Maxime Vignac1, Dorian Nezam2, François Grolleau3, Pauline Morel4, Dimitri Titeca-Beauport5, Stanislas Faguer6, alexandre Karras7, Justine Solignac8, Noémie Jourde-Chiche9, Francois Maurier10, Hamza Sakhi1, Khalil El Karoui1, Rafik Mesbah11, Pierre Louis Carron12, Vincent Audard1, Didier Ducloux13, Romain Paule14, Jean-François Augusto15, Julien Aniort16, Aurélien Tiple16, Cédric Rafat1, Xavier Puéchal17, Pierre Gobert18, Catherine Hanrotel19, Stéphane Bally20, Nihal Martis21, Cécile-Audrey Durel22, Pascal Godmer23, Aurélie Hummel24, François Perrin25, Antoine Néel26, Claire De Moreuil27, Tiphaine Goulenok28, Dominique Guerrot29, Aurelie Foucher30, Alban DEROUX12, Loic Guillevin31, Alexis REGENT32, Raphaël Porcher3 and Benjamin Terrier33, 1APHP, Paris, France, 2CH du Havre, Havre, France, 3Université Paris Cité, Paris, France, 4AURA Paris Plaisance, Paris, France, 5CHU Amiens, Amiens, France, 6CHU Toulouse, Toulouse, France, 7HEGP - APHP, Paris, France, 8APHM, Marseille, France, 9AP-HM, Marseille, France, 10Hôpitaux privés de Metz, Vaux / Frankreich, France, 11Boulogne Hospital (CH), Boulogne, France, 12CHU de Grenoble, Grenoble, France, 13CHU de Besançon, Besançon, France, 14Hôpital Foch, Paris, France, 15CHU d'Angers, Angers, France, 16CHU de Clermont Ferrand, Clermont Ferrand, France, 17National Referral Center for Rare Systemic Autoimmune Diseases, Paris, France, 18Clinique Rhône Durance, Avignon, France, 19CHU Brest, Brest, France, 20CH Métropole Savoie, Chambery, France, 21CHU de Nice, Nice, France, 22CHU Lyon, Lyon, France, 23CH Bretagne Atlantique, Vannes, France, 24CHU Necker, Paris, France, 25CH Saint Nazaire, Saint Nazaire, France, 26CHU de Nantes, Nantes, France, 27CHU de Brest, Brest, France, 28Assistance Publique Hopitaux de Paris, Paris, France, 29CHU Rouen, Rouen, France, 30CHU de la Réunion, Saint pierre, France, 31University Paris Descartes, Paris, France, 32CHU Cochin, Université Paris Cité, Paris, France, 33Department of Internal Medicine, Hôpital Cochin, AP-HP, Paris, France
Background/Purpose: Renal involvement in ANCA-associated vasculitides (AAV) is an organ- and life-threatening manifestation and therefore an important prognostic factor. However, the identification of predictive factors for renal failure remains a major challenge. Indeed, it may influence the intensity of induction treatment strategies. Furthermore, the benefit of plasma exchange (PLEX) has been questioned in recent years. The aim of this study is to describe the clinical outcome of patients requiring renal replacement therapy (RRT) at baseline and to identify clinical, biological and histological factors at baseline associated with their prognosis at one year.
Methods: This retrospective multicentre study included patients with anti-myeloperoxidase or proteinase 3 AAV with biopsy-proven renal involvement. Characteristics were evaluated stratified by dialysis requirement at baseline to identify determinants of renal prognosis. The primary composite outcome was the occurrence of death or end-stage renal disease at one year. Prognostic outcomes were modelized by generalized linear models to quantify the impact of predictors.
Results: Of the 395 patients enrolled, 106 (26.8%) were on dialysis at baseline. The mean age was 63.1±13.6 years and age was not associated with RRT at baseline (p=0.521). PR3-ANCA was associated to a greater prevalence of renal failure.
Among patients with dialysis at baseline, 61 (57.5%) achieved the one-year composite outcome of death or end-stage kidney disease (ESKD), whereas only 29 (10.0%) patients RRT-free at baseline reached the outcome at one year (p< 0,001). Thirty (28.3%) patients with RRT at baseline had an eGFR at one year superior to 30 mL/min/1,73m², with a null median of eGFR recuperation at one year (0,00 [IQR 0.00-31.5 mL/min/1,73m²]).
Among patients requiring dialysis at baseline, age at diagnosis was not associated with the composite outcome at one year in multivariate analysis (p=0.744). MPO-ANCA were associated with a higher prevalence of RRT or death at one year (OR 3,08; 95%CI 1.21–8.14; p = 0.02). In addition, Brix score at baseline was associated with worse renal prognosis at one year (OR 1.40; 95%CI 1.16–1.73; p=0.001).
Of the patients requiring dialysis at baseline, 80 (75.5%) underwent PLEX. Plasma exchanges were independently associated with a higher estimated glomerular filtration rate (eGFR) at one year of 9.15 mL/min/1.73m² [95%CI 0.26-18.04] (p=0.044). In addition, 41 (91.1%) of the surviving patients who were weaned from RRT at one year had received PLEX, whereas only 39 (63.9%) of the patients with the composite outcome (death or RRT at one year) had received PLEX (p=0.003). Thus, PLEX was associated with a reduced risk of one-year RRT or death in patients receiving dialysis at baseline (OR 0.24, 95%CI 0.06-0.82).
Conclusion: This study describes the clinical evolution of patients with AAV requiring RRT at baseline. It shows a strong association between plasma exchange and improvement in renal function with a higher rate of dialysis weaning. It opens perspectives for further studies in patients who benefit more from PLEX therapy.
M. Vignac: None; D. Nezam: None; F. Grolleau: None; P. Morel: None; D. Titeca-Beauport: None; S. Faguer: None; a. Karras: AstraZeneca, 6, GlaxoSmithKlein(GSK), 4, Novartis, 2, Pfizer, 6; J. Solignac: None; N. Jourde-Chiche: None; F. Maurier: None; H. Sakhi: None; K. El Karoui: None; R. Mesbah: None; P. Carron: None; V. Audard: None; D. Ducloux: None; R. Paule: None; J. Augusto: None; J. Aniort: None; A. Tiple: None; C. Rafat: None; X. Puéchal: None; P. Gobert: None; C. Hanrotel: None; S. Bally: None; N. Martis: None; C. Durel: None; P. Godmer: None; A. Hummel: None; F. Perrin: None; A. Néel: None; C. De Moreuil: None; T. Goulenok: None; D. Guerrot: None; A. Foucher: None; A. DEROUX: None; L. Guillevin: None; A. REGENT: None; R. Porcher: None; B. Terrier: AstraZeneca, 5, CSL Vifor, 2, GlaxoSmithKlein(GSK), 2.
