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Open Access 01-12-2017 | Research

Patients with ANCA-associated vasculitis admitted to the intensive care unit with acute vasculitis manifestations: a retrospective and comparative multicentric study

Authors: Julien Demiselle, Johann Auchabie, François Beloncle, Philippe Gatault, Steven Grangé, Damien Du Cheyron, Jean Dellamonica, Sonia Boyer, Dimitri Titeca Beauport, Lise Piquilloud, Julien Letheulle, Christophe Guitton, Nicolas Chudeau, Guillaume Geri, François Fourrier, René Robert, Emmanuel Guérot, Julie Boisramé-Helms, Pierre Galichon, Pierre-François Dequin, Alexandre Lautrette, Pierre-Edouard Bollaert, Ferhat Meziani, Loïc Guillevin, Nicolas Lerolle, Jean-François Augusto

Published in: Annals of Intensive Care | Issue 1/2017

Abstract

Purpose

Data for ANCA-associated vasculitis (AAV) patients requiring intensive care are scarce.

Methods

We included 97 consecutive patients with acute AAV manifestations (new onset or relapsing disease), admitted to 18 intensive care units (ICUs) over a 10-year period (2002–2012). A group of 95 consecutive AAV patients with new onset or relapsing disease, admitted to two nephrology departments with acute vasculitis manifestations, constituted the control group.

Results

In the ICU group, patients predominantly showed granulomatosis with polyangiitis and proteinase-3 ANCAs. Compared with the non-ICU group, the ICU group showed comparable Birmingham vasculitis activity score and a higher frequency of heart, central nervous system and lungs involvements. Respiratory assistance, renal replacement therapy and vasopressors were required in 68.0, 56.7 and 26.8% of ICU patients, respectively. All but one patient (99%) received glucocorticoids, 85.6% received cyclophosphamide, and 49.5% had plasma exchanges as remission induction regimens. Fifteen (15.5%) patients died during the ICU stay. The following were significantly associated with ICU mortality in the univariate analysis: the need for respiratory assistance, the use of vasopressors, the occurrence of at least one infection event in ICU, cyclophosphamide treatment, sequential organ failure assessment at admission and simplified acute physiology score II. After adjustment on sequential organ failure assessment or infection, cyclophosphamide was no longer a risk factor for mortality. Despite a higher initial mortality rate of ICU patients within the first hospital stay (p < 0.0001), the long-term mortality of hospital survivors did not differ between ICU and non-ICU groups (18.6 and 20.4%, respectively, p = 0.36). Moreover, we observed no renal survival difference between groups after a 1-year follow-up (82.1 and 80.5%, p = 0.94).

Conclusion

This study supports the idea that experiencing an ICU challenge does not impact the long-term prognosis of AAV patients.

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Jennette JC, Falk RJ. Small-vessel vasculitis. N Engl J Med. 1997;337:1512–23. doi:10.1056/NEJM199711203372106.CrossRefPubMed

Jennette JC, Falk RJ, Hu P, Xiao H. Pathogenesis of antineutrophil cytoplasmic autoantibody-associated small-vessel vasculitis. Annu Rev Pathol. 2013;8:139–60. doi:10.1146/annurev-pathol-011811-132453.CrossRefPubMed

Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill consensus conference nomenclature of vasculitides. Arthritis Rheum. 2013;65:1–11. doi:10.1002/art.37715.CrossRefPubMed

Rabe C, Appenrodt B, Hoff C, et al. Severe respiratory failure due to diffuse alveolar hemorrhage: clinical characteristics and outcome of intensive care. J Crit Care. 2010;25:230–5. doi:10.1016/j.jcrc.2009.04.009.CrossRefPubMed

West S, Arulkumaran N, Ind PW, Pusey CD. Diffuse alveolar haemorrhage in ANCA-associated vasculitis. Intern Med Tokyo Jpn. 2013;52:5–13.CrossRef

Thickett DR, Richter AG, Nathani N, et al. Pulmonary manifestations of anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis. Rheumatol Oxf Engl. 2006;45:261–8. doi:10.1093/rheumatology/kei217.CrossRef

Basu N, Watts R, Bajema I, et al. EULAR points to consider in the development of classification and diagnostic criteria in systemic vasculitis. Ann Rheum Dis. 2010;69:1744–50. doi:10.1136/ard.2009.119032.CrossRefPubMed

Lionaki S, Blyth ER, Hogan SL, et al. Classification of antineutrophil cytoplasmic autoantibody vasculitides: the role of antineutrophil cytoplasmic autoantibody specificity for myeloperoxidase or proteinase 3 in disease recognition and prognosis. Arthritis Rheum. 2012;64:3452–62. doi:10.1002/art.34562.CrossRefPubMedPubMedCentral

Kallenberg CGM, Heeringa P, Stegeman CA. Mechanisms of disease: pathogenesis and treatment of ANCA-associated vasculitides. Nat Clin Pract Rheumatol. 2006;2:661–70. doi:10.1038/ncprheum0355.CrossRefPubMed

10.

