Renato Alberto Sinico

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

The 10-year follow-up data of the Euro-Lupus Nephritis Trial comparing low-dose and high-dose intravenous cyclophosphamide

Objective: To update the follow-up of the Euro-Lupus Nephritis Trial (ELNT), a randomised prospective trial comparing low-dose (LD) and high-dose (HD) intravenous (IV) cyclophosphamide (CY) followed by azathioprine (AZA) as treatment for proliferative lupus nephritis. Patients and methods: Data for survival and kidney function were prospectively collected during a 10-year period for the 90 patients randomised in the ELNT, except in 6 lost to follow-up. Results: Death, sustained doubling of serum creatinine and end-stage renal disease rates did not differ between the LD and HD group (5/44 (11%) vs 2/46 (4%), 6/44 (14%) vs 5/46 (11%) and 2/44 (5%) vs 4/46 (9%), respectively) nor did mean serum creatinine, 24 h proteinuria and damage score at last follow-up. Most patients in both groups were still treated with glucocorticoids, other immunosuppressant agents and blood pressure lowering drugs. After 10 years of follow-up, the positive predictive value for a good outcome of an early drop in proteinuria in response to initial immunosuppressive therapy was confirmed. Conclusion: The data confirm that a LD IVCY regimen followed by AZA—the “Euro-Lupus regimen”—achieves good clinical results in the very long term.

International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies

Anti-nuclear antibodies (ANA) are fundamental for the diagnosis of autoimmune diseases, and have been determined by indirect immunofluorescence assay (IIFA) for decades. As the demand for ANA testing increased, alternative techniques were developed challenging the classic IIFA. These alternative platforms differ in their antigen profiles, sensitivity and specificity, raising uncertainties regarding standardisation and interpretation of incongruent results. Therefore, an international group of experts has created recommendations for ANA testing by different methods. Two groups of experts participated in this initiative. The European autoimmunity standardization initiative representing 15 European countries and the International Union of Immunologic Societies/World Health Organization/Arthritis Foundation/Centers for Disease Control and Prevention autoantibody standardising committee. A three-step process followed by a Delphi exercise with closed voting was applied. Twenty-five recommendations for determining ANA (1–13), anti-double stranded DNA antibodies (14–18), specific antibodies (19–23) and validation of methods (24–25) were created. Significant differences between experts were observed regarding recommendations 24–25 (p<0.03). Here, we formulated recommendations for the assessment and interpretation of ANA and associated antibodies. Notably, the roles of IIFA as a reference method, and the importance of defining nuclear and cytoplasmic staining, were emphasised, while the need to incorporate alternative automated methods was acknowledged. Various approaches to overcome discrepancies between methods were suggested of which an improved bench-to-bedside communication is of the utmost importance. These recommendations are based on current knowledge and can enable harmonisation of local algorithms for testing and evaluation of ANA and related autoantibodies. Last but not least, new more appropriate terminologies have been suggested.

Recommendations for the management of mixed cryoglobulinemia syndrome in hepatitis C virus-infected patients.

OBJECTIVE The objective of this review was to define a core set of recommendations for the treatment of HCV-associated mixed cryoglobulinemia syndrome (MCS) by combining current evidence from clinical trials and expert opinion. METHODS Expert physicians involved in studying and treating patients with MCS formulated statements after discussing the published data. Their attitudes to treatment approaches (particularly those insufficiently supported by published data) were collected before the consensus conference by means of a questionnaire, and were considered when formulating the statements. RESULTS An attempt at viral eradication using pegylated interferon plus ribavirin should be considered the first-line therapeutic option in patients with mild-moderate HCV-related MCS. Prolonged treatment (up to 72 weeks) may be considered in the case of virological non-responders showing clinical and laboratory improvements. Rituximab (RTX) should be considered in patients with severe vasculitis and/or skin ulcers, peripheral neuropathy or glomerulonephritis. High-dose pulsed glucocorticoid (GC) therapy is useful in severe conditions and, when necessary, can be considered in combination with RTX; on the contrary, the majority of conference participants discouraged the chronic use of low-medium GC doses. Apheresis remains the elective treatment for severe, life-threatening hyper-viscosity syndrome; its use should be limited to patients who do not respond to (or who are ineligible for) other treatments, and emergency situations. Cyclophosphamide can be considered in combination with apheresis, but the data supporting its use are scarce. Despite the limited available data, colchicine is used by many of the conference participants, particularly in patients with mild-moderate MCS refractory to other therapies. Careful monitoring of the side effects of each drug, and its effects on HCV replication and liver function tests is essential. A low-antigen-content diet can be considered as supportive treatment in all symptomatic MCS patients. Although there are no data from controlled trials, controlling pain should always be attempted by tailoring the treatment to individual patients on the basis of the guidelines used in other vasculitides. CONCLUSION Although there are few controlled randomised trials of MCS treatment, increasing knowledge of its pathogenesis is opening up new frontiers. The recommendations provided may be useful as provisional guidelines for the management of MCS.

