Glucocorticoid-free treatment of severe ANCA-associated vasculitis

Farrah, Tariq E.; Prendecki, Maria; Hunter, Robert W.; Lahiri, Rashmi; Cairns, Thomas; Pusey, Charles D.; McAdoo, Stephen P.; Dhaun, Neeraj

doi:10.1093/ndt/gfaa310

Cited by 8 publications

(8 citation statements)

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“…12,13,20,27 Given the vogue towards glucocorticoid-limiting, and altogether avoiding, treatment regimens, and with a shift towards more personalized medicine, the need for better strategies to confirm disease remission at the histological level is increasingly important. [8][9][10] Our data support the role of interval kidney biopsy in AAV on an individual patient basis to assess disease activity.…”

Section: Discussionsupporting

confidence: 71%

“…Other commonly used measures such as hematuria, circulating C-reactive protein (CRP) and serum ANCA titre lack specificity and sensitivity and do not adequately reflect disease activity. 6,7 Recent data suggest that glucocorticoid-sparing, 8,9 or indeed glucocorticoid-free, 10 regimens are able to treat AAV effectively whilst reducing treatment-related complications.…”

Section: Discussionmentioning

confidence: 99%

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Utility of interval kidney biopsy in ANCA-associated vasculitis

et al. 2021

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Objectives Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) is a rare autoimmune disorder that commonly involves the kidney. Early identification of kidney involvement, assessing treatment-response and predicting outcome are important clinical challenges. Here, we assessed the potential utility of interval kidney biopsy in AAV. Methods In a tertiary referral centre with a dedicated vasculitis service, we identified patients with AAV who had undergone interval kidney biopsy, defined as a repeat kidney biopsy (following an initial biopsy showing active AAV) undertaken to determine the histological response in the kidney following induction immunosuppression. We analysed biochemical, histological and outcome data, including times to kidney failure and death for all patients. Results We identified 57 patients with AAV who underwent at least one interval kidney biopsy (59 interval biopsies in total; median time to interval biopsy ∼130 days). Of the 59 interval biopsies performed, 24 (41%) patients had clinically suspected active disease at time of biopsy which was confirmed histologically in only 42% of cases; 35 (59%) patients were in clinical disease-remission, and this was correct in 97% of cases. The clinician’s impression was incorrect in 1 in 4 patients. Hematuria at interval biopsy did not correlate with histological activity. Interval biopsy showed fewer acute lesions and more chronic damage compared to initial biopsy and led to immunosuppressive treatment-change in 75% (44/59) of patients. Clinical risk prediction tools tended to operate better using interval biopsy data. Conclusion Interval kidney biopsy is useful for determining treatment-response and subsequent disease management in AAV. It may provide better prognostic information than initial kidney biopsy and should be considered for inclusion into future clinical trials and treatment protocols for patients with AAV.

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Utility of interval kidney biopsy in ANCA-associated vasculitis

et al. 2021

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“…In AAV, steroid-light and steroid-free regimens are beginning to be used with some success ( 134 , 146 ). Use of the targeted complement 5a inhibitor Avacopan offers promise as a GC substitute in AAV but more work is required ( 147 ).…”

Section: Bone Preserving Treatments In Vasculitis: the Role Of Steroi...mentioning

confidence: 99%

The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides

2022

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Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.

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“…This should be the focus of future studies in this space. Indeed, complete GC avoidance may be possible, 15 although at present may risk inadequate disease control (and the accrual of organ damage related to this and future treatment escalation), an increased risk of future relapse, and the potential for unchecked smouldering, subclinical inflammation to increase the longer-term risks of cardiovascular and thrombotic complications.…”

Section: Gcs During Remission-maintenancementioning

confidence: 99%