Assistance Publique-Hôpitaux de Marseille, University hospital de la Conception, Department of Nephrology, Marseille, France.
Aix-Marseille Univ, Center for Cardio-Vascular and Nutrition research, Institut National de la Santé et de la Recherche Médicale, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Marseille, France.
Clin J Am Soc Nephrol. 2021 Nov;16(11):1665-1675. doi: 10.2215/CJN.03190321.
Kidney impairment of ANCA-associated vasculitides can lead to kidney failure. Patients with kidney failure may suffer from vasculitis relapses but are also at high risk of infections and cardiovascular events, which questions the maintenance of immunosuppressive therapy.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients with ANCA-associated vasculitides initiating long-term dialysis between 2008 and 2012 in France registered in the national Renal Epidemiology and Information Network registry and paired with the National Health System database were included. We analyzed the proportion of patients in remission off immunosuppression over time and overall and event-free survival on dialysis (considering transplantation as a competing risk). We compared the incidence of vasculitis relapses, serious infections, cardiovascular events, and cancers before and after dialysis initiation.
In total, 229 patients were included: 142 with granulomatous polyangiitis and 87 with microscopic polyangiitis. Mean follow-up after dialysis initiation was 4.6±2.7 years; 82 patients received a kidney transplant. The proportion of patients in remission off immunosuppression increased from 23% at dialysis initiation to 62% after 5 years. Overall survival rates on dialysis were 86%, 69%, and 62% at 1, 3, and 5 years, respectively. Main causes of death were infections (35%) and cardiovascular events (26%) but not vasculitis flares (6%). The incidence of vasculitis relapses decreased from 57 to seven episodes per 100 person-years before and after dialysis initiation (=0.05). Overall, during follow-up, 45% of patients experienced a serious infection and 45% had a cardiovascular event, whereas 13% experienced a vasculitis relapse.
The proportion of patients with ANCA-associated vasculitis in remission off immunosuppression increases with time spent on dialysis. In this cohort, patients were far less likely to relapse from their vasculitis than to display serious infectious or cardiovascular events.
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_11_08_CJN03190321.mp3.
抗中性粒细胞胞浆抗体相关性血管炎导致的肾脏损伤可引起肾衰竭。肾衰竭患者可能会出现血管炎复发，但也面临着较高的感染和心血管事件风险，这使得免疫抑制治疗的维持受到质疑。
设计、设置、参与者和测量：纳入了 2008 年至 2012 年期间在法国接受长期透析治疗并登记在全国肾脏流行病学和信息网络登记处的抗中性粒细胞胞浆抗体相关性血管炎患者，并与国家卫生系统数据库相匹配。我们分析了随着时间推移免疫抑制治疗停药缓解的患者比例以及透析时的总生存率和无事件生存率（将移植视为竞争风险）。我们比较了透析前后血管炎复发、严重感染、心血管事件和癌症的发生率。
共纳入 229 例患者：142 例为肉芽肿性多血管炎，87 例为显微镜下多血管炎。透析开始后平均随访时间为 4.6±2.7 年；82 例患者接受了肾脏移植。免疫抑制治疗停药缓解的患者比例从透析开始时的 23%增加到 5 年后的 62%。透析时的总生存率分别为 1 年时 86%、3 年时 69%和 5 年时 62%。死亡的主要原因是感染（35%）和心血管事件（26%），而非血管炎复发（6%）。透析前后血管炎复发的发生率从 57 例降至 7 例/100 人年（=0.05）。总体而言，在随访期间，45%的患者发生严重感染，45%的患者发生心血管事件，而 13%的患者发生血管炎复发。
随着透析时间的延长，抗中性粒细胞胞浆抗体相关性血管炎患者免疫抑制治疗停药缓解的比例增加。在本队列中，患者发生血管炎复发的可能性远低于发生严重感染或心血管事件的可能性。
