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Outcomes of remission induction therapy for ANCA-associated vasculitis in the elderly

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Abstract

Objective

Treatment regimens combining glucocorticoids with cyclophosphamide or rituximab or both are used to induce remission in ANCA-associated glomerulonephritis (ANCA-GN). There is a paucity of data on the efficacy and safety of these regimens in elderly patients with ANCA-GN. This study aimed to examine outcomes and adverse events in elderly AAV patients with three induction regimens: cyclophosphamide (CYC), cyclophosphamide and rituximab (CYC + RTX), and rituximab (RTX).

Methods

This single-center retrospective cohort study included patients 60 years and older diagnosed with ANCA-GN. Baseline characteristics and outcomes across several clinical parameters were recorded and compared for significance using Kruskal–Wallis test, Chi-squared test, Fisher exact test, univariate, and multivariate logistic regression as appropriate. Cox proportional hazard regression model was used for survival analysis.

Results

Seventy-five patients were included. The mean (SD) age at diagnosis was 70 (± 6) years. The mean (SD) follow-up duration was 5.17 (± 3.47) years. Remission induction therapy with glucocorticoids plus CYC was used in 25 patients, glucocorticoids plus CYC and RTX in 12 patients, and glucocorticoids plus RTX in 38 patients. RTX-treated patients had a higher baseline estimated glomerular filtration ratio (eGFR) (p = 0.00009). High remission rates were achieved in all groups (100% vs. 100% vs. 94.6% respectively, p = 0.368). The incidence of end-stage renal disease (ESRD) at one year was 8% among all groups (p = 0.999). There was no difference in the number of infections requiring hospitalization (p = 0.822), but a statistical difference in leukopenia was noted (32% vs. 25% vs. 3% respectively, p = 0.005). The use of RTX only was associated with reduced leukopenia (aOR = 0.1, 95% CI = 0.005–0.8) after adjusting for other variables.

Conclusions

CYC, CYC + RTX, and RTX are equally effective for remission induction in elderly patients with ANCA-GN. Induction therapy with RTX only was associated with a lower risk of leukopenia compared to CYC-containing regimens. Infections requiring hospitalization were similar among all groups. End-stage kidney disease at one year was comparable among the 3 groups.

Key Points

• Cyclophosphamide, Rituximab, and Cyclophosphamide+Rituximab are equally effective in remission induction in elderly patients with ANCA glomerulonephritis.

• The use of Rituximab only was associated with a lower risk of bone marrow suppression compared to Cyclophosphamide only.

• More information is needed on the comparative safety of induction therapy strategies in elderly ANCA glomerulonephritis patients.

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Data availability

The data that support the findings of this study are available within the article or from the corresponding author upon reasonable request.

Abbreviations

CYC:

Cyclophosphamide

RTX:

Rituximab

PR3:

Proteinase-3

MPO:

Myeloperoxidase

ANCA:

Anti-neutrophil cytoplasmic auto-antibody

GN:

Glomerulonephritis

GPA:

Granulomatosis with polyangiitis

MPA:

Microscopic polyangiitis

eGFR:

Estimated glomerular filtration rate

ESRD:

End-stage renal disease

IgG:

Immunoglobulin G

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Acknowledgements

Duvuru Geetha is supported by the Johns Hopkins Center for Innovative Medicine

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Faten Aqeel, Yumeng Wen & Duvuru Geetha

  2. Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Lillian Xu

  3. Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Antonio Salas

  4. Department of Internal Medicine, Division of Hospitalist Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Shaker M. Eid

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  1. Faten Aqeel
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Correspondence to Faten Aqeel.

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Disclosures

Duvuru Geetha: Consultant to ChemoCentryx, GSK and Aurinia Inc.

Faten Aqeel: None.

Lillian Xu: None.

Antonio Salas: None.

Yumeng Wen: None.

Shaker Eid: None.

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Aqeel, F., Xu, L., Salas, A. et al. Outcomes of remission induction therapy for ANCA-associated vasculitis in the elderly. Clin Rheumatol 42, 2427–2435 (2023). https://doi.org/10.1007/s10067-023-06644-2

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