Caroline O. S. Savage

Rituximab versus Cyclophosphamide in ANCA-Associated Renal Vasculitis

BACKGROUND Cyclophosphamide induction regimens for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis are effective in 70 to 90% of patients, but they are associated with high rates of death and adverse events. Treatment with rituximab has led to remission rates of 80 to 90% among patients with refractory ANCA-associated vasculitis and may be safer than cyclophosphamide regimens. METHODS We compared rituximab with cyclophosphamide as induction therapy in ANCA-associated vasculitis. We randomly assigned, in a 3:1 ratio, 44 patients with newly diagnosed ANCA-associated vasculitis and renal involvement to a standard glucocorticoid regimen plus either rituximab at a dose of 375 mg per square meter of body-surface area per week for 4 weeks, with two intravenous cyclophosphamide pulses (33 patients, the rituximab group), or intravenous cyclophosphamide for 3 to 6 months followed by azathioprine (11 patients, the control group). Primary end points were sustained remission rates at 12 months and severe adverse events. RESULTS The median age was 68 years, and the glomerular filtration rate (GFR) was 18 ml per minute per 1.73 m(2) of body-surface area. A total of 25 patients in the rituximab group (76%) and 9 patients in the control group (82%) had a sustained remission (P=0.68). Severe adverse events occurred in 14 patients in the rituximab group (42%) and 4 patients in the control group (36%) (P=0.77). Six of the 33 patients in the rituximab group (18%) and 2 of the 11 patients in the control group (18%) died (P=1.00). The median increase in the GFR between 0 and 12 months was 19 ml per minute in the rituximab group and 15 ml per minute in the control group (P=0.14). CONCLUSIONS A rituximab-based regimen was not superior to standard intravenous cyclophosphamide for severe ANCA-associated vasculitis. Sustained-remission rates were high in both groups, and the rituximab-based regimen was not associated with reductions in early severe adverse events. (Funded by Cambridge University Hospitals National Health Service Foundation Trust and F. Hoffmann-La Roche; Current Controlled Trials number, ISRCTN28528813.)

Randomized Trial of Plasma Exchange or High-Dosage Methylprednisolone as Adjunctive Therapy for Severe Renal Vasculitis

Systemic vasculitis associated with autoantibodies to neutrophil cytoplasmic antigens (ANCA) is the most frequent cause of rapidly progressive glomerulonephritis. Renal failure at presentation carries an increased risk for ESRD and death despite immunosuppressive therapy. This study investigated whether the addition of plasma exchange was more effective than intravenous methylprednisolone in the achievement of renal recovery in those who presented with a serum creatinine >500 micromol/L (5.8 mg/dl). A total of 137 patients with a new diagnosis of ANCA-associated systemic vasculitis confirmed by renal biopsy and serum creatinine >500 micromol/L (5.8 mg/dl) were randomly assigned to receive seven plasma exchanges (n = 70) or 3000 mg of intravenous methylprednisolone (n = 67). Both groups received oral cyclophosphamide and oral prednisolone. The primary end point was dialysis independence at 3 mo. Secondary end points included renal and patient survival at 1 yr and severe adverse event rates. At 3 mo, 33 (49%) of 67 after intravenous methylprednisolone compared with 48 (69%) or 70 after plasma exchange were alive and independent of dialysis (95% confidence interval for the difference 18 to 35%; P = 0.02). As compared with intravenous methylprednisolone, plasma exchange was associated with a reduction in risk for progression to ESRD of 24% (95% confidence interval 6.1 to 41%), from 43 to 19%, at 12 mo. Patient survival and severe adverse event rates at 1 yr were 51 (76%) of 67 and 32 of 67 (48%) in the intravenous methylprednisolone group and 51 (73%) of 70 and 35 of (50%) 70 in the plasma exchange group, respectively. Plasma exchange increased the rate of renal recovery in ANCA-associated systemic vasculitis that presented with renal failure when compared with intravenous methylprednisolone. Patient survival and severe adverse event rates were similar in both groups.

