Coen A. Stegeman

Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis

BACKGROUND Cyclophosphamide and glucocorticoids have been the cornerstone of remission-induction therapy for severe antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis for 40 years. Uncontrolled studies suggest that rituximab is effective and may be safer than a cyclophosphamide-based regimen. METHODS We conducted a multicenter, randomized, double-blind, double-dummy, noninferiority trial of rituximab (375 mg per square meter of body-surface area per week for 4 weeks) as compared with cyclophosphamide (2 mg per kilogram of body weight per day) for remission induction. Glucocorticoids were tapered off; the primary end point was remission of disease without the use of prednisone at 6 months. RESULTS Nine centers enrolled 197 ANCA-positive patients with either Wegeners granulomatosis or microscopic polyangiitis. Baseline disease activity, organ involvement, and the proportion of patients with relapsing disease were similar in the two treatment groups. Sixty-three patients in the rituximab group (64%) reached the primary end point, as compared with 52 patients in the control group (53%), a result that met the criterion for noninferiority (P<0.001). The rituximab-based regimen was more efficacious than the cyclophosphamide-based regimen for inducing remission of relapsing disease; 34 of 51 patients in the rituximab group (67%) as compared with 21 of 50 patients in the control group (42%) reached the primary end point (P=0.01). Rituximab was also as effective as cyclophosphamide in the treatment of patients with major renal disease or alveolar hemorrhage. There were no significant differences between the treatment groups with respect to rates of adverse events. CONCLUSIONS Rituximab therapy was not inferior to daily cyclophosphamide treatment for induction of remission in severe ANCA-associated vasculitis and may be superior in relapsing disease. (Funded by the National Institutes of Allergy and Infectious Diseases, Genentech, and Biogen; ClinicalTrials.gov number, NCT00104299.)

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.

Association of Chronic Nasal Carriage of Staphylococcus aureus and Higher Relapse Rates in Wegener Granulomatosis

