to COVID-19 infection. Patients with ANCA-associated vasculitis (AAV) frequently require immunosuppression and may be at increased risk for developing COVID-19. The incidence and impact of COVID-19 on patients with AAV is currently not known. We aimed to investigate this impact via a telephone questionnaire-based patient survey and chart review.

METHODS

A cross-sectional study of AAV patients followed at two centers was conducted. Data regarding demographics, disease characteristics and therapy were confirmed by chart review. A telephone survey was conducted to ascertain symptoms and contact exposure related to COVID-19, as well as changes in health care delivery during the pandemic period between January and July, 2020.

RESULTS

Of the 206 patients surveyed, the median age was 64 years, 51% were female and mean (SD) disease duration was 7 (5) years. The majority had kidney (n = 160) and lung (n = 108) involvement. Seventy-five percent (n = 155) were receiving immunosuppression, with 77 patients (50%) receiving rituximab during the pandemic period. Of the 10 patients tested for severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) by PCR, three were positive. Patients had a significant disruption in care; none had an in-person visit and 69% had a telemedicine consultation. Rituximab maintenance was postponed in 21 patients. Twelve patients experienced disease relapse.

CONCLUSION

The incidence of COVID-19 in patients with AAV appears to be similar to that of the general population. For a patient population that requires active clinical surveillance, there is significant disruption in care as a result of the pandemic. Reduction of immunosuppression may not be indicated, and the risk of relapse likely far outweighs the risk of COVID-19.

Cutaneous Lupus Erythematosus: Progress and Challenges

PURPOSE OF REVIEW

The review provides an update on the diagnosis, pathogenesis, and treatment of cutaneous lupus erythematosus (CLE).

RECENT FINDINGS

Diagnostic challenges exist in better defining CLE as an independent disease distinct from systemic lupus erythematosus with cutaneous features and further classifying CLE based on clinical, histological, and laboratory features. Recent mechanistic studies revealed more genetic variations, environmental triggers, and immunologic dysfunctions that are associated with CLE. Drug induction specifically has emerged as one of the most important triggers for CLE. Treatment options include topical agents and systemic therapies, including newer biologics such as belimumab, rituximab, ustekinumab, anifrolumab, and BIIB059 that have shown good clinical efficacy in trials. CLE is a group of complex and heterogenous diseases. Future studies are warranted to better define CLE within the spectrum of lupus erythematosus. Better insight into the pathogenesis of CLE could facilitate the design of more targeted therapies.

IL-27 signaling activates skin cells to induce innate antiviral proteins and protects against Zika virus infection

In the skin, antiviral proteins and other immune molecules serve as the first line of innate antiviral defense. Here, we identify and characterize the induction of cutaneous innate antiviral proteins in response to IL-27 and its functional role during cutaneous defense against Zika virus infection. Transcriptional and phenotypic profiling of epidermal keratinocytes treated with IL-27 demonstrated activation of antiviral proteins OAS1, OAS2, OASL, and MX1 in the skin of both mice and humans. IL-27-mediated antiviral protein induction was found to occur in a STAT1- and IRF3-dependent but STAT2-independent manner. Moreover, using IL27ra mice, we demonstrate a significant role for IL-27 in inhibiting Zika virus morbidity and mortality following cutaneous, but not intravenous, inoculation. Together, our results demonstrate a critical and previously unrecognized role for IL-27 in cutaneous innate antiviral immunity against Zika virus.

Dielectrophoretic self-assembly of polarized light emitting poly(9,9-dioctylfluorene) nanofibre arrays

Conjugated polymer based 1D nanostructures are attractive building blocks for future opto-electronic nanoscale devices and systems. However, a critical challenge remains the lack of manipulation methods that enable controlled and reliable positioning and orientation of organic nanostructures in a fast, reliable and scalable manner. To address this challenge, we explore dielectrophoretic assembly of discrete poly(9,9-dioctylfluorene) nanofibres and demonstrate site selective assembly and orientation of these fibres. Nanofibre arrays were assembled preferentially at receptor electrode edges, being aligned parallel to the applied electric field with a high order parameter fit (∼ 0.9) and exhibiting an emission dichroic ratio of ∼ 4.0. As such, the dielectrophoretic method represents a fast, reliable and scalable self-assembly approach for manipulation of 1D organic nanostructures. The ability to fabricate nanofibre arrays in this manner could be potentially important for exploration and development of future nanoscale opto-electronic devices and systems.

