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Glucocorticoid Dosing and Outcomes in ANCA-Associated Vasculitis With Kidney Involvement
Maria Salman1, Mark Canney2,3, Ana Maria Naidas3
1Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Introduction:
There may be reservations about the guideline-recommended use of reduced glucocorticoid (GC) therapy in severe ANCA-associated vasculitis (AAV). We examined differences in outcomes based on oral GC use during induction therapy for AAV with kidney involvement.
Methods:
We conducted a single-center, retrospective cohort study (2010-2023) of patients with biopsy-proven kidney involvement from AAV. Patients were divided into eras 2020 onward (reduced-GC) versus pre-2020 (standard-GC) according to practice shift after adopting a reduced-GC regimen. The primary outcome was the composite of end-stage kidney disease (ESKD) or death within 12 months postbiopsy. Secondary outcomes included serious infection, clinical remission, and change in estimated glomerular filtration rate (eGFR).
Results:
There were 138 participants (mean age: 65.2 years, 46.4% female, 68.1% anti-myeloperoxidase), comprising 41 in the reduced-GC era and 97in the standard-GC era. The former group was older (70.3 vs 63.1 years) and had worse baseline kidney function (eGFR: 15.6 vs 22.6 ml/min). The reduction of cumulative GC for reduced-GC compared with the standard-GC era was 39% in the first month, 28% in the first 3 months, and 34% in the first 6 months. For reduced-GC compared with standard-GC era, there was no significant difference in ESKD or death (24.4% vs. 21.6%), serious infection (14.6% vs. 17.5%), or remission (63.4% vs. 63.9%); and both groups showed similar improvement in eGFR over 12 months.
Conclusion:
Reduced-GC during induction therapy in individuals with organ-threatening kidney involvement was not associated with a change in outcomes or kidney function recovery. This supports data from a large, randomized trial.
Insights
Reduced glucocorticoid (GC) therapy for severe ANCA-associated vasculitis (AAV) with kidney involvement did not alter outcomes. This approach showed no significant difference in end-stage kidney disease, death, infection, or remission rates compared to standard GC use.
Area of Science:
- Nephrology
- Rheumatology
- Immunology
Background:
- Severe ANCA-associated vasculitis (AAV) with kidney involvement often requires immunosuppressive therapy, including glucocorticoids (GCs).
- Guidelines recommend reduced GC doses to minimize toxicity, but clinical evidence for this approach in severe AAV with kidney disease is debated.
- Understanding the impact of reduced GC therapy on key outcomes is crucial for optimizing patient management.
Purpose of the Study:
- To compare outcomes in patients with biopsy-proven kidney involvement from AAV treated with reduced-GC versus standard-GC induction therapy.
- To evaluate the effect of reduced GC use on kidney function recovery, disease remission, and serious infections.
Main Methods:
- A single-center, retrospective cohort study of 138 patients with biopsy-proven AAV and kidney involvement (2010-2023).
- Patients were categorized into two eras: pre-2020 (standard-GC) and 2020 onward (reduced-GC) based on a practice shift.
- Primary outcome: composite of end-stage kidney disease (ESKD) or death within 12 months. Secondary outcomes: serious infection, remission, and change in estimated glomerular filtration rate (eGFR).
Main Results:
- The reduced-GC group (n=41) was older and had worse baseline kidney function compared to the standard-GC group (n=97).
- Cumulative GC reduction was 39% at 1 month, 28% at 3 months, and 34% at 6 months in the reduced-GC era.
- No significant differences were observed in ESKD or death (24.4% vs. 21.6%), serious infection (14.6% vs. 17.5%), or remission (63.4% vs. 63.9%) between the groups.
Conclusions:
- Reduced-GC induction therapy in AAV with organ-threatening kidney involvement is not associated with adverse changes in outcomes or kidney function recovery.
- These findings support the safety and efficacy of reduced GC regimens, aligning with data from larger randomized trials.
- This study provides further evidence for the guideline-recommended use of reduced GC therapy in severe AAV with renal compromise.
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