Wegener granulomatosis is a systemic disease characterized by necrotizing granulomatous inflammation of the upper and lower respiratory tract in combination with vasculitis and focal necrotizing crescentic glomerulonephritis [1]. Treatment with cyclophosphamide in combination with corticosteroids has proved highly successful, although side effects may be severe and sometimes lethal [2]. After remission is achieved, the course of the disease is highly variable and unpredictable. Most patients have relapses at variable intervals requiring re-institution of immunosuppressive therapy. Serial titration of antineutrophil cytoplasmic antibodies (ANCA) is helpful in predicting the occurrence of relapses [3-6]. The pathogenesis of the disease is not well known. Several anecdotal reports have noted beneficial results of sulfamethoxazole-trimethoprim in the treatment of refractory Wegener granulomatosis or limited Wegener granulomatosis localized to the respiratory tract [7-10]. These findings have raised speculation regarding a possible role for infectious agents in the induction of disease activity in Wegener granulomatosis. Recently, it was noted that patients with Wegener granulomatosis frequently have symptoms of a respiratory tract infection at the time of ANCA titer elevation [4]. Previous studies also found that many patients had respiratory tract infections either at the onset of the disease or before a relapse [11, 12]. Virtually every patient with Wegener granulomatosis has secondary infections of the paranasal tissues, predominantly with Staphylococcus aureus, and infections invariably respond to antistaphylococcal antibiotics [2]. Nasal carriage of S. aureus is considered a risk factor for S. aureus infections [13-16]. No prospective studies have been done on the frequency of these infections or the relation of nasal carriage rate of S. aureus to disease activity or levels of ANCA in patients with Wegener granulomatosis. We examined several possible risk factors for relapse of Wegener granulomatosis. Methods All consecutive patients with biopsy-proven Wegener granulomatosis visiting our outpatient clinic from January 1988 to July 1991 entered the study. The diagnosis of Wegener granulomatosis was based on clinical and histologic criteria [2]. At each visit, usually every 4 to 6 weeks, patients were evaluated for signs and symptoms attributable to active Wegener granulomatosis and infections; blood samples were obtained for ANCA determinations; a swab culture of the anterior nares was taken; and medication was noted, with special emphasis on current or recent use of antibiotics. Because antibiotics can influence the results of nasal cultures, results of cultures taken during or within 4 weeks after a course of antibiotics were disregarded, as were cultures taken during hospitalization because the carrier rate may be enhanced by hospital stay [13]. No attempts were made to eliminate S. aureus carriage, although proven or suspected infections were treated with appropriate courses of antistaphylococcal antibiotics. Relapses of Wegener granulomatosis were treated, and immunosuppressive agents were tapered according to a protocol described previously [3]. Briefly, patients were initially treated for active Wegener granulomatosis with cyclophosphamide, 2 mg/kg body weight daily, and prednisolone, 1 mg/kg daily. Doses of cyclophosphamide were adjusted to maintain the leukocyte count above 4.0 109/L. In the absence of signs of active disease, the daily dose of cyclophosphamide was tapered every 3 months by 25 mg. Daily prednisolone was tapered after 6 weeks by 10 mg every 2 weeks until the dose reached 30 mg and thereafter by 5 mg every 2 weeks. Given the possible beneficial influence of cotrimoxazole in Wegener granulomatosis, patients receiving prolonged continuous treatment with antibiotics, arbitrarily defined as more than 6 weeks, were excluded. To establish true stable nasal carriage of S. aureus, only patients with at least 1 year of follow-up were included in the analysis. Patients were considered to have relapsed when they satisfied one of the following criteria in which the manifestations in question had to be new or recurrent findings [4]: 1. Progressive glomerulonephritis, a decrease in renal function of 30% or more within 3 months in combination with (microscopic) hematuria or evidence of acute necrotizing lesions on renal biopsy. 2. Pulmonary infiltrates with or without cavitation with rising C-reactive protein levels in the absence of infection or signs of malignancy. 3. Sinusitis, otitis, ulceration of nasal mucosa, or proliferative mass, in combination with necrotizing granulomatous inflammation on biopsy. 4. Miscellaneous (progressive mononeuritis multiplex, cranial nerve palsy, cerebral vasculitis, necrotizing scleritis, orbital pseudotumor, progressive tracheal stenosis with active disease on biopsy, peripheral gangrene, necrotizing vasculitis of medium-sized or small muscular arteries). An upper-airway infection was considered present when patients had clinical signs involving the pharynx, trachea, nasal and paranasal tissues, and ear, in combination with a positive culture or serologic evidence, and when patients had clinical signs suggesting infection, without microbiologic evidence but with a prompt response to appropriate antibiotic treatment. Viral serologic tests were done only when clinically indicated, as were serologic tests for Mycoplasma, Chlamydia, and Legionella species. Urinary tract infections were defined by leukocyturia in combination with bacterial concentrations of 105 colony-forming units per mL or greater. Patients were considered to be chronic nasal carriers when 75% or more of their nasal cultures grew S. aureus [14] and nonchronic carriers when less than 75% (or no) nasal cultures grew S. aureus. Patients were also grouped according to their ANCA status during the study. Patients were considered persistently positive for ANCA when all ANCA measurements were positive during the study and intermittently positive when periods with positive ANCA test results were interrupted by at least two consecutive negative readings. Patients were considered persistently negative for ANCA when all consecutive ANCA measurements were negative from 6 months after the previous period with disease activity [6]. Destructive nasal lesions were defined as visible perforations of the nasal septum or saddle-nose deformity. Nasal cultures were taken by firmly rotating a sterile cotton-tipped swab (Transwab; Amies Med Elpo, Italy) in each anterior naris. The swabs were inoculated on 5% sheep-blood agar and salt mannitol agar (Oxoid; Basingstoke, England) for 48 hours at 35 C. Isolates were identified as S. aureus by the typical appearance of the colonies that were coagulase positive by slide coagulase testing and the ability to cleave DNA. Antineutrophil cytoplasmic antibodies were measured by indirect immunofluorescence on ethanol-fixed granulocytes [17]. Antineutrophil cytoplasmic antibodies were designated as c-ANCA when the fluorescence pattern was granular with a decrease in fluorescence intensity toward the periphery of the cells and as p-ANCA when a perinuclear-to-nuclear pattern was observed. The specificity and sensitivity of c-ANCA determinations in our laboratory for active Wegener granulomatosis have been previously reported [3]. In addition, the antigenic specificity of ANCA for either proteinase-3, myeloperoxidase, and elastase was tested by ELISA as previously described [18]. Statistical Analysis Differences in frequencies of categorical variables between groups were studied by the chi-square test. The continuous variables were tested with the Wilcoxon rank-sum test. Disease-free interval curves were calculated using the Kaplan-Meier method [19]. The first relapse during the study period was counted from the most recent period of disease activity, either diagnosis or a prestudy relapse. Patients without relapse were censored at the end of the study. Differences between groups in disease-free interval were studied by the log-rank test [20]. Confounding influences were tested by tests for trend and, when statistically significant, the log-rank test was done after stratification for the confounding variable [20]. Stepwise Cox proportional-hazards regression analysis (BMDP statistical software, BMDP, Inc., Cork, Ireland) with disease-free interval as the dependent variable was used to adjust the observed effect of S. aureus carrier status for other potential prognostic factors and to determine the independent influence of these other factors on disease-free interval [21]. Other variables included age, sex, disease-free interval before the start of the study, time since diagnosis, renal function measured as creatinine clearance (used as both a continuous and a categorical variable), nasal structure, number of documented infections during the study, history of previous relapses, and the time at which the patient was diagnosed as having Wegener granulomatosis (before or during the study). The termination of immunosuppressive therapy after the previous period of disease activity was included as a time-dependent covariate. Hazard ratios are reported as relative risks with 95% CIs computed from the exponential in the regression model using only covariates whose coefficients had a P value 0.10. Association of categorical variables was assessed by chi-square analysis, and associations were expressed by relative risk and its 95% CI [22]. A two-tailed P value < 0.05 was considered statistically significant. Results Of 71 patients who entered the study, 57 were analyzed, including 33 with an established diagnosis of Wegener granulomatosis before January 1988. The excluded patients included 11 patients initially referred for diagnosis or treatment but who requested follow-up at the referral hospital, 1 patient who died from gram-negative septicemia and pneumonia 8 months after being diagnosed with Weg