Pulse Versus Daily Oral Cyclophosphamide for Induction of Remission in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis A Randomized Trial

Context Because cyclophosphamide has many adverse effects, dosing regimens that maintain efficacy but improve safety would be welcome. Contribution In this randomized comparison of pulse and daily oral cyclophosphamide regimens for treatment of ANCA-associated vasculitis, equal proportions of patients had remissions, but the pulse regimen seemed safer, mainly because it caused less leukopenia. Caution Patients and providers were not blinded to the intervention, and the study was not powered to detect differences in relapse rate. Implication The efficacy of pulse cyclophosphamide for treatment of ANCA-associated vasculitis seems no different from that of daily oral treatment and may be safer. The Editors Wegener granulomatosis, microscopic polyangiitis, and the renal-limited variant of microscopic polyangiitis are all associated with antineutrophil cytoplasmic antibodies (ANCAs) and are therefore referred to collectively as ANCA-associated vasculitis. The justification for grouping these diseases together as a single clinical entity goes beyond ANCA seropositivity; they cause similar histologic changes in the kidney, are associated with similar pathogenic autoantibodies, and respond similarly to induction immunosuppressive treatment. However, they also differ in important respects; for example, granuloma formation and relapse after treatment are more common in Wegener granulomatosis (1, 2). Outcomes for these previously fatal diseases improved dramatically with the introduction of daily oral cyclophosphamide therapy (3, 4). However, cyclophosphamide has significant adverse effects that influence long-term morbidity and mortality (5, 6). Strategies to reduce these adverse effects include reducing the duration of cyclophosphamide use to 3 to 6 months (maximum, 9 months) (2) and switching to an alternative immunosuppressive regimen after induction of remission and using methotrexate instead of cyclophosphamide in patients without generalized disease and significantly impaired renal function (7). For many patients, however, cyclophosphamide remains the mainstay of therapy for inducing remission and treating relapse, so regimens that maintain efficacy while minimizing cyclophosphamide dose and maximizing safety would be welcome. Previous studies (8) suggest that pulse cyclophosphamide regimens are safe and provide less cumulative cyclophosphamide exposure than daily oral cyclophosphamide regimens. However, small study sizes and variations in treatment regimens, including the use of treatments alongside cyclophosphamide, make the findings preliminary. We designed this trial to test the hypothesis that a regimen of pulsed intermittent cyclophosphamide would be as effective but less toxic than daily oral cyclophosphamide for inducing remission in patients with generalized ANCA-associated vasculitis with active glomerulonephritis. Methods Trial Design and Participants Our trial was an open-label, multicenter, randomized, controlled trial conducted over 18 months. Patients, providers, and the investigators who assessed trial outcomes were not blinded to treatment assignment. Our inclusion criteria were newly diagnosed Wegener granulomatosis, microscopic polyangiitis, or renal-limited microscopic polyangiitis (diagnostic criteria adapted from the 1992 Chapel Hill consensus conference [9] and our groups previous studies [2, 7, 1012]); renal involvement attributable to active vasculitis (as defined by at least 1 of the following: serum creatinine level >150 mol/L [>1.7 mg/dL] and 500 mol/L [5.7 mg/dL], biopsy demonstrating necrotizing glomerulonephritis, erythrocyte casts, or hematuria [>30 erythrocytes per high-power field] and proteinuria [>1 g/d]); and confirmatory histology or ANCA positivity. Our exclusion criteria were coexistence of other multisystem autoimmune disease; hepatitis B or C virus or HIV infection; serum creatinine level greater than 500 mol/L (>5.7 mg/dL); previous cancer; pregnancy; or age younger than 18 or older than 80 years. We conducted our study according to the Declaration of Helsinki. Informed consent was obtained from each participant, and each participating center reviewed the trial protocol and granted ethical approval. Random Assignment Random assignments were computer-generated and performed centrally by permuted blocks of 4, stratified by country and disease. Patients were enrolled by their treating physician and registered with the central trial coordinating office by fax submission of a form that contained information on center, date of birth, sex, disease, and creatinine level. We randomly assigned patients on a 1:1 basis to receive pulse or daily oral cyclophosphamide. Data were collected in record books, entered into a central computerized database, and validated against the record books before analysis. Eleven patients withdrew before random assignment; we randomly assigned 149 patients. Interventions We