Javier D. Finkielman

Antiproteinase 3 Antineutrophil Cytoplasmic Antibodies and Disease Activity in Wegener Granulomatosis

Context Most patients with Wegener granulomatosis have antineutrophil cytoplasmic antibodies (ANCA). The role of ANCA testing in monitoring response to treatment is controversial. Contribution Using data from a large treatment trial, the authors found little association between disease activity and ANCA levels. Decreases in ANCA levels were not associated with remission, and increases were not associated with relapse. Caution Because follow-up duration differed by patient, standard measures of ANCA accuracy, such as sensitivity and specificity for detecting remission and relapse, could not be calculated. Implication Serial ANCA testing should not be used to monitor disease activity or to guide decisions about immunosuppressive treatment in patients with Wegener granulomatosis. The Editors Wegener granulomatosis is characterized by necrotizing granulomatous inflammation and vasculitis, most commonly affecting the respiratory tract and kidneys (1, 2). Remission can be induced in most patients by using glucocorticoids with cyclophosphamide or methotrexate (17), but most patients have relapse when immunosuppression is reduced or withdrawn (1, 2, 6, 8). Consequently, patients experience substantial illness and damage from both the disease and treatment toxicity (1, 9). Accurate assessment of disease activity and prediction of relapse remain the biggest challenges in management of Wegener granulomatosis (10). Most patients with Wegener granulomatosis have antineutrophil cytoplasmic antibodies (ANCA), which produce a cytoplasmic immunofluorescence pattern on ethanol-fixed neutrophils and react with the neutrophil serine protease proteinase 3 (PR3) (1115). Proteinase 3 is synthesized as a proenzyme (pro-PR3) containing an amino-terminal activation dipeptide that preserves PR3 in an inactive state (16). Subsequent cleavage of this dipeptide allows PR3 to assume its active enzyme conformation (mature-PR3) (16). The diagnostic value of ANCA is well established (17, 18); however, the role of serial ANCA measurements during follow-up and their utility in guiding treatment remain controversial (10, 19, 20). A recent study indicated that in individual patients with Wegener granulomatosis, ANCA against pro-PR3 had a stronger correlation with disease activity than did ANCA against mature-PR3 (21). Therefore, we sought to determine whether pro-PR3ANCA levels correlate more strongly with disease activity than do mature-PR3ANCA levels, whether a decrease in pro- or mature-PR3ANCA levels during remission-induction therapy is associated with a shorter time to sustained remission, and whether an increase in pro- or mature-PR3ANCA levels is associated with relapse. Methods This prospective study was done in the context of the WGET (Wegener Granulomatosis Etanercept Trial) (6, 22, 23), a randomized, placebo-controlled trial that evaluated etanercept for maintenance of remission in 180 patients with Wegener granulomatosis at 8 centers across the United States (Appendix 1). All patients met at least 2 of the 5 modified American College of Rheumatology criteria for classification of Wegener granulomatosis and had active disease within 28 days before enrollment and a Birmingham Vasculitis Activity Score for Wegener granulomatosis (BVAS/WG) of at least 3 (22, 24). Follow-up evaluations were done at baseline, after 6 and 12 weeks, and then every 3 months until the end of the trial. Two additional evaluations took place at 3 and 6 months after the end of the trial. During each visit, disease activity was measured by using the BVAS/WG, and serum samples were obtained, frozen, and stored at 80 C. Treatment Patients were treated in a protocol-defined manner with etanercept or placebo in addition to standard therapies. Patients with severe Wegener granulomatosis (life- or organ-threatening disease) received cyclophosphamide and glucocorticoids at enrollment (22, 24). Those with limited (that is, nonsevere) Wegener granulomatosis received methotrexate and glucocorticoids. Medication dosages were tapered according to protocol once disease activity was controlled (6, 22). Assessment of Disease Activity and Definitions of Sustained Remission and Relapse Disease activity was measured by using the BVAS/WG (24). This index considers all manifestations of active disease during the 28 days preceding the date of assessment. A BVAS/WG of 1 or greater is considered active disease, and a BVAS/WG of 0 indicates remission (24). Our analyses focused on first sustained remission and first relapse. Sustained remission was defined as a BVAS/WG of 0 for at least 6 months (6, 22). The PR3-ANCA level at the visit in the middle of this period was considered the PR3-ANCA level at sustained remission. Disease relapse was defined as an increase of at least 1 point in the BVAS/WG in patients who had sustained remission. ANCA Detection Methods A standard immunofluorescence assay and direct enzyme-linked