An outbreak of meningococcal meningitis in Gauteng, Spring 1996

OBJECTIVE

To describe a Neisseria meningitidis outbreak in Gauteng during the period 1 July to 31 December 1996.

DESIGN

A descriptive study.

SETTING

Patients with meningococcal meningitis in Gauteng who had been diagnosed by laboratory means, or notified during the period 1 July to 31 December 1996.

MAIN OUTCOME MEASURES

Data including age, sex, date of admission to hospital, N. meningitidis serogroup and outcome were collected from Gauteng notification lists, South African Institute of Medical Research (SAIMR) records, a linelist compiled by the Gauteng Health Department, and hospital records.

RESULTS

A total of 201 patients was studied; of this number 87 (43%) had been notified. Seventy per cent of cases were below 30 years of age and 78% were male. More than half (54%) of the cases were from the West Rand. The case fatality rate for 70 cases of known outcome was 14%. Serotyping of 85 isolates showed that a majority (76%) were serogroup A, with 57% being serogroup A clone I-1. Serogroup A clone III-1 accounted for 14% of the typed isolates. All isolates were sensitive to penicillin with minimum inhibitory concentrations of < 0.05 microgram/ml.

CONCLUSION

In 1996 Gauteng experienced an epidemic of serogroup A meningococcal meningitis. The serotype that caused the majority of cases had been recorded in South Africa before, but serogroup A clone III-1, responsible for epidemics spreading across two continents, was recorded in South Africa for the first time. Notification of cases by health workers was inadequate in this epidemic.

Community midwives' views and experience of home birth

This two-part study explored the home birth experiences of all full time practising community midwives within three health authorities. The study consisted of a self-completion questionnaire, followed by interviews with a random stratified sub-sample of the midwives. The study sample consisted of 56 midwives of whom 44 (78%) agreed to participate. The total experience of home birth by these midwives was limited. The mean number of home births undertaken in the previous year was only two and 14 midwives had not undertaken any. The average number of home births undertaken in their whole career was six. Four midwives (9%) had never undertaken any. Only two midwives (5%) routinely offered home birth at booking. Despite lack of experience, half the sample were strongly positive about home birth. Factors that influenced their feelings about home birth were more complex but were unrelated to the amount of their home birth experience, their age, training or own experience of childbirth. Positive feelings about home birth resulted from the quality of positive previous experiences, education and knowledge and an autonomous view of women and midwives. Negative feelings tended to result from a lack of specific skills, namely suturing, resuscitation and siting of IVIs, midwives' inadequate support networks, doctors' attitudes and a confused perception of the provision of emergency cover.

Peptidergic transmission in the brain. I. Vasopressin-like signal in the hippocampus

Studies of the action of arginine vasopressin (AVP) in the rat hippocampal slice have produced a model of the peptide's neural action. AVP excites local circuit inhibitory interneurons and causes consequent inhibition of pyramidal cells that is apparent as a reduction in the amplitude of the evoked population spike in field potential recording. Here we show that applied AVP does the same thing to the evoked population spike in the whole animal. Then we show that stimulation of the source of hippocampampal AVP, the medial amygdaloid nucleus, also inhibits the evoked population spike. Analysis of the synaptic potential indicates that the same mechanisms are employed by exogenously applied and endogenously released peptide. The inhibition can only be obtained by stimulating those brain structures known to project vasopressin fibers to the hippocampus. The stimulus-response characteristics and kinetics of the endogenous signal correspond to the properties of peptidergic signals in simple systems. The results are taken to support a transmitter role for AVP in the rat hippocampus.