Genetically Distinct Subsets within ANCA-Associated Vasculitis

BACKGROUND Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a severe condition encompassing two major syndromes: granulomatosis with polyangiitis (formerly known as Wegeners granulomatosis) and microscopic polyangiitis. Its cause is unknown, and there is debate about whether it is a single disease entity and what role ANCA plays in its pathogenesis. We investigated its genetic basis. METHODS A genomewide association study was performed in a discovery cohort of 1233 U.K. patients with ANCA-associated vasculitis and 5884 controls and was replicated in 1454 Northern European case patients and 1666 controls. Quality control, population stratification, and statistical analyses were performed according to standard criteria. RESULTS We found both major-histocompatibility-complex (MHC) and non-MHC associations with ANCA-associated vasculitis and also that granulomatosis with polyangiitis and microscopic polyangiitis were genetically distinct. The strongest genetic associations were with the antigenic specificity of ANCA, not with the clinical syndrome. Anti-proteinase 3 ANCA was associated with HLA-DP and the genes encoding α(1)-antitrypsin (SERPINA1) and proteinase 3 (PRTN3) (P=6.2×10(-89), P=5.6×10(-12,) and P=2.6×10(-7), respectively). Anti-myeloperoxidase ANCA was associated with HLA-DQ (P=2.1×10(-8)). CONCLUSIONS This study confirms that the pathogenesis of ANCA-associated vasculitis has a genetic component, shows genetic distinctions between granulomatosis with polyangiitis and microscopic polyangiitis that are associated with ANCA specificity, and suggests that the response against the autoantigen proteinase 3 is a central pathogenic feature of proteinase 3 ANCA-associated vasculitis. These data provide preliminary support for the concept that proteinase 3 ANCA-associated vasculitis and myeloperoxidase ANCA-associated vasculitis are distinct autoimmune syndromes. (Funded by the British Heart Foundation and others.).