designed the pulse cyclophosphamide regimen by investigator consensus, on the basis of published experience with pulse cyclophosphamide in ANCA-associated vasculitis. Patients received 3 intravenous pulses of cyclophosphamide, 15 mg/kg, given 2 weeks apart, followed by pulses at 3-week intervals (15 mg/kg intravenously or 5 mg/kg orally on 3 consecutive days, at the physicians discretion) until remission, and then for another 3 months. The maximum dose per pulse was 1.2 g. We reduced the cyclophosphamide dose by 2.5 mg/kg per pulse for persons age 60 to 70 years, 5 mg/kg per pulse for persons older than 70 years, and 2.5 mg/kg per pulse for persons with a serum creatinine level of 300 to 500 mol/L (3.4 to 5.7 mg/dL). At minimum, blood counts were checked on day 10 and 14 after each pulse and immediately before the next pulse. We reduced the dose of the subsequent pulse by 20% for patients with a leukocyte nadir of 2 to 3109/L and 40% for those with a nadir of 1 to 2109/L. The daily oral cyclophosphamide group received cyclophosphamide, 2 mg/kg per day, until remission, followed by 1.5 mg/kg per day for another 3 months. The maximum oral dose was 200 mg, and we reduced the dose by 25% for persons older than 60 years and 50% for those older than 70 years. At minimum, blood counts were checked weekly for the first month, twice-weekly for the second month, and monthly thereafter. We withheld cyclophosphamide for persons with a leukocyte count less than 4109/L, then resumed therapy at a dose reduced by 25 mg/d when their count increased to greater than 4109/L. Both groups continued the cyclophosphamide regimens for 3 months after remission, after which all patients received azathioprine, 2 mg/kg per day orally, until month 18 for remission maintenance. The maximum daily oral dose of azathioprine was 200 mg. Both groups also received prednisolone, 1 mg/kg orally, tapered to 12.5 mg at the end of month 3 and to 5 mg at the end of the study (month 18). 2-Mercaptoethanesulfonate sodium was optional in both groups. No patients received plasmapheresis. We recommended prophylaxis for Pneumocystis jiroveci for all patients. Treatment was allowed to follow local practice for patients who did not achieve remission at 9 months. We collected data on these patients but censored them for purposes of this analysis. For more details on the protocol, see Appendix 1. Outcomes and Follow-up We defined outcomes by using the Birmingham Vasculitis Activity Score (BVAS) index, which measures manifestations of active vasculitis during the 28 days before the date of assessment (13). Our primary outcome was time to remission, defined as the absence of new or worse signs of disease activity on the BVAS and no more than 1 item indicating persistent disease activity (BVAS 1). Secondary outcomes included the proportion of patients who achieved remission at 6 and 9 months and the proportion with major and minor relapses. We defined major relapse as the recurrence or first appearance of at least 1 BVAS item indicating threatened vital organ function attributable to active vasculitis. We defined minor relapse as the recurrence or first appearance of at least 3 other BVAS items related to nonvital organs. An investigator classified patients as achieving remission or having relapse, and an independent observer validated these classifications retrospectively. Additional secondary outcomes were death; change in renal function; adverse events, including leukopenia and infection; and the cumulative dose of cyclophosphamide and prednisolone, which we calculated as the total cumulative drug dose at each time point in the study (3, 6, 9, 12, 15, and 18 months) divided by the number of patients in the study at that point. For each time point, we considered only the dose of drug for those patients still in the study. Unless otherwise noted, we assessed these outcomes at baseline; at 1.5, 3, 4.5, 6, 7.5, 9, 12, 15, and 18 months after baseline; and at relapse, on the basis of standard recommendations. Clinical assessments included BVAS measures at every visit and measures of cumulative damage from any cause since disease onset, as scored by the Vasculitis Damage Index (14), at baseline and every 3 months. Laboratory assessments included measures of full blood count, C-reactive protein, alanine transaminase, serum creatinine, and glucose, as well as dipstick urine analysis. We calculated glomerular filtration rate at entry, remission, and study end by using the Modification of Diet in Renal Disease method (15). Statistical Analysis We determined the sample size for the trial by clinical rather than statistical considerations. We set a recruitment goal of 160 patients; we considered that number ambitious, given the rarity of these conditions (12 per 1 million persons) and the need to recruit patients and conduct the trial within a period (5 years) that was reasonable for our resources. We performed analyses by intention to treat. To account for censoring, we compared remission and survival by using survival methods instead of relat