Churg-Strauss angiitis

Churg-Strauss angiitis or syndrome (CSA) is defined as an eosinophil-rich and granulomatous inflammation involving the respiratory tract, and necrotising vasculitis affecting small- to medium-sized vessels, and is associated with asthma and eosinophilia. It is usually classified among the so-called anti-neutrophil antibody (ANCA)-associated systemic vasculitides (AASVs) because of its clinical and pathological features that overlap with those of the other AASVs. However, two recent studies on large cohorts of patients have found that ANCAs, usually P-ANCAs/MPO-ANCAs, were present in only 38% of patients. Moreover, the ANCA status was shown to segregate with clinical phenotype. ANCA-positive patients were significantly more likely to have disease manifestations associated with small-vessel vasculitis, including necrotising glomerulonephritis, mononeuritis and purpura, whereas ANCA-negative cases were significantly more likely to have cardiac and lung involvement. Vasculitis was documented less frequently in histological specimens from ANCA-negative patients in comparison with ANCA-positive ones. These findings have led to postulate the predominance of distinct pathogenetic mechanisms in the two subsets of patients: an ANCA-mediated process in ANCA-positive patients and tissue infiltration by eosinophils with subsequent release of toxic product in ANCA-negative cases. Preliminary results suggest that ANCA-positive and ANCA-negative patients also might have a different genetic background. Corticosteroids remain the cornerstone of the initial treatment of CSA. The addition of cyclophosphamide is indicated in treatment of patients with poor-prognosis factors or in patients without poor-prognosis factors but those that are prone to relapses. The length of the maintenance therapy remains to be established. However, the vast majority of patients require long-term corticosteroids treatment to control asthma.

Are laboratory tests useful for monitoring the activity of lupus nephritis? A 6-year prospective study in a cohort of 228 patients with lupus nephritis

Objectives: To evaluate the role of immunological tests for monitoring lupus nephritis (LN) activity. Methods: C3, C4, anti-dsDNA and anti-C1q antibodies were prospectively performed over 6 years in 228 patients with LN. Results: In membranous LN only anti-C1q antibodies differentiated proteinuric flares from quiescent disease (p = 0.02). However, in this group 46% of flares occurred with a normal value of anti-C1q antibodies versus 20% in proliferative LN (p = 0.02). In patients with antiphospholipid antibodies (APL), 33% of flares occurred with normal levels of anti-C1q antibodies versus 14.5% in patients that were APL-negative (p = 0.02). In proliferative LN, anti-C1q antibodies showed a slightly better sensitivity and specificity (80.5 and 71% respectively) than other tests for the diagnosis of renal flares. All four tests had good negative predictive value (NPV). At univariate analysis anti-C1q was the best renal flare predictor (p<0.0005). At multivariate analysis, the association of anti-C1q with C3 and C4 provided the best performance (p<0.0005, p<0.005, p<0.005 respectively). Conclusions: Anti-C1q is slightly better than the other tests to confirm the clinical activity of LN, particularly in patients with proliferative LN and in the absence of APL. All four “specific” tests had a good NPV, suggesting that, in the presence of normal values of each, active LN is unlikely.

IgG4 immune response in Churg–Strauss syndrome

Objective T-helper type 2 responses are crucial in Churg–Strauss syndrome (CSS) and may enhance the production of IgG4 antibodies. The authors assessed the IgG4 immune response in CSS patients. Methods The authors included 46 consecutive patients with CSS (24 with active and 22 with quiescent disease), 26 with granulomatosis with polyangiitis (GPA, Wegeners), 25 with atopic asthma and 20 healthy controls and determined serum IgG, IgM, IgA, IgE and IgG subclass levels. Tissue infiltration by IgG4 plasma cells was assessed in nine patients with CSS, 10 with GPA, 22 with chronic sinusitis (11 with and 11 without eosinophilia). Results IgG4 levels were markedly higher in active CSS patients than in controls (p<0.001 vs all control groups). Serum IgG4 correlated with the number of disease manifestations (r=0.52, p=0.01) and the Birmingham vasculitis activity score (r=0.64, p=0.001). Longitudinal analysis in 12 CSS cases showed that both the IgG4 level and IgG4/IgG ratio dropped during disease remission (p=3×10−5 and p=6×10−4, respectively). Tissue analysis did not show an increased IgG4 plasma cell infiltration in CSS biopsies compared with control groups. Conclusions Serum IgG4 levels are markedly elevated in active CSS and correlate with the number of organ manifestations and disease activity.

Eosinophilic granulomatosis with polyangiitis (Churg–Strauss) (EGPA) Consensus Task Force recommendations for evaluation and management

OBJECTIVE To develop disease-specific recommendations for the diagnosis and management of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) (EGPA). METHODS The EGPA Consensus Task Force experts comprised 8 pulmonologists, 6 internists, 4 rheumatologists, 3 nephrologists, 1 pathologist and 1 allergist from 5 European countries and the USA. Using a modified Delphi process, a list of 40 questions was elaborated by 2 members and sent to all participants prior to the meeting. Concurrently, an extensive literature search was undertaken with publications assigned with a level of evidence according to accepted criteria. Drafts of the recommendations were circulated for review to all members until final consensus was reached. RESULTS Twenty-two recommendations concerning the diagnosis, initial evaluation, treatment and monitoring of EGPA patients were established. The relevant published information on EGPA, antineutrophil-cytoplasm antibody-associated vasculitides, hypereosinophilic syndromes and eosinophilic asthma supporting these recommendations was also reviewed. DISCUSSION These recommendations aim to give physicians tools for effective and individual management of EGPA patients, and to provide guidance for further targeted research.

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.