immunosorbent assays (ELISAs) for PR3-ANCA and ANCA against myeloperoxidase were done as described elsewhere (25). Capture ELISA was used to measure PR3-ANCA (2527); levels are expressed as net absorbance, and a level of 0.10 or greater is considered positive (26, 27). The intra-assay and interassay coefficients of variation are 9% and 31%, respectively, for pro-PR3 capture ELISA, and 6% and 28%, respectively, for mature-PR3 capture ELISA. All baseline serum samples were screened at first thaw by using all methods. Patients whose baseline samples tested positive for perinuclear-staining ANCA or ANCA against myeloperoxidase (n= 24) were excluded from further analyses because of substantial differences in disease phenotype between patients positive for ANCA against myeloperoxidase and those positive for PR3-ANCA. In addition, the number of patients who were positive for ANCA against myeloperoxidase was too small for meaningful longitudinal analysis (5, 28, 29). Subsequently, all serum samples were tested for mature- and pro-PR3ANCA in parallel by using capture ELISA at first thaw (except for the baseline samples, which were retested at second thaw). To minimize variability, all serum samples from an individual patient were run at once in the same plate and the same lots of all reagents were used for all assays. Laboratory personnel were blinded to the clinical data. Increase and Decrease of PR3-ANCA Levels We defined an increase in PR3-ANCA levels a priori as an increase of at least 100% in the net absorbance over 6 months. An absolute increase of at least 0.4 was also required to ensure that small elevations were above the intra-assay coefficient of variation. We classified a negative-to-positive conversion of PR3-ANCA status as an increase only if the absolute increase was at least 0.4. Because 6 months corresponded to 3 clinical visits (except for the initial 6 months after enrollment, when it corresponded to 4 clinical visits), we compared the PR3-ANCA levels at each visit with those from the previous 2 to determine whether the criteria for increase were fulfilled. We first looked for an increase in PR3-ANCA 9 months after enrollment (the fourth visit), because that was the first time that a patient could meet the definition of sustained remission. Thus, the PR3-ANCA level at the fourth visit was compared with the levels at the third and second visits after enrollment. No increase in PR3-ANCA before the fourth visit after enrollment was analyzed (Appendix Figure 1). Appendix Figure 1. Diagram of the initial 4 clinical visits. The fourth clinical visit was the first point at which a patient could meet the study definition of sustained remission (SR) (a Birmingham Vasculitis Activity Score for Wegener granulomatosis [BVAS/WG] of 0 for 6 months) and was the first time we looked for an increase in proteinase 3 (PR3) antineutrophil cytoplasmic antibody (ANCA) levels. We compared the net absorbance of PR3-ANCA at this visit with that of the previous 2 visits or the previous 6 months (curved lines). The same comparison was done at every subsequent visit. We defined a decrease in PR3-ANCA levels during the initial 6 months of follow-up as a decline of at least 50% in the net absorbance with an absolute decrease of at least 0.4; for values between 0.1 and 0.4, the capture ELISA needed to yield negative results. Statistical Analysis Descriptive data are summarized as mean (SD), median (interquartile range), or percentages. Groups were compared by using the t test (or the rank-sum test) or the chi-square test (or Fisher exact test), with 95% CIs calculated as appropriate. A P value less than 0.05 was considered statistically significant. We performed unadjusted and adjusted analyses. The adjusting variables were age, sex, disease severity (severe vs. limited Wegener granulomatosis), treatment group (etanercept vs. placebo), disease duration, baseline BVAS/WG, and clinical center (see Appendix 2 for additional details). PR3-ANCA Levels and Disease Activity The cross-sectional and longitudinal associations between the BVAS/WG and the levels of mature- and pro-PR3ANCA were estimated by using random-effect models. We constructed the models with BVAS/WG as the dependent variable and included a random effect for each patient (random intercept) and 2 terms for PR3-ANCA levelsone term for the value of PR3-ANCA level at baseline and the other for the change in PR3-ANCA level from baseline to time t. To assess the magnitude of the association between PR3-ANCA levels and the BVAS/WG, we estimated the relative reduction in the residual variance by comparing the residual variance of the model that included a random effect for each patient and 2 terms for PR3-ANCA levels with the residual variance of a model that only included the random effect for each patient. These analyses included only observations in which both BVAS/WG and PR3-ANCA level were available (9% of the observations had missing PR3-ANCA information). For patients who achieved sustained remission, the mature- and pro-PR3ANCA level

