Gina Gregorini

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

Pregnancy in women with pre-existing lupus nephritis: Predictors of fetal and maternal outcome

BACKGROUND Only few data are available on pregnancy in patients with lupus nephritis (LN) diagnosed before conception. The aim of this study was to identify the risk factors for complicated pregnancy in women with pre-existing LN. METHODS In a multicentre study, we collected data on 113 pregnancies occurring in 81 women with pre-existing biopsy-proven LN. Primary outcomes were fetal loss including perinatal death and renal flares during and 12 months after pregnancy. Univariate and logistic regression analyses were used to identify predictors of outcomes. RESULTS Renal biopsy performed 7.2 +/- 4.9 years before pregnancy showed the following WHO classes: 6 patients in II, 8 in III, 48 in IV and 19 in V. At conception, most patients were in complete (49%) or partial (27%) remission. There were nine spontaneous abortions, one stillbirth and five neonatal deaths. Thirty-one deliveries were preterm. Birth weight was <2500 g in 34 newborns. During pregnancy or after delivery, there were 34 renal flares, most of which (20) were reversible. Three patients had a progressive decline of glomerular filtration rate (one on dialysis). At logistic regression analysis, the pregnancy outcome was predicted by hypocomplementaemia at conception (RR 19.02; 90% CI 4.58-78.96) and aspirin during pregnancy (RR 0.11; 90% CI 0.03-0.38). Renal flare was predicted by renal status (partial remission RR 3.0; 90% CI 1.23-7.34, nonremission RR 9.0; 90% CI 3.59-22.57). CONCLUSIONS Pregnancy can be successful in most women with pre-existing LN, even for those with a severe renal involvement at onset. Renal flares during and after pregnancy are not uncommon and can be predicted by renal status assessed before pregnancy. Normocomplementaemia and low-dose aspirin therapy during pregnancy are independent predictors of a favourable fetal outcome.

European therapeutic trials in ANCA-associated systemic vasculitis: disease scoring, consensus regimens and proposed clinical trials EUROPEAN COMMUNITY STUDY GROUP ON CLINICAL TRIALS IN SYSTEMIC VASCULITIS ECSYSVASTRIAL (BMHl-Cr93-1078)

In previous phases of this project, proteinase 3 (PR3) and myeloperoxidase (MPO), the main antigenic target molecules of antineutrophil cytopiasmic antibodies, were isolated and applied in standardized ELISAs. In this study, standardized ELISAs with three PR3 preparations (from Copenhagen (CO), Raisdorf (RS) and Leiden (LF)) and one MPO preparation (from Copenhagen), were evaluated in a large retro-and prospective clitiical study. New patients (n=174) with primary systemic vasculitis (Wegeners granulomatosis, microscopic polyangiitis and idiopathic rapidly progressive glomerulonephritis, classical PAN and Churg-Strauss Syndrome) were included. Retrospectively, another 190 patients were evaluated. Furthermore control sera were obtained from patients with other forms of vasculitis, glomerulonephritis or granulomatous diseases (disease controls, n = 184) and healthy donors (healthy controls, n = 728). All patients were categorized by a system based on clinical and histoiogical data. Patients were followed up for at least 1 year after diagnosis in order to evaluate a possible correlation between ANCA levels and disease activity. The sensitivity of the anti-PR3 assays for histologically proven WG was between 59% and 69% in new patients, with a sensitivity of 22% for the anti-MPO assay. Similar figures were found for patients with clinically suspected WG. This was comparable with the results of the IIF test. In MPA and IRPGN a larger percentage of patients had antiMPO antibodies than in WG. Only a few patients with PAN and CSS were investigated, and most of these were negative in the ELISAs. The specificity ofthe assays for disease controls was 89-91% for the anti-PR3 assays and 95% for the anti-MPO assay. In the healthy controls the specificity was 98-99%. The specificity of the IIF test was 97% for a cANCA pattern and 81 % for a pANCA pattern in disease controls. The combination of cANCA with anti-PR3 and pANCA with anti-MPO both had a specificity of 99%. Further details will be presented during the meeting, in addition to the results of a follow-up study with correlation ofdisease activity and ANCA level. From this study we can conclude that ELISAs using purified PR3 or MPO are not more sensitive than the IIF test. However, the anti-MPO assay is more specific for systemic vascuitis as compared to disease controls with related diseases. Furthermore, the combination of the IIF test with antigen-specific ELISAs is very specific for the diagnosis Wegetiers granulomatosis, microscopic polyangiitis and idiopathic rapidly progressive gtomerulonephritis.

