Chances of Renal Recovery for Dialysis-Dependent ANCA-Associated Glomerulonephritis

Wijngaarden, Robert A.F. de Lind van; Hauer, Herbert A.; Wolterbeek, Ron; Jayne, David; Gaskin, G.; Rasmussen, Niels; Nôël, Laure-Hélène; Ferrario, Franco; Waldherr, Rüdiger; Bruijn, Jan A.; Bajema, Ingeborg M.; Hagen, E. Christiaan

doi:10.1681/asn.2007010066

Cited by 112 publications

(54 citation statements)

References 27 publications

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“…The effect of cyclophosphamide therapy on patient survival agrees with the results of earlier studies (4,19,24,25) and emphasizes the importance of assertive immunosuppression in the setting of severe renal failure even on dialysis. Treatment response within 4 months was also the only variable associated with long-term renal survival retained by multivariate analysis after correcting for baseline eGFR, histopathologic chronicity index score, percentage of normal glomeruli, and treatment with cyclophosphamide.…”

Section: Discussionsupporting

confidence: 86%

“…In the absence of extrarenal active vasculitis, we therefore suggest that treatment with cyclophosphamide should be discontinued after 4 months if dialysis independence is not attained by that time. The previous study of histologic prognostic factors based on 68 dialysis-dependent patients had similarly identified the extent of tubular atrophy and glomerular injury as important prognostic indicators of poor renal outcome (24). In that study, investigators estimated that in patients treated with plasma exchange, the risk of death exceeded the likelihood of renal recovery only in patients with the most extensive glomerular lesions (#2% normal glomeruli).…”

Section: Discussionmentioning

confidence: 99%

“…The renal biopsy specimens of 153 patients were reviewed. The median number of glomeruli examined per biopsy specimen was 16 (IQR, [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. The pattern of glomerular injury according to the EUVAS schema was categorized as sclerotic in 32% of cases, focal in 6%, crescentic in 43%, and mixed class in 6%.…”

Section: Cohort Description and Outcomesmentioning

confidence: 99%

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Predictors of Treatment Outcomes in ANCA-Associated Vasculitis with Severe Kidney Failure

Lee

Gasim

Derebail³

et al. 2014

Clinical Journal of the American Society of Nephrology

128

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Background and objectives In ANCA-associated GN, severe renal dysfunction portends a poor prognosis for renal recovery and patient survival. This study evaluated the prognostic factors affecting renal and patient outcomes in patients presenting with severe kidney failure to guide immunosuppressive therapy.Design, setting, participants, & measurements This study retrospectively evaluated clinical and histopathologic characteristics of 155 patients who underwent biopsy between October 1985 and February 2011 (median eGFR at presentation, 7.1 ml/min per 1.73 m 2 ; 87% required hemodialysis), all treated with immunosuppressive medications. Three outcomes of interest were measured: patient survival, renal survival, and treatment response (defined as dialysis-free survival without active vasculitis by 4 months after biopsy). Competing risk, Cox, and logistic regression analyses were conducted for each outcome measure.Results Within 4 months after biopsy, treatment response was attained in 51% of patients, 35% remained on dialysis, and 14% died. In a competing risk analysis, estimated cumulative incidence rates of ESRD and diseaserelated mortality were 26% and 17% at 1 year and 32% and 28% at 5 years, respectively. Cyclophosphamide therapy and treatment response by 4 months were independently associated with patient and renal survival, adjusting for the percentage of normal glomeruli, histopathologic chronicity index score, and baseline clinical characteristics. Only 5% of patients still dialysis dependent at 4 months subsequently recovered renal function. Low chronicity index score (odds ratio [OR], 1.16; 95% confidence interval [95% CI], 1.04 to 1.30, per unit decrease) and baseline eGFR.10 ml/min per 1.73 m 2 (OR, 2.77; 95% CI, 1.09 to 7.01) were significantly associated with treatment response by 4 months. Among cyclophosphamide-treated patients, the likelihood of treatment response was .14% even with highest chronicity index score and eGFR,10 ml/min per 1.73 m 2 .Conclusions Although low baseline renal function and severe renal scarring are associated with lower treatment response rate, no "futility" threshold could be identified. Conversely, continued immunosuppressive therapy beyond 4 months is unlikely to benefit patients who remain dialysis dependent.Clin J Am Soc Nephrol 9: 905-913, 2014.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 99%

Section: Cohort Description and Outcomesmentioning

confidence: 99%

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Predictors of Treatment Outcomes in ANCA-Associated Vasculitis with Severe Kidney Failure

Lee

Gasim

Derebail³

et al. 2014

Clinical Journal of the American Society of Nephrology

128

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“…However, of the renal biopsies available for analysis, more patients who remained dialysis dependent had a significant degree of tubular atrophy than those patients who regained dialysis independence, whereas no difference in glomerulosclerosis was found, unlike previous analysis of MEPEX samples (13). Return to hemodialysis occurred in four patients in our cohort by 265 days, with no further patients progressing to ESRD after this period of time, whereas in the MEPEX cohort, only three patients returned to dialysis at 250, 1686, and 2008 days.…”