Mycophenolate Mofetil vs Azathioprine for Remission Maintenance in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis: A Randomized Controlled Trial

CONTEXT Current remission maintenance therapies for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are limited by partial efficacy and toxicity. OBJECTIVE To compare the effects of mycophenolate mofetil with azathioprine on the prevention of relapses in patients with AAV. DESIGN, SETTING, AND PARTICIPANTS Open-label randomized controlled trial, International Mycophenolate Mofetil Protocol to Reduce Outbreaks of Vasculitides (IMPROVE), to test the hypothesis that mycophenolate mofetil is more effective than azathioprine for preventing relapses in AAV. The trial was conducted at 42 centers in 11 European countries between April 2002 and January 2009 (42-month study). Eligible patients had newly diagnosed AAV (Wegener granulomatosis or microscopic polyangiitis) and were aged 18 to 75 years at diagnosis. INTERVENTIONS Patients were randomly assigned to azathioprine (starting at 2 mg/kg/d) or mycophenolate mofetil (starting at 2000 mg/d) after induction of remission with cyclophosphamide and prednisolone. MAIN OUTCOME MEASURES The primary end point was relapse-free survival, which was assessed using a Cox proportional hazards model. The secondary end points were Vasculitis Damage Index, estimated glomerular filtration rate, and proteinuria. RESULTS A total of 156 patients were assigned to azathioprine (n = 80) or mycophenolate mofetil (n = 76) and were followed up for a median of 39 months (interquartile range, 0.66-53.6 months). All patients were retained in the analysis by intention to treat. Relapses were more common in the mycophenolate mofetil group (42/76 patients) compared with the azathioprine group (30/80 patients), with an unadjusted hazard ratio (HR) for mycophenolate mofetil of 1.69 (95% confidence interval [CI], 1.06-2.70; P = .03). Severe adverse events did not differ significantly between groups. There were 22 severe adverse events in 13 patients (16%) in the azathioprine group and there were 8 severe adverse events in 8 patients (7.5%) in the mycophenolate mofetil group (HR, 0.53 [95% CI, 0.23-1.18]; P = .12). The secondary outcomes of Vasculitis Damage Index, estimated glomerular filtration rate, and proteinuria did not differ significantly between groups. CONCLUSIONS Among patients with AAV, mycophenolate mofetil was less effective than azathioprine for maintaining disease remission. Both treatments had similar adverse event rates. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00307645.

Prospective study of TNFα blockade with infliximab in anti-neutrophil cytoplasmic antibody-associated systemic Vasculitis

UNLABELLED Tumor necrosis factor alpha (TNFalpha) plays an important role in the pathogenesis of anti-neutrophil cytoplasmic antibody-associated systemic vasculitis. TNFalpha blockade is a potential therapy for these disorders. METHODS An open-label, multi-center, prospective clinical trial in two subgroups was performed. Study I examined acute disease, either first presentation or relapse (Birmingham Vasculitis Activity Score [BVAS] > or = 10; n = 16); study II examined persistent disease (BVAS > or = 4; n = 16). Patients received infliximab (5 mg/kg) at 0, 2, 6, and 10 wk. Concomitant therapy in study I included prednisolone and cyclophosphamide. Study II patients continued their existing treatment regimens, with prednisolone tapered according to clinical status. RESULTS Mean age was 52.4 yr, 53% of the patients were female, and follow-up was 16.8 mo. Twenty-eight patients (88%) achieved remission (14 per study group). BVAS decreased from 12.3 (confidence interval [CI] = 10.5 to 14.0) at entry to 0.3 (CI = 0.2 to 0.9) at wk 14 (P < 0.001). C-reactive protein (mg/L) decreased from 29.4 (CI = 16.8 to 42.0) at entry to 7.0 (CI = 3.3 to 10.9) by wk 14 (P = 0.001). Mean prednisolone dose (mg/d) in study II decreased from 23.8 (CI = 15.0 to 32.5) at entry to 8.8 (CI = 5.9 to 11.7) at wk 14 (P = 0.002). There were two deaths and seven serious infections. Relapse occurred in five patients (three in study II) after a mean of 27 wk. CONCLUSION TNFalpha blockade with infliximab was effective at inducing remission in 88% of patients with antibody-associated systemic vasculitis and permitted reduction in steroid doses. Severe infections were seen in 21% of patients, and despite continued infliximab, 20% of initial responders experienced disease flares. Infliximab is a promising new therapy for vasculitis both as a component of initial therapy and in the management of refractory disease. These results need confirmation in larger randomized trials.

