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      Intravenous pulse methylprednisolone for induction of remission in severe ANCA associated Vasculitis: a multi-center retrospective cohort study

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          Abstract

          Background

          Intravenous pulse methylprednisolone (MP) is commonly included in the management of severe ANCA associated vasculitis (AAV) despite limited evidence of benefit. We aimed to evaluate outcomes in patients who had, or had not received MP, along with standard therapy for remission induction in severe AAV.

          Methods

          We retrospectively studied 114 consecutive patients from five centres in Europe and the United States with a new diagnosis of severe AAV (creatinine > 500 μmol/L or dialysis dependency) and that received standard therapy (plasma exchange, cyclophosphamide and high-dose oral corticosteroids) for remission induction with or without pulse MP between 2000 and 2013. We evaluated survival, renal recovery, relapses, and adverse events over the first 12 months.

          Results

          Fifty-two patients received pulse MP in addition to standard therapy compared to 62 patients that did not. There was no difference in survival, renal recovery or relapses. Treatment with MP associated with higher risk of infection during the first 3 months (hazard ratio (HR) 2.7, 95%CI [1.4–5.3], p = 0.004) and higher incidence of diabetes (HR 6.33 [1.94–20.63], p = 0.002), after adjustment for confounding factors.

          Conclusions

          The results of this study suggest that addition of pulse intravenous MP to standard therapy for remission induction in severe AAV may not confer clinical benefit and may be associated with more episodes of infection and higher incidence of diabetes.

          Electronic supplementary material

          The online version of this article (10.1186/s12882-019-1226-0) contains supplementary material, which is available to authorized users.

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          Most cited references28

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          Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis.

          David Jayne, Gill Gaskin, Niels Rasmussen … (2007)
          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.
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            Long-term patient survival in ANCA-associated vasculitis.

            Caroline Heijl, Raashid Luqmani, Charles D. Pusey … (2011)
            Wegener's 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. 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. 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. 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. Patients with ANCA-associated vasculitis treated with conventional regimens are at increased risk of death compared with an age- and sex-matched population.
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              Early mortality in systemic vasculitis: relative contribution of adverse events and active vasculitis.

              David Jayne, , Caroline Savage … (2010)
              To contrast the effect of the burden of vasculitis activity with the burden of adverse events on 1-year mortality of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). This study assessed the outcome and adverse events in patients prospectively recruited to four European AAV clinical trials. Data on 524 patients with newly diagnosed AAV were included. The burden of adverse events was quantified using a severity score for leucopenia, infection and other adverse events, with an additional weighting for follow-up duration. A 'combined burden of events' (CBOE) score was generated for each patient by summing the individual scores. Vasculitis severity was quantified using the Birmingham vasculitis activity score and glomerular filtration rate (GFR). 1-year mortality probability was 11.1%; 59% and 14% of deaths were caused by therapy-associated adverse events and active vasculitis, respectively. Using Cox regression analysis, infection score (p<0.001), adverse event score (p<0.001), leucopenia score (p<0.001) and GFR (p=0.002) were independently associated with mortality. The risk of 1-year mortality remained low (5%) with CBOE scores less than 7, but increased dramatically with scores above this. Hazard ratio for death with a CBOE greater than 7 was 14.4 (95% CI 8.4 to 24.8). Age and GFR were independent predictors of CBOE score. The greatest threat to patients with AAV in the first year of therapy is from adverse events rather than active vasculitis. The accumulation of adverse events, monitored using this scoring method, should prompt increased awareness that the patient is at high risk of death.
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                Author and article information

                Contributors
                Dimitrios Chanouzas: d.chanouzas@bham.ac.uk
                Julie Anne G. McGregor: integrativenephrology@gmail.com
                Peter Nightingale: peter.nightingale@uhb.nhs.uk
                Alan D. Salama: a.salama@ucl.ac.uk
                Wladimir M. Szpirt: wladimir@szpirt.com
                Neil Basu: neilbasu@abdn.ac.uk
                Matthew David Morgan: m.d.morgan@bham.ac.uk
                Caroline J. Poulton: caroline_jennete@med.unc.edu
                Juliana Bordignon Draibe: jbordignon@bellvitgehospital.cat
                Elizabeth Krarup: Elizabeth.krarup@region.dk
                Paula Dospinescu: paula.dospinescu@nhs.net
                Jessica Anne Dale: jessicadale@nhs.net
                William Franklin Pendergraft: will_pendergraft@med.unc.edu
                Keegan Lee: keegan.lee.12@ucl.ac.uk
                Martin Egfjord: martin.egfjord@region.dk
                Susan L. Hogan: susan_hogan@med.unc.edu
                Lorraine Harper: 0121 371 3238 , L.Harper@bham.ac.uk , l.harper@bham.ac.uk
                Journal
                Journal ID (nlm-ta): BMC Nephrol
                Journal ID (iso-abbrev): BMC Nephrol
                Title: BMC Nephrology
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2369
                Publication date (Electronic): 18 February 2019
                Publication date PMC-release: 18 February 2019
                Publication date Collection: 2019
                Volume: 20
                Electronic Location Identifier: 58
                Affiliations
                [1 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, Institute of Clinical Sciences, University of Birmingham, ; Birmingham, UK
                [2 ]ISNI 0000 0004 0376 6589, GRID grid.412563.7, University Hospitals Birmingham NHS Foundation Trust, ; Birmingham, UK
                [3 ]ISNI 0000 0001 1034 1720, GRID grid.410711.2, University of North Carolina Kidney Center, ; Chapel Hill, North Carolina USA
                [4 ]ISNI 0000000121901201, GRID grid.83440.3b, Centre for Nephrology, University College London, ; London, UK
                [5 ]ISNI 0000 0004 0646 7373, GRID grid.4973.9, Copenhagen University Hospital, ; Copenhagen, Denmark
                [6 ]ISNI 0000 0001 2193 314X, GRID grid.8756.c, Institute of Infection, Immunity and Inflammation, University of Glasgow, ; Glasgow, UK
                Article
                Publisher ID: 1226
                DOI: 10.1186/s12882-019-1226-0
                PMC ID: 6378728
                PubMed ID: 30777023
                SO-VID: 3abb2185-0397-4b76-9d63-13cc9311d772
                Copyright © © The Author(s). 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 17 October 2017
                Date accepted : 23 January 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 097962/Z/11/Z
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100000062, National Institute of Diabetes and Digestive and Kidney Diseases;
                Award ID: P01DK058335
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                ScienceOpen disciplines: Nephrology
                Keywords: anca,vasculitis,methylprednisolone,infection,diabetes mellitus
                Data availability:
                ScienceOpen disciplines: Nephrology
                Keywords: anca, vasculitis, methylprednisolone, infection, diabetes mellitus

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