Vasculitis and rapidly progressive glomerulonephritis in the elderly

Abstract

SummaryThe proportion of patients with vasculitis and rapidly progressive nephritis aged 70 years or over has risen from about 10% in the 1980s to over 30% in series reported in the 1990s. This study was undertaken to examine the presentation and outcome of such older patients. Seventeen of 56 patients (30%) who presented at two renal units were aged 70 years or over. Mean creatinine level at presentation was 530 ytmol/l, and five patients received dialysis at presentation. Outcome was dependent on three factors, namely comorbid pathology, response to immunosuppressive therapy, and the occurrence in three cases of temporary spontaneous partial remission. Overall patient survival at one and two years was 62.5% and 50%, respectively, and 90% and 100% of surviving patients were independent of dialysis at one and two years, respectively. Response to chemotherapy was excellent, with full rehabilitation in many cases and no deaths directly attributable to adverse effects of immunosuppressive therapy. We conclude that diagnosis ofvasculitis and rapidly progressive glomerulonephritis by renal biopsy and the subsequent administration of chemotherapy (including cyclophosphamide in many cases) resulted in a worthwhile benefit in these elderly patients.

Treatment of Systemic Necrotizing Vasculitides in Patients Aged Sixty‐Five Years or Older: Results of a Multicenter, Open‐Label, Randomized Controlled Trial of Corticosteroid and Cyclophosphamide–Based Induction Therapy

“…A previous retrospective study by our group showed that patients aged 65 years or older who were diagnosed as having systemic necrotizing vasculitis (SNV; polyarteritis nodosa [PAN], granulomatosis with polyangiitis [Wegener's] [GPA], microscopic polyangiitis [MPA], or eosinophilic GPA [Churg‐Strauss] [EGPA]) had poorer outcomes than their younger counterparts, mainly because they developed more frequent and/or serious adverse events (SAEs; 68% versus 13%) while receiving conventional therapy . Several other groups have reported similar findings . Therefore, it is a common recommendation or practice to diminish, by up to one‐third, the dose of the most potent induction immunosuppressant, e.g., cyclophosphamide (CYC), for patients aged 65 years or older .…”

Vasculitis in the Very Elderly

“…As already reported in old people [2,[4][5][6][7], steroid and immunosuppressive treatments were effective in VS manifestations, but these treatments did not seem to influence the overall poor prognosis. The chosen therapy was adapted to each patient's status and was not directly the cause of death.…”

“…Published studies report a mortality rate of between 40 and 60% at 1-to 7-year follow-up in the elderly [2][3][4][5]. The main reported causes of death are complications due to infections and respiratory failure.…”

“…Three studies concerning Wegener's granulomatosis (WG) have reported a total of 56 patients over 60 years old [2][3][4]. Other authors have mentioned 43 subjects older than 70 years, from a total of 218 having a VS with glomerulonephritis [5]. For VS in very old patients, observations have concerned mainly small series: 3 cases of pulmonary fibrosis associated with WG in patients aged from 71 to 74 years [6]; 3 antineutrophil cytoplasmic antibody (ANCA) related VS in subjects Infl none ANA = Antinuclear antibody; Art = arthritis; Asc = ascites; Ast = asthma; cANCA = perinuclear antineutrophil cytoplasmic antibody; CE = cholesterol emboli; CIA = cerebral ischemic attack; CS = Churg-Strauss disease; Eos = eosinophilia; Fat = fatigue; Fv = fever; HF = heart failure; HyT = hypertension; Infl = inflammation; IV = infectious vasculitis; LC = lung cancer; Ly = lymphoma; MPA = micropolyangiitis; Ost = osteitis; PAN = polyarteritis nodosa; pANCA = cytoplasmic-antineutrophil cytoplasmic antibody; Ped = pulmonary edema; PG = pyoderma gangrenosum; PInf = pulmonary infiltrates; Pn = polyneuritis; PNV = paraneoplastic vasculitis; Prost = prostatitis; Ptub = peritoneal tuberculosis; Pur = purpura; RA = rheumatoid arthritis; RAS = renal artery stenosis; ReI = renal involvement; RF = rheumatoid factor; SU = skin ulcers; Urt = urticaria; WL = weight loss.…”

Plasma Exchange Therapy to Reduce Mortality in Japanese Patients With Diffuse Alveolar Hemorrhage and Microscopic Polyangiitis

“…However, only 22% of patients with MPA who were registered in the Japanese Ministry of Health, Labour and Welfare of Japan database from 2006 to 2008 were treated with cyclophosphamide combined with corticosteroids . Previous reports have described avoiding the serious adverse events of immunosuppressants in the elderly AAV patients, and MPA patients were older than other AAV patients . However, the lower rate of using immunosuppressants may cause the high mortality.…”