Section: Discussionmentioning

confidence: 58%

Intravenous Cyclophosphamide and Plasmapheresis in Dialysis-Dependent ANCA-Associated Vasculitis

Pepper

Chanouzas

Tarzi

et al. 2013

Clinical Journal of the American Society of Nephrology

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Study (EUVAS) investigators SummaryBackground and objectives Induction therapy with oral cyclophosphamide (CYP) has been a mainstay of treatment in patients with severe renal failure secondary to ANCA-associated vasculitis (AAV). Recent evidence proposes using pulsed intravenous CYP in less severe disease to minimize adverse events. It is unclear if this can be translated to those with dialysis-dependent renal insufficiency.Design, setting, participants, & methods All AAV patients presenting between 2005 and 2010 requiring dialysis at presentation were retrospectively analyzed. Patients were treated with plasma exchange, corticosteroids, and intravenous CYP. Rate of dialysis independence at 3 and 12 months and adverse effects were assessed and compared with the outcome of the plasmapheresis, prednisolone, and oral CYP arm of the randomized MEPEX (methylprednisolone versus plasma exchange) trial.Results Forty-one patients were included. At 3 months, 3 (7.3%) patients had died on dialysis, 12 (29.3%) remained dialysis dependent, and 26 (63.4%) were dialysis independent (creatinine, 2.5 mg/dl; GFR, 26 ml/min per 1.73 m 2 ). Four patients subsequently reached ESRD at a median time of 83 days. Thirty-seven (90%) patients reached 1 year follow-up, 13 (35%) remained dialysis dependent, and 24 (65%) had independent renal function. Eleven patients (27%) had episodes of leukopenia (white cell count ,4310 9 /L) during CYP therapy and 17 (41%) experienced infectious complications. This compares favorably with the dialysis-dependent cohort treated with plasmapheresis in the MEPEX study in which 51% were alive with independent renal function at 1 year.Conclusions Intravenous CYP used with corticosteroids and plasmapheresis may be an effective alternative to oral CYP in patients with dialysis-dependent AAV.

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“…In this issue of JASN, this same group of investigators, in a second study, extended their work in determining the rate of renal recovery. 17 In 69 dialysis-dependent patients who were part of the plasmapheresis trial, plasma exchange was superior to pulse methylprednisolone with respect to the chance of coming off dialysis. The outcome measure depended on the relative number of normal glomeruli.…”

Section: Removing Antibody and Preserving Glomeruli In Anca Small-vesmentioning

confidence: 99%

Removing Antibody and Preserving Glomeruli in ANCA Small-Vessel Vasculitis

Lionaki

Falk

2007

Journal of the American Society of Nephrology

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Welcome to the new JASN. This is the launch issue for a new editorial team, and all of us are honored to edit the finest kidney journal in the world. We accepted this exciting opportunity knowing Bill Couser and his associate editors have done a remarkable job in advancing the quality and substance of your journal during the past several years. We are grateful for their past leadership and recent guidance through our transition. They have left us big shoes to fill.Going forward, JASN is committed to publishing the very best work in renal science and clinical nephrology. Everything that we take for granted in kidney medicine today had its start somewhere in the laboratory, and as our science grows, so does the clinical success of the subspecialty. We instinctively believe this dynamic is an important value to preserve in the pages of your journal.JASN has built such a fine reputation that it now receives far more submissions than it can publish. This is both good and bad. At a final acceptance rate of less than 20%, we are able to offer really outstanding original contributions to our readers. Unfortunately, this also means the journal is unable to publish much of the great work coming from other laboratory and clinical investigators. The growing numbers of submissions also increases the pressure on our reviewers, and we must therefore return a larger fraction of our submissions without formal review, while at the same time working to expand our reviewer pool (you can help us by updating your keywords at the JASN submission site). We truly regret these difficulties.In planning our launch, we have added many new features to JASN to appeal to an ever-expanding readership. The journal has been redesigned inside and out, in print and online, which we hope will make the journal more appealing to browse and use. The cover has been updated, and we invite all members to submit interesting pictures as potential cover candidates. You can do this by going to the JASN submission site, choosing COVER as your manuscript type, and uploading your kidney-related image and figure legend. We hope that this collection of classic pictures will vividly represent the art in renal medicine.By shortening the page length of our articles, we will be able to publish a variety of new features in the front section of the journal. These include Brief Reviews, Occasional Observations, JASN Debates, Science in Renal Medicine, Pathophysiology of the Renal Biopsy, Clinical Commentaries, and Editorials. The Original Contributions section is divided into Basic Research, Clinical Epidemiology, and Clinical Research. These will feature the very best of both Regular Articles and Brief Communications, the latter in a new letter format.

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Chances of Renal Recovery for Dialysis-Dependent ANCA-Associated Glomerulonephritis

Cited by 112 publications

References 27 publications

Predictors of Treatment Outcomes in ANCA-Associated Vasculitis with Severe Kidney Failure

Predictors of Treatment Outcomes in ANCA-Associated Vasculitis with Severe Kidney Failure

Intravenous Cyclophosphamide and Plasmapheresis in Dialysis-Dependent ANCA-Associated Vasculitis

Removing Antibody and Preserving Glomeruli in ANCA Small-Vessel Vasculitis

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