The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate

IntroductionEtomidate blocks adrenocortical synthesis when it is administered intravenously as a continuous infusion or a single bolus. The influence of etomidate administration on the incidence of relative adrenal insufficiency in patients with septic shock has not been formally investigated. The objective of this study was to determine the incidence of relative adrenal insufficiency in patients with septic shock after etomidate administration compared with patients with septic shock who did not receive etomidate.MethodsIn this retrospective study, 152 adults with septic shock who had a consyntropin stimulation test between March 2002 and August 2003 in a tertiary medical center were included. Relative adrenal insufficiency was defined as a rise in serum cortisol ≤ 9 μg/dl after the administration of 250 μg of consyntropin. Patients were divided into those who did and those who did not receive etomidate before the stimulation test. The proportion of patients with relative adrenal insufficiency in these two groups was compared using Fischers exact test. A P of value < 0.05 was considered statistically significant.ResultsThe mean age of the patients was 64 years, 59% of patients were male, 97% of patients were white and their hospital mortality rate was 57%. Thirty-eight patients (25%) received etomidate before the cosyntropin stimulation test, and the median (interquartile range) time interval between the administration of the drug and the test was 7 (4–10) hours. The incidence of relative adrenal insufficiency was 76% in the patients who received etomidate compared with 51% in the patients who did not (P = 0.0077).ConclusionThe incidence of relative adrenal insufficiency in patients with septic shock is increased when the stimulation test is performed after the administration of etomidate.

Underweight is independently associated with mortality in post-operative and non-operative patients admitted to the intensive care unit: A retrospective study

BackgroundLow and high body mass index (BMI) have been recently shown to be associated with increased and decreased mortality after ICU admission, respectively. The objective of this study was to determine the impact of BMI on mortality and length of stay in patients admitted to the intensive care unit (ICU).MethodsIn this retrospective cohort study, the Acute Physiology and Chronic Health Evaluation (APACHE) III database of patients admitted to the ICUs of a tertiary academic medical center, from January 1997 to September 2002, was crossed with a Hospital Rule-based Systems database to obtain the height and weight of the patients on admission to the ICU. The cohort was divided in post-operative and non-operative groups. We created the following five subgroups based on the BMI: <18.5, 18.5 to 24.9, 25 to 29.9, 30.0 to 39.9, ≥ 40.0 Kg/m2. A multiple logistic regression analysis was used to determine the independent impact of BMI on hospital mortality. The ICU length of stay ratio was defined as the ratio of the observed to the predicted LOS. P-value < 0.05 was considered significant. The 95% confidence interval (CI) was calculated for the odds ratio (OR).ResultsBMI was available in 19,669 of the 21,790 patients in the APACHE III database; 11,215 (57%) of the patients were admitted post-operatively. BMI < 18.5 was associated with increased mortality in both post-operative (OR = 2.14, 95% CI, 1.39 to 3.28) and non-operative (OR = 1.51, 95% CI, 1.13 to 2.01) patients. Post-operative patients with a BMI between 30.0 to 39.9 had a lower mortality rate (OR = 0.68, 95% CI, 0.49 to 0.94). Post-operative patients with BMI <18.5 or BMI ≥ 40 had an ICU length of stay ratio significantly higher than patients with BMI between 18.5 to 24.9. The addition of BMI < 18.5 did not improve significantly the accuracy of our prognostic model in predicting hospital mortality.ConclusionsLow BMI is associated with higher mortality in both post- and non-operative patients admitted to the ICU. LOS is increased in post-operative patients with low and high BMIs.