Yates M, Watts RA, Bajema IM, et al. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis. 2016;75:1583–94. doi:10.1136/annrheumdis-2016-209133.CrossRefPubMed

11.

Jayne DRW, Gaskin G, Rasmussen N, et al. Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis. J Am Soc Nephrol. 2007;18:2180–8. doi:10.1681/ASN.2007010090.CrossRefPubMed

12.

Klemmer PJ, Chalermskulrat W, Reif MS, et al. Plasmapheresis therapy for diffuse alveolar hemorrhage in patients with small-vessel vasculitis. Am J Kidney Dis Off J Natl Kidney Found. 2003;42:1149–53.CrossRef

13.

Specks U, Merkel PA, Seo P, et al. Efficacy of remission-induction regimens for ANCA-associated vasculitis. N Engl J Med. 2013;369:417–27. doi:10.1056/NEJMoa1213277.CrossRefPubMed

14.

Stone JH, Merkel PA, Spiera R, et al. Rituximab versus cyclophosphamide for ANCA-associated vasculitis. N Engl J Med. 2010;363:221–32. doi:10.1056/NEJMoa0909905.CrossRefPubMedPubMedCentral

15.

Jones RB, Tervaert JWC, Hauser T, et al. Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis. N Engl J Med. 2010;363:211–20. doi:10.1056/NEJMoa0909169.CrossRefPubMed

16.

Hogan SL, Falk RJ, Chin H, et al. Predictors of relapse and treatment resistance in antineutrophil cytoplasmic antibody-associated small-vessel vasculitis. Ann Intern Med. 2005;143:621–31.CrossRefPubMed

17.

Pagnoux C, Hogan SL, Chin H, et al. Predictors of treatment resistance and relapse in antineutrophil cytoplasmic antibody-associated small-vessel vasculitis: comparison of two independent cohorts. Arthritis Rheum. 2008;58:2908–18. doi:10.1002/art.23800.CrossRefPubMedPubMedCentral

18.

Flossmann O, Berden A, de Groot K, et al. Long-term patient survival in ANCA-associated vasculitis. Ann Rheum Dis. 2011;70:488–94. doi:10.1136/ard.2010.137778.CrossRefPubMed

19.

Guillevin L, Pagnoux C, Seror R, et al. The five-factor Score revisited: assessment of prognoses of systemic necrotizing vasculitides based on the French Vasculitis Study Group (FVSG) cohort. Medicine (Baltimore). 2011;90:19–27. doi:10.1097/MD.0b013e318205a4c6.CrossRef

20.

Frausova D, Brejnikova M, Hruskova Z, et al. Outcome of thirty patients with ANCA-associated renal vasculitis admitted to the intensive care unit. Ren Fail. 2008;30:890–5. doi:10.1080/08860220802353892.CrossRefPubMed

21.

Khan SA. Outcome of patients with small-vessel vasculitis admitted to a medical ICU. Chest. 2007;131:972. doi:10.1378/chest.06-2464.CrossRefPubMed

22.

Cruz BA. Prognosis and outcome of 26 patients with systemic necrotizing vasculitis admitted to the intensive care unit. Rheumatology. 2003;42:1183–8. doi:10.1093/rheumatology/keg322.CrossRefPubMed

23.

Monti S, Montecucco C, Pieropan S, et al. Life-threatening onset of systemic vasculitis requiring intensive care unit admission: a case series. Clin Exp Rheumatol. 2015;33:S126–31.

24.

Burkhardt O, Köhnlein T, Wrenger E, et al. Predicting outcome and survival in patients with Wegener’s granulomatosis treated on the intensive care unit. Scand J Rheumatol. 2007;36:119–24. doi:10.1080/03009740600958611.CrossRefPubMed

25.

Watts R, Lane S, Hanslik T, et al. Development and validation of a consensus methodology for the classification of the ANCA-associated vasculitides and polyarteritis nodosa for epidemiological studies. Ann Rheum Dis. 2007;66:222–7. doi:10.1136/ard.2006.054593.CrossRefPubMed

26.

Luqmani RA, Bacon PA, Moots RJ, et al. Birmingham vasculitis activity score (BVAS) in systemic necrotizing vasculitis. QJM Mon J Assoc Physicians. 1994;87:671–8.

27.

Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707–10.CrossRefPubMed

28.

Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–63.CrossRefPubMed

29.

Mehta RL, Kellum JA, Shah SV, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care Lond Engl. 2007;11:R31. doi:10.1186/cc5713.CrossRef

30.