Immediate Postoperative Renal Function Deterioration in Cardiac Surgical Patients Predicts In-Hospital Mortality and Long-Term Survival

Postoperative renal function deterioration is a serious complication after cardiac surgery with cardiopulmonary bypass and is associated with increased in-hospital mortality. However, the long-term prognosis of patients with postoperative renal deterioration is not fully determined yet. Therefore, both in-hospital mortality and long-term survival were studied in patients with postoperative renal function deterioration. Included were 843 patients who underwent cardiac surgery with cardiopulmonary bypass in 1991. Postoperative renal function deterioration (increase in serum creatinine in the first postoperative week of at least 25%) occurred in 145 (17.2%) patients. In these patients, in-hospital mortality was 14.5%, versus 1.1% in patients without renal function deterioration (P < 0.001). Multivariate analysis significantly associated in-hospital mortality with postoperative renal function deterioration, re-exploration, postoperative cerebral stroke, duration of operation, age, and diabetes. In patients who were discharged alive, during long-term follow-up (100 mo), mortality was significantly increased in the patients with renal function deterioration (n = 124) as compared with those without renal function deterioration (hazard ratio 1.83; 95% confidence interval 1.38 to 3.20). Also after adjustment for other independently associated factors, the risk for mortality in patients with postoperative renal function deterioration remained elevated (hazard ratio 1.63; 95% confidence interval 1.15 to 2.32). The elevated risk for long-term mortality was independent of whether renal function had recovered at discharge from hospital. It is concluded that postoperative renal function deterioration in cardiac surgical patients not only results in increased in-hospital mortality but also adversely affects long-term survival.

Efficacy of Remission-Induction Regimens for ANCA-Associated Vasculitis

BACKGROUND The 18-month efficacy of a single course of rituximab as compared with conventional immunosuppression with cyclophosphamide followed by azathioprine in patients with severe (organ-threatening) antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is unknown. METHODS In a multicenter, randomized, double-blind, double-dummy, noninferiority trial, we compared rituximab (375 mg per square meter of body-surface area administered once a week for 4 weeks) followed by placebo with cyclophosphamide administered for 3 to 6 months followed by azathioprine for 12 to 15 months. The primary outcome measure was complete remission of disease by 6 months, with the remission maintained through 18 months. RESULTS A total of 197 patients were enrolled. As reported previously, 64% of the patients in the rituximab group, as compared with 53% of the patients in the cyclophosphamide-azathioprine group, had a complete remission by 6 months. At 12 and 18 months, 48% and 39%, respectively, of the patients in the rituximab group had maintained the complete remissions, as compared with 39% and 33%, respectively, in the comparison group. Rituximab met the prespecified criteria for noninferiority (P<0.001, with a noninferiority margin of 20%). There was no significant difference between the groups in any efficacy measure, including the duration of complete remission and the frequency or severity of relapses. Among the 101 patients who had relapsing disease at baseline, rituximab was superior to conventional immunosuppression at 6 months (P=0.01) and at 12 months (P=0.009) but not at 18 months (P=0.06), at which time most patients in the rituximab group had reconstituted B cells. There was no significant between-group difference in adverse events. CONCLUSIONS In patients with severe ANCA-associated vasculitis, a single course of rituximab was as effective as continuous conventional immunosuppressive therapy for the induction and maintenance of remissions over the course of 18 months. (Funded by the National Institute of Allergy and Infectious Diseases and others; RAVE ClinicalTrials.gov number, NCT00104299.)

Protective role of endothelial nitric oxide synthase

Nitric oxide is a versatile molecule, with its actions ranging from haemodynamic regulation to anti‐proliferative effects on vascular smooth muscle cells. Nitric oxide is produced by the nitric oxide synthases, endothelial NOS (eNOS), neural NOS (nNOS), and inducible NOS (iNOS). Constitutively expressed eNOS produces low concentrations of NO, which is necessary for a good endothelial function and integrity. Endothelial derived NO is often seen as a protective agent in a variety of diseases.