The initial Mayo Clinic experience using high-frequency oscillatory ventilation for adult patients: a retrospective study

BackgroundHigh-frequency oscillatory ventilation (HFOV) was introduced in our institution in June 2003. Since then, there has been no protocol to guide the use of HFOV, and all decisions regarding ventilation strategies and settings of HFOV were made by the treating intensivist. The aim of this study is to report our first year of experience using HFOV.MethodsIn this retrospective study, we reviewed all 14 adult patients, who were consecutively ventilated with HFOV in the intensive care units of a tertiary medical center, from June 2003 to July 2004.ResultsThe mean age of the patients was 56 years, 10 were males, and all were whites. The first day median APACHE II score and its predicted hospital mortality were 35 and 83%, respectively, and the median SOFA score was 11.5. Eleven patients had ARDS, two unilateral pneumonia with septic shock, and one pulmonary edema. Patients received conventional ventilation for a median of 1.8 days before HFOV. HFOV was used 16 times for a median of 3.2 days. Improvements in oxygenation parameters were observed after 24 hours of HFOV (mean PaO2/FIO2 increased from 82 to 107, P < 0.05; and the mean oxygenation index decreased from 42 to 29; P < 0.05). In two patients HFOV was discontinued, in one because of equipment failure and in another because of severe hypotension that was unresponsive to fluids. No change in mean arterial pressure, or vasopressor requirements was noted after the initiation of HFOV. Eight patients died (57 %, 95% CI: 33–79); life support was withdrawn in six and two suffered cardiac arrest.ConclusionDuring our first year of experience, HFOV was used as a rescue therapy in very sick patients with refractory hypoxemia, and improvement in oxygenation was observed after 24 hours of this technique. HFOV is a reasonable alternative when a protective lung strategy could not be achieved on conventional ventilation.

Relationship between markers of platelet activation and inflammation with disease activity in Wegener's granulomatosis

Objective. There remains a need for biomarkers to guide therapy in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Our objective was to determine whether measures of platelet activation or inflammation are associated with disease activity in Wegener’s granulomatosis (WG). Methods. Study subjects were participants in a clinical trial. Soluble CD40 ligand (sCD40L), C-reactive protein, interleukin 6 (IL-6), IL-8, monocyte chemoattractant protein 1 (MCP-1), P-selectin, vascular endothelial growth factor, and proteinase 3 (PR3)-specific ANCA were measured by ELISA using plasma samples obtained at baseline (active disease), at remission, and prior to, during, and after first flares. Disease activity was assessed by the Birmingham Vasculitis Activity Score for WG (BVAS/WG). Association of biomarkers with disease activity was determined with conditional logistic and linear regression. Results. Over a mean followup of 27 months, 180 subjects underwent 2044 visits; markers were measured in 563 samples. Longitudinally, all markers other than IL-6 were associated with disease activity. The strongest associations for active disease at baseline versus remission were observed for sCD40L (OR 4.72, 95% CI 2.47–9.03), P-selectin (OR 6.26, 95% CI 2.78–14.10), PR3-ANCA (OR 9.41, 4.03–21.99), and inversely for MCP-1 (OR 0.36, 95% CI 0.22–0.57). BVAS/WG increased by 0.80 (95% CI 0.44–1.16), 0.83 (95% CI 0.42–1.25), and 0.81 (95% CI 0.48–1.15) per unit-increase in PR3-ANCA, sCD40L, and P-selectin, respectively; and decreased by 1.54 (95% CI 0.96–2.12) per unit-increase in MCP-1. Conclusion. Cytokines arising from within the circulation, including those of platelet activation, correlate with disease activity in WG.

Accuracy of the ICD-9 Code for Identification of Patients with Wegener’s Granulomatosis

The International Classification of Diseases, 9th Revision (ICD-9) has been proposed as a valid tool for epidemiological research for some rheumatologic conditions1,2. We investigated the accuracy of the ICD-9 code 446.4 for the diagnosis of Wegener’s granulomatosis (WG). The Institutional Review Board of Saint Alexius Medical Center approved the study, and a waiver of informed consent was granted. Saint Alexius Medical Center is a 306-bed hospital, with primary and specialty clinics (including rheumatology, pulmonology, and nephrology). Patients coded for the first time with the ICD-9 code 446.4 were identified using the Health Data Management Reporter software (version 4.7.1000.11; 3M Health Information System Inc., St. … Address correspondence to Dr. J. Finkielman, Intensive Care Unit, Saint Alexius Medical Center, 900 East Broadway Ave., Bismarck, ND 58501. E-mail: jfinkielman{at}primecare.org