A multicenter survey of rituximab therapy for refractory antineutrophil cytoplasmic antibody–associated vasculitis

OBJECTIVE B cell depletion with rituximab has allowed remissions in relapsing or refractory antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis in small studies. The aim of this study was to determine the efficacy and safety of rituximab for ANCA-associated vasculitis in a larger multicenter cohort. This permitted comparison of rituximab dosing regimens, the value of continuing immunosuppression, and investigation of ANCA and B cell levels as re-treatment biomarkers. METHODS Retrospective, standardized data collection from 65 sequential patients receiving rituximab for refractory ANCA-associated vasculitis at 4 centers in the UK was used. RESULTS All patients achieved B cell depletion. Complete remission occurred in 49 of the 65 patients (75%), partial remission in 15 (23%), and no response in 1 (2%). The prednisolone dosage was reduced from 12.5 mg/day (median) to 9.0 mg/day at 6 months (P = 0.0006). Immunosuppressive therapy was withdrawn in 37 of 60 patients (62%). Twenty-eight of 49 patients who achieved full remission (57%) experienced relapse (median 11.5 months). B cell return preceded relapse in 14 of 27 patients (52%). Although ANCA levels fell after rituximab therapy, relapse was not associated with ANCA positivity or a rise in ANCA levels. Neither the initial rituximab regimen (4 infusions of 375 mg/m(2) each given 1 week apart or 2 infusions of 1 gm each given 2 weeks apart) nor withdrawal of immunosuppressive therapy (37 of 60 patients [62%]) influenced the timing of relapse. Thirty-eight patients received >or=2 courses of rituximab, and complete remission was induced or maintained in 32 of them (84%). IgM levels fell, although IgG levels remained stable. Forty-six serious adverse events occurred, including 2 episodes of late-onset neutropenia, which were attributed to rituximab. CONCLUSION Rituximab was effective remission induction therapy for refractory ANCA-associated vasculitis in this study. There was no difference in efficacy between the 2 main treatment regimens. Continuing immunosuppression did not reduce relapses. Relapses occurred, but re-treatment was effective and safe. There was no clear influence of rituximab on the frequency of serious adverse events. ANCA and B cell levels lacked sufficient sensitivity to guide the timing of re-treatment.

IgG antiendothelial cell autoantibodies from scleroderma patients induce leukocyte adhesion to human vascular endothelial cells in vitro. Induction of adhesion molecule expression and involvement of endothelium-derived cytokines.

IgG autoantibodies that bind human endothelial cells (AECA) were detected by ELISA in 30 of 42 samples of sera from patients with scleroderma. Pretreatment of human umbilical vein endothelial cells with AECA-positive scleroderma sera, or IgG purified from these sera, led to a dose- and time-dependent increase in the ability of the cells to bind human U937 monocytic cells. Threshold-active IgG concentrations were 1-10 micrograms/ml; effects were significant after 3 h and maximal after 6-12 h. IgG from AECA-negative sera or normal sera were without effect. Increased adhesion of U937 cells was accompanied by increased expression of endothelial intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin. Transfer of endothelial cell-conditioned media after pretreatment with AECA and immunodepletion of IgG demonstrated the presence of transferable activity that mimicked the effects of AECA. Treatment with neutralizing anticytokine antibodies indicated that IL-1, generated by the endothelial cells in response to AECA, was involved in the upregulation of adhesion molecules and U937 cell adhesion. We conclude that AECA can play a pathogenic role in scleroderma by activating endothelial cells, in part due to autocrine or paracrine actions of IL-1.

