Treatment Outcomes of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis in Patients Over Age 75 Years: A Meta-Analysis

Abstract

Background: The benefits of treating anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) in advancing age remains unclear with most published studies defining elderly as ≥65 years. This study aims to determine outcomes of induction immunosuppression in patients aged ≥75 years. Methods: A cohort of patients aged ≥75 years with a diagnosis of AAV between 2006 and 2018 was constructed from 2 centres. Follow-up was to 2 years or death. Analysis included multivariable Cox regression to compare mortality and end-stage renal disease (ESRD) based on receipt of induction immunosuppression therapy with either cyclophosphamide or rituximab. A systematic review of outcome studies was subsequently undertaken amongst this patient group through Pubmed, Cochrane and Embase databases from inception until October 16, 2019. Results: Sixty-seven patients were identified. Mean age was 79 ± 2.9 years and 82% (n = 55) received induction immunosuppression. Following systematic review, 4 studies were eligible for inclusion, yielding a combined total of 290 patients inclusive of our cohort. The aggregated 1-year mortality irrespective of treatment was 31% (95% CI 25–36%). Within our cohort, induction immunosuppression therapy was associated with a significantly lower 2-year mortality risk (hazard ratio [HR] 0.29 [95% CI 0.09–0.93]). The pooled HR by meta-analysis confirmed this with a significant risk reduction for death (HR 0.31 [95% CI 0.16–0.57], I2 = 0%). Treated patients had a lower pooled rate of ESRD, but was not statistically significant (HR 0.71 [95% CI 0.15–3.35]). Conclusion: This meta-analysis suggests that patients ≥75 years with AAV do benefit from induction immunosuppression with a significant survival benefit. Age alone should not be a limiting factor when considering treatment.

Application of biological agents in the treatment of anti-neutrophil cytoplasmic antibody-associated vasculitis

“…For specific patient populations, the KDIGO guidelines (, 2024) suggest that the use of RTX is superior to CYC for induction therapy in frail elderly patients, although the specific evidence remains unclear. Meta-analyses ( Morris et al, 2020 ) have shown that in patients with AAV aged 75 and older, the use of CYC or RTX for induction therapy is significantly associated with a lower risk of 2-year mortality. Another multicenter retrospective survival analysis ( Aqeel et al, 2023 ) indicates that CYC, CYC + RTX, and RTX alone are equally effective in inducing remission in AAV patients over the age of 60.…”

Prescribing Immunosuppressive Treatment for Older People with Glomerular Diseases: Time to Assess Frailty?

“…A recent meta-analysis demonstrated that older adults with AAV had better survival when receiving induction immunosuppression. 21 Recent research has delineated a less toxic but equally effective rituximab-based and steroid-reduced (or steroid-free) treatment regimen [22][23][24][25] that could be an effective way of maintaining disease-modifying treatment while mitigating steroid-associated adverse events.…”

Diagnose und Therapie der Granulomatose mit Polyangiitis und mikroskopische Polyangiitis – 2023: Konsens-Empfehlungen der Österreichischen Gesellschaften für Nephrologie (ÖGN) & Rheumatologie (ÖGR)

“…Bei älteren Patient*innen wurde ein signifikanter Überlebensnutzen bei denjenigen festgestellt, die eine Induktionstherapie erhielten [ 48 ]. Die Intensität der Therapie ist jedoch auf den Gesundheitszustand jeder Person anzupassen.…”