Kimmoun A, Baux E, Das V, et al. Outcomes of patients admitted to intensive care units for acute manifestation of small-vessel vasculitis: a multicenter, retrospective study. Crit Care. 2015. doi:10.1186/s13054-016-1189-5.PubMedPubMedCentral

31.

Dumas G, Géri G, Montlahuc C, et al. Outcomes in critically Ill patients with systemic rheumatic disease: a multicenter study. Chest J. 2015;148:927. doi:10.1378/chest.14-3098.CrossRef

32.

Hilhorst M, van Paassen P, Tervaert JWC, Limburg Renal Registry. Proteinase 3-ANCA vasculitis versus myeloperoxidase-ANCA vasculitis. J Am Soc Nephrol JASN. 2015;26:2314–27. doi:10.1681/ASN.2014090903.CrossRefPubMed

33.

Franssen C, Gans R, Kallenberg C, et al. Disease spectrum of patients with antineutrophil cytoplasmic autoantibodies of defined specificity: distinct differences between patients with anti-proteinase 3 and anti-myeloperoxidase autoantibodies. J Intern Med. 1998;244:209–16.CrossRefPubMed

34.

Wunsch H, Guerra C, Barnato AE, et al. Three-year outcomes for Medicare beneficiaries who survive intensive care. JAMA. 2010;303:849–56. doi:10.1001/jama.2010.216.CrossRefPubMed

35.

Iwashyna TJ, Netzer G, Langa KM, Cigolle C. Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions. Am J Respir Crit Care Med. 2012;185:835–41. doi:10.1164/rccm.201109-1660OC.CrossRefPubMedPubMedCentral

36.

Mitharwal SM, Yaddanapudi S, Bhardwaj N, et al. Intensive care unit-acquired infections in a tertiary care hospital: an epidemiologic survey and influence on patient outcomes. Am J Infect Control. 2016;. doi:10.1016/j.ajic.2016.01.021.PubMed

37.

Van Vught LA, Klein Klouwenberg PMC, Spitoni C, et al. Incidence, risk factors, and attributable mortality of secondary infections in the intensive care unit after admission for sepsis. JAMA. 2016;315:1469. doi:10.1001/jama.2016.2691.CrossRefPubMed

38.

Beck L, Bomback AS, Choi MJ, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis. Am J Kidney Dis Off J Natl Kidney Found. 2013;62:403–41. doi:10.1053/j.ajkd.2013.06.002.CrossRef

39.

Pagnoux C, Guillevin L, French Vasculitis Study Group, MAINRITSAN investigators. Rituximab or azathioprine maintenance in ANCA-associated vasculitis. N Engl J Med. 2015;372:386–7. doi:10.1056/NEJMc1414728.PubMed

40.

Charles P, Bienvenu B, Bonnotte B, et al. Rituximab: recommendations of the French Vasculitis Study Group (FVSG) for induction and maintenance treatments of adult, antineutrophil cytoplasm antibody-associated necrotizing vasculitides. Presse Medicale. 1983;42:1317–30. doi:10.1016/j.lpm.2013.08.003.CrossRef

41.

Cartin-Ceba R, Diaz-Caballero L, Al-Qadi MO, et al. Diffuse alveolar hemorrhage secondary to antineutrophil cytoplasmic antibody-associated vasculitis: predictors of respiratory failure and clinical outcomes. Arthritis Rheumatol. 2016;68:1467–76. doi:10.1002/art.39562.CrossRefPubMed

Title: Patients with ANCA-associated vasculitis admitted to the intensive care unit with acute vasculitis manifestations: a retrospective and comparative multicentric study
Authors: Julien Demiselle
Johann Auchabie
François Beloncle
Philippe Gatault
Steven Grangé
Damien Du Cheyron
Jean Dellamonica
Sonia Boyer
Dimitri Titeca Beauport
Lise Piquilloud
Julien Letheulle
Christophe Guitton
Nicolas Chudeau
Guillaume Geri
François Fourrier
René Robert
Emmanuel Guérot
Julie Boisramé-Helms
Pierre Galichon
Pierre-François Dequin
Alexandre Lautrette
Pierre-Edouard Bollaert
Ferhat Meziani
Loïc Guillevin
Nicolas Lerolle
Jean-François Augusto
Publication date: 01-12-2017
Publisher: Springer Paris
Published in: Annals of Intensive Care / Issue 1/2017
Electronic ISSN: 2110-5820
DOI: https://doi.org/10.1186/s13613-017-0262-9

ACC 2024 Congress

Springer Medicine

Patients with ANCA-associated vasculitis admitted to the intensive care unit with acute vasculitis manifestations: a retrospective and comparative multicentric study

Abstract

Purpose

Methods

Results

Conclusion

ACC 2024 Congress

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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