PTPN22 R620W polymorphism in the ANCA-associated vasculitides

OBJECTIVES PTPN22 is involved in T-cell activation and its R620W single-nucleotide polymorphism (SNP) has been shown to predispose to different autoimmune diseases. The aims of this study were to investigate the role of the PTPN22 R620W SNP in conferring susceptibility to the ANCA-associated vasculitides (AAVs), and to explore potential associations between the PTPN22 genotype and the disease manifestations. METHODS PTPN22 R620W SNP was genotyped in a cohort of 344 AAV patients [143 with granulomatosis with polyangiitis (Wegeners) (GPA), 102 with microscopic polyangiitis (MPA) and 99 with Churg-Strauss syndrome (CSS)] and in 945 healthy controls. RESULTS The frequency of the minor allele (620W) was significantly higher in GPA patients than in controls [P = 0.005, χ(2 )= 7.858, odds ratio (OR) = 1.91], while no statistically significant association was found with MPA or CSS. Among GPA patients, the 620W allele was particularly enriched in ANCA-positive patients as compared with controls (P = 0.00012, χ(2 )= 14.73, OR = 2.31); a particularly marked association was also found with ENT involvement (P = 0.0071, χ(2 )= 7.258, OR = 1.98), lung involvement (P = 0.0060, χ(2 )= 7.541, OR = 2.07) and skin manifestations of all kinds (P = 0.000047, χ(2 )= 16.567, OR = 3.73). CONCLUSION The PTPN22 620W allele confers susceptibility to the development of GPA (but not of MPA or CSS), and particularly of its ANCA-positive subset.

The long-term outcomes of systemic vasculitis

Patients with generalized ANCA-associated small vessel vasculitis (AAV) have a very poor outcome if the ANCA-associated vasculitis is not diagnosed, evaluated and treated properly. The introduction of treatment with immunosuppressive therapy has improved patient survival dramatically but with considerable side effects. Besides, almost 50% of surviving patients experience a relapse of vasculitis. Since 1995, the European Vasculitis Society (EUVAS) has designed and conducted several clinical trials on patients with AAV independently of pharmaceutical companies. The studies included patients with newly diagnosed AAV and were stratified according to renal function and generalized versus more localized forms. As the immediate patient survival has improved, the longer term outcome has become more important. There are several reports on outcome of patients with ANCA-associated vasculitis, but the patient groups were heterogeneous regarding diagnosis as well as treatment and follow-up. Therefore, EUVAS decided to further evaluate the effect and possible adverse events of the original randomized trials. This review presents an overview on long-term follow-up of patients with ANCA-associated vasculitis, with focus on relapse rate, patient and renal survival and development of cardiovascular disease and malignancy.

ANCA-associated vasculitis in childhood: recent advances

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides are rare systemic diseases that usually occur in adulthood. They comprise granulomatosis with polyangiitis (GPA, Wegener’s), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome). Their clinical presentation is often heterogeneous, with frequent involvement of the respiratory tract, the kidney, the skin and the joints. ANCA-associated vasculitis is rare in childhood but North-American and European cohort studies performed during the last decade have clarified their phenotype, patterns of renal involvement and their prognostic implications, and outcome. Herein, we review the main clinical and therapeutic aspects of childhood-onset ANCA-associated vasculitis, and provide preliminary data on demographic characteristics and organ manifestations of an Italian multicentre cohort.

Association of a TNFSF13B (BAFF) regulatory region single nucleotide polymorphism with response to rituximab in antineutrophil cytoplasmic antibody-associated vasculitis.

This study was supported by the National Institute of Health Research Cambridge Biomedical Research Centre (http://www.cambridge-brc.org.uk). F.A. has been supported by a European Renal Association-European Dialysis and Transplant Association long-term fellowship between September 2012 and September 2013. A.V. and D.M. were supported by the grant “A tailored approach to the immune monitoring and clinical management of viral and autoimmune diseases,” given by the Regione Emilia-Romagna within the Programma di Ricerca Regione-Universita 2010–12.

Identifying and managing lupus nephritis during pregnancy

ABSTRACT Introduction: Systemic lupus erythematosus (SLE) is a multi-organ disease that commonly affects women of child bearing-age, and lupus nephritis (LN) represents one of the most severe manifestations. Advances in treatment and better knowledge of the disease have resulted in an increasing number of women seeking pregnancy. Awareness of the relationship of the condition with respect to pregnancy and long-term prognosis is important for all clinicians involved. Presentation of LN can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. Areas covered: Here we detail the evolution of maternal disease, obstetrical and neonatal outcomes. We also report a practical approach to managing these pregnancies before, during and after analysing the predictors of poor obstetrical outcome or kidney worsening. Peculiar condition, as with kidney transplanted mothers, the onset of LN during pregnancy, or independent risk factors are also evaluated. Expert opinion: The improvement of LN therapies and better knowledge of the relationship has enormously enhanced the chance of uneventful pregnancies for LN women. A crucial step is to carefully plan the pregnancy with analysis of epidemiological, biological and therapeutic aspects that could interfere with the wellbeing of the mother and the child.