Long-term patient survival in ANCA-associated vasculitis

Background Wegeners granulomatosis and microscopic polyangiitis are antineutrophil cytoplasm antibodies (ANCA)-associated vasculitides with significant morbidity and mortality. The long-term survival of patients with ANCA associated vasculitis treated with current regimens is uncertain. Objective To describe the long-term patient survival and possible prognostic factors at presentation in an international, multicentre, prospectively recruited representative patient cohort who were treated according to strictly defined protocols at presentation and included the full spectrum of ANCA-associated vasculitis disease. Methods Outcome data were collected for 535 patients who had been recruited at the time of diagnosis to four randomised controlled trials between 1995 and 2002. Trial eligibility was defined by disease severity and extent, covered the spectrum of severity of ANCA-associated vasculitis and used consistent diagnostic criteria. Demographic, clinical and laboratory parameters at trial entry were tested as potential prognostic factors in multivariable models. Results The median duration of follow-up was 5.2 years and 133 (25%) deaths were recorded. Compared with an age- and sex-matched general population there was a mortality ratio of 2.6 (95% CI 2.2 to 3.1). Main causes of death within the first year were infection (48%) and active vasculitis (19%). After the first year the major causes of death were cardiovascular disease (26%), malignancy (22%) and infection (20%). Multivariable analysis showed an estimated glomerular filtration rate <15 ml/min, advancing age, higher Birmingham Vasculitis Activity Score, lower haemoglobin and higher white cell count were significant negative prognostic factors for patient survival. Conclusion Patients with ANCA-associated vasculitis treated with conventional regimens are at increased risk of death compared with an age- and sex-matched population.

Tubular kidney injury molecule-1 (KIM-1) in human renal disease.

KIM‐1, a transmembrane tubular protein with unknown function, is undetectable in normal kidneys, but is markedly induced in experimental renal injury. The KIM‐1 ectodomain is cleaved, detectable in urine, and reflects renal damage. KIM‐1 expression in human renal biopsies and its correlation with urinary KIM‐1 (uKIM‐1) is unknown. In biopsies from various renal diseases (n = 102) and controls (n = 7), the fraction of KIM‐1 positive tubules and different renal damage parameters were scored. Double labelling was performed for KIM‐1 with macrophages (MØ), α‐smooth muscle actin (α‐SMA), proximal (aquaporin‐1) and distal (E‐cadherin) tubular markers and a dedifferentiation marker (vimentin). uKIM‐1 at the time of biopsy (n = 53) was measured by ELISA. Renal KIM‐1 was significantly increased in all diseases versus controls (p < 0.05), except minimal change. KIM‐1 was primarily expressed at the luminal side of dedifferentiated proximal tubules, in areas with fibrosis (α‐SMA) and inflammation (MØ). Independent of the disease, renal KIM‐1 correlated positively with renal damage, negatively with renal function, but not with proteinuria. uKIM‐1 was increased in renal patients versus controls (p < 0.001), including minimal change, and correlated positively with tissue KIM‐1 and MØ, negatively with renal function, but not with proteinuria. In conclusion, KIM‐1 is upregulated in renal disease and is associated with renal fibrosis and inflammation. uKIM‐1 is also associated with inflammation and renal function, and reflects tissue KIM‐1, indicating that it can be used as a non‐invasive biomarker in renal disease. Copyright

Risk factors for relapse of antineutrophil cytoplasmic antibody-associated vasculitis

OBJECTIVE To determine the association between characteristics at diagnosis and the time to first relapse in a large cohort of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS We studied long-term followup data from 4 clinical trials that included newly diagnosed patients with a broad spectrum of AAV severity and manifestations. Patient and disease characteristics at baseline were used in competing risk regression models with relapse as the event of interest and death as the competing event. RESULTS We assessed 535 patients with 1,804 patient-years at risk of relapse. At diagnosis, the median age was 60.7 years (interquartile range [IQR] 48.8-69.1 years), 284 patients (53%) had granulomatosis with polyangiitis (Wegeners), and the median creatinine level was 203 μmoles/liter (IQR 97-498). A total of 201 patients (38%) experienced a relapse and 133 patients (25%) died, 96 of whom had not had prior relapse. Anti-proteinase 3 antibodies (subhazard ratio [sHR] 1.62 [95% confidence interval 1.39-1.89]) and cardiovascular involvement (sHR 1.59 [95% confidence interval 1.07-2.37]) were independently associated with a higher risk of relapse. Compared with patients with a creatinine level ≤100 μmoles/liter, patients with higher creatinine levels had a lower risk of relapse (sHR 0.81 [95% confidence interval 0.77-0.85] for a creatinine level of 101-200 μmoles/liter; sHR 0.39 [95% confidence interval 0.22-0.69] for a creatinine level >200 μmoles/liter). CONCLUSION Relapse of disease is common for patients with AAV. A creatinine level >200 μmoles/liter at the time of diagnosis is strongly associated with a reduced risk of relapse and may help guide monitoring and treatment of patients with AAV.