Pulse versus daily oral cyclophosphamide for induction of remission in ANCA-associated vasculitis: long-term follow-up

Introduction The previously reported randomised controlled trial of a consensus regimen of pulse cyclophosphamide suggested that it was as effective as a daily oral (DO) cyclophosphamide for remission induction of antineutrophil cytoplasm autoantibodies-associated systemic vasculitis when both were combined with the same glucocorticoid protocol (CYCLOPS study (Randomised trial of daily oral versus pulse Cyclophosphamide as therapy for ANCA-associated Systemic Vasculitis published de groot K, harper L et al Ann Int Med 2009)). The study had limited power to detect a difference in relapse. This study describes the long-term outcomes of patients in the CYCLOPS study. Methods Long-term outcomes were ascertained retrospectively from 148 patients previously recruited to the CYCLOPS Trial. Data on survival, relapse, immunosuppressive treatment, cancer incidence, bone fractures, thromboembolic disease and cardiovascular morbidity were collected from physician records retrospectively. All patients were analysed according to the group to which they were randomised. Results Median duration of follow-up was 4.3 years (IQR, 2.95–5.44 years). There was no difference in survival between the two limbs (p=0.92). Fifteen (20.8%) DO and 30 (39.5%) pulse patients had at least one relapse. The risk of relapse was significantly lower in the DO limb than the pulse limb (HR=0.50, 95% CI 0.26 to 0.93; p=0.029). Despite the increased risk of relapse in pulse-treated patients, there was no difference in renal function at study end (p=0.82). There were no differences in adverse events between the treatment limbs. Discussion Pulse cyclophosphamide is associated with a higher relapse risk than DO cyclophosphamide. However, this is not associated with increased mortality or long-term morbidity. Although the study was retrospective, data was returned in 90% of patients from the original trial.

Pathogenesis of ANCA-associated systemic vasculitis

The aetiology of primary systemic vasculitides remains unknown. Recent advances have been made in the understanding of relevant mechanisms of inflammation, particularly the role of the endothelium and interactions with inflammatory mediators and immune effector cells. In Wegener’s granulomatosis and microscopic polyangiitis the evidence suggests an autoimmune inflammatory process, characterized by an early lesion involving neutrophils and endothelial cells as both targets and active participants; priming of neutrophils and endothelial cells allows ANCA to activate neutrophils with damage localized to the endothelium. In the absence of immune complex deposition, the role of the ANCA is particularly intriguing. Endothelial cell damage and activation produces pro‒inflammatory mediators with influx monocytes and T cells intensifying damage. Increased understanding of the pathogenesis of systemic vasculitis is likely to provide the basis for the use of more selective immunomodulatory therapies in the future. Copyright

IgG anti–endothelial cell autoantibodies from patients with systemic lupus erythematosus or systemic vasculitis stimulate the release of two endothelial cell–derived mediators, which enhance adhesion molecule expression and leukocyte adhesion in an autocrine manner

OBJECTIVE To investigate the ability of anti-endothelial cell antibodies (AECA) to modulate endothelial cell function. METHODS The effects of purified IgG from 11 patients with systemic lupus erythematosus (SLE) and 4 patients with systemic vasculitis on the expression of adhesion molecules (intercellular adhesion molecule 1, vascular cell adhesion molecule 1, E-selectin) by human umbilical vein endothelial cells and on the adhesion of the human promyelocytic cell line U937 were examined in vitro. RESULTS IgG from 6 of 8 AECA-positive SLE patients and 3 of 3 AECA-positive systemic vasculitis patients up-regulated adhesion molecule expression and leukocyte adhesion to endothelial cells. The 4 AECA-negative samples had no effect. Transfer experiments demonstrated that at later time points (2-8 hours) after AECA addition, endothelium-derived interleukin-1 (IL-1) accounted for the ability of AECA to increase leukocyte adhesion. However, even within very short times after addition of AECA (<30 minutes), endothelial cells released a distinct transferable mediator with similar effects. CONCLUSION AECA in patients with SLE or systemic vasculitis may contribute to pathogenesis by increasing leukocyte adhesion to endothelial cells. AECA act by inducing the release of at least two endothelium-derived mediators, one (as-yet-unidentified) rapidly and another (IL-1) more slowly, both of which stimulate endothelial cells in an autocrine manner.